Readers of Mountains Beyond Mountains, by Tracy Kidder, know that Partners In Health in Peru has been fighting drug-resistant tuberculosis for years.

Since developing a successful program to cure a disease once deemed untreatable, staff at Socios En Salud have continued to fight tuberculosis in Peru. The country sees more than 25,000 cases of TB annually, of which more than 50 percent occur in the capital city of Lima. Of the total TB cases in Peru, about 2,000 are multidrug-resistant, and about 75 percent of those occur in Lima.

To support treatment efforts, PIH/SES opened a state-of-the-art laboratory in Carabayllo late last year to run tests for TB. The lab provides immediate, high-quality information to guide TB treatment—ensuring patients receive the medications that are most effective against the disease. And the scientists behind the lab hope it will prove to the world that a higher standard of TB services is feasible and necessary.

“The mantra for treatment and lab services over the last 25 years has essentially been, ‘keep it simple, stupid,’ said Carole Mitnick, a tuberculosis expert at Harvard Medical School and long-time PIH collaborator. “By opening this lab in Peru, we’re showing that we can bring new technologies close to the people in need and use them to help cure TB patients.”

Tuberculosis is a contagious disease caused by bacteria that infects people’s lungs. It spreads easily when people live in close quarters and have weakened immune systems—conditions that often affect poor people. When people fall sick with tuberculosis, it’s critical to diagnose the disease quickly and start them on treatment with antibiotics, which lessens the risk of them infecting others and expedites their recovery.

It’s also important to provide them the right medicines—those that will be effective against the strain of TB that’s infecting them. That includes multidrug-resistant tuberculosis, which does not respond to the main TB drugs.

In addition to supporting treatment, the facility also serves as a platform for training and research. There, laboratory workers learn to use new technologies to diagnose TB and monitor its treatment. The lab also supports research that aims to make treatment shorter and more effective and that enhances our understanding of how TB spreads.

With a Level 3 Biosafety classification, indicating it’s equipped to perform a range of tests on very dangerous bugs, the lab has some interesting attributes.

1. The lab is made from a recycled shipping container.

To conduct sophisticated TB tests, lab technicians must work with live tuberculosis bacteria. It’s a hazardous and sensitive process. If handled improperly, the bacteria could infect staff at the lab and people living in surrounding areas. And the tests are no good if other organisms have contaminated the bacteria samples. So the lab must be tightly sealed to prevent microorganisms from coming in and going out.

It turns out that one of the most easily sealed structures is recycled shipping containers, the big steel boxes used to carry goods from continent to continent on cargo ships. Socios En Salud bought a repurposed shipping container from a company in South Africa to form the core of the lab—the area where the riskiest tests are done.

Opening a lab in a shipping container is also quicker and cheaper than housing the TB lab in a building. Instead of constructing an entire facility and sealing a room within it, PIH/SES imported the container and began work almost immediately.

2. It’s the first in Peru to offer same-day turnaround on tests.

The lab is Peru’s first ever to offer molecular diagnostic and resistance testing with a same-day turnaround. Peru’s national referral lab offers the same test, but it’s on many samples at once, about once a week. Same-day results allow doctors and nurses to enroll patients more quickly on the treatment that will work best for them.

3. It’s breezy in there.

Negative air pressure pulls filtered air from clean areas toward more contaminated areas, helping prevent airborne bacteria from making contact with staff. The air is filtered before it enters and exits the lab, and the entire air supply changes more than 20 times an hour, almost twice as often as the 12 times per hour required for this safety level.

4. Lab technicians use chicken eggs for some tuberculosis tests.

Tuberculosis bacteria grow with the help of a protein called albumin, which is found in eggs. To test a patient’s TB infection for drug resistance, lab technicians grow bacterial cultures using egg whites and apply various antibiotics to see which drugs kill the bacteria. The drugs that wipe out the bacteria are then prescribed for the patients.

5. It serves as a TB bank.

In addition to conducting tests, the lab also needs storage of bacterial samples, functioning as a “’bank” for samples. With patients’ permission, these samples can be used to test new drugs, or to further refine our understanding of resistance. To store the tuberculosis samples, the lab is equipped with three freezers the size of a large household refrigerator. Each freezer is kept at –112 degrees Fahrenheit. This allows lab technicians to freeze samples, making them non-contagious, but still able to be thawed and grown for further testing.

6. It’s located in the heart of the epidemic.

Most referral labs are established near the center of a nation’s capital, but that’s not always where the most patients live. In Lima, tuberculosis is a big problem in the shantytowns on the capital’s outskirts, where poor people settled after leaving rural areas in search of work. This lab is located in Carabayllo, where PIH first discovered an epidemic of multidrug-resistant tuberculosis in 1995, as chronicled in Mountains Beyond Mountains. Locating this specialty lab in Carabayllo helps speed up the testing process for patients whose health depends on it.

7. It’s one of 14 labs in the world that allow for “gold standard” research to develop new TB drugs.

Only 14 labs in the world have the capacity to do quantitative cultures—to count the number of bacteria in a sample. This technique is known as the “gold standard” for measuring drugs’ effectiveness against tuberculosis bacteria. It’s used to develop new drug regimens to provide shorter, more effective treatment and cure more people.

8. Only highly trained personnel perform lab procedures.

Peruvian laboratories have begun requiring highly trained personnel to perform tests and other lab procedures. The lab’s staff received training in both the national reference laboratory and various regional reference laboratories in Lima, many of them training and working in other labs for several years. Now they are employing this training in service to poor communities.

9. It could be the first TB lab in Peru to receive international certification.

To protect the safety of staff and surrounding communities, the lab follows rigorous procedures for the proper handling and testing of bacteria. And the test results must be reliable for clinicians to use to make clinical decisions. The lab has established procedures according to international standards, and is seeking certification from the International Organization for Standardization to recognize the high quality of lab activities. No lab in Lima is currently certified for tuberculosis, and the PIH/SES lab may be the first. This certification will help the lab attract large-scale TB research studies, which are critical to the development of better diagnostics and treatment.

10. The mission of the PIH/SES lab is to improve public health.

Establishing new labs in Lima helps decrease the incidence of TB by allowing the decentralization of diagnostic tests and especially by improving the quality of lab services. PIH/SES has developed a systematic and sustainable plan to expand lab capacity and improve public health in Lima and all of Peru.

Read more about PIH/SES's work to support patients after they complete treatment for MDR-TB.

The burden of cancer in low-income countries is staggering. More than two-thirds of all cancer deaths occur in low- and middle-income countries, according to the World Health Organization. 

In Rwanda, Partners In Health has worked closely with the Ministry of Health to devise and implement a strategic approach that ensures access to high-quality cancer care for any patient who needs it. Last year we celebrated the opening of Butaro Ambulatory Cancer Center, which augments existing oncology services offered at Butaro Hospital. Our partners at the Dana Farber Cancer Institute, Harvard Medical School, and the MOH have helped train local health care workers to better diagnose and treat cancer. The challenges, however, remain enormous.

This week, Dr. Fidel Rubagumya, an intern doctor at Butaro Hospital, wrote a commentary piece for The New Times, a Rwandan newspaper, in which he discusses the burden of cancer in Rwanda, the shortage of oncologists, and the country’s integrated approach to fighting noncommunicable diseases.

Dr. Rubagumya writes:

While there has been a shift and the devastation caused by cancer is beginning to be addressed, the disease still remains a death sentence for many individuals living in poverty in the developing world.

Thanks to the Government of Rwanda, in partnership with Partners in Health, the Dana Farber Institute of Cancer, Brigham Women’s Hospital and the Clinton Foundation, the Butaro Cancer Centre of Excellence was established in 2012 as a response to the rapidly growing instances of cancer in the country.

Since its inauguration, the facility has received and treated over 1,000 cancer patients from within and outside the country, including some from the Democratic Republic of the Congo and Burundi.

Read Dr. Rubagumya’s full commentary here.

Last week, the headquarters of Inshuti Mu Buzima (IMB), Partners In Health’s Rwandan sister organization, turned into “Harvard East,” when more than 20 participants from the Rwandan health sector and PIH/IMB completed a five-day Harvard-Rwanda Global Health Delivery field (GHD) course. This marked the third year of the course, a joint effort by Harvard Medical School, the Rwandan Ministry of Health and PIH/IMB. The goal: empower local health providers, policy makers, and thought leaders to bridge the gap between knowledge and practice in global health.

“A lot of progress has been made in Rwanda’s health sector, and we don’t want to move backwards,” said Maurice Gatera, head of the Vaccines and Preventable Diseases Division at the Rwanda Biomedical Center. Gatera was one of the 25 students who lived and studied in the Rwinkwavu Center for Operational Research and Training over the course of the week. “The global health knowledge we have received in this course will help us continue making progress. Many examples from around the world were shared, [including] how progress can be achieved through different health interventions.”

The course combined several methods of instruction, including small group discussions, live interviews with health care leaders, case studies, and field visits, during which students were able to see theories discussed in the class put into practice. 

Without health, we slow down development, and without development we slow down access to health,” Dr. Agnes Binagwaho said.

Rwanda's Minister of Health Dr. Agnes Binagwaho has been instrumental in developing and implementing the GHD course, which is designed to give all leaders from the Rwanda health sector a solid foundation in the global health discipline. “Without health, we slow down development, and without development we slow down access to health,” Dr. Agnes Binagwaho said. “It’s very important that the participants feel it, and understand it—to help them to think more strategically.”

Strategic connections and new friendships were forged throughout the week, and former GHD course students helped lead discussions and lectures. All participants received a Harvard Medical School certificate at the end of the course.

Dr. Felix Cyamatare, clinical director at PIH/IMB, a former GHD student, served as faculty member this year and was encouraged by all that he saw. The lessons learned will be a driving force of positive change in Rwanda. “I was humbled by the honest discussion that were had between Ministry of Health and Partners In Health colleagues,” Cyamatare said.

One of Dr. Paul Farmer’s vivid memories from his early days in Haiti was a young woman who coughed up bright red blood.

She died of tuberculosis, a scourge that will kill about 1.4 million people this year, despite the existence of diagnostics and therapeutics to cure it.

On World TB Day, Farmer talked about how the world can reach zero tuberculosis deaths with Ray Chambers, UN special envoy for health financing, in The Huffington Post. Farmer said that better diagnostics, shorter treatment, and community-based care are critical components of meeting the Millennium Development Goal to achieve universal treatment of TB by the end of 2015.

Farmer highlighted the success of Tomsk, Siberia, in fighting multidrug-resistant tuberculosis as an example of how to overcome difficult-to-treat strains. He also commended the work of Dr. Mercedes Becerra, senior TB specialist at Partners In Health, to estimate the alarming number of children who become sick with TB every year. Still, Farmer said that a lack of public awareness of TB is a one obstacle to greater political will to address it.

“I can't tell you how many people, including policymakers, have said to me, ‘Oh, I thought that tuberculosis was a disease of the past,’” Farmer said. “There needs to be more work on the part of health care providers and activists to correct this error.“

Read the full conversation here.

Tuberculosis (TB) is a deadly, airborne infectious disease that is curable and preventable. Yet the annual human toll of TB remains appalling. In 2012, nearly 9 million people became sick with TB and about 1.5 million people died from it. Children are very vulnerable to TB but have for decades been neglected. TB treatment is very effective and saves lives: even children sick with highly drug-resistant forms of TB are almost always cured if they get the right treatment with the drugs they need. Unfortunately, child-friendly formulations of many TB drugs are often not available.

Today Dr. Mercedes Becerra, senior TB specialist at Partners In Health and associate professor of global health and social medicine at Harvard Medical School, publishes a groundbreaking study in The Lancet. She and her colleagues report alarming results: they estimate that 1 million children become sick with TB every year—double the number previously thought. They also provide another first-ever estimate: more than 30,000 children become sick every year with strains of multidrug-resistant TB (MDR-TB).

Becerra has worked with PIH for nearly 20 years, helping to build treatment programs for drug-resistant TB. She helped launch the PIH program in Lima, Peru, and has worked with PIH sites in Haiti, Russia, and Lesotho, and with the Indus Hospital in Pakistan. In 2011, Becerra co-founded a network called The Sentinel Project on Pediatric Drug-Resistant Tuberculosis. This is a global consortium of investigators, caregivers, and advocates joining forces to raise the visibility of children sick with drug-resistant TB, identify the new science needed to better serve them, and share valuable resources for their caregivers in the field.

To mark World TB Day, we spoke with Becerra about her new research, the barriers to effectively treating children with TB, and why efforts to quantify the burden of childhood TB have lagged.
 

You and your colleagues emphasize that the incidence of MDR-TB in children has never been estimated. Why is that, and why does it matter?

We realized that as long as there were no estimates of the number of children with MDR-TB, it would be very difficult to advocate for improved care and research that serve children specifically.

The trouble is that we have the perfect recipe for making children with TB invisible, especially children with drug-resistant TB.

First, for at least two decades, TB policies outside the United States and Europe have focused on finding and treating infectious cases, especially those that could be diagnosed using a sputum smear microscopy test. Since children are generally less infectious than adults or not infectious, they fell outside this priority group. So children haven’t been a priority for testing and when they are tested, the technology that we use also happens to be particularly bad at detecting TB in kids, finding fewer than 20% of children sick with TB. This test, called sputum smear microscopy, has been around for more than a century, but it’s still the most commonly used TB test around the world.

Second, TB in children looks different than TB in adults. Adults usually have symptoms like a cough, fever, and weight loss. Children with TB can present with a range of non-specific symptoms so TB is more likely to be missed. Children with pulmonary TB typically have a lower bacillary load than do adults, which makes it hard to culture a positive sample even when the germs are present. And very young children cannot expectorate on command, so we can’t obtain a sputum specimen for testing. All this means that with current tests it is far more difficult to obtain a definitive bacteriological diagnosis of TB in a child than an adult.

The trouble is that we have the perfect recipe for making children with TB invisible, especially children with drug-resistant TB.

Third, for children sick with drug-resistant forms of TB, the situation is even worse. A bacteriological diagnosis of drug-resistant TB requires that the TB germ be grown in culture and tested for susceptibility to TB drugs. This requires access to laboratory capacity and rapid point-of-care tests that are still not available in most of the world.

Finally, once infected with TB, children can progress more quickly to active disease and death than adults. That means that if TB is not recognized and the child remains untreated, that child can die without ever being “counted” as a TB case.  Remember, pediatric TB doesn’t look like adult TB. They’re not necessarily coughing blood, so when they die, it’s easy to say they died of a weird fever, not, “oh, we lost another one to TB.”

Which makes these children invisible.

Yes, these factors come together to make children with TB invisible—and seemingly unquantifiable—on a global scale. In most of the world, the number of childhood TB cases reported to state authorities (and on to the World Health Organization) does not reflect the true burden of childhood TB disease because most reported cases have a smear-positive diagnosis. As I said, we know those kind of childhood TB cases are only a small subset of all childhood TB cases.

My colleague Ted Cohen and I decided that despite all these challenges, we had to do our best to get an estimate of multidrug-resistant TB cases in children, and in so doing improve on the available estimates of all forms of TB in children. So we began pulling together a team to do this, almost three years ago. We persisted because putting a number on the unmet need for treatment is the first step in setting targets and starting to monitor progress to close treatment access gaps on a large scale.

What do you mean when you say a child with TB is a “sentinel event”?

This is a frequently-used term in the public health literature on childhood TB. The word “sentinel” comes from the Latin word sentire, which means “to perceive” or “to see.” When we say a case of childhood TB is a sentinel event, it means that each case is a warning signal on two fronts. First, each case is telling us about ongoing transmission: that child was infected recently by someone close to her—someone who was sick and infectious and is probably still untreated and infecting others. Second, each case is telling us about a system failure: this child should have received preventive therapy but did not. Even if she was infected, she did not have to become sick.

Each child with TB is pointing to at least one missed opportunity for prevention. So we are talking about more than 1 million missed opportunities for preventing TB in children every year.

This concept is actually the key to understanding the implications of our report. If each child sick with TB is pointing to at least one missed opportunity for prevention, this means that every year there are more than 1 million missed opportunities for preventing TB in children. This toll on children will continue year after year until enough resources have been invested to ensure that programs can both treat the patients already sick with TB and provide preventive therapy to those, including children, who have been recently infected with TB so that they don’t become sick.

In April of 2011, PIH's Dr. Hind Satti examined 13-year-old Pulane Molikoe, who had HIV and MDR-TB, at Botsabelo Hospital in Lesotho. Despite initial treatment progress, the young girl's disease was too advanced, and she passed away a few months after this photo was taken.

Can you tell us how the problem of pediatric MDR-TB landed on your radar and discuss your role with The Sentinel Project on Pediatric Drug-Resistant Tuberculosis?

I have worked with PIH in Peru for many years as part of the team building and evaluating our MDR-TB treatment program there. Ten years ago, I designed and led a large study where a team visited all the households of these patients to see what had happened to their family members. Basically, we were trying to count the TB toll in a group of 6,000 individuals—children and adults—that had unfortunately been exposed at home to MDR-TB over long periods of time. 

In April 2011, I was invited to present my unpublished data about the TB rates in these children at a workshop in Delhi that examined the barriers to scaling up drug-resistant TB treatment in India. There I met Dr. Soumya Swaminathan, director of India’s National Institute for Research in Tuberculosis, who presented unpublished data from across India on children with drug-resistant TB.

After our presentations, we realized we had had the same experience of looking for—and not being able to find—information about how drug-resistant TB is affecting children across the world. It seemed children with this disease were practically invisible from a global view. We realized this was itself a major barrier to advocacy for better science and expanded treatment access.

Dr. Soumya and I thought we should try somehow to raise the visibility of this vulnerable population, and that it should also be a way to link individuals who were themselves already stakeholders. We came up with an idea of linking in a virtual network like-minded people who shared the vision of a world where no child dies of drug-resistant TB. We reached out to colleagues we knew or whose work we had read, and all of them supported the idea and expressed eagerness to join.

At a TB conference in October 2011, we made a public announcement convening this virtual community and invited interested colleagues to join and spread the word. Today, the Sentinel Project network includes more than 300 people from more than 50 countries. We have had no funding, yet several task forces—all volunteers—have come together “virtually” to produce a number of practical resources for treatment, research, and advocacy. They can all be downloaded from this website: www.sentinel-project.org

One of the most important pragmatic ideas this network is advancing is that MDR-TB in a sick child can be treated and cured even in cases without bacteriological diagnosis, but where there is plenty of other evidence that should give the provider confidence that the child has MDR-TB. That child should be called a “probable” case of MDR-TB as opposed to a bacteriologically “confirmed” case of MDR-TB, and both groups of cases need treatment.

Every day around the world, children who only meet the definition of “probable MDR-TB” are falling through the cracks, because many programs still require a bacteriological diagnosis before second-line drugs can be approved for the patient. Children are dying because they cannot get this treatment.

What needs to be done right away to find and treat more children with TB? And what gaps need to be addressed in the future?

The most important action to be taken immediately is that public and private programs treating TB patients have to implement “contact tracing” around each patient, starting with the people who live with that patient. This strategy— often called TB contact investigation—is the most important tool we have right now to find, treat, and prevent childhood TB cases. Contact investigation means that when a TB patient is found, a systematic effort is undertaken to screen that patient’s close contacts in order to treat them promptly for active TB disease or latent TB infection.

TB contact investigation is the most important tool we have right now to find, treat, and prevent childhood TB cases.

To prevent child deaths from TB, time is of the essence—infected children can deteriorate quickly without treatment. Contact investigation greatly increases the chances that child contacts who are sick will be recognized as TB cases and treated promptly. Contact investigation is a fundamental pillar of TB policy in the U.S. and other rich countries, but it is not routinely implemented in other countries that have the highest burden of TB. The resources are often not available.

To do this right will require significantly ramping up resources, staffing, planning, and follow-through—but it will save lives. In 2013, a group of global pediatric TB experts and advocates produced a first-ever action plan titled “Roadmap for Childhood Tuberculosis: Toward Zero Deaths.” This document is a valuable resource that clearly identifies gaps to be filled to end child deaths from TB. Contact investigation is one of their key recommendations.

In terms of what needs to be done in the future, two priorities require more investment in research and delivery. The first is a non-invasive point-of-care TB test that works very well in children. The second is a new, shorter, safer regimen that consists of all oral drugs (no injectables) that are well-tolerated in children along with the child-friendly formulations of these drugs. Together, and only if they are made accessible to families living in poverty, these breakthroughs will save millions of lives.

Now that you and your colleagues have been able to devise estimates of the MDR-TB burden among children, what’s next?

Personally I’m eager to focus now on two tasks. First, I want to work with advocates and programs to use these new estimates to set treatment targets, devise action plans, and monitor progress. Along the way, we must also work on improving the estimates published today. Second, I want to work with collaborators at PIH and in the Sentinel Project network to ramp up contact investigations, learn from these experiences together as we go, and disseminate these lessons broadly and quickly.

A decade ago, Partners In Health, in collaboration with Harvard Medical School and Brigham and Women’s Hospital, published The PIH Guide to Medical Management of Multidrug-Resistant Tuberculosis. The pocket-size guide culled the best-available information from an array of agencies and organizations and distilled it into a portable format. It remains a go-to resource for clinicians in the field.

But over the past 10 years, PIH’s understanding of drug-resistant TB has evolved tremendously. We’ve collected enormous volumes of data that guide our decisions and programs. Our clinicians from Lesotho to Russia to Peru, among other countries, have devised and implemented evidence-based strategies to treat patients in a community setting and stem the transmission of the drug-resistant strains.

That’s why we’re delighted to announce the release of the second edition of The PIH Guide to Medical Management of Multidrug-Resistant Tuberculosis. With funding from USAID though the TB CARE II Project, more than a dozen experts from organizations such as University Research Co., LLC, Project HOPE, KNCV, and the International Union Against Tuberculosis and Lung Disease shared their expertise and contributed to the guide.

“This is an easy-to-use guide that contains all new information,” says Dr. KJ Seung, program director of PIH/Lesotho, deputy director of TB CARE II, and a co-editor of the guide. “It discusses the community-based treatment model from the clinician’s perspective and explains how the model fits into overall management strategies.”

Since the first edition of the guide was published, new diagnostic technologies, such as GeneXpert, and drugs, such as Bedaquiline, have emerged. As Seung says, “We’re capable of diagnosing more patients with drug-resistant tuberculosis, but that does not mean treating MDR-TB or XDR-TB has gotten any easier. Treatment for drug-resistant TB takes between 18 and 24 months. It is very challenging.”

The medications used to treat drug-resistant strains can trigger myriad side effects, including deafness and liver damage. The PIH guide offers a comprehensive analysis of side effects and provides best practices for management.

“Among the biggest changes to the guide is new information on managing side effects,” Seung says.

“Among the biggest changes to the guide is new information on managing side effects,” Seung says. “This is a major problem for all clinicians, especially when they’re new to treating drug-resistant TB.”

While the burden of MDR- and XDR-TB appears to be increasing globally, PIH remains committed to accompanying patients through treatment, training the next generation of clinicians to build local capacity, and carrying out thorough research to improve on our strategies.

If you’re a clinician interested in downloading the updated edition of The PIH Guide to Medical Management of Multidrug-Resistant Tuberculosis, please visit our Knowledge Center by clicking here. A digital version of the book is available here. An app containing the guide will be available for iPhones and the Android platform later this year.

Click here to download the full guide.

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.

"The journey continues," Gilford Mphugela said, sinking back into the driver seat of the Toyota Land Cruiser. He had spent the past 75 minutes skillfully navigating treacherous mountain roads, where torrential rains had cut deep ruts that threatened to swallow the truck’s wheels. The six Partners In Health and Malawian Ministry of Health (MOH) employees crammed in the back of the vehicle cracked jokes and shared laughs along the way, but when the vehicle tilted or the tires spun on a steep incline, everyone held their breath. In the weeks prior—during the peak of Malawi’s rainy season—the vehicle had gotten stuck several times on this same road and the team had to turn back. But today was hot and dry, ideal for the Nsambe mobile clinic to reach patients in Chawe, among the most remote regions PIH works in Malawi.

Before reaching Chawe, though, we had to make a pit stop at a small health facility run by the MOH and Christian Health Association of Malawi (CHAM). Here we picked up Elias Issack Okhoma, a health surveillance assistant working with the MOH. He piled a few boxes of vaccines into the back of the truck then wedged his way into the last remaining seat. The journey continued, as Mphugela promised, across another bumpy stretch. Mphugela worked the clutch as the truck climbed the winding path, his feet dancing across the pedals with the grace of a NASCAR driver. He pointed out the window toward a lush range of mountains, noting that we were near the border of Mozambique. A few huts specked the ridgeline, otherwise brush and tall grass dominated the landscape in every direction. 

After another 20 minutes, a small hollowed-out brick building came into sight. Outside, a crowd of approximately 200 mothers and children milled about. As the truck rolled to a stop, everyone merged into a snaking line. The team unloaded the truck and swiftly set up shop in the building. Inside, each member of the mobile clinic was responsible for a small station serving a very specific function, from patient registration to vaccine administration to HIV testing and counseling.

“Our mobile clinics are designed to offer general consultation for all type of diseases in adults: antenatal services for pregnant women; immunization and growth monitoring for children under 5; family planning for women of childbearing age; HIV testing and counseling; malaria rapid test; and typhoid rapid test,” explains PIH/APZU Clinical Director Dr. Junior Bazile.

Aaron Mapwelemwe, a PIH/APZU pharmacy assistant, provides antimalarial medication to a mother and her child at the mobile clinic in Chawe, Malawi. In the rainy season, cases of malaria soar. 

PIH’s Malawian sister organization began running the current version of the mobile clinic to Chawe at the end of October 2013. While there is the small health facility operated by CHAM and the MOH in the region, not all patients can reach it or afford the nominal consultation fees—200 Malawian Kwacha (approximately 50 U.S. cents). Though it’s a small sum, it could mean the difference between receiving health care for the poorest and most marginalized patients.

The mobile clinic to Chawe, which goes out every Tuesday, is always a mix of PIH and MOH employees. It has helped deliver care to more than 2,100 patients since it began operating at the end of October 2013. “Partnering with MOH has been key. Because we are here to support and supplement the MOH, we want them to take the lead in such activities and we can help in identifying, filling, and fixing the gaps,” Bazile says.

The mobile clinic has helped deliver care to more than 2,100 patients since it began operating at the end of October 2013.

Mobile clinics are only one part of the primary health care services to which all Malawians are entitled. They complement our strategic objectives of delivering health care, accompaniment, and socio-economic support to people in their communities and providing technical and financial assistance to MOH. They help link other active case-finding efforts carried out by village health workers and clinicians to the Neno District Hospital.

“We have been conducting mobile clinics in collaboration with MOH since we started operating in Neno,” Bazile says. “However, the weekly mobile clinics in Chawe have opened our eyes to how great the needs of the community are, and they have enabled us to go one step closer to the poor in that neglected part of Neno District.”

Elias Issack Okhoma, a health surveillance assistant working with the MOH, prepares to vaccinate a child during clinic hours in Chawe, Malawi.

After a few hours of steady work, Aaron Mapwelemwe emerged from the brick building and took a seat on the edge of the road. The sun was directly overhead, baking the dirt surface. “This program, this mobile clinic, is a relief to the community. Without this program people would have died. Some patients have to walk hours to get care at the district hospital,” he said, gesturing toward the mountains and a narrow dirt path. “They might sleep on the side of the road at night or take a short cut through the wilderness. There are ferocious animals out there. And the people are already sick. With this clinic, everyone is free to access quality health services.”

Mapwelemwe is a pharmacy assistant who’s been working with PIH/APZU since 2007. Within the mobile clinic, he’s responsible for stocking and dispensing an array of medications, from hypertension and epilepsy drugs to antimalarials. On this particular day, Mapwelemwe has dispensed several packets of antimalarial drugs—during the rainy season, malaria rates soar in PIH’s catchment area—and medication for children with persistent coughs.

All said, 195 patients were seen by mobile clinic staff that afternoon.

The line of mothers and children dwindled. Mapwelemwe’s bags and boxes of medications were packed into the back of the truck. We all squeezed into our seats. And once again Mphugela was back at the helm, ushering us down the same rutted road.

For Mphugela and Mapwelemwe and all the other staff who venture out on mobile clinics each week, the journey continues.

On this particular day, 195 patients, mostly mothers and children, received care from the mobile clinic. 

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 International Operations Director Kathryn Kempton.
 

I stood in the cold hangar at Massachusetts’ Hanscom Air Force Base in the early morning light, staring down the half-dozen anesthesia machines. The shrink-wrap had compressed hoses and cables securely into place, but the machines still measured about six feet tall and three feet wide. Nearby hospitals had donated the anesthesia units for immediate deployment to Haiti. They were desperately needed in the makeshift operating suites in Port-au-Prince to increase our ability to treat those injured in the devastating earthquake a few days earlier.

I looked over my shoulder at the jet. Sizing up the steep stairs and the plane’s narrow doorway to which they led, I felt a wave of frustration and defeat. There was no way these machines could get onto the plane. In all the arrangements we’d made to get this first group of surgeons, nurses, and equipment to Haiti, it never occurred to me to ask about doorway clearance.

In my defense, I’m not a disaster response specialist or a trained logistician. But as the director of international operations at Partners In Health, my team and I have often been asked to overcome the seemingly impossible. Whether it’s getting a suitcase of medications to a physician’s home the night before a flight to Africa or finding a safe way to send restricted, hazardous materials to Haiti, our team is called on to solve problems quickly and creatively. This was never truer than in the aftermath of the 2010 earthquake in Haiti, which forced everyone at PIH to create new systems and develop new skills.

The urgency of our work demands that we’re flexible, creative, and tenacious.

Whether we’re responding to a natural disaster or just handling day-to-day crises, the international operations team is responsible for the purchase of medicines, supplies, equipment, spare parts, and all the other materials that keep our clinical facilities running. Think of us as the “stuff” people. Because we work in resource-limited settings where many commercial goods are unavailable, the range of items to procure extends far beyond medical materials. Over the years, we’ve purchased and shipped everything from blood collection tubes to flashlights, from construction materials to fish food for the hospitals’ koi ponds.

I work out of our Boston office, where our team is based. From here we can interface with our colleagues in the PIH sites and with the dozens of vendors, freight forwarders, and international partners with whom we work. We’re also positioned to manage inventory, monitor stock levels, dispatch shipments to our hospitals and clinics, and field requests from the sites. In most PIH country sites, we employ local operations staff that handles importation and customs clearance.

Our team members have diverse and broad experience. Some are returned Peace Corps volunteers with deep knowledge of developing countries. Others have backgrounds in domestic project management. Some, like me, came with little formal training and have learned on the job. I had the unique opportunity to grow into my role concurrent with the growth of PIH’s global footprint. As the need for essential medicines increased in Haiti, I learned about international vendors and wholesale purchasing. When PIH expanded our drug-resistant tuberculosis work in Peru and Russia, I learned how to navigate global drug markets, patent laws, and concessional pricing for developing countries.

We’re hands-on people who like to get into the details of a situation, understand it, and devise solutions and improvements.

Regardless of our professional and educational backgrounds, there are universal traits found in those drawn to operations work. Everyone on the team is a “do-er.” We’re hands-on people who like to get into the details of a situation, understand it, and devise solutions and improvements. We are systems-focused, constantly looking for more efficient strategies. Often we play a detective role; when a colleague in the field sends a cryptic message like, “I need a cable for the ultrasound machine,” it’s up to us to extract the information we need from our records and from our colleague, then identify suppliers and find the right part—preferably at a discounted price. The urgency of our work demands that we’re flexible, creative, and tenacious.

Although we do not sit with patients in exam rooms, our work directly affects the delivery of health services. Before a new piece of equipment is purchased, our team researches past performance and analyzes its suitability. What are the power needs—will a converter or inverter be needed? Is it durable and able to withstand heat, dry conditions, humidity? Is it compatible with existing equipment? Will the staff using the equipment be able to receive training, technical support, and maintenance?

This work takes time but we know firsthand the problems that arise when these kinds of questions are not asked. By focusing on assessment and careful selection, the international operations team has built an extensive body of knowledge about hospital systems, including oxygen generators, neonatal equipment, and pathology laboratories. We are able to share our experience with other PIH sites, both to avoid repeat mistakes and to strengthen and eventually standardize the equipment used in PIH locations globally. Every day new challenges are presented, and every day we learn how to improve our work.

Through some miracle—or sheer force of will—we managed to get one of the anesthesia machines onto that jet at Hanscom Air Force Base. In the following week, all of the other units found their way to Haiti, along with the tubing, vaporizers, and medications necessary to make them work.

And now, importantly, we’ve added another item to the ever-growing list of questions we ask: the clearance of an airplane’s door.

For more expert advice on working in global health, click here.

"In life, anything is possible! As elders would say: You know how today is, you don’t know what tomorrow will look like. This is why the mental health service at Partners In Health is encouraging any person who is suffering from a mental health problem to seek attention at the hospital! Because! At the mental health department of Partners In Health, at the PIH sites, there is good help available for all kinds of mental health problems. Listen here! In the Central Plateau, at sites including: Mirebalais, Lascahobas, Belladère, Cange, Boucan Carre, Thomonde, Hinche and Cerca La Source. And in the Artibonite Valley including Verettes, Petit Riviere and St. Marc. At all of these sites, all days, all kinds of providers are available: psychiatrists, psychologists, nurses, generalist physicians, community health workers and social workers. Help for all people with mental health problems and all kinds of people: children, youth and all elderly people! So, no one should discriminate against people with mental health problems! Because! Anyone can have a mental disorder. It doesn't matter which people, or which social class! And don't forget, your mental health problem will be treated! This is a message of the Department of Mental Health of Partners In Health."

Read a Translation of Paul Mainardi's Radio Spot

Recognizing the significant global burden of mental disorders, Partners In Health, with generous support from Grand Challenges Canada, has been working to build a system of mental health care in Haiti that integrates mental health services into the primary health care system. Given the shortage of specialists such as psychologists and psychiatrists, this effort seeks as much as possible to include all health care providers in the delivery of mental health care—a role that is new to the Haitian context but one that has been hugely successful in central Haiti where PIH works.

Ours is a multipronged approach that includes not only the delivery of clinical services, but also the provision of social services to support those made vulnerable by mental illness and stigma. Staffed entirely by Haitians, aside from a visiting psychiatrist—the Dr. Mario Pagenel Fellow in Global Mental Health Delivery from PIH and Harvard Medical School—the program is building the foundation for mental health services to be delivered safely, effectively, and in the community.

One person who has benefited from this work is Paul Mainardi, 22, who began spontaneously hearing voices and hallucinating when he was about 20 years old. He began to believe that demons were persecuting him, and sought help through his church.

Afterward, Mainardi was taken to the PIH-supported hospital in Lascahobas, where he began psychotherapy and received medication for symptoms of psychosis. The following is his story in his words, translated from Haitian Creole.

The first thing I have to say is that I’m a religious person. When I started to feel unwell, I began spending a lot of time fasting in the mountains, praying, spending days without talking to people, without eating, and I reached a point where I was hearing and seeing things. I was feeling more and more that I was being persecuted. I saw people running after me. I told my family that I was persecuted, but my parents said it wasn’t true because I’m a servant of God.

I realized that I don’t have a spiritual problem, I have a mental health problem.

I went to a church, and I spent three days there. I spoke to the pastor, and he said he would perform an exorcism that would either set me free or I would die. Everyone from the congregation who was there made a circle, and they put me in the middle. The pastor restrained me by my neck to rid me of the spirits. I lost consciousness, and when I regained consciousness, I saw everybody crying including the pastor because they thought I died. This is why they brought me to Lascahobas, to the PIH hospital, where I met Emmeline the psychologist.

When I met with her in Lascahobas, I couldn’t see well, and I heard things but my thoughts were somewhere else. My mind was not there. I was thinking of something, I was hearing something, and I was seeing something. Emmeline continued to talk with me. I explained what was wrong. She said that you can survive with a mental illness, that people can support you and how you have to behave with other people.

When I went to Lascahobas, I didn’t feel very well. I didn’t feel well at all. When I was at the hospital, my mind told me I had to just flee. I had a very bad headache. At that time, my family and I thought I had a problem with the demons, and I was afraid someone would do something bad to me. But after I met Emmeline, I realized that I don’t have a spiritual problem, I have a mental health problem.

After I had an explanation of what was happening to me, I started to understand that when I heard a voice, I didn’t have to do what the voice told me. Before, if the voice told me to run away, I would run away, but then I learned that the problem is that I’m hearing this voice. When I see something, when I hear a voice, now I understand that it is not about the devil. I’m not afraid any more. I don’t have to obey them anymore. I sleep well. I can say there have been many changes.

My family has been very supportive. They took me to the hospital and took care of me. In my relationships with other people, in the beginning I was constantly saying nonsense. I met a pastor who could not understand. After I got better the pastor invited me to play drums at his church. He really valued me, and he acknowledged that he had treated me badly. So the relationship got better. I’ve also begun working more and more in radio communication and doing spots for people.

I feel truly good. Because where I came from comparing to today, I can say that the PIH/Zanmi Lasante staff have done a lot for me, and they did great work. I was doing very badly, and Dr. Fils-Aime also did a lot of work with me. So I feel really good. At the end of last year, I organized a big party for my radio show, with colleagues and friends from the show. If my mind wasn’t clear and organized, if I wasn’t feeling well in my mind, I wouldn’t have been able to do it. I feel really good now.

Mainardi was cared for by a collaborative team of providers, including Jospeh Israma, community health worker, Emmeline Affricot, psychologist, and Reginald Fils-Aime, a generalist physician. Mainardi was so moved by his experience that he wanted to share it with others and prevent the harm that can come from not receiving quality care. So he started a radio station in his home. He transmits messages over the airwaves about mental disorders as a treatable condition, and urges people to seek care from the mental health team at Partners In Health.

“In life, anything is possible,” he begins in one radio spot, in which he describes the range of clinical mental health services available in the community—community health workers, nurses, social workers, psychologists, generalist physicians, and, if needed, a psychiatrist.   

Paul Mainardi, 22, toasts his recovery with the Partners In Health mental health team in Haiti. Photo: Rebecca E. Rollins/Partners In Health

Dr. Luis Castillo is a Mexican physician who worked with Partners In Health in Chiapas, Mexico, for his required year of medical service to a rural community. In this essay, he reflects on how the experience transformed his interest in service into a strong commitment to changing the world.

I had the good fortune of growing up around people who were motivated to improve the situations of local communities in need. Nevertheless, to be honest, I dedicated just 21 days of the year to helping marginalized communities through volunteer work with Catholic missions.

I stepped foot in Chiapas for the first time in my life, full of uncertainty and doubts, but with my spirit awakened and ready for new challenges.

In this way, I had only a passing interest in service when I learned about Compañeros En Salud, Partners In Health’s sister organization that works to improve the primary health care system in rural Chiapas, Mexico. My first encounter with them was mere coincidence. I found myself in the hallway of my hospital, during a pediatrics rotation, when one of my colleagues told me about the adventure that was waiting in Chiapas for my social service year.

I learned the details through the Internet and contacted the program directors—strangers who before long became my mentors. And before I knew it, I stepped foot in Chiapas for the first time in my life, full of uncertainty and doubts, but with my spirit awakened and ready for new challenges.

I was surprised by the ecological diversity, the incredible scenery, and the magic that enveloped the Sierra Madre Mountains. My colleagues—the other social service year physicians—were interesting people with inspiring stories, social consciousness, and a skilled, thoughtful approach to the titanic daily struggle we had decided to undertake.

I heard for the first time the name of the place where I would spend one year of my life: Laguna del Cofre, a tiny community about seven hours via public transportation from Chiapas’s largest city. The truth is I hadn’t the least idea of what awaited me. I searched on Google Maps without a single result, heightening the sense of adventure.

I arrived as a total stranger. At the beginning I didn’t even understand the language, a rural Spanish with a smattering of indigenous words, let alone the perception of time or the course of an illness. Most of the people measured less than five feet tall, with a thin build and brown skin, accompanied everywhere by a machete, a sack, and a gallon of “pozol,” a traditional beverage good for filling hungry stomachs.

The transition I had heard about so many times in medical school happened: I became a community doctor. The Mexican Ministry of Health and PIH/CES accompanied me and introduced me to the community. I felt responsibility and a host of emotions as I took charge of the health of children, young people, men, women, and the elderly.

I went to my new house. It was an old health center: a large room with faded colors, notable only for its humidity, dysfunctional bathroom, and brownouts that made it impossible to use electronics. I had the basics: a cot, a couple of photos of family and friends, and a heart ready to work.

Just then, Doña Caty approached me. A humble woman with a steady gaze and a warm greeting, she had a wrinkled face that suggested a life dedicated to sacrifice on behalf of the people she most loved. “Doctor, would you like to have a cup of coffee?” she asked. That cup of coffee, bitter as the night, opened the doors of her home to me. She introduced me to her 10 children, accompanied by her grandchildren. I should confess that it took me a bit of work to learn their names, but they became friends, my confidantes, support, inspiration, and family.

I had an epiphany. I discovered a world that was divided in two: between the haves and the have-nots.

I accepted the challenge.

Waking in the morning, I felt excited by the smoke of neighborhood chimneys that circled the sheet-metal roofs, the sounds of the animals, and the chill of the mountains. Each day I faced a different challenge related to the difficulties of a place where resources are limited. I learned about family dynamics in which domestic violence was the common denominator, human rights were an abstract concept, and the primary goal of every day was to simply survive. All this contributed to a cycle that made health interventions complicated and seem impossible.

This series of problems, some imposed by our Spanish colonist forebears, joined with a lack of access to basic health services to plague Laguna del Cofre. I came to understand the term “global health,” from my experiences in the field and the trainings offered by PIH/CES to supplement our clinical work.

I had an epiphany. I discovered a world that was divided in two: between the haves and the have-nots. To me, the deepest and most painful injuries that affect our society today are poverty and disease. And most importantly, I learned they are not conditions imposed by God, but instead depend on social forces—on all of us. I refuse to accept that the world has to be this way. I reject the justification that says we can’t do anything.

PIH/CES, as a model of excellence in the field of global health, has provided me the tools to nourish my courage to face social injustices and to act upon my desire to fight each morning against the systems that disadvantage the most marginalized people.

Of course we can break the cycle of poverty and disease. It doesn’t matter what resources we have on hand, we need only science, innovation, and strong advocacy to influence decision-makers in the government.

So it was in Laguna where I had my change of heart, where my desire turned into action. There, I found my calling. There, where the air changed the color of the houses. Where dreams are humbled. The place I had chosen, where I felt my hope reinforced to build a better world.

What does it take to fix a broken neck?

Staff at University Hospital in Mirebalais, Haiti, had to learn when two patients with that same injury arrived at the emergency room days apart.

One was a 48-year-old farmer who fell out of a tree while he was cutting a branch to sell as firewood. The other was a high school senior who broke his neck in a traffic accident when the brakes of his bus gave out on the winding highway from Mirebalais to Port-au-Prince.

A broken neck—in this case, a fracture of the second vertebrae of the cervical spine—is a dangerous injury. If not handled, diagnosed, and treated properly, it can result in permanent paralysis—a grim fate especially in a poor country like Haiti, where disabilities sink families even deeper in poverty.

So when Marcenne Desanm, the first patient, showed up at the emergency room entrance of the hospital, clinicians handled his neck with care. They were able to quickly diagnose the injury with the CT scanner at the hospital, which showed the fracture in the spine. Then they realized they would need a device called a halo collar to heal the injury.

A halo collar is a type of brace that holds the neck still, allowing the fracture to heal. A metal band runs around the head like a halo and screws into the scull. The metal band then connects to a brace around the torso and waist to keep the neck from bending or turning.

“It’s not the most pleasant experience to be in a halo collar,” said Dr. Luther Ward, a Paul Farmer global surgery fellow who is training Haitian surgical residents at University Hospital. “But it’s a matter of being permanently disabled compared to being able to be back in society.”

But the team didn’t have a halo collar. So they made Desanm comfortable as he waited, and called Boston, where a PIH-affiliated surgeon at Boston Children’s Hospital arranged for two halo collars, a donation from the manufacturer, to be sent to Haiti with the help of PIH Boston’s procurement team.

“For 14 days, I told Desanm not to move—just lie on his back and wait—because we were searching for the halo collar for him,” said Dr. Regan Marsh, director of the emergency department at University Hospital and attending physician at Brigham and Women’s Hospital. “He never complained and is incredibly strong and kind.”

It was a lucky coincidence that they managed to send two, because by the time the collars arrived, so too had the second patient, Guerrier Wilcliphe, 21.

The surgical team still needed help to place the collars. In the United States, this procedure is done by a neurosurgeon, and the hospital’s surgery team didn't have that skill set. So the team reached out to a partner institution, Port-au-Prince’s Hospital Bernard Mevs, operated in conjunction with Project Medishare.

A Haitian neurosurgeon at Bernard Mevs was available to help, and so Ward and another surgical fellow, Dr. Jacky Fils, who is Haitian-American, traveled with the two patients to Port-au-Prince. The neurosurgeon there taught them how to properly place the collars. The surgical team and the patients returned to Mirebalais, where the patients received follow-up care and then were discharged home.

Guerrier Wilcliphe, 21, broke his neck in a bus crash in Haiti. After three months in a brace called a halo collar, he should be able to resume living as before. Jacky Fils/Partners In Health

Desanm and Wilcliphe will continue receiving follow-up care in Mirebalais over three months, at which point doctors hope their fractures will be healed, the collars removed, and they can resume living normally. Desanm’s fracture is more complicated, and he may require further care.

“God put me here with these doctors,” Desanm said. “I hope to return to work after the collar is taken off, but I will follow whatever instructions the doctors give me. I have so much hope in life now. I just hope that I will be able to continue working so that I can provide for my family.”

The halo collars can be reused, so future similar injuries can also be treated, with the new skills of the University Hospital surgical team, the right equipment, and a team of specialists to handle complex cases.

“This is the amazing thing about this hospital,” Ward said. “You have to have a CT scanner to make the diagnosis. You have to have an ER that is keen enough to handle these patients. The fact that we can diagnose the problem opens up a whole new world, because we can treat the injury. Putting on the halo collar is probably the smallest part of the whole thing.”

Desanm and Wilcliphe told their stories to hospital staff. Below is what happened in their own words, translated from Haitian Creole.

Guerrier Wilcliphe, 21, from Mirebalais

I was in a tap-tap on the way to Port-au-Prince, about 25 minutes from Mirebalais on Route Nationale 3, when the brakes stopped working. The car flipped on its side and during the crash I broke my neck. An ambulance arrived and brought me to the emergency room at University Hospital in Mirebalais. I was in the ER from Thursday to Monday. On Monday afternoon I went down to Port-au-Prince in an ambulance with Dr. Luther Ward and Dr. Jacky. They put the collar on me and I returned to HUM the same day. I was able to return to my house the next day.

Now I sometimes get headaches on my right forehead but overall I don't have too much pain. I come for a consultation once a month and will take the collar off after three months, or earlier, if Dr. Luther says it is okay.

You never expect an accident like that to happen. I found really good care here, and I think this collar will help me return to the way I was before the accident. I'm in my last year of high school and hoping to go to university next year. I also love to play soccer and am hoping that one day I'll be able to play again.

Marcenne Desanm, 48, from Savanette Cabral

I am a farmer who lives in Savanette Cabral. I have a wife and eight kids—seven are in primary school and one is in secondary school. I grow grain, corn, and plantains, and sell wood.

The accident occurred when I climbed a tree to cut off a branch to sell the wood. I stood on a lower branch and was sawing a branch above me. When the branch broke, it didn't fall on the ground; instead, it fell on me and crushed me in between the two branches. My stomach was bleeding and I was completely stuck. My wife saw me and cried for help; my neighbors then rushed to my assistance. They climbed the tree and pulled the branch off of me, but when they did this I fell backward onto the ground and broke my neck. I lost consciousness.

I live a two-hour walk from the closest road, so my neighbors had to put me on a stretcher and carry me to the road where the ambulance could meet them. I came to HUM and spent 13 days in the emergency room. They put a catheter in me and took care of my wounds where the branch had crushed me.

I went down to Bernard Mevs with Luther and Jacky and had the collar placed on my neck. I came back to the hospital and stayed for four more days. For the next few months while I am recovering I am renting a house in Cange, because my house in Savanette is too far from the road for me to walk to return for consultations. An ambulance now comes to pick me up at my rented house whenever I have an appointment and takes me home afterward. Two of my kids and my wife are staying with me too.

They took great care of me from the moment I arrived. God put me here with these doctors. I don't feel too bad anymore. I used to have problems sleeping, but now I just sleep sitting up or leaning on my hand, and it doesn't feel too bad. I can also now stand up from a chair by myself! I hope to return to work after the collar is taken off, but I will follow whatever instructions the doctors give me. I have so much hope in life now. I just hope that I will be able to continue working so that I can provide for my family.

Learn how PIH and others are working to ensure all people have access to high-quality surgical care.

Ophelia Dahl, executive director of Partners In Health, Dr. Dan Palazuelous, chief strategist of Compañeros En Salud, and Pat Daoust, chief nursing officer of Seed Global Health, talk about health care prescriptions from the developing world. 

Visit Radio Open Source to read the full article.

Victor Kanyema is the manager of the Program on Social and Economic Rights (POSER) for Abwenzi Pa Za Umoyo, PIH’s Malawian sister organization. POSER is designed to alleviate the social determinants of poor health in Neno District, Malawi, by improving housing, providing workforce training, economically empowering women, and ensuring access to education. We recently asked the 36-year-old Kanyema to share the story of how he came to work with APZU and why his work is so important. The below transcript has been edited for brevity.

When I saw an advertisement in the newspaper for Partners In Health, I got interested and thought it’s high time that maybe I should join an international organization and contribute to the development of other parts of the country where I was born.

At the time, I was working with the youth movement in Malawi at a very popular and prominent organization called Active Youth Initiative for Social Enhancement. I had served with that organization for about 11 years, joining after I graduated from secondary school. I went to college on a part-time basis while I was also working so that it would balance out and I’d have qualifications relevant to my field.

After I applied to Partners In Health, I got invited to Neno for interviews. A truck came to take me and several other people to the interviews. I knew of Neno, of course, but I had never been there. We passed through mountains, we crossed the river, we climbed the mountains. There were five of us and we kept on asking, “Driver, are we there yet?” He said, “No, we are going there, wait.” Inside I was nervous, thinking about what type of community this is. Because I could see we still had a lot of driving to do, even after 1 hour and 30 minutes of just going and going. It looked like there was nothing. Within myself, I thought, “I don’t think I can work in this community.” I was nervous—it was so far out there. So I said a prayer within myself.

I eventually started seeing some positive signs of development on the car ride. I saw houses for health workers near the hospital. During the interview, I first told the Partners In Health people that I didn’t think I could work here. But after I saw the buildings and the other various structures that Partners In Health has constructed in partnership with the government, I told them that I think I am ready to work in this community. Almost everybody laughed.

This is how I came to Partners In Health.

*

At first, it was so challenging in Neno. My wife and whole family was in Blantyre, two hours from Neno, and there are not many good roads between. So every week, every Friday, I had to make sure I could find myself transportation to Blantyre. It wasn’t an easy thing. I had to make sure I got back to see my family.

For your information, my wife is a nurse. She was working at a position in Blantyre Adventist Hospital, which is one of the best. So she was working there and it was hard for me to keep on moving up and down, going to Blantyre on Friday and coming back on Sunday. The challenge was to get out of Neno. We’d pack ourselves to the maximum in cars. We did not care what is happening or who you are sitting with as long as you find yourself going to your family.

It was a new environment, an environment where I had never worked before. I was excited because I wanted the experience of working in an international organization. The biggest difference with my previous job and my job in Neno was the scale. I find it to be good because we are able to touch so many lives through the various support and programs we have, even though there are many challenges.

It’s not a one-man show. We work together and learn from each other so that we can reach our goal.

The first thing I concentrated on was understanding the concept of the Program on Social and Economic Rights (POSER). Who were the families we were to work with? What tools do we have to help us make decisions about who we should support and why? How do we reach them? I had so many questions. Who are the partners that we are working with?

I came to know the team in Neno well. I learned what their roles are and how to help each other and develop as a team. It’s not a one-man show. We work together and learn from each other so that we can reach our goal. (Read more about POSER's work.)

*

During this early period, my first assignment was to go into the community and visit the patients, chat with them, talk with them, get data. The clinical department refers patients to POSER. We have three steps to support. The first step is the patient himself or herself presenting their grievance to POSER or to the clinic or hospital or health center based on the proximity to where they are coming from. The second step is following up to see what challenges this particular patient or client is faced with on a daily basis in their community. Third is to develop a strategy and deliver support. So after going into field and getting the data, we sit down and analyze it all. And we make a decision to say let’s support families A, B, C, D based on what we have seen.

We believe as PIH and Abwenzi Pa Za Umoyo (APZU) that treatment alone is not enough to meet the needs of the patients. If we are missing elements of social and economic accompaniment, clinical treatment itself may not work because our patients are so vulnerable. By helping them have habitable homes, we are addressing multiple issues: psychologically, physically, and even economically.

We are serving and lifting somebody from extreme poverty to a certain level of hope where he or she can start living a life of independence.

We are serving and lifting somebody from extreme poverty to a certain level of hope where he or she can start living a life of independence. Independence cannot be realized if we cannot intervene and help lift somebody to that level. That’s why we are constructing new houses and renovating existing ones. Those houses serve as part of our strategy to prevent communicable diseases or other opportunistic infections.

Poorly constructed houses, poorly ventilated houses can raise the risk for pneumonia. Other houses in poor shape can be a breeding ground for malaria because there are so many mosquitos. If we treat a patient for pneumonia and he goes home to a damp hut with a leaky roof, he’s going to get sick again. But if we are creating a good environment for the patient to live in, then we contribute positively to the health of a particular individual and the community.

*

After working in Neno for a time period of a year, I admit that it was becoming difficult. Every weekend going to my family was challenging. At the end of the day it was becoming problematic on my part. I was failing to have enough to feed my family and also feed myself here. I was spending on going back and forth between Neno and Blantyre, and it was hard to save anything.

I had to communicate with our country director and I said, “Doctor, I need to talk to you. I’m having challenges here and I need help. I wish my wife could come to Neno.” I said that if my family was here, I could better concentrate on my work. The country director understood and said that if there was ever an opening, he would give my wife a chance to apply. Later on there was a need for a palliative care nurse. Luckily, my wife, Judith, was a capable palliative care nurse. She had to apply. She had to go and interview. She did well, and they knew she was capable.

Victor with his wife, Judith, and son, Eugene, at their house in Neno, Malawi.

It still wasn’t easy for either of us. She had visited me twice or so and the first time she said, “This is where you’re living? I don’t think I can make it.” I knew what she meant. So we had to sit down to discuss it. I said, “Let’s try. I know there is an opportunity here. There are so many other people that are staying here. If they are making it, then we can also do it. There’s no difference between them and us. I love this community, I think in time you too are going to love this community.”

Now we are so motivated because all of us are in Neno. And we bought a piece of land in Neno because we are planning to stay—we just love the community, and we are so attached to the people that we are working with. Buying land in Neno is a sign that we want to continue serving the people here.

*

There are many changes that have taken place in Neno since I arrived two years ago. The health system is improving and getting stronger every day, and we are providing great medical care. And POSER is helping in many ways, socially and economically.

We have two restaurants that we are using to help empower women economically. Part of this process is to help empower women to become independent. They receive training on managing a small business. We work hand in hand with the government’s Office of Social Welfare. They provide facilitators who have knowledge of business skills and customer care so that participants become business-oriented and knowledgeable enough to stand with other competitors that are there in the market. These women normally go through a two-year period of training. After that, they need to graduate so that they can pave the way for other women to come in and use the same facility and go on to graduate.

What matters is this: Are we there to serve humanity? That is what is important.

Economic empowerment is very important for women in Neno. We have seen that a good number of women we have supported through the restaurant programs have become independent. They are economically empowered and independent. They can construct their own houses. They can send their children to school.

Education is another important area. Education is the backbone of any development, and it is part and parcel of POSER. This is very important because so many parents—because of the high level of poverty that exists in the district—might have difficulties getting their children into school, both primary and secondary school. They find it difficult to supply them with learning materials and food and transport. But because of our intervention, we are relieving the parents of the burden of having to supply scholastic materials for their children.

We are working hand in hand with the Ministry of Education, Science, and Technology. We are working with teachers, and we have a team of what we call “teacher point persons.” These point persons work with children on a daily basis to provide psychosocial counseling and to motivate them to understand the importance of education. 

We are also helping children that have lost parents and are without parental care. We can help ensure that they do not end up in an impoverished cycle. If they do, they may end up compromising their decision-making and health, especially girls. If a girl has reached a certain age, she may think that maybe the best way to survive is to sell her body. So we need to prevent people from entering into that cycle by making sure that we provide basic necessities, encourage children to go to school, help people have sturdy homes, and empower them economically. 

This is what we want to see happening in Neno, and it is. It doesn’t matter where we are. What matters is this: Are we there to serve humanity? That is what is important. That is what motivated me and inspired me to believe in this community. Together we are going somewhere.
 

Malita Gondwe* needed shelter. The single mother of two had been living behind a few crumbling brick walls in the remote Nelesani Village of Neno District, Malawi. There was no floor, only dirt and rock covered with straw. There was no roof, again only straw, which Gondwe bundled together and wedged into the corner.

Gondwe, who receives health care at the PIH-supported Lisungwi Community Hospital, is HIV-positive. For someone with a compromised immune system, a sturdy, dry, well-ventilated shelter could be the difference between life and death. In 2012, Gondwe met with representatives from the Program on Social and Economic Rights (POSER), a project managed by PIH’s Malawian sister organization Abwenzi Pa Za Umoyo (APZU). After a detailed review and consultations with other village members, the POSER team decided that renovating the dilapidated structure wasn’t an option. Gondwe needed a new home.

POSER bolsters PIH/APZU’s clinical efforts by providing social and economic accompaniment to families and individuals in the greatest need. To ensure our efforts are integrated with broader development goals, POSER, like all of APZU’s departments, works closely with various government ministries. We’ve partnered with the Ministry of Education, Science, and Technology to equip students with necessary school supplies. The District Office of Social Welfare has helped POSER staff run an economic-empowerment program for women that gives participants paid, real-world experience managing a set of small restaurants.

If we treat a patient for pneumonia and he goes home to a damp hut with a leaky roof, he’s going to get sick again.

POSER staff also addresses substandard housing, a critical issue in Neno.  “Poorly constructed houses, poorly ventilated houses can raise the risk for pneumonia. Other houses in poor shape can be a breeding ground for malaria because there are so many mosquitos. If we treat a patient for pneumonia and he goes home to a damp hut with a leaky roof, he’s going to get sick again,” POSER Program Manager Victor Kanyema says. Another trip to the hospital means additional strain on the health system and missed days of school or work or both for patients and their families. “But if we are creating a good environment for the patient to live in, then we contribute positively to the health of a particular individual and the community,” Kanyema says. (Read more about Kanyema and his work.)

POSER identifies families and individuals to accompany through two main channels. Families can request POSER assistance directly, and clinicians can refer patients to POSER. Poverty is pervasive in Neno, and it can be difficult to specify a family’s greatest needs. That’s why after the initial connection is made, a small team from POSER makes a home visit and conducts an in-depth survey, involving extensive patient input on their needs. This field-based fact-finding allows staff to gather qualitative evidence and tailor the assistance.

Malita Gondwe at the home she lived in before teaming up with POSER staff.

Due to the high level of poverty and limited resources in Neno, upwards of 30 percent of the people who are visited qualify for housing support. While POSER may not have the capacity to help everyone in need, its achievements are impressive. To date, more than 70 houses have been built through POSER, and another 120 homes have been renovated.

Renovating a home or providing a new one can alleviate stress for the inhabitants, making it easier for people to focus on new pursuits. “We were living in fear of the house collapsing when the rains come,” said Mphatso Malichi, a 62-year-old who lives in upper Neno with his wife and two children. “When we received the news to say they will construct the house, we stopped getting worried. So it helps us to improve our mental health.”

After POSER decides to renovate a home or build a new one, local contractors are hired and the necessary supplies are acquired locally. While construction is under way, POSER staff is in constant communication with the families and continues to provide support. For instance, Gondwe, the above-mentioned mother, was able to get school supplies for her daughter.

Now that the house is completed, POSER and APZU village health workers continue to work with Gondwe. With a home of her own, Gondwe is focused on new opportunities. “Because I am not being bothered by the issue of the house, I can use money for other things,” Gondwe says, noting that she’s saving to start a small business selling clothes. “It becomes a motivation.”

*POSER participant names have been changed. 

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 Software Engineer Ellen Ball, who’s been working on PIH’s medical informatics team for a decade.

In my past life as a software developer for a Fortune 100 company, the goal was always the bottom line. At Partners In Health, and many other nonprofits working to improve global health, it’s not about making the most money for shareholders and chasing bigger paychecks. It’s about social justice and human rights. The passion and dedication are indescribable.

After graduating in 1984 with degrees in electrical and biomedical engineering, I was attracted by a generous job offer from the biggest and most prestigious tech company at the time. Although the work was interesting, the feeling that there must be a more meaningful path and a way to return to the medical field lingered. I knew my technical background and coding expertise could be leveraged to improve the lives of vulnerable and marginalized populations. After two decades in the corporate world, an opportunity to combine software and global health seemed like the perfect fit. Global health was a totally new world, but it was exciting. After 10 years at PIH, I don’t look back.

Follow and adapt the latest technological advances while appreciating the differences in other settings—settings where Internet access and electricity are not always available.

Software has so many uses, which is why it is immensely satisfying to build programs that improve patient care in rural health centers across the world. The work of PIH’s medical informatics team has helped clinicians gain a better understanding of the cholera epidemic in Haiti, monitor HIV patients in Rwanda, and design effective tuberculosis treatment platforms in Lima, Peru, to name just a few of our accomplishments. 

Over my time at PIH, it’s become evident that clear communication with colleagues is essential, so learn a second language or more. Listen attentively and don’t hesitate to speak. Follow and adapt the latest technological advances while appreciating the differences in other settings—settings where Internet access and electricity are not always available. Bleeding-edge isn’t always the best solution. Jump into the community by volunteering your time and talents.

Whereas most of my work in the private sector was proprietary, PIH’s intent is quite the opposite. Our electronic medical record system is free and open source. It is designed, built, maintained, and used by a worldwide community of volunteer contributors in more than 40 countries. We collaborate digitally through software and over the Internet. Anyone can contribute code, documentation, or expertise. Although we work in different parts of the world, we encounter the same challenges. Problems in post-earthquake Haiti and typhoon-affected areas of the Philippines are not different—there is sickness, poverty, malnutrition, devastation, and recovery.

Our colleagues are thirsty for mentorship and technical know-how. We learn from each other to build a more extensive and robust system. PIH and the OpenMRS community have participated in the Google Summer of Code program for the past seven years. It’s a great way to improve coding skills and work with an experienced mentor while improving OpenMRS.

Whether you’re new to the workforce or a well-versed expert looking to change paths, find ways to get involved and stay open to new challenges.

To learn more about PIH’s medical informatics team, read this story.

For more expert advice on working in global health, click here.

Hepatitis C is a chronic infection that causes liver failure in many of the approximately 170 million people who suffer from it. But a new treatment will make it curable in most cases.

What would stop this lifesaving treatment from reaching the people who need it? The prohibitive cost, the same obstacle that kept antiretroviral therapy (ART) from saving the lives of poor people with HIV in the mid-1990s.

To bridge the gap, Partners In Health began treating Haitian patients dying of AIDS with ART in 1999. The success of this project, called the HIV Equity Initiative, equipped HIV activists with the evidence they needed to advocate for greater access to the drugs and lower prices. (Read more about the HIV Equity Initiative).

The new treatment for hepatitis C is priced between $80,000 and $90,000 per 12-week course. In the op-ed, Farmer says we are at a critical juncture in the fight against hepatitis C. We can effect “precipitous drops” in the price of these drugs for poor patients, just as activists did for HIV, or allow this infectious disease to continue to grow among people who cannot afford treatment.

“As infectious pathogens such as HIV and hepatitis remind us, our hopes are tied together more closely than we might imagine,” Farmer writes.

Read the full article at www.washingtonpost.com.

Compañeros En Salud, our sister organization in Mexico, marks its second anniversary this month. To mark the occasion, country director Dr. Hugo Flores Navarro reflects on progress and challenges of working in rural Chiapas.

The story of the founding of Partners In Health in Mexico begins for me while I was doing my social service year in Monterrey, Mexico. All new doctors are required to work one year in a public clinic, and as I was finishing my year, I felt a spiritual motivation to serve patients in marginalized areas. I didn’t know the term “global health” then or what organizations might be engaged in it.

Within a month I found myself in Chiapas with my tent, toys for the kids, and all the typical paraphernalia of a well-intentioned medical tourist.

The last week of my stay in Monterrey, I learned there was a vacancy in a project in Chiapas with PIH and a local community group that trained health promoters, called El Equipo de Apoyo en Salud y Educación Comunitaria. I’d never heard those names before, but Chiapas sounded interesting. I knew it was a big state, the poorest in Mexico, with inadequate infrastructure and lots of communities in very remote areas. I applied for the position, and within a month I found myself in Chiapas with my tent, toys for the kids, and all the typical paraphernalia of a well-intentioned medical tourist.

Working with EAPSEC, a well-respected community group, left me with a deep knowledge of the region where we work now, the Sierra of Chiapas. I learned how to enter a community, how to gain the trust of the people, and how to work in solidarity with our patients. I thought we could do more than medical missions that visited a community for a couple of days every two months.

There were unused clinics in several communities, and I knew in my mind that we could revitalize them and provide better, more comprehensive, and more constant services to the people. These clinics had one or two nurses who vaccinated children and provided family planning and nutrition services, but without doctors or medicines, they had little or no care for sick patients. Residents of these communities had to travel hours to nearby towns and cities to see a doctor, and many spent their entire monthly incomes to receive care.

We had the connection with the Mexican Ministry of Health, with the country’s premier medical school at the Tecnológico de Monterrey, and the expertise of PIH. We got the approval from PIH Boston to create a Mexican sister organization, Compañeros En Salud, and started to plan how we would revitalize our first clinic. Instead of just one, we ended up starting by supporting two clinics and moved to six clinics in six months—a rapid expansion for such a new project.

I think PIH/CES is acting as a vehicle to spread the message and the mission of universal access to health care.

Two years later, I think our biggest accomplishment has been the tens of thousands of patients we have treated from so many communities. Many of them come from communities that are several hours away by foot or vehicle, and some even come from towns that have hospitals and doctors of every kind, but they can’t afford those services or aren’t happy with the quality of care. People who have a health complaint even look for us at our offices. The demand is a little bit too much, but it reflects the quality of services our team provides.

Another accomplishment is that we have inspired an increasing interest in global health among students, residents, doctors, and volunteers of all kinds. Now, I understand what we do to be global health equity, the movement to provide the same, high-quality medical care to all people, not just those who can pay for it out of pocket. I think PIH/CES is acting as a vehicle to spread the message and the mission of universal access to health care.

One of the biggest challenges we have faced, which is common in global health projects, is the high turnover of staff. For most people, working for the poor in rural areas represents a departure from common career and life paths, and it’s still difficult for people to overcome that pressure. Another challenge is our financial dependence on donations. Until governments recognize the value of health system strengthening and invest more money directly in providing universal health coverage to their people, institutions like us will always face the uncertainty of fluctuations in the philanthropic world. In other words, our work will be more secure when global health is no longer a charitable hobby, but rather the essential exercise of realizing health as a human right.­­­

Our work will be more secure when global health is no longer a charitable hobby, but rather the essential exercise of realizing health as a human right.­­­

In the future, I hope more institutions, both governmental and nongovernmental, adopt the goal of reaching the poorest and most marginalized people. I also hope more organizations adopt the idea of a public-private partnership, in which nonprofits such as PIH/CES support the public sector to fulfill its role. I would like to see that schools of medicine include global health in their curricula, and that more people understand that health is a human right that must be available to all people regardless of their ability to pay. I think PIH/CES is a pioneer in global health in Mexico and Latin America, and by working through partnerships, we can be a major player in this revolution.

In the past decade, sub-Saharan Africa, the world’s poorest region, has made enormous strides in the fight against HIV. There are now more than 7.5 million people receiving antiretroviral therapy, 150 times as many as a decade ago. Medications have become more effective and easier to take, and they are now combined so that many patients take as little as one pill a day. HIV testing has become more widely available, and we are detecting the virus at earlier stages before too much damage is done.

With World AIDS Day upon us, however, it is important to keep in mind that the needs in this part of the world are still grim. The U.N. estimates that only 45 percent of pregnant women are tested for HIV and only 35 percent of infants born to mothers with HIV are tested for the virus on time. Treatment for children and adolescents lags dramatically behind that of adults. Around the world, 1.7 million people die of the disease every year. Unfortunately, the UNAIDS goal of 15 million people on treatment by 2015 seems a long way off, and HIV vaccines and “cures” remain in early investigatory phases.

Yet in Rwanda, where just 20 years ago a genocide claimed approximately 1 million lives, the government has transformed HIV care for the poor by redefining the standards for successful treatment. More than three decades into the epidemic, many national and international agencies are still counting the basics—how many people get infected, how many people receive medication, how many patients die. Success in Rwanda, meanwhile, is measured not in the number remaining alive, but rather in how many are actually able to take their medications as directed and suppress the virus in their bodies to a level where it is essentially non-existent. In Rwanda, success is achieved when people living with HIV can earn a living, support their family, raise their children, and care for their community no differently than their peers.

I’ve come to realize that this tiny East African country may have large lessons to share with the global HIV movement.

As a physician working for Partners in Health in Rwanda, I have witnessed the impact of this relentless approach to HIV care and treatment, and the stabilizing and uplifting impact it has had on the lives of Rwandans. Patients who would have previously been hospitalized with severe and end-stage complications of HIV are now coming for regular, preventive care. Families and communities previously devastated by the dual impact of insecurity and HIV are now thriving hubs for HIV prevention and treatment. I’ve come to realize that this tiny East African country may have large lessons to share with the global HIV movement.

Rwanda is not without its challenges. Though roughly the size of New Hampshire, it is home to more than 200,000 people living with HIV, including 27,000 children. In the capital city of Kigali, nearly one in 12 women between the ages of 15 and 49 are infected with the virus. The average life expectancy, though rising, remains 55 years (compared with 79 years in the U.S.).

Still, in a country where the average income is less than $2 a day, more than 120,000 patients are now being treated for HIV, a tenfold increase since 2004. Put another way, 91 percent of patients in Rwanda requiring HIV medications have access to life-saving treatment, compared with 54 percent worldwide.

Perhaps even more encouraging is that 98 percent of women receive HIV testing during their prenatal visits. Rwanda is one of the first sub-Saharan countries to virtually eliminate the transmission of HIV from mothers to newborn babies. As a result, the number of new HIV cases has been cut by half in the last decade, and Rwanda has made a big step toward fulfilling the dream of “an AIDS-free generation.”

How has Rwanda, one of the 20 poorest countries in the world, managed to become a model for HIV care?

While many countries continue to approach the HIV epidemic in isolation, Rwanda has managed to integrate its response to HIV within its broader platform for social and economic development.

While many countries continue to approach the HIV epidemic in isolation, Rwanda has managed to integrate its response to HIV within its broader platform for social and economic development. Having spent the past three years working in rural Rwanda, it’s astonishing to see how investments in health care infrastructure have manifested in some of the country’s hardest-to-reach areas. More than 400 new health facilities dot the rural landscape, effectively decentralizing health care from major cities to villages. To ensure care is accessible, the government offers community-based health insurance that costs barely $5 per year, which has resulted in health care coverage for more than 90 percent of the population.

In a country with only one doctor for every 17,000 people, nurses and community health workers have been trained and mentored to provide HIV services that were previously only available from physicians at referral centers. While aggressive mass media campaigns by the government and international organizations feverishly encourage the general public to “Know Your Status,” targeted outreach programs are simultaneously focusing on high-risk groups. Rwanda is taking the lead here by providing antiretroviral medications to groups that did not previously receive them: pregnant women, young children, female sex workers, men who have sex with men, and those with sexual partners who are not infected. This combined strategy is progressively transforming HIV from a stigmatized infectious disease to a chronic condition similar to hypertension, diabetes, and depression. I am confident that replicating Rwanda’s approach in other countries, both rich and poor, could effectively globalize this transformation.

Recent studies show that 83 percent of Rwandans living with HIV are successful in suppressing the virus, more than double the success rate that has been reported for patients in the U.S. Partners in Health, which helps to provide treatment services for over 10,000 patients in Rwanda, has demonstrated that additional social, economic, and nutritional support, largely delivered via community health workers selected and trained from the patients’ own villages, further increases the likelihood that a patient is able to suppress the virus.

More and more evidence is emerging that the earlier HIV medications are started, the better it is not only for the individual patient, but also for preventing the spread of the virus to others. It’s no surprise then that Rwanda is poised to be one of the first developing countries to roll out new World Health Organization (WHO) guidelines that recommend starting HIV medications earlier for all patients rather than waiting for the body’s immune system to be severely compromised, a move WHO predicts will save 3 million lives and prevent 3.5 million infections worldwide by 2025.

The global community should take a moment on World AIDS Day to celebrate its successes and improve on its failures. But most of all, it should learn from its high achievers—even those that are found in the least expected places.

This article originally appeared in The Atlantic. 

Dr. Neil Gupta is the deputy clinical director for Partners in Health in Rwanda. He is an associate physician in the Division of Global Health Equity at Brigham and Women’s Hospital and an instructor at Harvard Medical School.

Dr. Ruth Damuse, oncology program director for Partners In Health in Haiti, helped establish formal cancer care in Haiti in 2010, first at the PIH hospital in Cange, and then at University Hospital in Mirebalais. Between September 2012 and August 2013, the cancer program in Haiti screened more than 2,000 patients for breast and cervical cancer, diagnosing and treating more than 600 patients. To mark World Cancer Day, which is Feb. 4, the Haitian physician reflects on the moral imperative to treat cancer and recounts her experience providing care not previously available to poor Haitians.

Some think people in poor countries don’t get cancer.

But death from cancer is higher in poor countries than in rich countries. I know because the patients come in my door every day. I believe that if the patients are there, if they’re dying, we need to do something. And I think we’re doing something with this program in Haiti.

Partners In Health and Zanmi Lasante, our sister organization in Haiti, have always treated some cancer patients. We have seen patients with cancer since the beginning, and though we didn’t have comprehensive services available in Haiti, we did whatever we could to help them. We saw patients one by one, and sometimes we sent them to Boston for treatment.

If we weren’t doing it, there would be no way our patients would be treated. Now there’s hope for many patients.

I first got involved with Zanmi Lasante working in a hospital in the Central Plateau for my social service year, the year the government requires new doctors to spend working in a poor area. After this experience, I did specialty training at the general hospital in Port-au-Prince in internal medicine and then moved to Belgium to receive further training in immuno-hematology. But then the earthquake happened. I came back because I felt I had to do something to help rebuild after the earthquake.

In 2010, the Avon and LIVESTRONG foundations provided us a grant to develop comprehensive cancer care. We started from scratch, with nothing, but we had to just start. I opened the cancer clinic in Cange one day, and told the other clinicians to send me the cancer patients. From the beginning, we have relied on the Dana-Farber Cancer Institute and Brigham and Women’s Hospital to help us make diagnoses, develop treatment plans, and procure drugs. Soon we started to focus on breast cancer, because we see it often and it’s relatively easy to treat. We provide surgery and chemotherapy.

What’s really hard is that we don’t have a clear line between what we can treat and what we can’t treat, because of a lack of expertise or access to diagnostics and therapies. We don’t have all the resources of a cancer program in the United States, such as radiation or all chemotherapy drugs to treat different cancers. But everybody’s coming to us, because we give free care.

Sometimes we get a patient with very advanced disease, and even in the States they couldn’t be cured. We can’t treat them, but at least we can ease their pain, which is something. And we’re helping them understand what they have, so they don’t just go home and die without knowing. In those cases, we now have training to give palliative care, but it’s not something people want to talk about in Haiti. Doctors want to believe they can cure the patients, and the patients do as well. In the United States, you have hospice care, but that doesn’t exist in Haiti. We knew palliative care was a huge need we couldn’t avoid.

I saw a patient last month from Milot, in the very north of the country, who came all the way to Mirebalais on a Sunday. She had a CT scan, and the report showed she had advanced lung cancer with metastasis everywhere. Physicians feel like they fail the patient when they can’t fix it. Her doctor had heard there was a cancer program in Mirebalais and that maybe we would be able to treat her, but it was clear she needed good palliative care. Many times, I say to patients “I can’t treat, but I can help and ease the pain and suffering.” That’s very hard on me; it’s very hard on our small team. I try to forget about it when I go home, but it’s not easy.

We can’t just say that cancer doesn’t happen in poor countries, because we are seeing the patients and they are in need.

Still, there are a lot of patients we can treat, and if we weren’t doing it, there would be no way our patients would be treated. We provide care free of charge, so anyone who needs it can access it. I feel good about it because before there was no free treatment available, and now we have most treatment available. Now there’s hope for many patients. I’m happy when I see a patient early so we can start chemotherapy and do surgery.

We’re a small program, but we’re doing well. I tell my patients they’re only seeing me, but there are a lot of people behind me, including cancer specialists, so they know they’re receiving the best care possible. Now we’ve treated many patients, many who are now free of cancer. We have a social worker who talks to patients about their disease, the shame they feel, and about dying if we’re providing palliative care. We’re not only treating, but we’re doing a lot of community outreach about breast cancer and how to check for it. It’s a good start.

In the future, we want to be able to provide radiation therapy, see more patients with breast cancer, and treat more cancers—especially cancers of children and young people, which are so hard.

I think cancer care is a human right, and we need to provide it. We can’t just say that cancer doesn’t happen in poor countries, because we are seeing the patients and they are in need. We can’t leave them without anything. It’s not just about HIV, tuberculosis, malaria, and cholera, because cancer is there too. Before I started working in this program, I didn’t know about the extent of cancer in Haiti, but now that we’ve started, we’ve seen the patients. And we’re seeing the difference we’re making in their lives.

Haiti hasn’t always been home for Barnaby Riche, a locksmith at University Hospital in Mirebalais.

Riche, 37, was born to Haitian parents in the Caribbean island of St. Martin. At age 2, he moved to the United States. But in 2003, he was deported to Haiti—a country he had never known—with little family, few resources, and no job prospects.

In 2011, he heard about the hospital Partners In Health was building in Mirebalais in partnership with the Haitian Ministry of Health and convinced the project's leaders to hire him onto the crew of more than 100 Haitian construction workers. (Read about how the construction and ongoing operation of the hospital are creating jobs and stimulating the local economy).

Everybody puts you down, and no one gives you a chance. It’s like being convicted a second time. By the grace of God, I am still standing. The hospital is definitely a second chance. This job changed my life.

Riche was honest about his background—his deportation followed several years in prison for a nonviolent drug offense when he was 20 years old. Many nonprofits working on Haiti’s recovery wouldn’t hire deportees, and discrimination from other Haitians made it hard for him to earn a living in the informal economy.

“Everybody puts you down, and no one gives you a chance,” Riche said. “It’s like being convicted a second time. By the grace of God, I am still standing. The hospital is definitely a second chance. This job changed my life.”

A rough start

Riche wouldn’t describe his childhood as Haitian. He remembers only one or two Haitian friends.

“When I was growing up in Brooklyn, lots of Haitians tried to hide their nationality,” he said. “Haitian kids were picked on constantly and jumped in the street. There were lots of fights. It was bad to be Haitian in New York and in Boston back then.”

Riche dropped out of high school after tenth grade and enrolled in night school. He did well, earning As and Bs, he said. He was two weeks from graduation when he was arrested and sentenced to prison for the drug offense.

The night school secretary cried when she heard the news, he said.

In prison, Riche continued studying for his GED. He remembers his teacher well—Mary was fantastic, he said. He wrote a paper about Frederick Douglass and the movie Glory, which told the story of one of the first all-black units in the U.S. Army to fight against slavery in the U.S. civil war. His teacher said it was the best work she’d seen in prison.

Struggling for survival

When Riche finished his six-year sentence, he was deported to Haiti—a place he had never known. He arrived in 2003, with few family members to help him adjust to his new home. He found a little work tutoring English, and some relatives in the U.S. sent money to help him get by.

Riche, his wife, and their young daughter lived on the second floor of a cement building with no stairs. They had no door, just a curtain in the entryway, and it was so short he had to duck to get inside. He would enter the house by climbing the wall “like Spiderman.” He said the neighborhood was dangerous, but people were scared of him because he was a deportee.

In 2009, he was strapped for cash and decided to try his luck in Lascahobas, a rural community in the Central Plateau where he had distant relatives. He left his wife and daughter in Port-au-Prince.

In January 2010, the earthquake crumbled their home, killing his daughter. His wife ended up in a makeshift shelter, like nearly a million other homeless Haitians. She gave birth to their second child there later that year, and soon became sick with pneumonia.

His wife went to a hospital in Port-au-Prince but didn’t get better, and the family didn’t have enough money to seek better care. Riche believes she was given the wrong medicine. In the end, he says, her lungs collapsed, and she died.

His daughter came to live with him in Lascahobas.

A second chance

In 2011, Riche pursued a job at University Hospital, traveling to the construction site day after day to convince PIH’s Dr. David Walton and construction supervisor Jim Ansara to hire him. They were concerned about whether the staff and community would accept him as a deportee, but they were impressed by his honesty and tenacity. They hired Barnaby as a translator, but he soon joined the construction team. He woke up at 4 a.m. each day to reach the work site by 6 a.m., and often stayed well into the evenings, even in the oppressive Caribbean summer.

“Barnaby has been an invaluable part of this team,” said Jean-Brucely Joseph, a Haitian-American who served as site supervisor of University Hospital during construction. “Haitians blame problems on deportees. Not all of them are bad people. Maybe they made a bad choice. They are very productive people when given a chance.”

It’s so important to give a chance to people who need one. People will surprise you. That’s the only way there is going to be a real change in Haiti or the world.

Riche worked with Ansara, an expert contractor who volunteered his time overseeing the hospital’s construction, and learned as much as he could. When construction was finished, Riche joined the facilities maintenance crew as a locksmith, his specialty.

“Barnaby has grown tremendously,” Ansara said. “He has become a highly skilled leader who has helped set a standard for the team of incredible positivity and doing whatever it takes to maintain this incredible asset for Haiti.  Dr. Walton and I are both incredibly proud of Barnaby and appreciative for his commitment and his contributions.”

Riche is proud of the work he’s done to help build a hospital that provides care to the poor. He believes his wife would have survived if she’d received care there.

“The hospital is amazing,” Riche said. “Just looking at it, I can say I was part of that. I put these doors up, I put this ceiling up.”

Riche dreams of starting his own construction company. But for now, he’s grateful to have paid off the debt he accrued before he found work and to support his family, including his second wife and his children.

“It’s so important to give a chance to people who need one,” Riche said. “People will surprise you. That’s the only way there is going to be a real change in Haiti or the world.”

Andrew Johnston, former University Hospital project coordinator, contributed to this story.

Nearly a year after officially opening, University Hospital in Mirebalais, Haiti, is proving to be a transformative force. Beyond the obvious impact of improved health outcomes, the hospital—the largest post-earthquake reconstruction project completed to date in Haiti’s public health sector—is a catalyst for economic development in one of the country’s least developed regions.

When fully staffed, University Hospital will provide more than 800 jobs for Haitians—Haitians who shop in local markets, invest in nearby housing, and grab lunch at neighborhood restaurants and food stands. New businesses and opportunities are cropping up—take for instance Linda Marçone, a mother of three who sells egg sandwiches. She recently moved her operations outside of University Hospital and is now selling dozens of sandwiches each morning.

This transformation isn’t a surprise. Investments in critical infrastructure, such as hospitals, spur development. To measure how large-scale private and public investments spill over onto a country’s various economic sectors, economists use what’s known as an input-output model.

PIH’s Monitoring, Evaluation and Quality team recently partnered with researchers from Haiti and the U.S. to apply an input-output model to University Hospital. “The idea behind the input-output approach is intuitively simple,” the researchers note in a working paper. Essentially, the influx of resources into some sectors of the economy—health care and teaching in the case of University Hospital—will affect other sectors of the economy through what is called the “multiplier effect.” This will result in an economic impact far greater than that of the original investment.

PIH has been working in the Central Plateau for more than 25 years. University Hospital provides access to high-quality health for everyone who needs it. It is the training ground for Haiti’s next generation of doctors, and it is an engine of economic development. We couldn’t have built it without your partnership.

Support PIH’s work

Four years after an earthquake struck Haiti’s capital—damaging its already-weak medical infrastructure—a new public teaching hospital in Mirebalais, Haiti, is transforming the lives of people in the Central Plateau and beyond.

Since opening in March 2013, University Hospital has treated thousands of people who previously had little—or no—access to health care. The facility, built by Partners In Health and Haiti’s Ministry of Health, also serves as a training ground for Haiti’s future clinicians, and is a catalyst for economic growth in the region.

New access to medical services

University Hospital provides care for a referral area in which 3.4 million people live, including people in Mirebalais and two surrounding “communes,” or regions.

Since opening, staff members have registered more than 42,000 patients, providing more than 55,000 clinical visits. About 60 percent of patients are from the three regions closest to the hospital, and about the same proportion are women, according to data from the hospital’s electronic medical record system.

“The quality of care patients are receiving is speaking for itself, and the word is getting out,” said Marc Julmisse, University Hospital chief nursing officer, who is Haitian-American. "Our staff is doing an amazing job, and it goes to show—from outpatient services to inpatient care to the emergency room—that Haiti needs a hospital like this.”

Clinicians see more than 700 patients on a typical day.

The hospital employs about 700 people, including about 300 nursing staff and 50 doctors. Seventy percent of its employees are from the Central Plateau.

The hospital has an emergency department, state-of-the-art operating rooms, and a specially designed electronic medical record system. A system of 1,800 solar panels produces most of the facility’s energy needs. To read more about University Hospital’s solar energy system, click here.

Demand for services has grown as referrals from other facilities increased and word spread about free specialty care at University Hospital that was unavailable elsewhere in Haiti. For example, analyses of where surgery patients live show that people travel from all over Haiti to receive surgical care at the hospital.

Since the maternity wards opened, clinicians have delivered more than 800 babies, about 25 percent of which were born through cesarean sections—a rate that reflects the hospital’s role as a referral center for pregnancies with expected complications.

Since March, the following services have opened at University Hospital:

• HIV and tuberculosis clinic
• Outpatient clinic
• Women’s reproductive health services
• Community health services
• General surgery and orthopedic surgery (see “Cancer Patient Receives First Surgery at University Hospital”)
• Rehabilitation (see “After a Three-Story Fall, a Haitian Girl Recovers”)
• Emergency department (see “An Accident Tests University Hospital’s Emergency Department")
• Maternity wards
• Mental health
• Dental
• Cancer care (see “Cancer Care Expands at University Hospital”)
• Pediatrics and newborn care (see “After Grief, Joy: Haitian Woman Delivers Healthy Premature Baby”)
• Internal medicine
• Noncommunicable disease clinic
• Advanced diagnostics, including CT scanner

Training the next generation of clinicians

A key function of the hospital is to train Haiti’s next generation of social justice doctors, nurses, and other health professionals. Workshops and trainings began before the first patient stepped foot in the building, but training has ramped up as specialty services come online. Since June, the hospital has hosted more than 165 trainings, including cardiac resuscitation training for 91 medical staff.

In fall 2013, the teaching hospital marked a significant milestone with the entrance of its first class of medical residents. These 14 young Haitian doctors are training to become specialists in pediatrics, internal medicine, and surgery, and a new class will enroll every year. Read more about this first enthusiastic class of residents here.

In 2014, hospital leaders will begin training for other specialties. Nurses will be trained in anesthesiology and critical care, skill sets that are necessary for emergency and surgical care. New medical residencies are being planned for obstetrics-gynecology, orthopedic surgery, anesthesiology, and emergency medicine, which would be the first such residency in the country.

“You don’t learn how to be a doctor in medical school,” said Dr. Michelle Morse, who has helped plan medical education programs at University Hospital. “It’s during residency that you dive in and begin to understand what it’s all about.”

Catalyzing economic growth

University Hospital has also helped grow the economy of the Central Plateau.

Researchers from PIH, Haiti, and the United States teamed up to analyze the economic impact of University Hospital, using what’s known as an input-output model. They estimated that for every $1 invested in the hospital, $1.82 is pushed into the Haitian economy.

Essentially, the influx of resources in one sector of the economy—health care and teaching in this case—will affect other sectors of the economy through what’s called the “multiplier effect.” This will result in an economic impact far greater than that of the original investment.

“The idea behind the input-output approach is intuitively simple,” the researchers note in a working paper.

Researchers used an input of $16.2 million, the estimated long-run annual full-capacity operating cost of University Hospital. Using the model, the team found that a $16.2 million investment in the hospital spills over into other sectors of the economy, resulting in an impact of $29.4 million in the broader Haitian economy. To learn more and see a graphic illustration of this model, click here.

Four years after the earthquake, Partners In Health is grateful to the many supporters and partners who helped make University Hospital a reality for the people we serve, and we look forward to making an even greater impact through our sustained commitment to Haiti in the years to come.

Editor’s note: To celebrate Martin Luther King Day, we’re re-reading Dr. Paul Farmer’s 2009 speech at Boston University, Dr. King’s alma mater. Published in his 2013 book, To Repair the World, Farmer reflects on King’s final speech about the “drum major instinct.” 

The Drum Major Instinct: Reflections on Dr. Martin Luther King, Leadership, and the Challenges Still Before Us

By Paul Farmer

Speech delivered at Boston University, 19 January 2009

1. I have a dream

Everybody knows Dr. Martin Luther King’s four most famous words. They were spoken during his 1963 speech on the Mall in Washington. It’s an event that is on a lot of people’s minds these days because of another event that is shortly to take place in Washington and which might be taken to confirm the ability of majority Americans, after decades of being pushed, educated, and transformed, to judge each other “not … by the color of their skin but by the content of their character.”

In particular, he had his eye on the treacherous point where the quest for excellence and for personal efficacy compromises the broader goals of equality and justice for all.

Today I’ve been invited to reflect on another of Dr. King’s sermons, less well known than the “I have a dream” speech, but one with a message for this week and this moment in our country’s history. I am honored to make these comments at Dr. King’s alma mater, on the day people across the world honor his memory. I am grateful to draw on his work, which continually inspires my own, and to use it to reflect on the challenges now before us. And although my remarks will engage the worldwide struggle to reach our full promise as humans, with rights inalienable in principle but far from obtained, I will not be coy about their meaning for Americans on the eve of the inauguration of President Barack Obama.

It is fitting that this year’s MLK celebration has blurred into our inauguration of a new president. I’ll bet we’ll hear references tomorrow not only to Lincoln but also to King. Both have much to teach us, both fit on that arc of history that bends, however slowly, towards justice. And as Lincoln’s brooding marble image presides over the proceedings, so too will MLK’s rhetoric of dreams suffuse our hearts, today and tomorrow.

The dream described in the 1963 speech on the National Mall was about equality. “The Drum Major Instinct,” Dr. King’s last sermon at Ebenezer Baptist Church, in 1968, is about leadership. Don’t these two speeches seem to head in opposite directions: equality being for all of us, leadership a role only a few of us can play? But as Dr. King analyzes it, what he calls the “Drum Major Instinct” is the desire, most likely innate in all of us, for the praise and recognition that come with leadership. Who doesn’t fantasize about being in charge, whether as drum major in a marching band or as leader of a movement or head of a department or, even, as president of a flawed but promising democracy? These roles gratify our hunger for applause and approval. But King also saw the darker side of leadership. He spoke rawly and honestly about the dangers inherent in “keeping up with the Joneses” and of striving to impress through material advantage. In particular, he had his eye on the treacherous point where the quest for excellence and for personal efficacy compromises the broader goals of equality and justice for all.

What do all of us, with our potential for leading and for following, have to offer in a struggle that may echo the past, but is necessarily the present, and thus new?

Dr. King is now an American icon. But we can’t forget that he was a controversial figure in his time—controversial even among his supporters, who couldn’t always see where he was going or how the parts of his program fit together. If it was difficult, for some people in 1968, to understand the complexity of King’s reflections on theology, or on the struggle of poor people in far-off Vietnam, it can’t be so difficult for any of us, for all of us, to see how the greater good might be damaged by one person’s overweening efforts to be the best, to lead. We recognize ourselves in the straw man of the “Drum Major Instinct.” There’s a reason, surely, that Coretta Scott King asked that this sermon be replayed at his funeral. For in this homily, Dr. King, Nobel laureate and hero to millions, refers presciently to his own funeral and asks that no mention of his many awards and honors be made. Let it only be said, he asked, that he strove to “feed the hungry,” to “clothe the naked,” to “be right on the [Vietnam] war question,” and to “love and serve humanity.”

To feed the hungry, clothe the naked, stand up for peace, and love and serve humanity: These issues, transcendent today, are central to any ideas a doctor might have regarding, say, the right to health. They are precisely the priorities that should guide public policy and private action in times of economic turmoil. How do we accomplish these aims without making them serve our own love of glory and admiration? How do we, gathered here today, on January 19th, 2009, at Boston University, fit into a plan larger than ourselves, a plan that might move us beyond our own ineradicable Drum Major Instinct without dampening our desire to succeed? What do all of us, with our potential for leading and for following, have to offer in a struggle that may echo the past, but is necessarily the present, and thus new?

If MLK were with us today, in flesh and not (as he is) in spirit, he would surely be pleased by the events that will unfold tomorrow in our nation’s capital. But he would not regard this momentous event, the inauguration, as the end of the struggle, but as an opening, a chance, a space in which a much broader social-justice agenda might be pursued. In making this claim, I do not also claim to know King personally. I was eight years old when he was taken from us. But all of us can know his mind through his speeches, sermons, and actions. And these can leave us little doubt about his views on justice, views which would not be vindicated by Barack Obama’s gaining high office unless that office were used to pursue a more just vision of our nation and our world. Likewise, there’s little doubt about Dr. King’s views on the wars conducted on the basis of lies: simply speaking out, even from a position of power, against such wars will not suffice.

If MLK had a dream towards the end of his life, it was the dream of a much more radical equity. It is for this reason that he has never faded away, as have many other noble people martyred for their just beliefs. MLK’s mature dreams, those laid out with clarity in the last months of his life, are precisely those we need to inspire us in a time of great need.

2. Dream or nightmare?

In a celebration like this one, and in a time like ours (fraught with promise and peril), it’s possible to forget the hard work still before all of us. Yes, we stand on the shoulders of giants and yes, it was harder then, when the civil rights movement as we know it was played out in this country. I may have been only eight when Dr. King was killed, but I lived in Birmingham at the time and I bring my own interpretive grid to a modern reading of his works and life. In “Letter from Birmingham Jail,” he famously noted that “we will have to repent in this generation not merely for the hateful words and actions of the bad people but for the appalling silence of the good people.” Just as it was the silence of good people that permitted some of the excesses of recent years—and for me these excesses include not only the war in Iraq but also the overthrow, yet again, of democracy in Haiti and also our appalling silence on the right to health care in our own country—it is also the collective roar of good people that promises to redress them. Many of you will agree: we are even today filling appalling silences with a loud and optimistic chorus of commitment to doing better. Certainly, I hear the loud roar of the students!

The ghost of white supremacy continues to fade, here as elsewhere. But the all-encompassing struggle for social justice is in some ways in its infancy.

We know, of course, that good intentions are not sufficient to do the job, any more than is reluctant compliance with progress. After leaving the tumult of Alabama shortly after King’s death, I still remember waiting, with my five brothers and sisters, for the school bus in a small Florida town. Jim Crow had been struck down legally, perhaps, but at the gas station that was our bus stop were two bathrooms. They were labeled “Men” and “Women,” but above these labels were, still readable, the ghostly shadows of the five letters that had been painted over not too long before. The image sticks in my mind as much as the grainy, black-and-white-photographs of MLK in D.C.

The stain of Jim Crow, itself the legacy of slavery, will, like the fates meted out to Native Americans, be with us always. But what is the message in such dramatic changes as we have seen since MLK made the ultimate sacrifice? Or even since 1992, when the theologian James Cone wrote a book called Martin & Malcolm & America: A Dream or a Nightmare? In it, Cone asked not so much how far we’ve come, but rather how the visions of MLK and Malcolm X came together towards the end. Both were fighting, in their own ways, for a vision of social justice. MLK embraced a Gandhian perspective on this struggle, and was criticized for it by some in the movement. In many ways, he has been vindicated. Malcolm was less ready to limit the struggle to nonviolent resistance, and his legacy has been more mixed, but it would be incorrect to deny him credit as a motivator of social change. The difference between the conditions that brought MLK to the Mall in the sixties and that will bring Barack Obama to the Mall tomorrow is patent, and deserves to be celebrated—and we should do so on both of these days.

The ghost of white supremacy continues to fade, here as elsewhere. But the all-encompassing struggle for social justice is in some ways in its infancy. MLK understood this, especially towards the end of his life, as clearly as anyone.

3. Human rights and social justice

In some ways, King is like other iconic leaders, especially those martyred, a screen against which we can project our hopes and aspirations. The same has been said about our president-elect, and that’s a heavy burden to carry. Let’s take King, not as an icon, but as a work in progress. Take him in those years between 1963 and 1968. He was moving forward on his own intellectual and moral and political path, learning about the world. After all, there was MLK the seminarian and MLK the doctoral student at BU and MLK the preacher and MLK the national leader and MLK the Nobel laureate and MLK of the poor people’s movement. He was, as they say, all that. He knew what he was talking about when he warned against the drum-major instinct. He was changing and growing and learning all the time, and guarding against any tendency in himself to take credit, to take charge, to treat a social movement as his personal accessory.

We need to acknowledge that he was working towards a goal, which was the fight for social justice for all, a fight against poverty.

In celebrating Dr. King, we need to respect his own trajectory and growth, not just the final form of a name, a postage stamp, a monument, a chapter in the history books. We need to acknowledge that he was working towards a goal, which was the fight for social justice for all, a fight against poverty. “The curse of poverty has no justification in our age,” he wrote in 1967. “The time has come for us to civilize ourselves by the total, direct and immediate abolition of poverty.”

As in his final sermon, he spoke of the hungry, the naked, the homeless, the thirsty, the vulnerable. Elsewhere, he spoke explicitly of health disparities, and in a way that no doctor should fail to appreciate. “Of all the forms of inequality,” he said, “injustice in health care is the most shocking and inhumane.” Will this form of inequality be addressed in our lifetimes? And he took on the great controversies of the day. Here’s what he said about the Vietnam War: “The bombs in Vietnam explode at home; they destroy the hopes and possibilities for a decent America.” He opposed the war for several reasons, but perhaps the most important ones were that he regarded the justification for the war as fraudulent: “We are adding cynicism to the process of death, for they [US troops in Vietnam] must know after a short period there that none of the things we claim to be fighting for are really involved. Before long they must know that their government has sent them into a struggle among Vietnamese, and the more sophisticated surely realize that we are on the side of the wealthy, and the secure, while we create a hell for the poor.”

MLK also believed the resources spent on war should be spent on the war on poverty. He argued that “a nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual death.” In expressing these views, King was not seeking to win a popularity contest. A significant fraction of the mainstream media, journals that had previously praised King, voiced their opposition to his opposition. Life magazine termed the speech in which these words were uttered “demagogic slander that sounded like a script for Radio Hanoi.” The Washington Post opined that he had “diminished his usefulness to his cause, his country, his people.” The Drum Major Instinct, if not held in check, might well have led King to accept postures more palatable to the mainstream media, the newspapers, magazines and television programs that had celebrated him in previous years.

Here’s what he said about hunger: “I started thinking about the fact that we spend millions of dollars a day to store surplus food in our country. And I said to myself, "I know where we can store that food free of charge: in the wrinkled stomachs of the millions of God’s children in Asia and Africa, in South America, and in our own nation, who go to bed hungry tonight.” 

This is not ancient history. Don’t we, here today, still need to deplore unjust wars? The bombing of civilian populations? Don’t we still need to think about social justice? About hunger that causes food riots in cities across the globe? Don’t we need, in the midst of financial crisis, to reflect on King’s argument that “true compassion is more than flinging a coin to a beggar . . . [True compassion] comes to see that an edifice which produces beggars needs restructuring”?

4. Accepting our need to celebrate

It would be possible to end these remarks in a scolding or otherwise negative tone. I might have reminded all of you that Dr. King was willing to die for his convictions, did not shrink from danger, and faced death bravely and calmly. I might have insisted that because we still confront injustice, and even racial injustice, we have made no or too little progress. I might have underlined only what is wrong and failed to signal what it right and promising and new.

I do not choose to do that today.

Today we celebrate the life and legacy of Martin Luther King. Today we celebrate his courage and his paradoxical relationship to the drum-major instinct. Without that instinct, he would not have pursued either his career or his vocation. Had he lacked it, he would not have gone to jail, nor would he have spoken to millions, directly and with courage. But Dr. King was aware of the risks of seeking to elevate himself above others, and it is for this reason, among others, that he sought to ground himself in the struggles of the poor in this country and elsewhere. It is for this reason that he never became a gaudy and flashy “brand,” to use the language of our day.

The greatest thing about King’s redemptive vision is that all of us may, at any time, choose to place the well-being of others above our own.

Let us all take inspiration from a man who, years after receiving a Nobel prize, would seek to learn and to grow, a man willing to take on conventional wisdom, even when it rankled some of his supporters and many of his fair-weather friends.

And finally, let us celebrate the optimism of MLK. He never failed to believe in the promise of our species. Fallible humanity was his inspiration every bit as much as his God. Redemption is always possible. “We must accept finite disappointment,” he cautioned, “but never lose infinite hope.”  

Finally, we need to acknowledge the drum-major instinct within all of us, the urge to be somebody and to succeed. If not for that impulse, who among us would be here today, at one of the great universities of this country? I know I would not be here as a physician and teacher. Barack Obama would not be our nation’s 44th president. But the greatest thing about King’s redemptive vision is that all of us may, at any time, choose to place the well-being of others above our own. All of us may strive for compassion, justice, and altruism. None of us need have the vision, talent and heroism of an MLK to succeed in this humble and necessary task. “Everybody can be great,” said Dr. King, “because anybody can serve.”

Now, as our country and our world faces financial crisis, environmental disaster, war, and growing inequality, is the time to serve. It’s a great time to serve a just cause, to concern ourselves with the oppressed or those less fortunate. It’s a great time to do what many BU students have done: to draw on deep reserves of compassion and solidarity and, above all, to engage. If this is what we do with our Drum Major Instinct, we need not be troubled by it. Everybody can be great, because anybody can serve. Thank you all.

[Originally published January 2009]

Read many other reflections by Dr. Farmer in his book, To Repair the World.

PIH Chief Nursing Officer Sheila Davis reflects on recent experiences in Haiti in the following essay, which originally appeared on Huffington Post Impact. 

I am on the bus heading back to Boston after visiting my family in Brewer, Maine over the holidays and it was, as most travel is, an interesting experience. The characters that fill the bus are amusing and I enjoy people watching. I spend a lot of time traveling as the Chief Nursing Officer at Partners in Health. Travel can be exhausting -- long plane rides, unexpected delays, and many hours in cars traveling on dirt and half-paved roads. In mid-December, when Boston and many parts of the U.S. were in a deep freeze and digging out from snow, I was in Haiti where it was sunny and hot, working with the Zanmi Lasante/PIH Haiti's nursing team.

We traveled for hours in between our sites throughout the Central Plateau and Artibonite regions and one stop was in Belladère, a community near the Dominican Republic border. The hospital there is old and in disrepair. There are many patients and there is not enough staff, supplies, medications or reliable running water. As we walked past overcrowded wards and through throngs of people to meet the hospital's Chief Nurse, I was anticipating meeting a stressed out and de-motivated nurse leader. Who I met instead was a dynamic, larger than life personality who filled the small room with her warmth, humor and energy. Miss Chachoute has been at this small public hospital for over 20 years. She spoke passionately about the needs of her patients and literally danced in her seat when we talked about putting a nurse mentor/educator full-time at the hospital.

During our visit, Miss Chachoute talked about her nursing staff -- many had also been there for a decade or more. Magically, as we spoke, a few of the nurses she had been praising showed up in her office. Miss Alix stood there proudly as her praises were sung by her manager. It was only later in the car ride back to Port-Au-Prince did others tell me that the nurses had been called by Miss Chachoute while we were talking. I had been so enthralled with her enthusiasm and our conversation that I did not even notice she had picked up her cell phone and made a few quick calls. When I asked the secret of her success of such dedicated nurses working with her, she talked about the need to care for and recognize hard work. She mentioned providing juice and a snack for the night shift nurses as she worries they don't have enough money to bring food for their long shift. It is only when I specifically asked, did she tell us that she uses her own money to provide the juice and snacks for her staff.

Although the poverty and need was still painfully obvious, laughter followed us throughout the day.

As we walked through the hospital, Miss Chachoute greeted patients and staff with kind words, hugs and warm humor. Although the poverty and need was still painfully obvious, laughter followed us throughout the day. Roodeline Valcourt, the Zanmi Lasante nurse educator, had begun her nursing career at the hospital in Belladère so she had many stories about her time there. It is a hard place to work as a nurse, it is even harder to be a patient. We were in the maternity ward, the pediatrics ward, and finally in a makeshift building alongside the hospital, the cholera treatment unit.

Haiti is a tough place to live and be healthy. According to the CIA Factbook, it ranks 34th in maternal mortality and 41st for infant mortality globally. The mothers that make it to a hospital like Belladère and receive care are the lucky ones.

The cholera tent was hot and had 12 patients of all ages receiving intravenous fluids for treatment -- a very slow day. A law suit was filed against the United Nations (UN)) on behalf of five cholera victims by the Institute for Justice and Democracy in Haiti, a Boston-based rights group. The lawsuit asserts that the UN in Haiti was responsible for introducing the disease through sewage contamination from its barracks of a peacekeeping force from Nepal.

"Forensic studies, including one ordered by the United Nations, have identified the culprit bacteria as an Asian strain imported to Haiti by Nepalese members of the United Nations peacekeeping force," a New York Times article reported.

The UN still has not conceded any responsibility and the organization has asserted diplomatic immunity from any negligence claims.

After spending a few days at Hospital Universitaire de Mirebalais, a national teaching hospital that PIH, in collaboration with the Haitian Ministry of Health, opened this past April, we were off again in the car -- this time to Petite-Rivière-de-l'Artibonite. Accompanying us on this visit was also Miss Amazan, a long time Zanmi Lasante nurse educator and leader. Miss Amazan is a quiet and dignified nurse who has been a nurse for decades in Haiti.

Although it is a Saturday, the Nurse in Charge Miss Tilien comes in to meet with us. She is a young and serious nurse who speaks softly, but eloquently about the needs of her patients and community. When in conversation about the needs of the nursing staff, instead of asking for computers or gifts for her nurses, she asks about sheets for the patients, dressing supplies, and medication stock-outs. The responsibility that this young nurse -- who could earn much more in the private sector, but chooses instead to work in the public system -- has on her shoulders is sobering.

I was silent for a moment or two then told her honestly that she was doing an amazing job and that we could all learn a lot from her and her patient advocacy.

As we were leaving and piling in the car, she asks me one last question, "What suggestions do you have for me and what can I do to improve as a nursing leader?"

Humbled by her earnest and sincere question, I was silent for a moment or two then told her honestly that she was doing an amazing job and that we could all learn a lot from her and her patient advocacy.

On the ride home, we were quiet. It was almost the end of a two-week trip for me in Haiti and Kate, the new nurse educator for PIH who is working as a "nurse accompagnateur" for the Zanmi Lasante nursing team, was beside me. Roodeline Valcourt, the lead nurse educator for Zanmi Lasante, was in the front seat answering an urgent text from another site and Julnet -- our kind and accommodating driver was at the wheel.

I was tired. My to-do list was an arm's length long and I was anticipating the Christmas frenzy that would greet me when I flew back home. I watched out the window as the country side of rural Haiti passed by me and for a few moments I closed my eyes. With my mind wandering and frenetic as always, I was drawn back to the present when I heard a beautiful voice from within the car. Miss Amazan sitting in the back with Kate and I softly started singing Christmas carols in Creole.

On my bus ride back to Boston a few weeks later, I was tired again from the holidays. I looked out the window and saw the layers of ice coating every surface and bending the trees until they looked like they would snap. I closed my eyes again and was brought back to the extraordinary women that I had spent time with in Haiti -- new nursing leaders like Kate who have enthusiastically been embraced by the Zanmi Lasante nursing team. She will blossom under their kind guidance. Haitian Nurse leaders like Beatrice, Roodeline, Miss Chachoute, Miss Tilien and Miss Amazan are all tireless, patient and nurse advocates who inspire us daily to continue our fight against poverty and health inequities.

It is an uphill battle. We don't have enough resources and have an ever increasing line of patients at the door, but our nursing leaders and the quiet strength and sweet voice of Miss Amazan will keep us going. Happy New Year.

Read about how PIH is using solar energy to help power University Hospital.

Meet University Hospital's first medical residents. 

This month, Rwandan Minister of Health Dr. Agnes Binagwaho, Dr. Marie Aimee Muhimpundu, NCD program director of the Rwanda Biomedical Center, and PIH Senior Health and Policy Advisor Dr. Gene Bukhman published a commentary in The Lancet detailing a new “80x40x20” initiative. Its goal is clear: An 80 percent reduction in deaths from noncommunicable diseases (NCDs) and injuries among those 40 years old and younger living in low-income countries by the year 2020. The three authors wrote on behalf of the NCD Synergies group, which is comprised of nearly 100 authors.

First conceived by Dr. Binagwaho and announced via Twitter at the inaugural meeting of the NCD Synergies network in July 2013, 80 under 40 by 20—or “80x40x20”—follows on the heels of the World Health Assembly’s “25x25” target, announced last May. The “25x25” framework aims to cut deaths from cardiovascular disease, chronic respiratory issues, diabetes, and cancer due to unhealthy lifestyles in those older than 30 by 25 percent globally by the year 2025.

While an important and ambitious goal, The Lancet authors contend a tailored approach that more accurately reflects the epidemiology of low-income countries is needed to make lasting progress. They write, “the poorest billion people suffered about 800,000 excess deaths in 2010 from NCDs and injuries in those younger than 40.”

NCDs causing the unacceptable deaths of children and young adults in this population were generally not driven by classic lifestyle risk factors.

That the underlying causes of NCDs among the poorest billion differ from the wealthier inhabitants of Earth isn’t surprising. Folks in Copenhagen and New York City and Tokyo aren’t getting respiratory infections from cooking over an open fire in a poorly ventilated hut, as we’ve seen countless times in Haiti. Their children are not developing heart disease from strep throats or falling into fires during epileptic seizures, as we’ve seen in the countries we work. As Dr. Binagwaho and colleagues write, “NCDs causing the unacceptable deaths of children and young adults in this population were generally not driven by classic lifestyle risk factors.”

Through an integrated strategy that treats and prevents NCDs and injuries in the world’s poorest populations and supports broader economic and social development, we know that countries can substantially reduce needless deaths. Rwanda, for instance, reduced NCD and injury-related mortality by 49 percent between 2000 and 2010 among those younger than 40.

Already, 10 African ministries of health have signed on to the “80x40x20” initiative. As the authors of The Lancet piece conclude, “Perceived financial scarcity should not justify large inequalities in access to health care. We hope that the 80x40x20 target will capture the imagination of activists and evoke the same sense of solidarity and fierce resolve that has fuelled the HIV movement.”

We at PIH are pleased to stand with our partners as they push toward a more equitable world.

To read The Lancet piece in full, please click here.

Follow NCD Synergies and the authorship of this article on Twitter at #80x40x20, @agnesbinagwaho, @maimee02, @gbukhman, and @NCDSynergies

To download PIH’s guide to chronic care integration for endemic NCDs, click here. 

To learn about the inaugural meeting of the NCD Synergies Network, click here. 

Global health is a terrific field, offering chances to improve the lives of millions. But how do you start your career? We asked current and former Partners In Health staffers for advice.  

Sheila Davis
Chief Nursing Officer

The word “global” to me is not a geographic term but better describes a lens from which one approaches global health delivery. Viewing health care as a human right, preferentially working with marginalized and underserved populations, and providing care in low-resource settings are all factors that contribute to my view of what defines “global.” I first became a global nurse in Boston and in Washington, D.C., and then applied my experience in other places in the world such as Haiti, Rwanda, and Malawi.

As for advice, concentrate on developing the skills you will need to contribute meaningfully. If you are a nurse or other health care provider, become an excellent clinician. We need your skills and experience to join with the seasoned clinical colleagues we are so fortunate to learn from and work with globally. Appreciating and respecting different cultures is the key, and the best place to begin to do that is in your own community.  Seek out opportunities to volunteer and work with immigrant and refugee communities in your local community, and you can develop vital skills and experience.  Learning a new language, seeking cultural experiences in art, music and theater, and reading literature from around the world are all ways to engage.

Joining the greater global community is a way to both learn about global health delivery and to make connections with other likeminded people. A good place to start is Global Health Delivery Online, a diverse online global community. 

Flying first class and staying at fancy hotels means nothing. What’s important is being part of the change.

Askar Yedilbayev
Medical Officer/Program Officer for Russia

There are two words that best describe why I work in global health: Impact and change. For those interested in working in global health, you should understand that while you may not see immediate results, your work will become part of something bigger and it will impact people’s lives and make a change for the better. Understanding this is key to being passionate about your work and will compel you to look for new ways to affect change. Passion is important because, to be perfectly honest, you will not become rich working in global health. You will not stay in fancy hotels or fly first class, and you will travel to poor and remote areas of the world. And you’ll understand that flying first class and staying at fancy hotels means nothing. What’s important is being part of the change. 

Nedgine Paul
former Human Resources Manager

Global health—and more broadly, the international development and social justice sectors—is an ever-evolving field. I would encourage taking advantage of opportunities to remain informed about past and present perspectives, research, and innovations in the field. Articles, books, and conferences are some formal options, but informal conversations with those who have worked in or influenced your field of interest (including interdisciplinary sectors such as international education, public policy, and anthropology) can provide tremendous learning experiences as well. To remain informed includes honing one’s craft even as an established professional, such as identifying the management and leadership competencies to develop as related to your career aspirations. 

Do not underestimate the power of hearing the voices of those in need, whether reading the unabridged story of a patient treated in a rural clinic, speaking to a community organizer with a career working on behalf of a disadvantaged group, or speaking with a local resident of a country in which you are interested in working. Their voices may not always be included in headlines or publications, but they are the ones who have so much to teach us about the true purpose, challenges, and impact of global movements for social justice.

Emmanuel Kamanzi
Rwanda Program Officer

Global heath is all about understanding the health of populations in a global context, reducing disparities, and making worldwide improvements. While clinicians mostly see health issues and disparities at the clinics, health centers, and hospitals in which they work, global health is broad and requires diversified skills and interests.

Everyone can be a global health worker; it just has to start in your heart.

My experience working for Partners In Health in rural Rwanda for the last five years revealed to me that in order to develop relevant policies that can address health issues and be replicated globally, you need to work closely with communities and central and local governments. Building health care platforms that deliver high-quality care to the most poor and vulnerable communities requires a collaborative workforce that can build partnerships. Designing appropriate and effective movements and policies requires a deep understanding of the local context and extensive assessment of financial, social, and political perspectives. Everyone can be a global health worker; it just has to start in your heart and you must be committed to fighting disparity and inequality.
 

Shinichi Daimyo
Clinical Program Officer

Persevere passionately—it becomes practical down the line if you make the commitment. Mental health has always been my passion, and all the professional and educational choices I’ve made along the way have been driven by this. I’m not going to lie; it was difficult. Upon finishing graduate school, all the feedback I got was “you need to pay your dues,” which equated to “you need to work for two years in the field for little to no money.”

After a search for full-time jobs in global health proved frustrating and unsuccessful, I accepted a job that paid for my room, board, and a $500 stipend (all while shouldering significant student debt) to work in quality improvement and health systems strengthening, while simultaneously learning how to incorporate mental health work into the government’s primary care system in Lesotho. From there I moved to a domestic policy job, and then I took a significant pay cut to work for an organization that provided psychological support for torture survivors and individuals traumatized by natural disaster. The work was not only critically important, it allowed me to blend my past experiences and skills in a way that opened the door to more opportunities in global health.

Specifically, I got a job working at PIH to manage their mental health programs, but not for all the reasons you might think. My experience and passion fit the job description, but it was my connections with colleagues from school and work that eventually got me an interview. They vouched for me because they saw firsthand how hard I worked and how committed I was. In global health, this will make the difference between your application and hundreds of other similar applications.

When I think of all my colleagues from school and the field who are still working in global health, there are two common themes: First, we all made long-term commitments to short-term sacrifices. Second, we refused to work in anything else but what we were passionate about. If you can do these two things and persevere through the rough patches, you will get to where you want to be in global health.

A Haitian proverb says, “It’s easier to go to the mountains than to wait for the mountains to come to you.”

At Partners In Health, our mission to increase access to health care means that doctors and nurses don’t wait for patients to come to them. They go to the patients, especially those in the most remote areas.

In April 2013, PIH and our Haitian sister organization, Zanmi Lasante, began conducting mobile clinics, which extend the reach of the health care system into communities.

Mobile clinics take place in community hubs such as schools and churches. Community health workers identify under-served areas that would benefit from health services, find a community building that can host the clinic, and then spread the word that the team will be conducting a mobile clinic in advance of the daylong event.

Then, clinicians from PIH/ZL facilities set up shop in the chosen place, registering patients, providing check-ups, including tests for pregnancy and HIV, and prescribing treatments or referring them to follow-up care at stationary facilities. Because mobile clinics make it easier for patients to access care, they often reach the most vulnerable people—those who wouldn’t otherwise have access to health care.

So far, the approach has worked. Since spring, PIH/ZL has seen more than 33,000 patients at the mobile clinics, referring more than 450 people who tested positive for HIV to receive further care. The demand for care has exceeded PIH/ZL’s expectations.

“The communities we serve always welcome the mobile clinics,” said Dr. Kenia Vissieres, one of the project’s leaders. “They help us reach the most vulnerable patients with earlier prevention, diagnosis, and care.”

PIH/ZL’s mobile clinic team uses donkeys, motorcycles, and vehicles to transport staff and supplies to conduct clinics in some of Haiti’s hard-to-reach areas. Photo: Abraham Jacquet/Partners In Health

But mobile clinics don’t work if they occur in isolation, without follow-up. For example, women who are pregnant, patients diagnosed with diabetes, and people who test positive for HIV all need further care at stationary facilities.

To meet those needs, PIH/ZL staff designed health information and referral systems to ensure effective patient follow-up, and invested in software to collect information about patients’ visits to pass along to facilities for further care.

Data clerks have hauled laptops to mobile clinic sites and registered patients into a specially designed electronic medical record system. If patients require follow-up care, they receive a referral voucher that they take to the stationary clinic, where staff then have all the information about their mobile clinic visit.

It’s been challenging to put this referral system in place, especially when mobile clinic teams travel to remote areas with washed-out roads and no electricity. But it makes a huge difference in ensuring patients receive the care they need.

To learn more about the importance of the electronic information and referral system, we spoke with Gertruna Hilaire.

Gertruna Hilaire works as monitoring and evaluation coordinator for the mobile clinics project.

What kind of background do you have, and why were you interested in working on this project?

I have a bachelor’s degree in planning with extensive training in statistics. After three years working for the Haitian Ministry of Health and two years working in an HIV program, I wanted to face new challenges. That’s the main reason why I was really excited to join the PIH/ZL staff for two new projects—this mobile clinics project and a project to improve mental health care.

I hope that because we have gone to the mountains, people living there will have seen the quality of services available at the facilities. We hope that will encourage them to attend the clinics for their health problems.

How does the electronic medical record system make the mobile clinics more effective?

The electronic system helps us collect data about patients and their care to use our resources more strategically, both the effective provision of services at mobile clinics and the referral network of stationary facilities. It’s a database that allows us to securely keep the patients’ charts and help reduce the waiting time during mobile clinics for patients who are already registered.

The system has been created specifically for the mobile clinic project. We built on our previous experience in implementing the electronic medical record for program management at other sites where PIH/ZL works.

What have you learned about patients who come to the mobile clinics?

Distance and poor economic status are factors that limit access to health facilities. The mobile clinic data analysis has shown that the difficulty and cost of traveling to facilities impedes patients not only from getting treatment when they are sick, but also from knowing their overall health status—including whether or not they have HIV—and from getting certain medications. 

How have you overcome the logistical challenges of using the EMR at mobile clinics?

Because we don’t always have access to electricity, we make sure that the laptops are fully charged before the mobile clinics. The teams are well trained in the simple software application being used. 

What has the team learned about conducting mobile clinics from this project?

Our staff has learned how to organize mobile clinics in a way that allows us to collect data and report them properly.  Before this project, mobile clinics used to be done, but we only recorded the number of people seen, and planning and resource allocation to the mobile clinics were not based on the data collected. Now, we can deploy our resources to communities most in need and ensure that those patients receive follow-up care.

What do you hope will be the lasting impact of the mobile clinics?

Now the staff is seeing this community activity as a strategy that can complement our efforts at the permanent health facilities. It will be good for us to increase the scope of services provided at the mobile clinics in order to cover other neglected conditions at the community level such as tuberculosis and mental health.

I also hope that because we have gone to the mountains, people living there will have seen the quality of services available at the facilities. We hope that will encourage them to attend the clinics for their health problems.

This essay originally appeared in Sojourners.

Two of my greatest teachers were Latin American men, both ordained as Catholic priests. One, Archbishop Oscar Romero, was assassinated in 1980. I never met him, being a 20-year-old American who’d never set foot in El Salvador or anywhere else in Latin America. But Romero made me, a lapsed Catholic, wonder why his views—our views, if Christian social teaching means anything at all—would be viewed with murderous hostility by the Salvadoran elite. After all, it was all right there in the Book. Wasn’t it?

The truth was, I didn’t know. Was it worth looking at books about these matters? That’s what we believed in medical school: Look it up! So Romero led me to the second of these teachers who, I’m happy to say, is alive and well and living (mostly) in Lima, Peru. Gustavo Gutiérrez, a diminutive and humble Dominican priest and a great friend of Romero’s, taught me through his books, from The Power of the Poor in History to We Drink from our Own Wells, and later through his friendship and his almost mystical (to me, in any case) optimism.

Over the course of my 20s, the slender, frayed thread of my own faith, which I had believed cut, slowly came back into view. There was a filament a bit stronger than imagined, made visible in part by my Haitian hosts and patients and friends, and in part by Catholic social activists working against poverty in settings as different as tough neighborhoods in Boston, the farms of North Carolina, and the slums of Lima.

Some were nuns or priests, some were engaged laity, from many professions. Most were people living in and struggling against their own and others’ poverty. Their activism taught me a lot about a space in the Catholic Church I’d not seen clearly before, and about the promise of long-term engagement in the monumental struggle against poverty and discrimination in all its forms. That includes gender inequality, no stranger to the institution. Most of the most inspiring activists were women.

NOW THERE IS a third Latin American priest on my mind. And happily for our troubled but beautiful world, both Archbishop Romero and Father Gutiérrez are on Pope Francis’ mind. You can’t be a Jesuit from Argentina and not have liberation theology in your thoughts. But now the man is the pope in Rome, and progressive, indeed radical, ideas have not always found warm welcome there. That may be changing, just by Francis’ words and actions, which have included how best to honor Romero’s memory and a recent consultation with Father Gutiérrez. Just knowing of the recent meeting between the two South Americans, knowing they said a Mass together, warmed my heart, and not just “for the good of all the Church” (in the words of that liturgy). It warmed my heart, and wove those strings tighter, because the secular world also needs liberation theology.

Over the past 25 years, I’ve not learned much theology (medicine and anthropology were more than enough for me), but some of us have taken a number of key concepts from liberation theology and applied them in medicine. Let me comment on three that have been important to the work of Partners In Health, an organization I cofounded to make “a preferential option for the poor in health care” in settings ranging from rural Latin America (Haiti, Guatemala, Mexico) and Africa (Rwanda, Malawi, Lesotho) to areas of urban poverty (Peru, the United States) and even into the prisons of Siberia. Gutiérrez has written books about all of these ideas and has sought to teach and learn about them through his own ministry.

The first notion is the preferential option for the poor. Any serious examination of epidemic disease has always shown that microbes also make a preferential option for the poor. But medicine and its practitioners, even in public health, do so all too rarely. Imagine how much unnecessary suffering we might collectively avert if our health care and educational systems, foundations, and nongovernmental organizations genuinely made a preferential option for the poor?

The second is the notion of structural violence. Sure, bad things happen. But they don’t often happen randomly. Violence is done to some people in this world by poverty, racism, gender inequality, homophobia, and xenophobia. Just as this violence, which Gutiérrez and others term structural violence or “structural sin,” can be institutionalized through unjust social arrangements, so too can it be undone with the help of more just ones.

The secular world needs to understand that what would “free us from all anxiety” is opening up to the poor and otherwise marginalized the chance to flourish. This cannot happen if there is hunger, unfair political arrangements, ongoing assaults on the environment, and no safety net to protect the sick, the unemployed, and the frail. The current rules of modern capitalism cannot rid us of structural violence any more than wars or other forms of “event violence” can. But understanding how the social worlds in which we live are constructed might help us to do so, as can the mystery of hope.

The third notion is accompaniment. The power of this simple idea, a staple in liberation theology, came to me in contemplating patients facing both poverty and chronic disease. They missed appointments, didn’t fill prescriptions, didn’t “comply” with our counsel. And this was true in every country in which I’ve worked. But when we began working with community-health workers to take care to patients, the outcomes we all sought were much more likely to happen. Instead of asking “why don’t patients comply with our treatments?” we began to ask, “How can we accompany our patients on the road to cure or wellness or a life with less suffering due to disease?” Again, the notion would be welcome in the world beyond the church: How many institutions, including those responsible for foreign aid, desperately need to replace time-limited, contractual, and almost invariably inegalitarian arrangements—the aid worker and the aid recipient—with genuine accompaniment and solidarity? My guess: almost all of them.

Just these notions alone are reminders of an institution stretching back 2,000 years that can still nurture leaders such as Archbishop Romero and Father Gutiérrez. It’s my fervent wish that the church led by Pope Francis will canonize the first man and continue to listen to the second. We can all learn from both of them, just as they have learned by listening to the poor and oppressed. 

Paul Farmer is the Kolokotrones University Professor at Harvard University and cofounder of Partners In Health. His most recent book is In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez (Orbis Press). He has worked as an infectious disease physician in Haiti, Peru, Rwanda, and Boston.

Read “Reimagining Accompaniment: A Doctor’s Tribute to Father Gustavo Gutiérrez,” the first chapter of In the Company of the Poor.

To mark the end of 2013, we wanted to share 29 images that capture the dedication of our clinicians, the ambitions of our founders, and the lives of our patients. Please visit the accompanying links for the full stories. 

1: Construction of University Hospital in Mirebalais, Haiti, wrapped up at the end of 2012. Before the facility even opened its doors, its 1,800 solar panels generated more than 140 megawatt hours of clean energy. 

Rebecca E. Rollins/PIH

2: Dr. Paul Farmer and Lesotho Prime Minister Dr. Motsoahae Thomas Thabane, right, celebrate the opening of Lesotho’s new National TB Reference Laboratory in February. 

Rebecca E. Rollins/PIH

3: More than 20 members of PIH's Monitoring, Evaluation, and Quality team from six sites gathered in Rwinkwavu, Rwanda, in February to share insights on how to improve data and put them to good use.

PIH

4: Dr. Abelardo Vidaurreta, among the first social service year physicians to work with PIH's sister organization in Mexico, stitches a patient's knee in Chiapas, Mexico. 

Balam-ha' Carrillo/S4C

5: HIV Treatment Coordinator Charles Phiri uses a dirt bike to consult hard-to-reach patients in Neno, Malawi, who have stopped taking their daily medications.

Victoria Smith/PIH

6: Teboho Mohami (an alias), center, was referred to Botsabelo Hospital in Lesotho at the end of January for extreme fatigue. The 37-year-old patient, who also has HIV, had been treated unsuccessfully for tuberculosis in 2005 and 2011. Along the way, he lost his hearing, likely a side effect of the drugs. 

Rebecca E. Rollins/PIH

7: Nurse Rosa Huet Pale weighs and measures a baby at a rural clinic in Chiapas, Mexico.

Naira Arellano/PIH

8: Two hundred people: That’s the average number of patients testing positive for malaria each day of the month-long rainy season at a single hospital in Malawi. Malaria attacks red blood cells, which become infected by parasite-carrying mosquitos.

Rebecca E. Rollins/PIH

9: Nelson Moreta, a community health worker with PIH's Dominican sister organization Socios En Salud, crosses the Artibonite River on his way to visit patients living with HIV in Haiti.

Stephanie Garry/PIH

10: Marita Banda (an alias) went into labor while in transit to Lisungwi Hospital, a PIH-supported facility in Malawi with a full maternity ward. She began to bleed steadily and couldn’t remove the placenta. By the time Banda and her newborn son made it to the hospital, she had lost a significant amount of blood.

Victoria Smith/PIH

11: Partners In Health supporter Erin Manuel takes a break from selling bookmarks and greeting cards to play the violin at her local farmers market. She has raised more than $5,000 for PIH.

The Manuel family

12: Malineo Sethobane, a maternal health worker in Lipeneng, Lesotho, has accompanied more than 11 mothers throughout their pregnancies.

Rebecca E. Rollins/PIH

13: Community health representative Marie Begay heads out to visit patients in the Navajo Nation, where noncommunicable diseases such as diabetes are an increasing burden. 

Rebecca E. Rollins/PIH

14: Isemelie Bazard, 60, received a lifesaving mastectomy as University Hospital's first surgical patient.

Rebecca E. Rollins/PIH

15: Fabrice, after completing chemotherapy for Wilms’ tumor, and his mother, near their home in Rwanda. 

Dave Shulman/PIH

16: Clinicians in University Hospital’s emergency department deliver timely care to accident victims.

Rebecca E. Rollins/PIH

17: In August, PIH and the Rwandan Ministry of Health celebrated the opening of the Butaro Ambulatory Cancer Center in northern Rwanda.

Rebecca E. Rollins/PIH

18: From San Francisco to Boston, these seven FACE AIDS riders pedaled more than 4,000 miles to raise money for PIH and awareness of HIV/AIDS. 

FACE AIDS

19: Neza Guillaine, a Java developer for PIH’s Rwandan sister organization, leads a session on computer programming at Camp TechKobwa in Gashora, Rwanda. The program is part of a wider effort to close the gender gap in technology. 

Mike Goren

20: In early October, volunteers from around the United States gathered in Boston to learn how to advance global health equity in their communities. PIH co-founder Dr. Paul Farmer dropped in to discuss the importance of building a movement for global health. 

PIH

21: Kilogram containers of Nourimanba, a ready-to-use therapeutic food for malnourished patients, are sorted and organized for storage at the newly opened Nourimanba Production Facility in Haiti's Central Plateau.

Jon Lascher/PIH

22: These 14 physician trainees represent the first cohort of medical residents at University Hospital in Haiti. They'll receive specialized training in pediatrics, internal medicine, and general surgery.

Michelle Morse/PIH

23: Carlos Cántaro, at his home outside Lima, Peru, is being treated for multidrug-resistant tuberculosis. He decided to take up running again after a group therapy session with Partners In Health in Peru and recently completed a 10K. 

Raúl Silverio Carbajal/Socios En Salud

24: Wadley Germain, 10, met with U.S. Secretary of Education Arne Duncan in Port-au-Prince, Haiti. Germain recieved support from PIH after the 2010 earthquake destroyed her family's home. This year she was featured in Girl Rising, an innovative documentary that tells the story of girls around the world who persevered in gaining access to education.

Cate Oswald/PIH

25: Dr. Paul Farmer, right, and Dr. Sergey Mishustin, center, of the Tomsk Oblast TB and Pulmonology Medical Center, accept the Karel Styblo Public Health Prize at the annual International Union Against Tuberculosis and Lung Disease meeting in November.

International Union Against Tuberculosis and Lung Disease

26: Blessings Banda, nutrition and HIV coordinator at Abwenzi Pa Za Umoyo, PIH's sister organization in Malawi, sits with 2-year-old Rachel Namazongo. Banda helped treat Rachel, who is HIV-positive, for malnutrition.

PIH

27: Adeline Uwera, right, and her sister Doris. Adeline was severely malnourished three years ago when she arrived at Rwinkwavu District Hospital in Rwanda. Her family enrolled in a food security and livelihood program, a collaboration between PIH and Rwanda's Ministry of Health that provides education and accompaniment.

Maria Kaitesi/PIH

28: PIH rehab technician St. Lot Odeus visits Roseline Bernard, 17, and her aunt at their home this month. Roseline fell from an avocado tree in August and required surgery and cognitive therapy. She also received treatment for malnutrition.

Jonah Feldman/PIH

29: Looking forward to 2014 from the roof of University Hospital, in Mirebalais, Haiti! 

Jon Lascher/PIH

Isemélie Bazard was the first patient at Haiti’s University Hospital to undergo surgery—a mastectomy to treat her breast cancer—and now her chemotherapy is almost complete.

Before her surgery in May, Bazard was worried for her life. With the surgery, chemotherapy, and counseling, she and her family have hope that she can recover. Bazard has just one more infusion. “I am looking forward to finishing chemotherapy so I can start working again to help my daughter pay for university,” Bazard said.

This summer, PIH and our Haitian sister organization, Zanmi Lasante (ZL), transitioned oncology services from a crowded, inadequate space in Cange to University Hospital in Mirebalais, where more patients can receive cancer prevention, treatment, and education efforts that are integrated with other services at the hospital.

Between July and November, the cancer care team provided services to about 700 patients, illustrating a huge demand for cancer care in Haiti.

Despite the perception that cancer only affects people in wealthy countries, cancer actually causes more deaths in low- and middle-income countries. And while about 80 percent of the global burden of cancer is born by people in the developing world, just 5 percent of the world’s expenditures on cancer care happen there.

Partners In Health has been working to save lives and demonstrate that the disease is treatable in poor, rural areas.

This year, PIH and our partners marked the one-year anniversary of the Butaro Cancer Center of Excellence in northern Rwanda, the first-ever comprehensive cancer center in rural East Africa. And in August, we celebrated the expansion of this facility by inaugurating the Butaro Ambulatory Cancer Center, which will provide chemotherapy to patients who don’t require hospitalization.

PIH/ZL is the only provider of free oncology services in Haiti. While PIH/ZL has always cared for cancer patients, even with limited capacity for treatment, an interdisciplinary team has worked over the last three years to formalize and integrate services for patients with cancer while building their skills through training.

The move to University Hospital has allowed the cancer care team to treat more patients; the demand has shown the need for more cancer care across Haiti. Between July and September, most patients—64 percent—came from the Port-au-Prince area, and only 22 percent from central Haiti, many referred by PIH/ZL clinics or other providers.

In the same period, breast cancer was the most common diagnosis for oncology patients, at 40 percent, followed by cervical cancer, at 12 percent, according to data from University Hospital’s electronic medical record system.

The cancer care team, headed by Haitian oncology director Dr. Ruth Damuse, has worked hard to provide comprehensive care for cancer patients. Their work has been supported by partners including the Avon Foundation, the LIVESTRONG Foundation, and the Dana-Farber Cancer Institute, which helps develop treatment plans for PIH/ZL patients. The DFCI has also created a special fellowship enabling expert oncology nurses from Boston to work at the hospital in three-month rotations and train staff on administration of chemotherapy and wound care. 

Cancer care at University Hospital addresses  the many needs of  patients, including:

• Cancer screening, including biopsies and pathological testing
• Surgery and post-surgical wound care
• Intravenous chemotherapy in designated beds and chairs for infusion
• Oral chemotherapy
• One-on-one counseling and support groups to help patients cope with their cancer diagnoses and treatment side effects
• Referrals to a partner hospital in the Dominican Republic for radiation therapy
• Education on cancer, including breast self-exams and community awareness events to encourage people to seek care early
• Palliative care

Oncology social worker Oldine Deshommes described one patient’s experience with breast cancer:

“The first time I saw Mrs. A, she was crying. She felt humiliated because of her cancer. Her wound was infected and had a bad smell. She said even though she was not yet dead, she was ashamed to sit near others.

We talked about how she should not feel excluded from others, showing her that she is not responsible for her illness. We also talked about what she can do to get healthy; reminding her that she is not alone, that we are with her in this fight.

In our group sessions she talked about how she felt before coming to the support group. She actively participates in the groups, and it helps her see that she is not alone in experiencing changes to her life from cancer. She said she no longer feels lonely and she has made friends from the support group who encourage her.”

With support from Deshommes, Bazard was able to delay her last round of chemo a couple of weeks, until January. She wanted to feel well for her daughter’s wedding.

In a lecture published this week in The New England Journal of Medicine, Dr. Paul Farmer digs into the past to draw lessons for the future. In “Chronic Infectious Disease and the Future of Health Care Delivery,” he argues that successes from the world’s response to tuberculosis and HIV can be applied to improving care for chronic illnesses, which make up an increasing burden of disease in poor and wealthy countries—including the United States.

Read the full Shattuck Lecture, explore interactive graphs, and watch a slideshow narrated by Farmer on the NEJM website.

Here are five highlights from the lecture:

1. In an era of antibiotic resistance and chronic disease, medicine must take on the work of bridging the “know-do gap”—the often-neglected work of getting effective therapies (the “know”) to people who need them (the “do”).
2. No disease should be considered “untreatable.” In treating HIV with antiretroviral therapy in Haiti, Partners In Health resolved so-called obstacles to treatment by employing community health workers to deliver complex drug regimens and improve patients’ access to social support, such as food and housing. Farmer writes, “‘Untreatable’ often really means difficult or costly to treat, just as ‘resistant’ sometimes means resistant to our best efforts to deliver care.”
3. Prevention and treatment are complementary, not in competition. With AIDS, people were reluctant to learn whether they had a disease for which there was no treatment. When patients learned that they could be treated for the disease, and mothers could prevent the spread of HIV to their children, demand for HIV testing and prevention services increased.
4. With AIDS, debates about feasibility were really about funding. Delivering antiretroviral therapy to the millions of people who couldn’t afford it was feasible, but required a financial commitment from wealthy countries—which came about in the form of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and PEPFAR.
5. Funding designated for specific diseases, such as HIV, tuberculosis, and malaria, can strengthen primary care to tackle a broad range of illnesses.

United States, take note. As many wealthy countries have minimized deaths from infectious disease, the growing threat is chronic disease—hypertension, diabetes, and cancer, for example—which require ongoing care and attention to social needs such as access to healthy foods.

Farmer writes, “The know-do gap is readily visible in the United States, where resources are plentiful but outcomes are uneven and health disparities persist …. Our system does a poor job of linking hospital-based care to that delivered in clinics, homes, or workplaces. Care delivered with the help of community health workers, and attuned to the social needs of the patients, is meant to do just that.”

He concludes, “If only we could develop the right community-based and equitable delivery platforms in advance, we could spare our patients a lot of suffering, and ourselves a lot of headaches and acrimony.”

Read the full lecture.

For the past five years, our partners at the Harvard School of Public Health and Harvard Medical School have brought together some of the brightest and most ambitious minds around the world for the Global Health Delivery Summer Intensive (GHDI), a month-long program for global health professionals. We’re happy to announce that the application process for the 2014 program is officially open. 

Over the month of July, participants will explore epidemiologic methods, applications of biostatistics, and the principles of health care delivery in resource-limited settings, among many other subjects. The non-degree program features three credit-bearing courses and draws on the expertise of various Partners In Health clinicians, including Drs. Paul Farmer and Joia Mukherjee.

The program is tailored specifically for mid-career professionals who have a demonstrated commitment to global health and experience in global health organizations, with a substantial background in health care or a related field.

In years past, PIHers from various sites have excelled in the GHDI, returning to their respective countries with fresh insight on how to strengthen the health system and improve services.

Applications will be accepted through Feb. 1, 2014, but program administrators encourage applicants to submit materials early if possible.

Learn more about the program and the application process by clicking here.

Blessings Banda, nutrition and HIV coordinator at Partners In Health’s sister organization in Malawi, was a member of the 2013 GHDI session. Read about his experience here.

This week, Foreign Affairs published an essay by PIH Co-founder Dr. Paul Farmer that delves into the discussion over foreign aid effectiveness. Dr. Farmer starts off by explaining that, “So much is written and said about foreign aid that it has become difficult to contribute meaningfully to the debate about whether it is effective.”

Nevertheless, he dispels myths about aid and offers suggestions about how to make it work, drawing on lessons from Haiti and Rwanda, and PEPFAR and the Global Fund. He makes the case that aid can save lives and make an enduring impact, and offers five recommendations to improve aid’s effectiveness.

“None of these proposals is easy,” he concludes. “But the rewards awaiting us at the end are well worth the arduous journey of getting there.”

To read the essay in full, click here.

A paper published this week in the peer-reviewed journal PLOS ONE describes how a new model for health care delivery in Yirimadjo, Mali, may have helped reduce the rate of child mortality from 155/1000 to 17/1000 over a three-year span.

The paper, which is co-authored by PIH’s Drs. Paul Farmer and Joia Mukherjee, among other colleagues from Harvard Medical School, the University of California San Francisco, and the Malian Ministry of Health, notes that there was an approximately tenfold increase in the number of home and clinic patient visits over the course of the study.

The new health care model used several strategies, including active case-finding by community health workers; removing health service fees for those who couldn’t afford to pay; and community education and empowerment programs.

In a statement on the paper, the authors explain that the “model aims to avert child deaths by reaching children early with medicines and prevention tools already proven to save lives. To achieve this, the model builds demand for health services together with a route to ultra-rapid access.”

The researchers found the rate of early treatment for malaria, within 24 hours of a child’s first symptom, nearly doubled during the study period. The team notes that the study has various limitations and calls for further researcher to more deeply evaluate the model.

To read the article in full, click here.

To learn more about Project Muso, the NGO that piloted the model, click here.

In 1995, Andree LeRoy’s life changed when her aunt in Haiti chose death over amputation.

Her aunt’s diabetes had led to a foot ulcer, and she didn’t want to become an amputee. She didn’t want to be called “kokobe,” a pejorative Haitian Creole term for a disabled person. In Haiti, poverty has led to stigma around disability. People who are missing limbs cannot contribute to household income through manual labor but still require family support.

Her aunt’s needless death inspired LeRoy, a Haitian-American, to become a rehabilitation doctor. She hoped to help disabled people function to their potential, and fight the idea that the disabled bring others down. LeRoy attended the University of Illinois College of Medicine, and was selected for a residency at Boston’s Spaulding Rehabilitation Hospital, a teaching hospital of Harvard Medical School.

It’s actually how we integrate all members of society that allows us to rise above our economic difficulties. You can’t leave people behind.

Then, in 2010, she watched the news of the earthquake in Haiti on television, reliving her feeling of powerlessness when her aunt chose death over amputation. She worried about the amputees, who she knew would need help regaining mobility and battling the stigma of being disabled.

“Here it is, I’m looking at the television, and 15 years later people are saying they’d rather die than have an amputation. That’s when I said, ‘I have to do something,’” LeRoy said. “Oftentimes people with disabilities are marginalized. They’re not integrated; they’re living on the fringes. For the most part, they’re the most vulnerable of the poor.”

LeRoy went to Haiti with a team from Spaulding Hospital just a month later. They assessed the country’s need for rehabilitation care and found many gaps. There are no full-time, practicing rehabilitation doctors. Without specialty training programs, Haiti has no occupational or speech therapists, who, in the U.S., help patients with cognitive damage in cases such as Roseline’s, a University Hospital patient who recovered from a three-story fall. Nor are there residency programs to allow doctors to specialize in physical therapy.

“I realized I have to spend time on the ground, training others,” LeRoy said. “It’s not my goal to be in charge forever; we just don’t have Haitian physicians who are trained.”

LeRoy believes that with more access to medical training, Haiti can build its workforce of rehab health specialists and provide care to people who are disabled, helping them make the most of their lives. With care, she believes, stigma will lessen, just as it did when treatment became available for tuberculosis and HIV.

University Hospital in Mirebalais, where the rehab program is now based, is a hub of this training. The hospital and its staff can refer patients to the rehab program for care. There, patients can regain their cognitive and physical abilities. In cases of permanent disability, the rehab team offers physical therapy and mobility devices such as prosthetics, walkers, and wheelchairs. These services both help patients in need and allow health professionals to learn to provide rehab care.

“We’re trying to create a transnational movement to reintegrate people after a temporary or permanent disability,” LeRoy said. “It’s actually how we integrate all members of society that allows us to rise above our economic difficulties. You can’t leave people behind.”

Late summer is avocado season in Haiti, and people lucky enough to have a tree on their property gather the fruit to eat and sell.

Roseline Bernard, 17, lives with her grandmother and her aunt in Lascahobas, a small community in Haiti’s Central Plateau. Her mother died when she was young, and her father hasn’t been around, so Roseline’s work harvesting avocadoes is a big contribution to the household.

On Aug. 8, Roseline climbed high into her family’s avocado tree to collect the fruit before it ripened and dropped to the ground. She was nearly three stories high when she fell.

A year ago, Partners In Health could have treated her, but her odds of recovering from such a fall would have been slim. A year ago, there would have been no emergency room to receive her, no modern surgery suite to repair her damaged abdomen, no CT scanner to identify her most complex injury.

A lot of people didn’t feel there was much hope for recovery. We saw this young girl come to life.

Hôpital Universitaire de Mirebalais was designed to handle cases like Roseline’s—complex, urgent, inter-connected—that a community clinic or district hospital isn’t equipped to manage. With Roseline in tremendous pain, her family took her on the two-hour journey to University Hospital, first carrying her on a wooden board for the 45-minute hike from her home to Lascahobas and then taking a motorcycle to the hospital in Mirebalais.

There, staff stabilized her and began to diagnose and treat her injuries. Using X-ray and other diagnostics, they found she had shattered both wrists, broken her face, and had an internal abdominal injury.

The surgery team wheeled her into the operating room to repair her abdominal injury, and other clinicians set her broken bones. After the operation, she began healing in the inpatient ward. But Roseline was agitated and restless. She couldn’t walk. For the first week, she couldn’t even speak.

Doctors began to piece together the problem. She had lost consciousness for hours after the fall. A CT scan revealed that she had suffered a traumatic brain injury—a diagnosis that’s rarely made in Haiti, despite countless cases from injuries in traffic accidents and falls.

“Traumatic brain injury often goes under-recognized in Haiti,” said Dr. Andree LeRoy, director of rehab at University Hospital. “Sometimes clinicians make the assumption she was always like that, or they might not be able to do anything about it.”

University Hospital rehab technician St. Lot Odeus worked with Roseline Bernard, 17, and her aunt, to provide cognitive stimulation and help her recover.

For traumatic injuries like Roseline’s, surgery and emergency care are just the beginning of a long road to recovery. Suffering from malnutrition in addition to physical and cognitive injuries, Roseline would need cognitive and physical rehabilitation to function normally again.

Partners In Health has been working to strengthen rehab care in Haiti, especially in referral facilities like University Hospital. LeRoy, who is Haitian-American, has led this work as director of rehab for PIH, while juggling her day job as a rehabilitation doctor at Spaulding Hospital, a teaching hospital of Harvard Medical School. (Read more about Dr. LeRoy and how the 2010 earthquake led her to Haiti.)

This summer, the rehab program based in Cange moved to University Hospital, where it could be better integrated with the other critical care services that depend on rehab to help patients recover from disability, such as surgery, the emergency department, and mental health.

Between June and August, the rehab team evaluated 123 patients for care, including 14 patients who suffered traumatic injuries in a July bus crash. The team has also provided mobility devices, including crutches, canes, walkers, and wheelchairs, for 50 patients to use at home once they’re discharged from the hospital.

University Hospital, in addition to PIH-supported Hôpital St. Nicolas in St. Marc, also offers community-based rehab services. After patients return home, community rehab educators support patients during the transition, helping them use their mobility devices, take their medicines, complete their physical therapy exercises, and return to the hospital for follow-up care.

During their home visits with existing patients, staff members also identify patients in need of rehab care in the community.

The system worked for Roseline.

“She had every kind of injury,” LeRoy said. “Rehab requires care from many different fields—nurses, physicians, physical therapists, rehab technicians, nurse auxiliaries, and psychologists all work together to maximize the function of an individual. It’s a beautiful thing.”

For a chance to recover, Roseline needed cognitive stimulation—quickly. With training from LeRoy and others, St. Lot Odeus, a rehab technician with Zanmi Lasante—PIH’s sister organization in Haiti—began working with Roseline even when she was too weak to leave her bed. He helped her family understand that they needed to speak to her to help her brain heal.

At first, Odeus helped her do exercises lying down, then sitting at the edge of the bed. Roseline’s constant bed rest and inability to eat after the injury had left her very weak. Slowly, she began to stand with the help of a walker. Then, she took her first few steps. With her caretakers’ help, she explored the courtyards at the center of University Hospital, and watched koi fish in the ponds designed to create a sense of beauty, calm, and healing for patients.

“I am very happy because I can walk again,” Roseline said. “That was my first time going outside in a long time and it felt really good.”

University Hospital rehab staff accompanied Roseline Bernard on a walk through the hospital’s courtyard this fall.

With hospital nutrition staff providing healthy meals, her malnutrition also improved. Two weeks later, Roseline was able to take a few steps on her own. Just before she was discharged home, she could walk more than the length of a football field on her own. When she was ready for discharge on Oct. 5, she had grown two inches taller during her stay.

Today, she is doing well, although she’s still unable to walk through the mountainous terrain of her home to reach school.

"A lot of people didn’t feel there was much hope for recovery," LeRoy said. "We saw this young girl come to life."

Roseline returned home from the hospital recovered and two inches taller. Photo: Jonah Feldman/Partners In Health

Roseline fell about 30 feet from this avocado tree near her house. Photo: Jonah Feldman/Partners In Health

When 3-year-old Adeline Uwera was brought to Rwinkwavu District Hospital three years ago, she was pencil thin with sunken eyes and an extended stomach. It was immediately apparent that she was suffering from protein-malnutrition, or kwashiorkor.

Through a partnership with the Rwinkwavu District Hospital, Partners In Health/Inshuti Mu Buzima (PIH/IMB) provided medical treatment and food supplements to aid in her recovery.

But PIH/IMB knows that giving malnourished patients food packages is simply not enough. In order to empower patients and keep them healthy, education and accompaniment are necessary. Through its Food Security and Livelihood Program, PIH/IMB equips families with the knowledge and tools needed to grow their own nutrient-rich foods and make healthy eating choices.

It was this program that transformed the lives of Adeline, now 6 years old and healthy, and her entire family.

“All my life, I had never known that some foods, especially vegetables and fruits, are high in nutrients and good for consumption. I have never been to school, so I didn’t know much about nutrition and the causes of malnutrition until my daughter suffered from kwashiorkor,” says Alphonsine Mukagaceri, Adeline’s mother.

In Rwanda, more than 40 percent of children under the age of 5 suffer from malnutrition or stunting, according to 2010 Rwandan Demographic and Health Survey. The Ministry of Health recently launched a 1,000-day campaign aimed at eradicating malnutrition. Because Rwanda is a landlocked country, improving agricultural practices is critical to achieving long-terms nutrition gains.

“The people from the PIH/IMB food security program taught me how to plant different vegetables and fruits such as carrots, greens, and passion fruit, among many others. They didn’t just teach me how to plant them, but they gave me seeds as well. They also sent people over to my place to follow up and teach me the proper techniques of growing fruits and vegetables in my kitchen garden,” Mukagaceri says.

Since its inception in 2008, the Food Security and Livelihood Program has enrolled more than 900 households.

Since its inception in 2008, the Food Security and Livelihood Program has enrolled more than 900 households throughout the PIH/IMB-supported districts, according to Vincent Nsabuwera, the program director. Nsabuwera noted that an additional 600 families were enrolled in the program this year.

As with all of PIH’s efforts in Rwanda, the Food Security and Livelihood Program was designed to work in coordination with similar government-led efforts. By working with families in the three districts PIH/IMB operates in to address nutrition issues, we’re helping bolster Rwanda’s National Multi-Sectorial Strategy to Eliminate Malnutrition.

Assisted families are given seeds that include iron- and zinc-fortified beans, cabbage, carrots, onions, avocado, mango trees, passion fruit, and moringa, among many others. They are also given fertilizer to boost production.

“Our program isn’t only to improve nutrition of the people, but it also aims at boosting the income of the targeted, vulnerable households as they plant not only for their consumption but for commercial purposes as well,” Nsabuwera said.

Our program isn’t only to improve nutrition of the people, but it also aims at boosting the income of the targeted, vulnerable households.

“Before, I didn’t own a garden and had no job, so I could hardly provide a decent meal for me and my children,” Mukagaceri says. “When I learned how to make my own garden, I started planting enough for my family to eat well. Additionally, I started to sell some of the food so that I could earn money to buy basic items and supplemental foods to balance our diets.”

Mukagaceri continues, “My daughter had suffered from kwashiorkor for one and a half years, and I thought this disease would claim her life. Today, she is a healthy and living testimony of how the kitchen garden is vital and something that every family should have… With the kitchen garden and all the skills that I now have, I believe that no one in my family will ever suffer from malnutrition again. My daughter is so healthy - she hardly falls sick. Every time I look at her, I am filled with joy.”

While Mukagaceri is a success story, there are many families that still need assistance and accompaniment. By the end of September 2013, Rwinkwavu District Hospital had registered more than 150 kids in need of supplementary feeding. 

“We mostly received children less than 5 years of age. The most common malnutrition-related diseases seen are kwashiorkor and marasmus. We also received 46 cases of severe acute malnutrition between February and May of 2013,” said Immaculate Nyirandinda, the head of nutrition at Rwinkwavu District Hospital.

Nyirandinda added that most of the malnutrition cases are seen between October and January, when families are planting crops and waiting on yields.

By expanding the reach of the Food Security and Livelihood Program and enrolling more families, PIH/IMB is poised to help prevent future cases of malnutrition while simultaneously strengthening the local economy.

To learn more about PIH's efforts to treat malnutrition around the world, consider these stories:

Nourimanba: Fighting Malnutrition, Fighting Poverty in Haiti

Need to Know: MUAC and Malnutrition

World Food Day: A Q&A With PIH’s Haiti Nutrition Coordinator

Cell phone signal doesn’t reach the remote mountains of Mexico where our patients live.

So what good could mobile technology do to help improve health care?

A lot, it turns out.

Twice a year, Partners In Health staff make door-to-door visits in the some of the six rural communities PIH serves in Chiapas, Mexico. Volunteers with Compañeros En Salud, our sister organization, ask families about their health and refer them to clinics for care.

Called active case finding, these home surveys help ensure that people in need of care get it. Instead of waiting for patients to show up at health facilities, staff visit patients’ homes to look for signs and symptoms of diabetes, hypertension, epilepsy, asthma, depression, and tuberculosis.

“Our community health workers say that one of the best things about active case finding for chronic diseases is that people can learn when they have an illness,” said Rosabelle Conover, research assistant for PIH/CES. “Otherwise, they die without knowing why or receiving any treatment.”

But the paperwork had a tendency to pile up. Screening patients and crunching the numbers using paper forms was a time-consuming and error-prone process.

So this July, PIH/CES turned to mhealth technology, the topic of the 5^th annual mHealth Summit in Washington, D.C., this week.

The team decided to use low-cost Android tablets with a specially designed app based on the open-source program CommCare.

Jon Payne, now a technical advisor for the mHealth Alliance at the United Nations Foundation, worked with student consultants at the Boston University School of Public Health to design the user-friendly program specifically for PIH/CES. It automates the referral process based on criteria defined for the team. It also decreases dependence on staff memory for referral criteria, helping the team adhere to medical protocols for disease screening.  It allows staff to easily view all referred cases, determine which patients have attended their referral, and identify those who need a second home visit.  

The CommCare app allows PIH/CES staff to refer patients for care and see whether they visited community clinics for follow-up.

Mexican medical students made door-to-door visits with the tablets, using the app to screen for the same illnesses. The program adapted the survey questions for efficiency and accuracy—for example, triggering questions about diabetes depending on the patient’s age. In all, the team screened more than 5,000 people for chronic disease, a growing problem in Latin America.

The program decreased errors, allowed the team to quickly aggregate the data in the field, and improved follow-up care for people found to have symptoms of chronic disease.

With the success of the pilot, PIH/CES will use the tablets again this month to screen more families in isolated communities. The team is continuing to refine the program for best results.

A volunteer with PIH/CES uses an Android tablet to interview a mother in Chiapas about her health. Photo: Patrick Elliott/Partners In Health

Rose Kaliwo was too weak to walk when she arrived at Neno District Hospital in rural southwestern Malawi. It was the end of December 2012, and the 50-year-old mother of nine who spent most of her days selling rice in a nearby market was vomiting and had a high fever with stomach pain.

Clinicians with Abwenzi Pa Za Umoyo (APZU), PIH’s Malawian sister organization, collected a sputum sample from Kaliwo to test for tuberculosis. It was the most likely diagnosis given that in Malawi, as in many countries in southern Africa, the burden of TB is daunting. The World Health Organization estimates that 163 of every 100,000 people in Malawi will become sickened with TB each year. In the U.S., for comparison, it’s estimated that 3.2 of every 100,000 people are annually sickened with the ancient scourge.

But as the lab staff inspected the small amount of mucus from Kaliwo’s lungs under a microscope, they found no indication of TB. They tested her for HIV, and that initially came back negative, too.  Clinical Officer Bright Mailosi started her on antibiotics and, with the help of his team, monitored Kaliwo around the clock. They treated her for chronic gastritis due to Helicobacter pylori, a bacterium in the stomach. Things didn’t get better, though. She continued to shed pounds. Her pain persisted.

“The clinicians were trying their best,” Kaliwo recalls.  “And though no one knew what I had at first, they weren't willing to give up on me.”

Despite the negative test results, Mailosi couldn’t shake the hunch that TB, an ailment that kills more than 1 million people every year, was devouring the patient.

It wasn't the health system that almost failed her—she'd received a great deal of medical attention from the team in Neno—but rather diagnostic algorithms that have long failed people with atypical presentations of TB.

In February 2013, a few weeks after Kaliwo was admitted, PIH Co-founder Dr. Paul Farmer visited Neno District Hospital. Kaliwo’s gaunt frame was tucked under a thin yellow blanket. “Her lung exam was unremarkable: the symptoms were mostly localized to her gastrointestinal tract and by the time I saw her she was wasted away to half her body weight and dying,” Farmer says. “She was also very anemic.” 

Farmer sat on her bed and struck up a conversation with Kaliwo and the nearby APZU clinicians, including Mailosi. Together they ran through the history of her illness and attempts at treatment. After a short while, Farmer seconded Mailosi’s original suspicion—that TB was the culprit. The challenge was that Kaliwo had extrapulmonary TB and the bacteria were confined to her gastrointestinal tract, not her lungs. It would be impossible for anyone to properly diagnose her from the sputum sample.

“International guidelines for TB diagnosis are still fixated on smear-positive pulmonary TB, which by definition misses cases like Mrs. Kaliwo’s. We need better diagnostics, and have for a century, but we also need this to be our default diagnosis for patients with wasting or consumptive disease and few localizing signs,” Farmer says. “It wasn't the health system that almost failed her—she'd received a great deal of medical attention from the team in Neno—but rather diagnostic algorithms that have long failed people with atypical presentations of TB.”

In Malawi, extrapulmonary TB comprises nearly a quarter of all TB cases. 

A recent image of Rose Kaliwo, who has returned to selling rice in a nearby market and is helping educate community members about the risk of TB and HIV. Photo: Emily Wroe/Partners In Health.

The APZU team started Kaliwo on a standard TB treatment regimen. Then Mailosi and his team ordered additional HIV tests because they knew the TB and HIV co-infection rate is high in Malawi. After additional tests showed that Kaliwo was HIV-positive, she was immediately placed on antiretroviral therapy (ART).

Within a few weeks, her turnaround was discernible—she gained weight, her eyes appeared rejuvenated, and she was no longer perpetually fatigued. Kaliwo was discharged from the hospital soon after, given nutritional assistance, and assigned a village health worker who visited on a daily basis to ensure she was doing well and not suffering from the all-too-common and potentially severe side effects associated with TB drugs.

“There's nothing, alas, unusual about Rose Kaliwo's course—until after she was diagnosed. Then things changed, and for the better, since her care was soon delivered at home and through a community-based delivery platform, with nutritional assistance,” Farmer says. “That's why she's doubled her body weight: right diagnosis, right meds, right delivery platform.”

Kaliwo is back to selling rice in the market and taking care of her family. She’s also taken on a new role—that of an expert patient who’s working with APZU to help inform community members of the risks extrapulmonary TB poses.

By meeting with small groups and sharing her story, Kaliwo is helping the residents of Neno realize that a headache or fatigue or stomach ache—not only a cough—could be a sign that they have tuberculosis and need treatment.