It’s been fifteen months since cholera was detected in Haiti. Today it is the largest cholera epidemic in the world.

PIH's Dr. Ralph Ternier told emphasized that the international community must remain vigilant in the fight against cholera.

More than 7,000 people have died from cholera, and over 500,000 Haitians – roughly 5% of the country’s total population – have been diagnosed with the disease. Although cholera is preventable and treatable, resources for controlling it have not kept pace with the expansion of the epidemic.

From January 23-25, dozens of members of the Haiti Advocacy Working Group (HAWG) – a collaboration of human rights and social justice organizations working with U.S. Congressional allies – are meeting to assess reconstruction efforts in post-earthquake Haiti.

As part of these conversations, a panel of cholera and health policy experts – including PIH’s Director of Policy and Advocacy Donna Barry and Director of Community Health in Haiti Dr. Ralph Ternier – met in the U.S. House of Representatives Rayburn Office Building to discuss strategies for refocusing aid as thousands of Haitians continue to contract the disease.

The HAWG cholera panel was sponsored by U.S. Representatives Barbara Lee, Yvette Clarke, Donald Payne, Frederica Wilson, and Maxine Waters. Introductory remarks were given by Ambassador Eric Goosby, United States Global AIDS Coordinator. Panelists included: Dr. Jon Andrus, Deputy Director of the Pan American Health Organization; Dr. Jordan Tappero, Director, Health Systems Reconstruction Office, Center for Global Health; and, Dr. Mark Weisbrot, Co-Director for the Center for Economic Policy Research.

PIH’s representatives came with a clear message. Efforts to combat cholera should be redoubled with a focus on working with the Government of Haiti and local partners to:

• Strengthen water and sanitation infrastructure:  The international cholera response must prioritize major investments in Haitian-developed plans for improving access to safe drinking water and sanitation.

• Identify and treat all those with cholera symptoms:  Resources are needed to train and retain public health workers and equip them with the supplies necessary for aggressive case finding and treatment.

• Roll out a safe, affordable, and effective cholera vaccine:  Under the leadership of the Ministry of Health in Haiti, PIH and GHESKIO are rolling out a cholera vaccination campaign as part of a comprehensive approach to slowing cholera in Haiti.

• Strengthen Haiti’s public health system:  Rather than creating private, parallel systems that drain resources from the public sector, NGOs should work with the Government of Haiti to make comprehensive medical care affordable and accessible for all Haitians. 

• Improve effectiveness of foreign assistance to Haiti:  Foreign assistance, if rooted in human rights and aid effectiveness principles, can save lives and strengthen local government approaches to breaking the cycle of disease and poverty.

Download PIH’s Cholera Advocacy Recommendations (PDF).
Download the Haiti Advocacy Working Group’s three-day schedule (PDF).

Thousands of patients served during Butaro Hospital's first year. Facility shows health care can be provided at a world-class level, even in poor, remote communities.

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By Aubrey Davis, PIH/IMB External Relations Coordinator, Rwanda

There’s something electric in the air around Butaro Hospital. It sizzles through the bustling wards, around the angular, elegant buildings, down the hospital’s mountaintop perch, and flows into the spectacular backdrop of northern Rwanda’s hills and valleys. The buildings themselves buzz with the sounds of lab coats swishing down the portico halls, oxygen pumping from the walls in the wards, and lights humming in the operating rooms.

But the doctors and nurses here don’t dwell for too long on the buzz; there’s too much work to be done. Since the hospital opened one year ago on January 24, 2011, PIH and the Rwandan Government have worked closely together to provide health care at a level never seen before in any part of rural East Africa. And word of the state-of-the-art facility has spread—heavy streams of patients began arriving from far and wide since Butaro officially opened its doors. In its first month, the hospital admitted 266 inpatients, completed 64 deliveries, and tested 308 people for HIV.

	Inside a ward at Butaro Hospital. ©Matthieu Zellweger

One year later, the numbers have continued to grow. Butaro hospital staff has seen 16,638 outpatients and 7,206 inpatients suffering from conditions ranging from malaria, TB, and pneumonia to broken bones, burns, and a variety of cancers. Impressively, 941 women have given birth at Butaro Hospital, 416 of those being Caesarian deliveries, and with only a single maternal death. That’s no small feat when one considers that most of the deliveries that take place at the hospital are high-risk or involve complications—women who have routine deliveries almost always give birth at one of the district’s 15 health centers.

The Road to Butaro

In 2008, the Burera District in the Northern Province of Rwanda was the only district in the country without a functioning district hospital, and it suffered from the worst health indicators in the country. In fact, there was one doctor in the district for a population of more than 320,000 people.

PIH’s Rwandan sister organization Inshuti Mu Buzima (which means “Partners In Health” in the local language of Kinyarwanda), had been producing impressive results in the rural Eastern Province since 2005 by fostering a strong partnership with the Rwandan Ministry of Health to improve the entire district health system. Based on this relationship, the Ministry asked Inshuti Mu Buzima (IMB) to spread its operations to the Northern Province, and IMB agreed to build a world class public hospital on a hilltop in the village of Butaro in Burera District.

Construction began in 2009 after careful planning from a partnership including PIH/IMB, the Rwandan Ministry of Health, and MASS Design Group, the social justice architecture firm. Most materials were chosen from local sources, such as the volcanic stones that beautify the exterior of the buildings. Drawing on 25 years of experience in hospital construction, PIH/IMB saved millions of dollars by engaging the local community to build the hospital in what was a massive act of umuganda, or community service. In total, 3,500 jobs were created for local workers, and invaluable skills were transferred that are still in high demand today. Reflecting on the construction and design process, PIH co-founder Dr. Paul Farmer says, “The architecture here responds to real problems, and does so in creative and efficient ways.” 

	Rwandan President Paul Kagame cuts the ribbon to officially open Butaro Hospital. ©Adam Amoroso

The hospital construction was complete in December 2010, and on January 24, 2011 it was inaugurated; Rwandan President Paul Kagame cut the ribbon himself.

"Overseeing the construction of Butaro Hospital was a great innovative experience,” reflects Emmanuel Kamanzi, the District Project Manager for the PIH/IMB. He adds that construction was only one part of the overall goal. “Keeping it functioning to achieve its vision of serving as a model in providing high quality medical care and a center of excellence in medical education is greater one. We will make efforts to make the function follow its form."

Redefining the expectations for health care in poor, rural communities

Today, Butaro Hospital provides more than basic medical needs. Thirteen doctors, 96 nurses, and 37 paramedical and administrative staff offer services that eclipse the standards of healthcare for this region, proving that world-class facilities can and do work, even in the most remote corners of the world. Every day, IMB redefines the limits of what a rural African hospital can do, while striving to help the Rwandan Ministry of Health meet their ambitious goals for their country.

For patients at Butaro, miracles seem to happen every day. While these “miracles” would be routine acts of care at a Western hospital, such routine care simply did not exist in this area. Three examples include the hospital’s surgical, neonatal care, and mental health programs.

	Dr. Josh Lamb with Rwandan colleagues Dr. Thotho Kolombo, Dr. Eric Rutaganda, and nurse Kamanzi Elia, repairing a femur fracture in an operating room at Butaro Hospital.
	The Neonatal Special Care Unit at Butaro Hospital.

Butaro’s surgical program has performed a staggering 636 surgical procedures since opening its two operating rooms. Dr. Thotho Kolombo, a general practitioner who focuses on surgery, has taken on the lion’s share of surgical responsibilities. And in October, the hospital’s first full-time orthopedic surgeon, Dr. Josh Lamb, and anesthesiologist Dr. Emily Nelson, arrived at Butaro. Between the three of them, they have treated conditions including uterine ruptures in pregnant women, cancers, skin infections, burns, and broken bones. In addition, these clinicians are helping to provide surgical and anesthesiology training for a team of Rwandan doctors and nurses, which will help ensure that in the long term, surgical care will be available for Rwandans by Rwandans.

“Many of our patients cannot travel to the capital for health care, so we are trying to create a system that can effectively care for patients who present with surgical emergencies,” says Dr. Nelson. “This process will take years, not months, but we are beginning to see improvements in the surgical services we can safely provide at Butaro Hospital.”

In April 2011, the Neonatal Special Care Unit opened. Since then, a team of doctors, eight specially trained nurses, and a row of incubators have treated 230 premature and severely sick infants weighing as little as 1.2 kg and as young as 29 weeks. Without access to these advanced medical services, nearly all of these babies would likely have died.

Caring for patients with mental health disorders has become a focus over the past year. With the arrival of PIH’s first psychiatrist in Rwanda, the district physicians and mental health staff have worked diligently to care for patients with mental disorders at Butaro, consistent with the Ministry of Health’s goal to decentralize psychiatric services rather than transfer patients three hours away from their families to the neuropsychiatric hospital in Kigali.

Partnerships key to addressing new challenges

And while there is much to be celebrated on the one-year anniversary, there is much more left to be done. Despite improvements in the quality of care at the community and district levels, chronic malnutrition persists. Despite a nearly 60 percent drop in child mortality, newborn deaths remain unacceptably high. And as life expectancy has increased for the community, more patients are being diagnosed with non-communicable diseases (NCDs) like hypertension and cancer. Preventing, treating, and curing NCDs on a wide scale is a new challenge to the country and the continent that will require resources, both financial and human, and new protocols and policies across the board.

	A view of Butaro Hospital. ©Iwan Baan

Partnerships will be a key to addressing these challenges. An exciting new partnership with the Jeff Gordon Children’s Foundation (JGCF), the Dana Farber Cancer Institute, and the Ministry of Health, will open Rwanda’s first cancer referral center at Butaro later this year, bringing world-class oncology care to the rural poor in Rwanda. The Butaro Center of Excellence in Cancer Care will feature an on-site pathology lab, an intensive care unit, surgical services, chemotherapeutic medications, and committed clinicians.

Partnerships will also be vital in working to reduce newborn deaths and improve neonatology care. In consultation with PIH/IMB and Children’s Hospital Boston, the Ministry of Health has designed national neonatal care protocols that draw on lessons learned from PIH/IMB’s neonatal programs. As part of the Ministry of Health plans, PIH/IMB’s facilities will become national models for neonatal care, and will train neonatal care providers and continue to develop innovative care strategies that reach beyond the hospital’s walls into the health centers and community.

PIH/IMB’s close partnership with the Rwandan Ministry of Health will be crucial to increasing and improving the services offered at Butaro Hospital. Impressively, the Government of Rwanda now contributes 48 percent of the hospital’s operating costs, which this year total $3.1 million. “The Republic of Rwanda has been the best of all partners: heavily engaged in every step of the way and assuming responsibility for Butaro’s maintenance and management,” says Dr. Farmer.

Underscoring all these new efforts is PIH/IMB’s mission to uphold the dignity of each patient. “My wish for the year ahead is to reach not only the expectations of our patients, but to reach their rights,” says Dr. Joel Mubiligi, District Clinical Director. “I want this hospital to be the example not only in terms of equipment capacity, innovations, and quality of services, but also in terms of caregiver-patient relationships in order to treat not only their bodies, but all their being, and to make a real change in their lives.”

These achievements of the past year and goals for the next do more than help heal patients. They show the community, the country, the region, and the rest of the world that superior care can and should be delivered not only in the West or in cities, but wherever there are sick people without access to care. In the poorest, most remote corners of the world, world-class health facilities can and do work.

Butaro Hospital at dusk. ©Iwan Baan

Watch CNN news coverage of Butaro Hospital.

Watch a video of PIH co-founder Dr. Paul Farmer discussing Butaro Hospital.

Partners In Health is proud to announce the launch of its new Fellowship Training Program, which offers specialized training to healthcare professionals in the field of multidrug-resistant tuberculosis (MDR-TB). When launched in mid-2012, the project will host trainings for MDR-TB care providers in Russia (Tomsk), Lesotho and Peru (Lima) through an exciting new project run in cooperation with the Tuberculosis CARE project, TBCARE II, and the United States Agency for International Development (USAID).

PIH’s work over the past 15 years has proven that patients living in resource-poor settings can be effectively treated for MDR-TB with innovative, community-based programs. From saving thousands of lives to participating in the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, PIH has established itself as a leader in the treatment of MDR-TB. In 1996, the organization launched a first-of-its-kind direct observation therapy (DOTS-Plus) project for MDR-TB patients in Lima, Peru. Since then, those lessons have been tailored and refined as we've expanded our MDR-TB work to Russia, Lesotho and Kazakhstan.

The FTP program aims to train clinicians dedicated to providing first world care to people living in poor and underserved regions of the world. Fellows participating in the training program will gain hands-on experience as they train to become the next generation of MDR-TB specialists.

To apply for the Russian MDR-TB fellowships click here (English) or here (Russian). To apply for the Peruvian fellowship click here (English) and here (Spanish). Applications are due March 1, 2012.

Learn more about PIH’s work fighting tuberculosis.

A group of international health experts – including Dr. Giuseppe Raviola, Partners In Health’s Director of Mental Health – has called for a special session of the United Nations to focus global attention on mental, neurological and substance use disorders. The proposed meeting would allow experts and policymakers to find ways to improve access to care, promote human rights and strengthen prevention and treatment services for people living with mental health issues, especially in developing countries.

Writing in the January 2012 issue of PLoS Medicine, the health experts say: “The time has come for recognition at the highest levels of global development, namely the UN General Assembly, of the urgent need for a global strategy to address the global burden of MNS disorders.” 

Mental, neurological and substance use disorders (MNS disorders) are leading contributors to the global burden of disease and profoundly impact the social and economic well-being of individuals and communities around the world. Yet the majority of people affected by MNS disorders lack access to treatment, even worse many experience discrimination and abuses because of their illness.

The authors outline three broad areas of action needed globally:

1. Enhancing access to treatment of MNS disorders
2. Ensuring that people living with mental health disabilities have full access to their basic rights and live a life with dignity
3. Expanding knowledge about MNS disorders

“Securing the commitment of a majority of governments for a UNGASS will require a concerted effort from the diverse group of stakeholders concerned with MNS disorders,” say the authors. They advocate for a ‘‘People’s Charter for Mental Health’’ which would be “developed in consultation with the organizations from 96 countries who have signed up to the ‘Great Push’ initiative so far, representing over one million people including consumers, family members, advocates, researchers, professional organizations, and policy makers.”

Beyond advocating for changes in mental health policy and funding, for more than 10 years PIH has run exactly these types of programs in many of its health centers, specifically in Haiti, Peru and Rwanda – countries affected by various natural, pathological and man-made disasters. Addressing the mental health needs of those people who’ve experienced traumatic events is a crucial component of recovery.

PIH reaffirmed this belief by quickly ramping up psychosocial and mental health programs in Haiti after the 2010 earthquake. Since that event, PIH’s mental health and psychosocial services team has provided direct services to more than 25,000 adults and children in Port-au-Prince and throughout central Haiti.

Read “A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come”

The Women and Girls Initiative Scholarship Program sends 41 young women and girls back to school in rural Rwanda.

Some of the recipients of a new scholarship for young women and girls in Rwanda.

By Grace K. Ryan, Department of Community Health and Social Development, Partners In Health/Inshuti Mu Buzima Rwanda

The “New Life” club is starting to live up to its name, according to Marie*, age 18, an orphan and unwed mother from the Nyamirama sector of Eastern Rwanda. Next week, she and 40 other at-risk girls ages 12 to 19 from her sector will be starting school for the first time in years, formally launching the Women and Girls Initiative scholarship program.

The Women and Girls Initiative was founded in 2009 by Didi Bertrand-Farmer, Director of Community Health and Social Development at Partners In Health’s Rwandan sister organization, Inshuti Mu Buzima (IMB). “The objective,” Ms. Bertrand-Farmer says, “is to produce girls who are independent, who have access to information so that they can make healthy decisions about their lives.” With the help of local authorities, health center staff, and representatives from IMB, over 120 out-of-school girls in Nyamirama sector were organized into six clubs, including “New Life.” These clubs meet weekly to discuss health and reproductive issues, offering peer-to-peer psychosocial support and a platform for health outreach programs organized through the health center.

“But this is only the beginning,” says Ms. Bertrand-Farmer. “We want to eliminate barriers to education for these girls and ensure their economic independence.” IMB is currently seeking partnerships with local and international organizations experienced in vocational training, micro-finance, and women’s cooperatives, in order to empower the girls economically. In the meantime, the clubs have identified 41 members who are ready to complete their education. These girls will receive school fee support, uniforms, sanitary products, and other necessary materials to continue their schooling.

“Educating a girl is important,” explains Marie, “because a girl who can go to school can find work and money for her future. Otherwise she will look to a man to give her money.” These are not empty words.

After the traffic accident that killed both of her parents ten years ago, Marie was adopted by a single mother of seven, named Therèse. Now in her fifties and often in poor health, Therèse struggles to provide for her family as a farmer. Two years ago, she realized she could no longer afford her children’s school fees. Marie was forced to drop out of secondary school, and became pregnant not long afterward.

The links between health, poverty, and education are palpable in the stories of girls like Marie, who show not only remarkable resilience, but also creativity in the face of adversity. Another scholarship beneficiary, Lucille, also age 18, describes a special support system her club has developed. Each of the 20 members tries to bring 100 Rwandan Francs (about 17 cents) to their meetings, to be pooled together and donated to a different girl each week. With the 2,000 francs ($3.30) collected, she can buy hygiene and sanitary products. “So we don’t rely on men,” Lucille explains.

In the Rwandan health system, community health workers are responsible for pregnant women, infants, and children up to age five, but adolescents must rely on school programs for health education. Girls who cannot afford school fees are not only economically vulnerable, they are also lost to the health system until they become pregnant—which is often all too soon. With limited access to the cash economy, girls struggling to make ends meet in rural communities may leverage their romantic relationships in order to survive. They may not fully understand the potential consequences—a teenage pregnancy or sexually transmitted infection—or how to protect themselves.

Girls in Nyamirama are particularly vulnerable. The sector was hard hit by Rwanda’s 1994 genocide, leaving a rash of HIV-infection and many child-headed households in its wake. Of the girls who will be returning to school next week, 10 percent are orphans, and a further 68 percent have only one living parent. Among those girls who do have two living parents, 33 percent have at least one parent who is incapacitated by illness or disability. Many of the girls themselves bear the scars of conflict, including Lucille, who was wounded in the leg as an infant during the genocide.

When asked if she might have become pregnant even if she had been enrolled in school over the past two years, Marie responds with a firm “No,” adding, “It’s time to change ideas.” She plans to take advantage of this educational opportunity to pursue a career as a deputy in local government, so that she can help development in her sector move forward, even as she helps herself, her baby daughter, and her adopted family.

As Partners In Health Co-Founder Dr. Paul Farmer writes, “You will never break the cycle of poverty or disease without educating girls.” For the girls of the Nyamirama Women and Girls Initiative, scholarships are a humble first step.

*The names of the participants have been changed to protect their privacy.

"PIH/IMB staff and partners from Nyamirama Health Center and local government, with scholarship recipients and their parents.

The model and activist pens a 5 part series in the Huffington Post.

Model, entrepreneur, and activist Christy Turlington Burns recently blogged about her recent visit to PIH's partner organization in Haiti, Zanmi Lasante (ZL). In a series of five articles published by the Huffington Post, she and Every Mother Counts Executive Director Erin Thornton examined different aspects of PIH and ZL's work. Below is an excerpt of part three of the series, “Give a Wo(man) a Fish... Or a Farm... Or Both.” 

According to a well-known Chinese proverb, we are told: "Give a man a fish, you feed him for a day. Teach a man to fish and you feed him for a lifetime." 

While this expression is arguably used too often within the developmental world and humanitarian aid communities, Zanmi Lasante, a sister organization to Partners in Health, has given this phrase a new meaning; one that will provide post-earthquake Haiti with self-reliant foundations for their future health and survival.

PIH has placed an emphasis on fostering a sustainable and self-sufficient system of food production in order to better treat ongoing issues of poor nutrition, as well as to further the progress of economic empowerment.

In other words, PIH isn't just teaching fishing to the Haitian people, they are bringing in tools and equipment, and are cultivating new grounds for lasting success. Even a seemingly modest operation, such as then new Lacheteau Fish farm, could be a real game-changer in a region where malnutrition is abundant and sources of protein are few and far between.

Here the goal is not only to increase food for local farmers themselves, but also to encourage those farmers to sell their fish to local clinics to both feed patients and to stimulate sales on the local market. More proceeds will also help those farmers to better feed their families and yield a higher quality of health overall.

Read “Give a Wo(man) a Fish... Or a Farm... Or Both” in its entirety, and check out the rest of the series:
Part 1: "All People Are People (Tout Moun Se Moun)"
Part 2: "Every Mother Is a Mother (Chak Manman Se Yon Manman)"
Part 4: "Effective Service Delivery: Accompaniment"
Part 5: "The Future for Haiti: Building Back Better" 

Photos of Zanmi Lasante's work to fight malnutrition and help local families produce food to feed and support their families:

On Saturday, January 21, the CBS Evening News's Jon LaPook sat down with Dr. Paul Farmer, PIH’s cofounder, in the new Mirebalais National Teaching Hospital, the state-of-the-art medical complex being built by PIH and Haiti’s Ministry of Health. 

Learn more about Mirebalais Hospital.
Watch CBS’s story about Mirebalais Hospital.

Rapid recoveries are becoming common at a new Nutritional Rehabilitation Unit in Malawi.

By Robbie Flick, Health Programs Coordinator, Malawi

Two-year-old Rachel Namazongo has just started to grow her first strands of hair. Giggling, she eagerly munches on a piece of bread with an appetite that didn’t exist just a few weeks ago.

Blessings Banda, the HIV and Nutrition Manager for PIH’s sister organization in Malawi, APZU, recalled Rachel’s condition when she first came to a children’s clinic in the village of Ligowe in the rural southwestern corner of the country. Listless and with sunken eyes, the toddler was dehydrated and severely malnourished. The circumference of her upper arm, a standard method of assessing the nutritional status of children, was less than 9 centimeters — about the circumference of a plastic bottle cap. At this acute stage of malnutrition, she was so sick that she did not want to eat, said Banda. Her mother was frightened.

Clinicians from APZU and the Malawian Ministry of Health saw that Rachel needed immediate medical care, and quickly transported her to Neno District Hospital for admission into the new Nutritional Rehabilitation Unit (NRU).

A complex battery of health issues most likely contributed to the young girl’s malnutrition. She was treated for parasites and given antibiotics to help fight other possible infections. She was also diagnosed with HIV, and quickly began a course of life-saving antiretroviral therapy (ART). The medication soon helped spark a renewed appetite, said Banda. And the NRU staff was well-equipped to provide her with food specially formulated to combat her condition.

	Rachel one week after being discharged from the Nutritional Rehabilitation Unit, with Blessings Banda, HIV and Nutrition Manager for APZU.

Every day, she ate packets of a special calorie-rich therapeutic food. Thanks to partnerships with UNICEF and Two Degrees Food, APZU has access to a peanut-based therapeutic formula for treating malnourished patients. The special calorie-rich product quickly helped put weight onto her small frame. After just two weeks of the intensive therapy, which also included drinking a daily concoction of nutrients, Rachel was well enough to return home. As an enrolled patient in APZU’s outpatient nutrition program, she is provided with food packets from our partners and other food supplies to help prevent malnutrition from returning, reported Banda. She will also continue to receive ART for the rest of her life.

Rachel is one of more than 30 children who are enjoying healthy childhoods thanks to the lifesaving care provided by the NRU since it opened in May. The space — with its walls of colorful, hand-painted cartoon animals and hanging dioramas of repurposed plastic — allows clinicians at PIH to provide a full spectrum of care for acutely malnourished children, from treatment of underlying infections like HIV and malaria, to a balanced food regimen that allows rapid recovery. Because of the NRU, a child like Rachel can quickly recover from a critical state, and begin living a healthy childhood in just two weeks.

“Malnutrition is really the most common cause of death in children under 5 around the world,” says PIH Chief Medical Officer Joia Mukherjee. “You have to treat this as a medical emergency.”

Across the world, a staggering 200 million children suffer from malnutrition. This debilitating condition is the lurking giant behind some of the world’s greatest killers – from malaria to dehydration – and is indirectly responsible for the death of some 6 million children each year. In young children the effects of malnutrition are magnified, and if untreated, cause life-long debilitating conditions that can be passed on to future generations.

“Although it’s a massive problem, it’s also a treatable problem,” adds Dr. Mukherjee. Two Degrees Food is partnering with Partners In Health to address malnutrition in developing countries by selling all natural food bars in the US.

“For every bar we sell in the United States, we give a medically formulated nutrition pack to a malnourished child in Africa,” says Two Degrees Co-founder and CEO Lauren Walters. “Our aim at Two Degrees is to give away millions of nutrition packs.” These nutrition packs, known as ready-to-use-therapeutic foods (RUTF), have been shown to be up to 95% effective at completely curing severe acute malnutrition in children. 

The Two Degrees model relies on partnerships with global development groups working to alleviate malnutrition in communities all over the world, and Partners In Health was the first of these partners. So far, the partnership has provided 21,600 RUTF treatment packs to malnourished children in Malawi, and is expected to expand to PIH’s projects in Rwanda, Lesotho, and Haiti in the coming months.

Two Degrees bars are available at Whole Foods Stores nationally. Find your local retailer and learn more about Two Degrees at http://www.twodegreesfood.com.

On Saturday, January 14, CBS Evening News featured a story about an agricultural initiative that will create new jobs and help treat malnourished children in Haiti’s Central Plateau. A partnership between Partners In Health and Abbott Laboratories is building a manufacturing plant which, when completed in late 2012, will increase PIH’s production of Nourimanba – a therapeutic peanut-based product used to fight malnutrition – more than ten-fold.

As CBS’s Maurice Dubois notes in his story, this new venture will employ local Haitians, expand PIH’s existing sustainable agricultural system, and, most importantly, offer life-saving nutrition to thousands of under-nourished children.

Fighting childhood malnutrition in Haiti

While PIH first began producing Nourmanba and Nourimil – a second therapeutic supplement made from beans – in 2006, efforts were quickly ramped up after the 2010 earthquake. In the first 18 months after that devastating event, Zanmi Agrikol (ZA), PIH’s agricultural sister organization in Haiti, produced more than 570,000 pounds – nearly 260 tons – of nutritional supplement. This effort brought food to tens of thousands of Haitian children.

The UN estimates that 1.5 million children and young people under the age of 18 were affected by the 2010 earthquake, nearly a half-million of whom were under the age of five. At least 300,000 young people were forced from their homes, with hundreds of thousands ending up in the settlement camps located in and around the capital city of Port-au-Prince. Too many of these young people still lack consistent access to nutritious foods. 

Even before that event, Haiti was already suffering from widespread malnutrition. In late 2009, the UN estimated that one in four children had stunted growth, with an estimated 2.2 percent of children under the age of five suffering severe acute malnutrition.

Cultivating an economic recovery 

Today, ZA’s farms employ 46 farmers and 72 day laborers. Beyond its own farms, ZA supports 300 farming families throughout the Central Plateau in running their own farms. Families receive seeds, the use of a tractor, and a guaranteed market price in exchange for growing crops of peanuts for Nourimanba. 

As construction begins on the new manufacturing plant, ZA is working to expand its agricultural programs. To meet this need, ZA is enrolling 1,240 families in its family assistance program, which provides seeds, training, and support to aid the families in establishing farms that will support both the production of Nourimanba and food for local communities.

In November, the New York Times profiled the PIH and Abbott Laboratories partnership and the building of a new Nourimanba factory.
Learn more about PIH’s Zanmi Agrikol program.

PIH co-founder Paul Farmer reflects on Mirebalais and meliorism.

Haiti: Two years later

	PIH co-founder Paul Farmer
	Download a PDF of "Two Years After the Quake." Part 1: Haiti: Two years later Part 2: Three resources Part 3: PIH 3.0: Looking ahead Part 4: Curbing cholera Part 5: Existing work, new projects

I’ve just returned from two brief trips to Haiti. Conditions there are harsh, but improving, and that’s cause for some joy. I wish to translate my own uplift into a New Year’s message of gratitude and determination. Because the backdrop is admittedly stark, it’s only fair to acknowledge the possibility that I am writing this to give myself hope and to spur all of us to launch, continue, or finish some ambitious and urgently needed projects.

You know the phrase: hope is not a plan. But hope is, in our line of work, a necessary ingredient and sometimes the “secret sauce.” My time in Mirebalais, Cange, and Saint-Marc, our meetings with Haitian officials in the tiny trailer that now serves as the office of the country’s leading public health experts, and even yesterday’s commemorations of the two-year anniversary of the quake, gave me hope—hope worth sharing with all those who support a vision of building back better in Haiti. To see, in Mirebalais, a lovely and gleaming hospital and medical campus taking shape across what was once a bit of broken terrain running from steep conical hills down to an unproductive rice paddy—more of a swamp, really—is a stirring image for any visitor.

When complete, the Mirebalais National Teaching Hospital campus will be the largest public hospital in rural Haiti.
Photo by John Chew, PIH

But it’s especially moving for one who remembers, as Partners In Health founders do, our modest and often discouraging beginnings in this very town. The time was 1983, the year that so many of us—Haitian and American and British—met in Mirebalais, the sleepy town where we tried to deliver quality medical services to people in great need of them.

It’s not easy to admit, even today: we tried and mostly failed. Sometimes we succeeded: a patient with acute malaria received chloroquine, a patient with scabies received the right topical medication, another patient’s fractured bone was set with competence and compassion. But if we look back honestly at our first years of hard work and 18-hour days, I’m not at all sure we can claim to have done a good job delivering quality health services. We were delivering something as hard and fast as we could, but surely the quality of the deliverables matters more than the good intentions of the caregivers or the pace of their work.

That was our conclusion when we closed the Mirebalais clinic in 1985 and started anew in Cange. And as we grew, we again faced serious problems of standards of care. Such problems have always been with us—and with all who seek to promote global health equity. We have a long, long way to go before we raise the standard of care to the level that our patients and their families deserve. But in the two years since the earthquake we have all worked hard to give substance to the hope that the quality of care we deliver in Mirebalais might be as good as anywhere else in the world. To make good on that hope, improvement in the quality of training programs and personnel is essential, but it cannot happen without a proper hospital. Put another way, it’s possible to deliver poor-quality medical care in a high-quality facility, but it’s probably not possible to deliver high-quality medical care in a poor-quality facility. After more than 25 years of working in the region, we will, along with our partners, have a first-class hospital there. Our efforts to drag up the standards of care in Mirebalais will benefit, I have no doubt, everywhere we work in Haiti (and many places where we don’t work). If central Haiti or northern Rwanda or rural Malawi or urban Lesotho teach us lessons about hospital construction, shouldn’t we be sharing these lessons with everyone who may be trying to do something similar? This alone would be a good set of New Year’s wishes for 2012.

Three resources

We can entertain such wishes and see them through to fruition as long as we have three kinds of resources. Financial ones, of course. How else could we build (let alone run) a modern hospital in a place where clean water, electricity, and modern infrastructure are all but absent? Modern medical resources, obviously enough. How could we deliver modern medicine without the clinics and hospitals and the tools of the trade—preventives and diagnostics and therapeutics—made readily available to those who need them, regardless of ability to pay? But we also need human resources: well-trained and committed doctors and nurses and managers, and the greatest number of people on our payroll—those who run labs, take x-rays, and deliver services within the homes and villages of our patients, and also those who transport patients and specimens, who service and repair equipment, and who tend to the needs of patients and fellow employees alike.

The human resources challenge is perhaps the biggest one. Rural Haiti has long lacked trained medical professionals; even prior to the 2010 earthquake, most studies of this topic suggest that the majority of Haiti’s physicians and nurses have left the country altogether, and those who remain are concentrated in the capital city. (At the launch of a new family practice residency in Saint-Marc last week, the dean of Haiti’s oldest and largest medical school guessed that 80% of medically trained Haitians now reside outside the country.) The loss of Haiti’s nursing school to the 2010 quake, with heavy damage to other institutions of medical education, has worsened an already tough situation. To this end, we have worked to rebuild the training facilities destroyed during the quake and sought to reopen the UNIFA medical school, largely staffed by Cuban faculty. Just last month, we met with the Cuban Ambassador in Mirebalais. The Cubans have been the leaders in supplying long-term medical volunteers, and all of PIH/ZL’s public sites have benefited from the hard work of our Cuban colleagues. The ambassador committed a substantial number of specialists to help make Mirebalais a site of high-quality specialized medical care.

Dr. Kerline Israel (far left) joins Dean Gladys Prosper and the first six family practice residents at Saint-Marc.
Photo by Franciscka Lucien, PIH

But the long-term goal, as we all agree, is building capacity locally, among young Haitian professionals. The Mirebalais National Teaching Hospital, like the new family practice residency in Saint-Marc (and others to follow), is meant to address this need over the next few years. But addressing problems locally—in a district or two—is never enough: once services are offered to the poor, the entire notion of “catchment area” or “district” falls out the window until the problems are addressed on a national level. This is the great dilemma of every Minister of Health, including our friends Dr. Florence Guillaume and Dr. Agnes Binagwaho in Haiti and Rwanda. They can and do encourage local initiatives, pilots, and real engagements to introduce new programs, but they can and must imagine, or re-imagine, health care delivery at the national level. Think of rural Rwanda or rural Haiti, with plenty of cancer, but zero oncologists. The establishment of “Centers of Excellence” (to use what is, alas, usually an aspirational term) able to deliver even the most basic cancer diagnosis and care lead to a national and even international stampede of patients and family members seeking expert mercy—diagnosis and comfort and cure (or at least care)—for ailments too often declared “untreatable” in poor areas. As was the case with HIV and MDRTB, every scourge that affects predominantly poor people is slated for similarly dismissive assessments from those seeking to carve up a tiny pie. Whether these discussions mark the beginning or the end of efforts to address problems as diverse as leukemia and cholera will depend on the success of efforts like those we’ve launched from hospitals in Peru, Haiti, Lesotho, Malawi, Rwanda, Russia, and elsewhere.

Dr. Florence Guillaume, Haiti’s Minister of Health (in blue dress), plants a tree in front of central Haiti’s first public teaching hospital. Photo by John Chew, PIH

If this is such a noble effort, then why are we inhabited by anxiety? Hospitals, like health centers and community-based care, are needed, but they are larger, more expensive, more complex institutions to run. Our survival and growth depend on a massive bolus of new support. The complexity of hospital-based care is one of the reasons that global public health, and public health in general, starts with the low-hanging fruit. Low cost, high return: that’s why we’re always pushing bednets, vaccines, family planning, prenatal care, handwashing, and latrines. We will continue to cull the low-hanging fruit as best we can.

But the other ranking health problems, the higher-hanging fruit—from AIDS to drug-resistant tuberculosis to trauma to mental illness to cancer—cannot simply be wished away by the gurus of cost-effectiveness (the ones with the tiny pies). The low-hanging fruit hangs, after all, under a larger canopy of fruit. Do the models now dominant in global health permit us to harvest the higher-hanging fruit, from chronic non-communicable disease to new and explosive epidemics such as cholera in Haiti? Can we answer more of the need.

The short answer: of course we can, with innovation and resolve and a bolder vision than has been registered in public health over the past century. And that bold vision has a name: global health equity.

Some of you will remember PIH’s first mission statement, written 25 years ago. We pledged to link the vast resources of U.S. academic medical centers to the problems (many of them of the low-hanging varieties) of the destitute sick. Hence our most recent flagship project, a national teaching hospital in rural, central Haiti. All of our flagship projects, and indeed all of our work, should spring from our bedrock vision of global health equity. For example, the ambitious project we are seeking to launch with the Rwandan Ministry of Health draws on academic medical centers at Harvard and 16 other universities to train a generation of specialized doctors and nurses. The health centers and hospitals they staff will provide the sort of care that would be considered routine—mundane—in any community hospital in the United States, while simultaneously training large numbers of future health providers. The difficult, bracing, and promising integration of service and training and research is the heart of our history and the compass of our future.

PIH 3.0: Looking ahead

How might we best sustain our work over the next 25 years? What might PIH 3.0 look like? More correctly, what is Partnership 3.0?  Although there’s not always full agreement about the notion of a “flagship” project, there is full agreement that our efforts are meant to improve the quality of services and grow from the principle of partnership. Sometimes, these are partnerships among service providers, teachers, and researchers—the original notion of “three pillars.” Always they are partnerships among people from very different backgrounds (within one country or across many). Sometimes the partnerships link different sorts of medical expertise (surgical, medical, psychiatric, and so on). Sometimes they bring together people who design and build hospitals—Ann Clark and Nicholas Clark Architects and Jim Ansara has guided us since the early planning stages—with those who know how to power them with renewable energy or link them to the information grid. (Building a first-class hospital in central Haiti would have been unthinkable without skilled labor from the Dominican Republic, Ireland, the union halls of New England, Ann Clark and Nicholas Clark Architects, Brigham and Women’s Hospital, and most of all, from Haiti.) Sometimes partnerships match expert managers and logisticians with those who seek to learn such skills. Always they depend on a broad and durable set of supporters, like the many individuals and organizations that have made generous in-kind and cash donations to our efforts in Mirebalais. (Marjorie Benton has helped us build new networks of support.) Above all, such partnerships link those who can serve with those who need services—and seek to bring the latter group into the former. That’s our “sustainability model.”

Dr. David Walton of PIH and Brigham and Women’s Hospital, project director of Mirebalais’ new teaching hospital, addresses press and supporters after January 10 walkthrough.
Photo by Ulysse Toussaint, Professionals for Higher Education Entrepreneurship & Leadership

Why isn’t this transformative model—which would break the cycle of poverty and disease in part by moving people from “patient” to “provider” and from “needy” to “donor”—more widely embraced? Too often we see competition where partnership and cooperation are needed (and were promised). Too often we are all socialized for scarcity. Take the challenges of opening up rural Haiti’s first public teaching hospital. If key personnel are drawn from one institution in Haiti to help get Mirebalais up and running, the effects will certainly be felt. (Just as there were equally draining, and vociferously discussed, challenges in getting the Butaro Hospital in Rwanda on-line.) In every country in which we’ve worked, one effort or another, or one professional group or another (nurses or community health workers or generalists or lab personnel or residents), has occupied the place of “neglected stepchild” of PIH or Harvard Medical School or Brigham and Women’s Hospital or the global health movement or whatever parent organization is identified. But in our best moments, we the collective know that the term “neglected” applies, always and chiefly, to the poor, whatever their current ailments. We need to remember, over the coming years, that the preferential option for the poor needs not just to inspire but to drive our strategy. What is really neglected? Where are the gaps? Where does the burden of disease fall?

Let me give an example. Less than a decade ago, hardly a penny of aid money was devoted to taking care of people dying from the leading infectious cause of young adult death in the world: HIV disease. Now, AIDS is regarded as “overfunded” while other afflictions of the poor are regarded as somehow pushed to the side because too much money is going into AIDS prevention and care. This is absurd. A month ago I was lucky enough to award Dr. Louise Ivers the American Society of Tropical Medicine and Hygiene’s prestigious Ashford Medal, which was widely discussed within “the NTD community.” NTD stands for “neglected tropical diseases,” but on presenting the award I took the occasion to remind the audience that all diseases that afflict primarily the poor are by definition neglected. The idea that AIDS programs are overfunded is silly, since we have a long way to go before poor people living with AIDS have access to diagnosis and quality care. We’re not even halfway there. And yet, by 2004, when many public health professionals declared that AIDS was over-funded, there were probably almost zero poor people with AIDS—and the great majority of people with AIDS are poor—receiving publicly supported treatment or any meaningful treatment at all. Of course, such claims of overfunding were untrue, especially from the perspective of those living in the poorest parts of Africa or Asia or Latin America.

The reason I’m bringing up this fairly recent history is that we are all—the poor and those who serve them—socialized for scarcity. Some part of our brain assumes that if Mirebalais gets the lion’s share of attention—if it actually becomes a flagship project—then some other effort (Cerca Lasource, say, or Cange or Saint-Marc) must suffer. The same holds for elevating Butaro Hospital in Rwanda or the Tomsk prison in Siberia or one teaching hospital over another, or Malawi projects versus those in Lesotho.

But in our best moments, all of us know that this sort of thinking is wrong-headed. The Mirebalais National Teaching Hospital will not drag down the quality of care in the other settings in which we work, but will rather lift it up. We are so socialized for scarcity that we assume that if we focus on educating doctors we will neglect educating nurses (to say nothing of the other allied health professions, from laboratory technicians to community health workers). That if we focus on cholera vaccination we will neglect water and sanitation. That if we focus on research and teaching, service will suffer—when, again, we know in our best moments that simply adding training and research components to a service project, even one as straightforward as treating acute childhood malnutrition, will improve outcomes. We’ve shown it again and again, and so has every other group taking the trouble to study the impact of research and training on quality of care.

And that’s just talking about what everyone thinks of as health care. But every care provider—nurse or doctor or social worker or community health provider—working on the frontlines of global health knows full well that the great majority of our patients’ clinical problems are directly linked to poverty. Hence PIH-affiliated projects like “A Thousand Jobs for Haiti” or the Fritz Lafontant Vocational School or Zanmi Agrikol or the Nourimanba plant supported by Abbott Laboratories/Abbott Fund or the fish farms in Boucan Carré and Zanmi Beni. Hence scholarly work in Rwanda to try to document collateral benefits that investments in health and education provide for economic development. Hence our peculiar obsession with the efflorescence of hotels, small businesses, beauty shops, and other small enterprises around PIH-affiliated hospitals. Hence our efforts to bring friends like Joey Adler, Denis O’Brien, and Donna Karan to rural Haiti as not just as donors but also as investors looking for businesses that can and will lessen the burden of premature suffering and death among those we serve. The people we serve don’t yet have jobs in the generative sector beyond agriculture. But they will.

Where joblessness is the status quo, building new hospitals and health centers and schools can bring disappointment to some: everyone wants to work there—and usually not because they want a better job, but because they want a job, period. Before joining us, the majority of PIH’s 15,000 employees never held a salaried job in what economists term the “formal sector.” Meaning they’d never earned a salary for their work, as do most of those who will read this. Our colleagues are also socialized for scarcity—the assumption that if someone else gets a job, even someone in their own family, then they will not. This sort of limited-good, zero-sum thinking is to be expected among the poor, but is unacceptable from those who seek to attack poverty. Too many of these experts display a worshipful regard for cost-effectiveness analysis, no matter how banal or unscientific in terms of rigorous assessment of either cost (how big or rigid is the pie, really?) or effectiveness. Too many experts in public health have failed to scrutinize the way that capital, like microbes, moves. Few of us have endured real scarcity or lived on the edge of survival. But for those seeking jobs in Mirebalais and elsewhere in our global network, getting a job is a matter of survival. Turning health care needs into much-needed jobs is sure to be a core principle of Partnership 3.0.

Artist Laurel True and her Mirebalais team putting the finishing touches on one of her beautiful mosaics.
Photo by Rebecca Rollins, PIH

Curbing cholera 

Finally, a word about cholera. With the mission statements of PIH and our closest Harvard affiliates in mind, it was obvious that we needed to mobilize all effective deliverables and pull together all potential partners to prevent a major epidemic in the Americas. We failed to do that, and Haiti now endures the world’s largest cholera epidemic in recent history. Socialization for scarcity in responding to cholera has had the same pernicious effects—pitting water projects against vaccination, one form of treatment against another—I’ve just described. What is needed, rather, as we’ve all argued from the beginning of the epidemic, is an aggressive and integrated approach that might lead in a decade or so to the eradication of a disease previously unknown in Haiti and the Dominican Republic. An integrative approach would help in other cholera hotspots, too. As of this past month, the Haitian Ministry of Health has vocally supported the modest vaccine roll-out that we are doing in concert with them and with GHESKIO, another medical nonprofit that has worked in Haiti for more than two decades. Integrating vaccination into an ambitious water and sanitation effort would surely reduce fatality rates and slow the epidemic. That itself would be a victory. But we also hope to show how this cholera vaccine effort might strengthen the national vaccination program (low-hanging fruit again), and generate new knowledge about how to stop cholera and other vaccine-preventable illnesses across Haiti and elsewhere in the world. We hope to bring down the price of the vaccine and relevant medications, to control all waterborne diseases, and to lead efforts for a global stockpile of vaccine for Haiti and for other cholera-afflicted countries in Asia and Africa.

Judith St. Fort of the American Red Cross speaks about the role of public-private partnerships in rebuilding Haitian institutions after the earthquake (Mirebalais, January 10, 2012).
Photo by Ulysse Toussaint, Professionals for Higher Education Entrepreneurship & Leadership

It’s no accident that the NGOs leading this charge are the very two that link direct service to the poor to training and research; that they are formally affiliated with research universities of global repute; and that they work closely with the Ministry of Health. No one imagines the cholera vaccine initiative will be easy, especially given the need for meticulous monitoring and evaluation and the need to accomplish the basics before the next rainy season in a couple of months. But we can succeed by drawing on the core competencies of PIH—delivering service to the most vulnerable, training others to do so, and improving quality of care through feedback loops—and of its key partners, which include, of course, the MOH, but also community organizations, academic medical centers, and research universities like Dartmouth and Duke.

Existing work, new projects

Building hospitals, starting new training programs, launching a new vaccination effort, and simply keeping other projects going requires more effort and energy when many of us, especially the post-quake Haiti team, are worn down; it requires renewed commitment to working with new partners when we all know how much energy existing partnerships consume. It requires a subtle shift in focus: not so much shrinking our service commitments but growing our training and research efforts in order to continue delivering quality health care. No PIH service project should be unleveraged by formal training programs and research. That’s what our original mission statement, written 25 years ago this year, promised. And it remains a noble goal.

We have always prided ourselves on keeping our operating expenses low. But raising the ambitions of our installations requires spending more on managing them, on recruiting personnel, on designing programs that serve patients.

Finally, none of our ambitious programs should be curbed by the pernicious notion of goodness as a limited commodity. We need to expand the notion of good and the notion of excellence and the idea that one flagship project might raise the aspirations of all of our efforts. The launch of the Mirebalais Hospital will permit us to improve the quality of our infrastructure from Belladère to Saint-Marc. Each of these sites needs significant physical plant improvements, just as our staff needs (and deserves) more continuing education to improve the quality of the services we offer.

On the intellectual and philosophical level, none of this is news. PIH supporter Bob Richardson (husband of another of our greatest supporters, Annie Dillard) has written a wonderful biography of William James, which I’d like to quote in closing:

In one of his talks to teachers he said, “Spinoza long ago wrote in his Ethics that anything that a man can avoid under the notion that it is bad he may also avoid under the notion that something else is good. He who acts habitually sub specie mali, under the negative notion, the notion of the bad, was called a slave by Spinoza. To him who acts habitually under the notion of good he gives the name of freeman. See to it now, I beg you, that you make freemen of your pupils by habituating them to act, whenever possible, under the notion of a good.”

Acting under the notion of good, in places like rural Haiti or Rwanda or Malawi or urban Peru or the United States or Russia, is our task. Acting under the notion of good does not provide us with a ready-made strategic plan for our next 25 years of work. But it does help us to cultivate the hope and optimism—the “meliorism”—that underpins our efforts to improve the quality of our services. And that’s the main thing we need to meet our mission.

January 14, 2012
Mirebalais

Mirebalais National Teaching Hospital at dusk, January 2012.

Though Carmen lost both legs during the earthquake, she never gave up hope. Instead, she became a community health worker, offering guidance and care to others.

An estimated 300,000 people were injured by the massive earthquake that rocked Haiti in 2010. Patients suffering from crush wounds, compound fractures, amputations, and other serious injuries flooded into facilities supported by PIH and its Haitian sister organization Zanmi Lasante (ZL).

To address the special needs of these patients, PIH/ZL launched an ambitious program to provide short- and long-term rehabilitation services. After hiring and training specialized staff, purchasing unique equipment and procuring prosthetics, PIH/ZL was soon providing rehabilitative care to hundreds of patients. This included preparing staff to accompany 136 patients with amputations through a partnership with Hanger International and l’Hôpital Albert Schweitzer. This program is managed by one of the first PIH/ZL patients to receive a prosthetic, Shelove Julmiste.

“Rehabilitation is the indivisible comrade of medical and surgical services in comprehensive trauma care,” says Dr. Koji Nakashima, Director of PIH/ZL’s Rehabilitation Services. “If emergency medical and surgical services save lives, it is rehabilitation services that save livelihoods, transforming dependence into dignified independence. This was clear from the first patients who found themselves alive but wheelchair-bound in a country of boulder-strewn roads and shanty houses clinging to eroded hillsides.”

Over the course of the past two years, PIH/ZL’s staff of clinicians, nurses, rehabilitation technicians and rehabilitation community health workers – some of whom suffered amputations themselves as a result of the earthquake – have delivered care to hundreds of patients throughout central Haiti. This team, led by Dr. Nakashima, Dr. Andree LeRoy, Rehabilitation Program Advisor, and Megan Brock, DPT Rehabilitation Program Coordinator, are developing a community-based, integrated rehabilitation program to serve as a model for and answer to the Haitian Ministry of Health’s call for comprehensive, dignified care for Haitians with disability.

The team currently provides ongoing, daily rehab care in the community to roughly 24 patients. At the same time, they manage the long-term health needs of 136 patients with amputations. In total, the team accommodates 1,500 inpatient encounters and 550 outpatient visits annually. More broadly, PIH/ZL has trained 10 community health workers (CHWs) to provide long-term, daily support (accompaniment) to people with disabilities, including case finding in local, often rural, communities.

PIH/ZL’s program brings hope to those affected by the earthquake, while creating a rehabilitative healthcare initiative long needed in rural Haiti.

Two years after the earthquake, the Rehabilitation Team held a commemorative event with patients – many first seen in the days and weeks after the earthquake – on January 12, 2012.

A long-needed intervention

Even before the earthquake, the majority of Haitians living with physical disabilities lacked access to medical or rehabilitative services.

Like other woman in rural central Haiti, Lelan spends her days taking care of her family – cooking, cleaning, and tending to her children. But for her, having suffered paralysis after contracting spinal tuberculosis, each chore is infinitely more difficult.

She couldn't walk. Instead, she would lie on her back and drag her body across the dirt floor of her family’s small hut. When it rained, the ground turned to mud. Because she could only move about 20 feet at a time, she was literally cut off from her community.

Lelan’s situation was far from unique. In 1989, the Pan-American Health Organization estimated that approximately 7 percent of Haitians – roughly one of every 14 people – was living with a disability. 

And then the earthquake struck.

Post-earthquake estimates suggest that upwards of 300,000 Haitians were injured as a result of that catastrophic event, bringing the total number of Haitians living with disabilities to nearly one million. With fractured bones never set, amputations, spinal cord injuries caused by falling debris, and various other disabilities, thousands of Haitians will require specialized ongoing rehabilitation.

PIH/ZL’s rehab team also has the capacity to work with patients with rehabilitation needs unrelated to the earthquake, including survivors of car accidents and strokes. Functional capacity is also maximized through the provision of rehabilitation equipment. Lelan – the mother suffering from infection-related spinal paralysis – received a specially-designed wheelchair just a few months after the earthquake, the result of a partnership among PIH/ZL, the Walkabout Foundation, and Whirlwind Wheelchair International. With this chair and the strength Lelan gained with therapy, she has now gained the mobility she desperately needed to get around her home. In early 2011, PIH/ZL was able to distribute wheelchairs to 250 other Haitians living with disabilities.

Providing rehabilitative care in rural Haiti

PIH/ZL’s rehab team uses a multidisciplinary, team-based approach to patient care. Once a patient’s needs are understood, a customized team of doctors, nurses, physical therapists, rehabilitation technicians, and community health workers provides each patient with comprehensive, integrated rehabilitation services.

In rural Haiti, Dr. Nakashima (third from right) and a small rehab team meet with a patient living with a disability.

Upon entry into the program, the team works with patients and their families to complete a comprehensive assessment, formulate an individual rehabilitation plan, and teach them about their condition. Each person is assigned a specially-trained rehabilitation CHW at the onset of his or her therapy, who provides continuity across inpatient, outpatient, and community care.

While CHWs meet with patients on a regular, often daily basis, an interdisciplinary mobile rehabilitation team also regularly travels to each patient’s home to provide critical monitoring and adjustments to individual care plans. These small teams meet regularly with patients in hour-long sessions to conduct evaluations, continue rehabilitation and community reintegration, and have meaningful conversations with patients and their families.

After a rehabilitation patient graduates out of the intensive need program – ideally after a one-year period, depending on the severity of the injury – he or she will continue to be accompanied as appropriate by a CHW for as long as necessary. This complete array of services is currently offered across several communities in the Central Plateau and is in development in the Lower Artibonite.

PIH/ZL is committed to offering dignified care to Haitians with disabilities. This care extends beyond the hospital or clinic where advocacy, individualized accompaniment, environmental modifications and psychosocial support are key if these individuals are to regain the strength and confidence to fully reintegrate into their communities.

Believing that public sector strengthening is critical to building back better in Haiti, PIH/ZL has partnered with Spaulding Rehabilitation Hospital, MASS Design Group, Shelpley Bulfinch Architects, Partners Harvard Medical International, The Institute for Human Centered Design, and Massachusettes General Hospital Institute of Health Professions to develop plans for the first universally accessible rehabilitation center in the public sector in Haiti. 

Budgetary constraints have delayed construction, but not before plans had been completed and ground broken for a 6,750-square-foot, two-story facility, on the grounds of Hôpital St Nicolas, located in the northern city of St Marc. The plans call for a facility that will serve as a model for accessible design and a nexus of disability advocacy through rehabilitation, education, and vocational training in a dignified space integrated into the public health care system. In the future, the Center for Excellence in Rehabilitation and Education will house specialized training in the PIH/ZL rehabilitation services model for eight rehabilitation technicians over nine months who will then be hired to reinforce and scale up the program.

Read more about PIH's work in Haiti two years after the earthquake.

IHSJ Reader     January 2012     Issue 15         

Note: Triple asterisk (***) indicates subscription-only sources.

HAITI

Haiti's "Unnatural Disaster'' (Joia Mukherjee and Ruth Messinger, The Boston Globe, January 11, 2012)
Haiti’s recovery requires long-term support aimed at strengthening government, Haitian citizens’ and grassroots organizations’ capacity to address systemic inequalities and cope with so-called “natural disasters”.  Until more resources are channeled through Haiti’s local government and community partners, what could pass as natural events will continue to be unnatural disasters for the poor.

Haiti’s Slow Recovery (Editorial, The New York Times, January 8, 2012)
Though the success of the Interim Haiti Recovery Commission is contested, there has been some progress and recovery in Haiti since the devastating earthquake two years ago. But gaps remain. This editorial discusses the need for the Martelly Administration to develop a comprehensive strategy for housing, resettlement and employment, and for donors to fulfill aid pledges. Foreign assistance should support Haiti’s efforts to control and guide their rebuilding and development.

Haiti Can Be Rich Again (Laurent Dubois and Deborah Jenson, The New York Times, January 8, 2012)
Highlighting Haiti’s history as a country of agricultural innovation, this article argues for greater investment in Haiti’s rural economy, particularly the small farming sector. Supporting and sustaining local agricultural capacity with a focus on women is critical to achieving long-term food security for the Haitian people.

Where the Relief Money Did and Did Not Go: Haiti After the Quake (Bill Quigley and Amber Ramanauskas, Counter Punch, January 3, 2012)
Foreign assistance should be invested in poor people and governments. Yet two years after the earthquake, insufficient amounts of donor funds for humanitarian relief have been channeled through the Government of Haiti.  The myriad structural challenges facing Haiti cannot be addressed by foreign militaries, nongovernmental organizations and private contractors. Instead, they merit a human rights-based approach that employs and trains local people, strengthens public infrastructure and extends access to essential services.

GLOBAL HEALTH FUNDING

Aid Cuts to Middle-Income Countries Worsen Global Poverty and Ill-Health (Andy Sumner and Amanda Glassman, Poverty Matters Blog, January 2, 2012)
When Round 11 of the Global Fund for AIDS, Tuberculosis and Malaria was cancelled in December, the Global Fund Board made the tough decision to stop funding projects in middle-income countries (MIC). The European Union and the World Bank’s International Development Association have also cut off aid to MICs, where the majority of the world’s poor actually live. This article warns that extreme reactions to tough economic times could negatively impact many of those most in need. Instead, the donor community should design health and development assistance to benefit poor people, including by supporting more inclusive social protection policies in new and old MICs.

The Best Way to Save Lives, Accelerate Progress on Global Health, and Help Advance U.S. Interests (Frontline Health Workers Coalition, January 11, 2012)
The Global South faces a shortage of at least one million frontline health workers. Yet community-based health workers are currently the best way to serve millions of families who live beyond the reach of hospitals and clinics. In this issue brief, the new Frontline Health Workers Coalition, of which PIH is a founding member, calls upon the U.S. Government to help address the shortage of skilled, supported and motivated health workers by training and retaining an additional 250,000 new frontline health workers, and better supporting the capacity and impact of existing health workers. Addressing the health worker shortage is one of the best ways to strengthen health systems and reduce suffering and premature death worldwide.

FOOD AND WATER SECURITY

Water For the World Act (Rep. Earl Blumenauer and Rep. Ted Poe, Press Release, December 14, 2011)
On December 14^th, Representatives Earl Blumenauer (D-OR) and Ted Poe (R-TX) introduced the “Senator Paul Simon Water for the World Act of 2012” (H.R. 3658).  The Act seeks to expand access to safe drinking water and sanitation for millions of people in the Global South, increase local country-ownership, and improve the sustainability, coordination, oversight and integration of water and sanitation programs within and between U.S. Government agencies. The World Health Organization estimates that 3.5 million people die every year from water-related illnesses every year and access to clean water and sanitation has become a critical issue in Haiti since the cholera outbreak.

***Food Insecurity: Special Considerations for Women (Louise Ivers and Kim Cullen, The American Journal of Clinical Nutrition, December 2011)
In this article, Kim Cullen and Dr. Louise Ivers, Partner In Health’s Senior Health and Policy Advisor, discuss the disproportionate effects of food insecurity on women. The authors focus on three key areas in which food insecurity heightens the vulnerability of women including household economics, pregnancy and mental health. Women produce up to 80% of the food in developing countries, yet represent 70% of the world’s poor. Short-term assistance and long-term development strategies are required to improve women’s access to not only food, but also land, opportunity and economic power. 

The Sticky Challenge Facing Africa (Esha Chhabra, Poverty Matters Blog, The Guardian, December 20, 2011)
Ready-to-Use Therapeutic Food (RUTF) is the most effective treatment for reversing severe acute malnutrition.  This article highlights efforts by Steve Collins, Partners In Health and others to shift RUTF production to food insecure regions, rather than in Europe and North America. By generating consistent and predictable demand for local agricultural products, RUTF production can help stimulate local economies and safeguard rural livelihoods in order to secure proper nutrition in the long term.  

MULTIMEDIA/ADDITIONAL RESOURCES

Rwandans Welcome HPV Vaccine Program (Here & Now, National Public Radio, January 2, 2012)
Listen to Dr. Peter Drobac, Director of Inshuti Mu Buzima, Partner In Health’s Rwandan sister organization, discuss the success of Rwanda’s nationwide program to vaccinate 11-year-old girls against human papillomavirus (HPV). The enormous strides Rwanda has made in rebuilding its health system and community outreach and engagement are evidenced by the fact that 96 percent of girls have received this free vaccine due to strong public education and awareness campaigns. 

Haiti Special Coordinator: Releases (Office of the Haiti Special Coordinator, U.S. State Department, December 28, 2011)
The U.S. State Department released multiple fact sheets on the U.S. government’s work in Haiti over the past two years. Each fact sheet presents specific challenges, the U.S. strategy and what has been accomplished to date.

The entrance to Mirebalais Hospital in early 2012.

On January 12, 2012, PIH’s Dr. David Walton updated listeners across the country on the construction of Mirebalais Hospital on NPR’s All Things Considered. Walton also discussed the country’s cholera epidemic and outlined his long-term hopes for Haiti’s health care system. 

Dr. Walton at the Mirebalais construction site in early 2011.

“Our hopes are actually quite ambitious,” said Dr. Walton. “With the construction of this hospital in the reconstruction phase of Haiti, we really hope to create a new paradigm for health care delivery in this country, particularly in the public sector where...[it] has been very difficult to find quality care and care that is reliable for the millions of people who can't afford private care.”

When a devastating earthquake struck Port-au-Prince two years ago, the capital city’s largest hospital was severely damaged and hundreds of doctors, nurses and support staff were either killed or injured. Haiti’s medical infrastructure was overwhelmed as 300,000 people injured in the quake – nearly a third of the city’s population – sought medical care. Because PIH/ZL’s network of 12 health facilities is located in rural Haiti, our staff of 4,000 was able to respond to the nation’s crisis within hours, partnering with the national government and other NGOs to offer help and create a long-term roadmap for reconstruction.

At the center of PIH/ZL’s response is Mirebalais National Teaching Hospital which, when its first wards open this summer, will be the largest teaching and referral hospital in Haiti, serving an estimated 500 patients a day, with 320 patient beds. The campus will employ 900 Haitians, boost the local economy, and educate the country’s next generation of clinicians, nurses and community health workers.

Listen here, or on All Things Considered’s website.

On January 12, 2012, PIH Chief Medical Officer Dr. Joia Mukherjee and Ruth Messinger, President and Executive Director of the American Jewish World Service, co-authored an op-ed on the Boston Globe blog titled Haiti's "unnatural disaster." Read an excerpt below:

Jan. 12 marks two years since Haiti’s devastating earthquake. Though the tragedy was billed a “natural disaster,” an earthquake is not enough to explain the loss of hundreds of thousands of lives and the destruction of millions of homes. It isn’t enough to explain the acute food shortage immediately following the quake or the humanitarian crisis that continues today, with more than half a million Haitian people tented in over-crowded, sweltering IDP camps without access to basic services, and the cholera epidemic that has infected more than 500,000 people in the past 15 months. What has happened in Haiti is better termed an “unnatural disaster.”

To place blame solely on the earthquake is to miss the political and historical underpinnings of poverty in Haiti. The damage was far worse than it should have been because Port-au-Prince was home to hundreds of thousands of slum dwellers whose fragile shanty homes folded like cards. The slums existed in part because the collapse of the farming sector led rural poor to the city in search of nonexistent jobs. The farming sector collapse, in turn, was caused by factors including U.S. free trade and food aid policies that flooded Haiti’s market with cheap imported food for decades. And all of these problems were compounded by the fact that the institution charged with confronting and solving these challenges – the government – lacked the infrastructure and ability to respond and itself was decimated by the earthquake.

Read Haiti's "unnatural disaster" in its entirety. 

An update of PIH's work in Haiti, two years following a massive earthquake.

Two years ago, a massive earthquake struck Haiti, killing over 250,000 people and leaving 1.5 million homeless. PIH’s staff in Haiti and around the world immediately launched into action, bringing emergency medical care and supplies to survivors. Over the past 24 months, PIH and its Haitian sister organization Zanmi Lasante (ZL) have continued to provide health care to hundreds of thousands of people, including earthquake survivors and nearly 80,000 cholera patients, and have nearly completed construction of a new national teaching hospital in central Haiti. The team has also expanded agriculture, nutrition, education, and income-generation programs to help survivors feed and support their families.

Once the scope of need in Haiti became apparent, PIH/ZL designed and began implementing the Stand With Haiti Fund, a 2.5-year, $125-million plan to help the country rebuild. By June 2012, PIH will have spent the entirety of that fund, fulfilling the promises made in the weeks after the earthquake.

The Stand With Haiti Fund allowed PIH to expand and strengthen healthcare services, with an emphasis on specialties like rehabilitative medicine and mental health that had been weak before the earthquake and were even more desperately needed after it. PIH increased its Haitian staff by over 30 percent, from 4,400 to nearly 6,000 people, and strengthened the country’s health infrastructure.

But much remains to be done. Working in partnership with Haiti's Ministry of Public Health and Population and the Port-au-Prince-based organization GHESKIO, PIH and Zanmi Lasante are preparing to implement a cholera vaccine demonstration campaign. And within months, the doors to the new 320-bed Mirebalais National Teaching Hospital will open. 

Program updates

		Rehabilitation Over the past two years, a team of clinicians, nurses, technicians, and community health workers has delivered care to hundreds of patients throughout central Haiti recovering from amputations and debilitating physical conditions, including injuries sustained during the earthquake. The team accommodates 600 inpatient visits and 1,000 outpatient visits annually. In addition, 400 community health workers have been trained to provide services to disabled patients and identify new patients.
		Mental Health Since January 2010, PIH’s mental health and psychosocial support team has provided services to more than 25,000 adults and children in Port-au-Prince and throughout the Central Plateau and Lower Artibonite regions of Haiti. A 64-member team — comprised of psychologists, social workers, and community mental health workers — provides care to people affected by the earthquake and the cholera outbreak. More
		Cholera Since a deadly cholera epidemic broke out just eight months after the earthquake, PIH has treated more than 80,000 patients and trained over 1,000 health workers to identify and treat cholera in the community. Plans are now being finalized for a cholera vaccination demonstration project that will provide a proven oral cholera vaccine to 100,000 people in Port-au-Prince and in a rural community in the Artibonite region where the epidemic first broke out. More
		Mirebalais For the past 18 months, construction crews have been working tirelessly to build the new Mirebalais National Teaching Hospital, a state-of-the-art complex that will soon become the country's largest public teaching and referral hospital. At a time when Haiti desperately needs skilled professionals, Mirebalais Hospital will provide high-quality education for the next generation of Haitian nurses and physicians. More

Media coverage on the challenges and accomplishments two years after a massive earthquake struck Haiti.

Thursday, January 12, marked the second anniversary of the 7.0 earthquake that leveled the Haitian capital of Port-au-Prince and its surrounding areas. One of the ways we remember this natural disaster that killed hundreds of thousands, injured countless and sent one of the poorest countries in the world into even deeper poverty is through the stories of the people, communities and institutions affected by that event.

Across PIH’s website and social media, we are gathering updates about those who were injured on that day, assessing the work we’ve accomplished in Haiti, while also looking forward to the work that still needs to occur. But capturing a fuller picture of where Haiti is two years out requires listening to and learning from other NGOs, government sources, news outlets, and, most importantly, the people of Haiti. 

On this page we are collecting links to various news stories printed on and around January 12, a day for remembering, for reporting on achievements and for taking a serious and critical examination of the many gaps in care and aid that still exist.  

USAID's Shaw assesses pace of Haiti recovery
NPR, January 12, 2012
Many Haitians have left the tent camps and much of the rubble has been removed from the streets since Haiti's 2010 earthquake. Yet questions remain about the flow and efficacy of international aid to the country. 

Haiti's long road to recovery
PRI's The World, January 12, 2012 
This has been a solemn day for Haiti. The small island nation is marking the second anniversary of the earthquake that devastated so many lives there. 

Sean Penn talks Haiti recovery
Anderson Cooper 360, CNN, January 12, 2012
Anderson Cooper talks to Sean Penn about his work in Haiti, and the progress and obstacles in the effort to recover from the 2010 earthquake.

Haiti struggles to 'build back better' two years after earthquake
Christian Science Monitor, January 13, 2012
Many of those displaced by Haiti's devastating 2010 earthquake have been relocated, and buildings and roads repaired. But reconstruction in Haiti has been complicated by deep economic and social problems.

Haiti: the republic of NGOs?
Al Jazeera, January 13, 2012 
As rebuilding work continues two years after the quake, we ask where billions of dollars in international aid ended up. 

Two years after devastating earthquake, Haiti's rebuilding weighed down by legacy of foreign meddling
Democracy Now, January 13, 2012
Share On the second anniversary of the devastating earthquake in Haiti that killed roughly 300,000 people and left more than 1.5 million homeless, we speak with Randall Robinson, author of "An Unbroken Agony: Haiti, from Revolution to the Kidnapping of a President. 

Two degrees energy bars support famine relief
San Francisco Chronicle, January 13, 2012
To extend its reach, Two Degrees is going beyond commitments to Partners in Health and Valid Nutrition by identifying potential partners in Pakistan who can produce a chickpea-based paste and in India, where it will be providing meals through the school system. 

Time for change in Haiti: TED senior fellow Peter Haas responds
TED Blog, January 13, 2012
In total, the following 10 NGOs raised $1.4 billion out of the estimated $2.6 billion of private aid funding given for Haiti earthquake relief. 

On second anniversary of earthquake, cholera continues to cripple Haiti
PBS NewsHour, January 12, 2012
With more than 7,000 dead and half a million people sickened, a U.N. health agency is calling the cholera outbreak in Haiti "one of the largest epidemics of the disease in modern history to affect a single country. 

Haiti, two years later
Emily Rooney Show, WGBH
Interview with Jim and Karen Ansara: It’s been two years since a devastating earthquake leveled much of Haiti, killing hundreds of thousands and injuring and displacing millions more. Though the situation remains dire, many have moved on. We’ll talk to one local couple who hasn’t forgotten. 

Cholera in Haiti: from control to elimination
Al Jazeera, January 13, 2012
Two years after a massive earthquake and susequent cholera outbreak, Haitians are trying to improve public health. 

Haiti by the numbers
Boston Magazine, January 13, 2012
Local non-profit Partners in Health (PIH) had been working in Haiti for 25 years when the earthquake struck, and in the past 24 months has been one of the leaders in the recovery effort. 

PIH's Dr. David Walton discusses aftermath of Haiti quake
NPR, January 12, 2012
Melissa Block talks to David Walton of the nonprofit group Partners in Health about the two-year anniversary of the earthquake in Haiti. 

On Second Anniversary of Earthquake, Cholera Continues to Cripple Haiti
PBS Newshour, January 12, 2012
With more than 7,000 dead and half a million people sickened, a U.N. health agency is calling the cholera outbreak in Haiti "one of the largest epidemics of the disease in modern history to affect a single country." 

Haiti embarks on economic recovery plan with help from private sector
The Guardian, January 12, 2012
Two years after Haiti's earthquake, the government is stepping up help for displaced people and working with the private sector to kickstart the economy. 

Haiti struggles to recover from 2010 earthquake
National Public Radio, January 12, 2012
Two years after a massive earthquake leveled Haiti's capital and killed roughly 300,000 people, the nation's recovery is slowing picking up speed. 

Haiti's displaced people grow increasingly frustrated
The Guardian, January 12, 2012
Haitians protest against conditions in camps as President Michel Martelly announces massive resettlement project. 

Half a million people still living in camps
The Journal.ie, January 12, 2012
A charity dedicated to vulnerable young people, has said that half a million people are still living in dire conditions in temporary camps. 

Two years on, Haiti still reeling from quake
CNN.com International, January 12, 2012 

Haiti on slow road to earthquake recovery
BBC News, January 12, 2012
Although some reconstruction projects have been successful, most of Haiti still lies in ruins. 

Haiti earthquake anniversary: photos
The Christian Science Monitor, January 12, 2012 

6 easy ways to help in Haiti
USAToday, January 12, 2012
For $60 to Partners in Health, help a Haitian family boost food production, ending malnutrition. 

Two years after quake, signs of progress slow
The Washington Post, January 12, 2012
Hope here is measured in bags of cement. Progress is a city park without a tent. The future is a bus that takes children to school without charge. 

Can a vaccine cure Haiti's cholera?
Scientific American, January 12, 2012
Two years after the earthquake and thousands of deaths later, the debate about whether to use the cholera vaccine in Haiti continues... Those at Partners In Health, a health care organization, say that imperfect efficacy should...

Video: Progress slow two years after Haiti quake
AP, January 12, 2012 

Pews from St. Cecilia Church in Boston's Back Bay find new life in Haiti at hospital being built by Partners In Health
The Boston Globe, January 12, 2012
In a haven of mercy, they are meant to provide comfort, rest for the infirm, a spiritual seat in a secular institution. 

Haiti earthquake: did appeal money make a difference?
BBC News, January 11, 2012
The British public donated $168 m after the 2010 Haiti earthquake, an amount second only to that raised for the Indian Ocean tsunami. But how has that money helped Haiti two years on? 

Two years after the earthquake
The Huffington Post, January 11, 2012
Today marks two years since Haiti's devastating earthquake. Though the tragedy was billed a "natural disaster," an earthquake is not enough to explain the loss of hundreds of thousands of lives and the destruction of millions of homes. 

Covidien donates additional $1 million to support Haitian hospital
Yahoo! Finance US, January 11, 2012
Company’s Contributions to Partners In Health for Haiti Now Total $3.5 Million. 

Haiti's "Unnatural Disaster"
Boston Globe, January 11, 2012
Jan. 12 marks two years since Haiti’s devastating earthquake. Though the tragedy was billed a “natural disaster,” an earthquake is not enough to explain the loss of hundreds of thousands of lives and the destruction of millions of homes.

Though world stood still, things moving forward in Haiti
Chicago Tribune, January 11, 2012
PIH's Dr. Evan Lyon, a University of Chicago professor of medicine, discusses helping to launch a residency program in Haiti, marking 2nd anniversary of the earthquake.

No time to despair
Miami Herald January 11, 2012 
Haiti’s progress has been slow, but improvements are underway. 

Slow recovery in Haiti two years after earthquake
Miami Herald, January 11, 2012
Almost two years after the devastating 7.0 earthquake destroyed much of Port-au-Prince, full recovery appears to be years away.

Haiti transitions from relief to rebuilding
CNN, January 10, 2012 
Two years after massive quake, organizations are helping Haiti get back on its feet. 

Questions arise about how Haiti earthquake donations have been spent
Miami Herald, January 10, 2012 
Half the money world governments pledged to Haiti never showed up. Half the money American private donors raised for Haiti hasn’t been spent.

Haiti: Cholera Epidemic’s First Victim Identified as River Bather Who Forsook Clean Water
New York Times, January 9, 2012
The first Haitian to get cholera at the onset of the 2010 epidemic was almost undoubtedly a 28-year-old mentally disturbed man from the town of Mirebalais, researchers reported Monday. 

How cholera in Haiti began
CNN, January 9, 2012
Two years after an earthquake shook Haiti, the small country grappled with the death, the destruction and the debris. After the earthquake on January 12, another health crisis struck about 10 months later: cholera.

Two years after quake, Haiti still struggles with cholera
Toronto Star, January 9, 2012
Two years after an earthquake levelled Port-au-Prince, Haiti is in the grip of one of the most devastating cholera outbreaks in modern history.

The Truth About NGOs
BBC World Service, January 8, 2012
Why does there seem to be so little co-ordination between NGOs in a place like Haiti? Why, despite the vast effort and resources that flowed after the earthquake two years ago, are people still living in tents without basic amenities?

Haiti 2 Years Later: Half a Million Still in Camps br />ABC News, January 8, 2012
While U.N. Secretary-General Ban Ki-moon, former U.S. President Bill Clinton and others vowed that the world would help Haiti "build back better," and $2.38 billion has been spent, Haitians have hardly seen any building at all.

Haiti Can Be Rich Again
New York Times, January 8, 2012 
Haiti should look to the past, and the system of small farms and the decentralized economy that once provided Haitians with dignity, autonomy and wealth.

Haiti’s Slow Recovery
New York Times, January 8, 2012
Two years after the earthquake, some progress has been made, but the Haitian government badly needs a national strategy to do much more.

Through farming, stricken Haiti seeks both food and rebirth
Seattle Times, January 7, 2012
In Haiti, 15-acre cooperative farm represents a small but promising program: saving the country by developing the countryside.

Haiti’s wings need to soar
Toronto Star, January 6, 2012
Many Haitians are having a hard time keeping up their spirits as they prepare to mark the second anniversary of the Jan. 12, 2010, earthquake that levelled much of Port-au-Prince, killed 220,000, caused $8 billion in damage, left a million homeless and shattered a desperately poor country. While time has marched on, reconstruction has not.

Cholera cripples Haiti, two years after quake
USA Today, January 5, 2012
In February, Haiti's Health Ministry, with help from Partners in Health, a U.S.-based aid organization, will begin vaccinating 100,000 people in a Port-au-Prince slum and a rural commuity with an oral cholera vaccine, said Louise Ivers, senior health and policy adviser for Partners in Health.

PIH joins over a dozen global health organizations in urging more investment in frontline health workers in the developing world.

Partners In Health, Save the Children, and over a dozen other global health organizations launched a Frontline Health Worker Coalition on January 11, urging the U.S. Administration to invest in more and better-trained frontline health workers in the developing world.  

The World Health Organization estimates that the developing world is facing a shortage of at least one million frontline health workers — community health workers and midwives, as well as doctors and nurses serving at the community level. Yet frontline health workers are the backbone of effective health systems and currently the best way to serve millions of families who live beyond the reach of hospitals and clinics. They connect patients to health services at the community, clinic, and hospital levels. And with adequate training and support, they provide families with a range of proven, life-saving services, including maternal and newborn care, child health, and management of chronic and communicable diseases, such as tuberculosis, HIV/AIDS, and diabetes.  

192 UN member states, including the United States, agreed to achieve the eight Millennium Development Goals by the year 2015, yet many developing countries lack the health workforce needed to reverse the incidence of disease and reduce deaths of mothers and children. Every day, nearly 21,000 children die from mostly preventable causes, and 1,000 girls and women die in pregnancy and childbirth. Without health workers there is no health care.

To help address the shortage of skilled, supported, and motivated frontline health workers, the Coalition is asking the U.S. for a commitment and a strategy to: (1) train and support an additional 250,000 new frontline health workers, and (2) better support the capacity and impact of existing workers, beginning with a strategic review of policy, skills, and supply gaps that constrain health worker effectiveness.

“The U.S. Global Health Initiative is well positioned to identify where the need is greatest, and to accompany countries in implementing emergency and long-term plans to address the heath workforce crisis,” said Meredy Throop, PIH’s Policy and Advocacy Coordinator. “But the longer we wait, the more lives will be lost.” 

Please visit www.frontlinehealthworkers.org to learn more.

By Kaitlin Keane

Of the 24,000 children that die every day from preventable diseases, 60 percent of those deaths are the result of malnutrition and could be avoided if children received the protein and nutrients necessary to help fight the diseases prevalent in the resource-poor countries where they live.

Among the most crucial tools used by Partners In Health to combat childhood malnutrition are ready-to-use foods, such as enriched peanut butter, that provide the essential nutrients needed to save a starving child's life.

Getting these food packs into the hands of children who need them is the mission of Two Degrees, a health food company devoted to sending one life-saving pack to a child for every snack bar sold in the United States. 

In this three-part video series, PIH Chief Medical Officer Dr. Joia Mukherjee, also a board member at Two Degrees, discusses the tragedy of preventable childhood deaths from malnutrition and the importance of such campaigns in raising public awareness and empathy for childhood starvation. 

"I don't think there will be large scale change without a movement, and this could be part of that movement," Dr. Mukherjee said. "What if it was a coalition of parents around the world saying my kid's not dying, and your kid shouldn't die either?"

Learn more about PIH's food security programs.
Buy a Two Degrees bar.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

Recent trainings give health workers new tools to bring family planning services to their communities.

Community health workers at a family planning training in Rwanda.

By Celia Reddick

Giggling ran through the classroom. It was an odd scene in rural Rwanda. Mothers and their infant babies, well-dressed older men, and young women in veils stared at the plastic models of penises in front of them. One by one, each of them practiced putting condoms onto the donated props, part of a recent training collaboration between PIH’s Rwanda-based Community Health and Training Departments.

This training on family planning dovetails with the Rwandan Ministry of Health (MOH)’s priorities. The MOH is taking an active approach to family planning, encouraging all women of childbearing age to consider contraceptive methods. In addition, the MOH is working to make contraceptives available at rural health centers, and through community health workers serving their communities throughout Rwanda.

	PIH training manuals were used at the community health worker training.
	Participants at a family planning training demonstrate the proper way to put on a condom.

These efforts address a growing issue in Rwanda. The small country in eastern Africa is home to an estimated 11 million people, and is the most densely populated country on the continent. Nearly 50 percent of Rwanda’s population is under the age of 14, and the average Rwandan family has as many as five children, putting a strain on already limited resources.

In the past few months, many community health workers have received MOH trainings on modern family planning methods, learning how to give contraceptive injections and how to discuss various contraceptive pills with women. In collaboration with PIH’s Community Health Department in Rwanda, PIH’s training team organized its training to align with the MOH’s work.

At a recent PIH training held at Ruramira Primary School in southern Kayonza, facilitators guided participants through a lively discussion of human rights and family planning. “Family Planning is connected to human rights, because it is the right of a child to have access to education and health care,” said one community health worker, adding that large families make realization of this right impossible. “Family Planning is a woman’s human right, because having many children can be very dangerous to her health. She and her husband must understand this,” added a facilitator.

After learning how to demonstrate the proper way to put on a condom (using the plastic props), the participants requested their own supplies so they could hold similar demonstration sessions in their communities.

These family planning trainings are just one part of PIH’s larger effort to improve the quality of community-level services. In the coming month, community health worker supervisors will use observation checklists (developed in partnership with PIH’s Rwanda-based Monitoring and Evaluation Department) to assess the impact of these trainings on community health worker home visits. And in the past two months, community health workers have received PIH-developed trainings in Reproductive Health (focusing on the health of a pregnant woman and her fetus), Nutrition, and PMTCT (Prevention of Mother-to-Child Transmission of HIV). High-quality participatory learning activities in support of MOH national initiatives have the potential to transform community-based health interventions. With training and support from PIH, hundreds of community health workers are now better-equipped to lead the charge.

Celia Reddick serves as the Curriculum and Training Specialist for Partners In Health in Rwanda.

Since the 2010 earthquake, PIH has provided mental health and psychosocial support services to help thousands of survivors, and those suffering from mental disorders.

Since January 2010, PIH’s mental health and psychosocial services team has provided direct services to more than 25,000 adults and children in Port-au-Prince and throughout the Central Plateau and Lower Artibonite regions of Haiti.

Life in the settlement camps around Port-au-Prince came with untold stresses and hardships. Beyond people recovering from the trauma of the 2010 earthquake, families living in these makeshift communities have had to deal with epidemics of sexual assault, physical abuse, depression, anxiety, and other emotional challenges.

Since the earthquake, PIH and its Haitian sister organization Zanmi Lasante (ZL) have employed a 64-member team — comprised of 14 psychologists, 35 social workers and social worker assistants, and a cadre of community mental health workers — to meet these needs.

For nearly two years PIH/ZL worked in Parc Jean Marie Vincent, the largest of the settlement camps in Port-au-Prince. There, the team provided 6,843 total psychosocial encounters, including 44 psychiatric evaluations, 2,431 psychosocial evaluations, and 2,223 ongoing mental health visits. An additional 678 patients participated in group therapy sessions.

	Patients receiving mental health services in Port-au-Prince.
	Zanmi Lasante's mental health and psychosocial support team in Haiti.

Beyond treating acute problems, PIH/ZL has organized relaxation and leisure groups to address stress-related mental health issues for 193 adults who were experiencing extreme stress or anxiety. The team also organized activites for 751 children, which included art therapy sessions, film screenings, and song and dance time. PIH also organized an excursion day for 242 children in the camps to provide much-needed playtime (sports, games, and other activities) in a safe environment off the campgrounds.

PIH/ZL has conducted school-based mental health education sessions for 13,694 high school-aged students and their teachers. These sessions taught children the signs and symptoms of mental illness, provided sensitization and anti-stigma messages surrounding mental illness, and taught strategies for combating stress.

PIH/ZL have developed a basic collaborative care service model at all ZL hospital sites, with each site assigned one psychologist whose responsibilities encompass both psychosocial services related to HIV/TB and management of clinically severe presentations, including trauma-related symptoms and chronic mental disorders. The psychologists work in multidisciplinary teams, with each team incorporating a physician for prescribing medications. One psychiatrist serves the entire ZL hospital system, the Dr. Mario Pagenel Fellow in Global Mental Health Delivery.

PIH participates in World Mental Health Day in Haiti.
New medical fellowship brings psychiatrists to Haiti.
With cholera killing thousands, PIH mental health team organizes mourning sessions.

In 2011, thousands of children received new TOMS shoes. Plans for 2012 shoe distributions in the works.

Last fall, PIH staff distributed new TOMS shoes to thousands of school children in Malawi, Lesotho, and Rwanda. Many of these children have never owned a new pair of shoes.

The distributions were part of PIH’s overall work to improve the health of poor communities – which includes programs to address the communities’ medical as well as socioeconomic needs. "You can build a hospital and you can give people medicine, but if you don't address their other needs, people are not going to get better,” says PIH Partnerships Manager Amanda Schwartz, who helped to organize the distributions.

	In Lesotho, children gather at a remote mountain clinic to receive new shoes.
	13-year-old Alfred (left) with some of his classmates after receiving their new shoes. “[The shoes] make me feel happy and that everything will be OK,” said Alfred.

Bare feet carry a number of ramifications in the communities served by PIH. For example, children without shoes are at a greater risk of becoming infected with soil-transmitted parasites, such as hookworm. These common infections can have debilitating effects on a child’s health and long-term development, including cognitive development. In addition, bare feet are at a higher risk of injury and resulting infections. Many students walk several kilometers each way to school, a journey that often takes them across huge stretches of scorching sands and rocky river beds, sometimes even discouraging students from attending school.

In addition to protecting children’s feet from cuts, infection and diseases, shoes also bring less tangible benefits, says Schwartz. “New shoes give children a sense of self, a feeling of pride, and the universal satisfaction that comes from feeling taken care of and provided for.” 

“[The shoes] make me feel happy and that everything will be OK,” beamed Alfred Benson, a student whose parents are both subsistence farmers. His new black canvas TOMS slip-ons were the first pair of shoes he’s ever owned. 

“Our goal isn’t simply to give shoes one time, but to continue to provide shoes to PIH for these children as they grow, so together we can truly have an impact on the health and well-being of this community,” said TOMS Shoes Senior Giving Accountant Manager Jenise Steverding. The partnership is already planning for future distributions in 2012, including a March distribution in Malawi.

Read more about TOMS shoes distributions in Malawi and Rwanda. 

Children in Rwanda admire each others' new TOMS shoes. Photo courtesy of TOMS Shoes.

A boy is fitted for new shoes in Rwanda.

How does PIH do the work it does? And can it be replicated in other communities around the world?

In 2011, we published the PIH Program Management Guide – a comprehensive resource devoted to addressing these questions and enabling others to learn from PIH’s own challenges and accomplishments.  A collective effort of PIH leadership from around the world, this new guide captures the elements of how our work is designed, implemented, and evaluated.

“We hope [the PIH Program management Guide] will serve as a practical and useful tool for program managers, and for others engaged in this work around the globe,” says PIH Director of Programs Jenna LeMieux.

“For me, this manual not only gives a glimpse into health programming for anyone interested, but also serves as a practical guide for those of us working with these complex challenges every day,” says Aaron Shapiro of Gardens for Health International, a young organization that has helped to pilot the guide. “It sheds light on ways to accurately collect data, efficiently train community members, and demonstrates the critical importance and value of working collaboratively with host governments.” 

“The guide provides crucial information on how to approach health problems in resource-poor settings, understand what needs to be done, and leverage every resource necessary, from medicines and technology to connections and advocacy networks, to build sustainable, effective heath systems,” writes Jill Shah of GlobeMed, an organization that engages students in global health issues.

Topics covered include PIH’s experiences working around the clock to to identify and treat patients while also trying to get medicines and supplies through customs, manage finances, secure clean water for the site, set up power and an Internet connection, hire clinic-based and community staff, locate an ambulance and driver, identify potential partners, and ultimately strengthen local public health systems.

In November, PIH helped to organize an online expert panel discussion with GHDonline to share experiences and perspective on an NGO’s role in strengthening health systems and partnering with local Ministries of Health. Thousands of people from 58 different countries visited the online panel, and the discussion threads are still posted. Similar panels are being organized for 2012.

In 2012, PIH’s training team plans to update and add to the online resource. The team will be working closely with the Praxis Network and other organizations to gain additional insights from others who support social justice and global health programs around the world.

Check out the PIH Program Management Guide. 

By Amy Scheffler, Global Health Delivery Project, Harvard University

Update: Course application deadline extended to March 1, 2012.

Are you a public health specialist, medical leader, or mid-career health practitioner? Do you have a passion for improving service delivery to patients?

	Participants from last summer's Global Health Effectiveness Program.

This summer, PIH's partners at the Global Health Delivery Project at Harvard University is offering a special intensive three-week Global Health Effectiveness (GHE) Program. The course will provide in-depth learning in value-based health care delivery from renowned leaders in the field, including PIH co-founder Paul Farmer and PIH Chief Medical Officer Joia Mukherjee.

Students in the program are required to take three courses at the Harvard School of Public Health, each with a different teaching approach. The curriculum features seminar-style lectures and problem sets in epidemiology, global health delivery case study analysis, and the opportunity to hear from experts’ first-hand perspectives and experiences in management science.

For the past four years, GHE has enabled and empowered more than a hundred health care professionals to effectively design and manage programs that improve health outcomes for the populations they serve. Past participants represent a wide variety of cultural and professional backgrounds and hail from the far stretches of the globe, from Haiti, to Ethiopia, Kenya to India. GHE alumni range from a public health doctor in South Korea to a Global Health Fellow with Partners In Health/Inshuti Mu Buzima in Rwanda.

One 2010 GHE alum credits the program as inspiration for developing a community health program. This new program is based on a case study covered in the course on the successes of a community health worker project in Maharashta, India. “[The GHE program provided] a valuable opportunity to learn from and apply the lessons of others to my own work,” says 2009 GHE alum Dan Schwarz, Chief Operating Officer for Nyaya Health, a nonprofit that operates a hospital and mobile medical care services in Achham, a large rural district in western Nepal.

The 2012 program runs July 5 through July 27, and will be held at the Harvard School of Public Health (HSPH) in Boston, Massachusetts.  GHE is co-sponsored by the Harvard School of Public Health and Harvard Medical School, under the direction of Harvard faculty on the staff of Brigham and Women’s Hospital. 

Learn more and apply.

On November 2, the New York Times published an article about Nourimanba, a peanut and vitamin supplement produced and distributed to malnourished children in Haiti by Partners In Health.

In Haiti, local communities grow and harvest the peanuts used to make Nourimanba.

“The uniquely Haitian product…is an essential medicine for about 10,000 severely malnourished children a year,” writes Duff Wilson in his article “Making Nutrition a Sustainable Business in Haiti.”

“Even before the 2010 earthquake heaped more misery atop the poverty in Haiti, one in four children had stunted growth,” continues Wilson. “An estimated 2.2 percent of Haitian children under the age of 5 had severe acute malnutrition, according to the United Nations Children’s Fund.”

In early 2008 Abbott Laboratories began supporting PIH projects in Malawi and Haiti. “In early 2009 we began thinking about how we could work with Abbott in a more comprehensive fashion, we decided to focus on our nutrition work in Haiti,” says PIH’s Brandie Conforti. “In December 2009, Abbott leadership toured our work in Haiti and then in May 2010 we formalized our partnership and began laying out plans for a Nourimanba facility. By June we were working on the design.”

“Groundbreaking on the new factory was delayed this year by an outbreak of cholera,” writes Duff. “Now groundbreaking is planned for January and production before the end of 2012.

“While the rudimentary production plant makes about 70 tons of Nourimanba for 10,000 children a year, the new one will push capacity to more than 350 tons and 50,000 children,” according to PIH’s Andrew Marx. “Children receive it daily for six to eight weeks. The new operation will also expand on the 300 or so farmers who have a guaranteed market for their peanut crops.”

“The relationship with Abbott goes beyond the Abbott Fund and it engages their employees,” continues Conforti. “It really has buy-in from the entire company and it models a new trend in corporate giving. What’s unique about this factory is the notion that eventually Nourimanba production will be self-sustaining.”

Read the New York Times article in its entirety.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

DR. RUTH'S STORY:
A young physician opens the first breast cancer clinic in rural Haiti.

“The smell was overwhelming,” recalled Dr. Ruth Damuse. “Many of the women waiting for breast exams covered their faces. Some actually left the clinic.”

“There was a woman, Patricia, she was by herself. I took her into the exam room and lifted her shirt,” continued Dr. Damuse. “Her left breast was gone. Cancer had eaten it. All that was left was a large, open infection.”

	Dr. Ruth Damuse

During the course of that visit, Dr. Damuse, who heads up PIH’s oncology program in Haiti, learned that her patient’s cancer had been growing for at least a year — slowly eating her breast until nearly nothing remained. Living far from the nearest health center and unsure what to do, the patient, Patricia, had regularly packed the wound with mixtures of herbs and leaves in hopes that these holistic remedies would combat the infection.

Breast cancer affects more women in Haiti than any other cancer. Roughly 831 out of every 100,000 women are diagnosed each year — this in a country where few women have access to regular medical care. And although breast cancer is often treatable when it is diagnosed early, most women in Haiti only come to a clinic when something is noticeably wrong — often when the disease is quite advanced, Dr. Damuse said. Because women don't always seek care, the actual breast cancer rate is likely much higher.

Since starting a weekly breast cancer clinic in June 2011, Dr. Damuse has diagnosed some strikingly advanced cases of breast cancer. Patricia’s case was the most complex that she’d seen — an arresting reminder of the work that remains to be done, from basic education to healthcare access.

PIH and its Haitian sister organization Zanmi Lasante (ZL) are working to address this dire issue. With generous support from the Avon and Lance Armstrong Foundations, they began scaling up the oncology program earlier this year.

Since it opened in 2011, ZL's breast cancer clinic at Clinique Bon Sauveur in Cange, Haiti, has served hundreds of women. Each week, Dr. Damuse performs approximately 40 exams and diagnoses three or four cases of cancer. 

As of April 2012, ten patients were receiving chemotherapy for breast cancer, and an additional 30 to 40 were on Tamoxifen, a hormonal drug that slows the growth of new cells in the breast. ZL staff perform two to four surgeries (mastectomies and lumpectomies) on women with breast cancer each week. That number increases to roughly 10 operations a week when visiting surgeons assist in the clinic.

A little knowledge can save women’s lives

	Zanmi Lasante clinicians learn how to give breast exams at a recent training.

“The people living in the Central Plateau don’t know cancer,” Dr. Damuse said. “It’s not a word they know. People living in Port-au-Prince might know what cancer is; people working in health care know. That’s it.”

In response to the need for better education, Dr. Damuse, working with ZL’s women’s health, community outreach, and training teams, has trained a cadre of community health workers (CHWs) about breast cancer. CHWs are ZL's most effective strategy against a wide range of health challenges because they work and often live in the community with patients.

Once trained to recognize the signs and symptoms of breast cancer, community health workers will become key members of the team in identifying and treating the disease.

Dr. Damuse is also holding breast cancer trainings and refresher courses for clinicians at all ZL sites. Dr. Damuse uses a breast exam torso — a life-size replica — to demonstrate where growths might occur and how they might feel. She encourages doctors and nurses to teach women how to check for signs and symptoms related to breast cancer.

Though Haiti has one of the highest breast cancer rates in the Western Hemisphere, just a handful of cancer-focused doctors serve a population of 10 million people. Dr. Damuse hopes that by training ZL staff to screen for breast cancer more effectively and regularly, more women will receive lifesaving care and early detection screenings.

Diagnosis and treatment of a complex disease in rural Haiti

If a woman has an unusual lump or swelling, Dr. Damuse will perform a biopsy. ZL staff in Cange — working in a room just yards away — quickly inspect and diagnose the extracted cells. More complex tissue samples are either sent to a laboratory in Port-au-Prince or to the Brigham and Women’s Hospital in Boston for further analysis.

Biopsy results may take anywhere from a few hours to a few weeks. Dr. Damuse uses the time to explain to each patient what breast cancer is and what it can do to her body.

For women whose cancer results are positive, ZL provides chemotherapy and surgery in Cange. Health care providers spend about a month to complete prep work to treat a cancer patient, including initial diagnostic tests, biopsy and surgery, and receiving results of pathology studies, Dr. Damuse said.

Because Dr. Damuse is an internist, not an oncologist, she relies on colleagues in the U.S. for training, feedback, and advice. “We work with an oncologist at Dana-Farber Cancer Institute who helps to triage our patients in Haiti,” Dr. Damuse said. “We have a weekly call with her to discuss the current cases and to establish treatment plans.”

During the first three months of 2012, surgeons at Cange removed lumps or performed mastectomies on 80 women — about four a week. Roughly 75 percent of surgeries result in total mastectomies. However, ZL lacks the resources for reconstructive surgery.

Little can be done in Haiti for cases of advanced cancer that require more than surgery and chemotherapy. Radiation therapy is not yet a part of Haiti’s health infrastructure, so ZL sends some patients to the neighboring Dominican Republic for radiation treatment. For women with advanced cancer, Dr. Damuse also works closely with ZL’s psychosocial support team to offer palliative care and pain management.

Patricia’s prognosis is still uncertain. She has been prescribed antibiotics and pain medicine, which Dr. Damuse reports are working. Once her infection subsides, the ZL team will have a better understanding of how far Patricia's cancer has spread and what next steps will need to be taken. 

The future of PIH/ZL cancer services

Though they did not train specifically to treat cancer, Dr. Damuse and her team are serving as one of the strongest cancer clinics — if not the only one — offering free services at a hospital in Haiti.

“In Haiti, access to cancer care is limited and only people who can pay will receive it,” said Dr. Damuse. The few private oncologists located in Port-au-Prince charge for their services. In Haiti, few people can afford that expense.

Though the challenge seems daunting, this is only the beginning of ZL’s cancer initiative. Dr. Damuse recently added two full-time nurses and a social worker to her team. Beyond helping Dr. Damuse keep the clinic running, this small staff provides psychological support, organizes surgeries, and coordinates care outside the clinic.

The oncology program is slated to move from Cange to ZL’s new state-of-the-art Mirebalais National Teaching Hospital in late 2012.

Until then, Dr. Damuse will continue providing breast cancer services to women in Cange — screening and caring for girls, mothers, and grandmothers from across Haiti’s Artibonite and Central Plateau Departments.

Learn more about PIH’s work in Haiti, and Mirebalais National Teaching Hospital.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

STELLA'S STORY:
A former sex worker finds new employment at a restaurant in Malawi.

Once forced to work as a commercial sex worker, Stella is now running a small business.

Stella's eyes are tired, her face weary and aged beyond its years. She was born in rural Malawi to a poor family of subsistence farmers. At age 11, she went to live with an uncle in hopes that he would support her education. After enduring sexual and psychological abuse, she dropped out of primary school and ran away to Zalewa, a trading center, where she found work as a "waitress" in the Ufulu Night Club and Bottle Shop.* It was there that she began engaging in commercial sex work. She was barely 14 years old at the time. Her life continued to be filled with trauma. Once, she was abandoned in neighboring Mozambique by a truck driver who had hired her for the week. Penniless, alone and terrified, she made her way back to the border, only to be raped by four men in a roadside guesthouse. She ultimately returned to Ufulu—the closest thing to a home that she knew.

Zalewa trading center lies on the edge of rural Neno District. It is situated at the crossroads between Lilongwe and Blantyre, Malawi's two largest cities, and the country's western border with Mozambique. The corridor is a major trucking route for the region and is estimated to house over 1,000 commercial sex workers, the highest concentration in the country. Human trafficking is prevalent both within and beyond national boundaries, and Zimbabwean women now account for nearly half of the commercial sex workers operating in the area.

Poverty and gender inequality are woven into these women's life stories. Few have had the opportunity to pursue an education, which would have given them the skills and means to find other ways to economically support themselves and their families. Nearly all have been bribed or assaulted by the same men who in one moment condemn them and in the next are their regular clients. The language of individual blame and immorality that many, including the women themselves, use to describe those who practice commercial sex work fails to recognize the structural violence that lies at the core of its existence.

The national response to the HIV/AIDS pandemic in Malawi has focused primarily on testing and treatment, with a stated focus on vulnerable populations. However, the needs of this population have been largely neglected—in part a reflection of the stigma attached to the women. Aside from the individual risks of exploitation and violence to which the women themselves are regularly subjected, the public health consequences posed by the commercial sex work industry are dire in a country with one of the highest rates of HIV on the planet.

	The restaurant co-op in Zalewa, which is run by former sex workers.

In 2008, Abwenzi Pa Za Umoyo (APZU), PIH's partner organization in Neno, began a project with a group of commercial sex workers in an effort to strengthen health services and help them find alternative forms of employment. The center hired 15 of the women to work as community health educators in three busy trading centers. The center provided them with ongoing training focused on counseling sex workers and their clients on sexual and reproductive health, making referrals for HIV testing and counseling, and cervical cancer screening. In the first few months after establishing this partnership, HIV testing at the center increased by more than 125 percent. The number of commercial sex workers in the catchment area who have started antiretroviral treatment at PIH-supported sites has also increased substantially. The center also began offering daily adult literacy training and business managment classes to help give the women an opportunity to lift themselves out of poverty. Based on the training, the participants developed a business plan for opening a restaurant cooperative in Zalewa.

“We learned to be self-reliant by learning how to run our own business,” says Stella. 

In 2009, Stella and the other women opened the doors to Mtendere (which means "Peace" in the local Chichewa language). With support from APZU, the newly renovated restaurant—complete with chairs, tables, and bright red tablecloths—began serving hot meals and cold drinks to travelers stopping at one of the busiest trucking corridors in southern Africa. The women quickly began turning a profit, and some of its members were able to take their earnings and start their own small businesses. 

"There has been a tremendous improvement in my life, because this time I am no longer risking my life," says Stella. "When I was doing commercial sex work, I didn't know what might happen that night. It was always my wish to not to have to do that work, but with such poverty, I was desperate and needed cash." Before she began working with APZU, Stella could not sign or even recognize her own name. Thanks to the Zalewa literacy class, she has finally learned to read and write—as well as scribble down orders as a real waitress.

Stella practicing her new writing skills.

*Name has been changed.

Childhood brings threats such as diarrheal disease and malnutrition to girls in poor countries. A lack of clean water and proper nutrition weaken their immune systems and invite infectious diseases, leading to health problems that can last a lifetime and into the next generation.

CHILDHOOD SUCCESS STORIES

Taisha's Story: A young girl avoids cholera because of a water project in Haiti

Rachel's Story: In Malawi, PIH's Nutritional Rehabilitation Unit allows for rapid and dramatic recoveries

Mother to Child (VIDEO): Slowing the spread of HIV through transmission from mother to child

RACHEL'S STORY:
In Malawi, PIH helps malnourished children make rapid and dramatic recoveries.

By Robbie Flick, Health Programs Coordinator, Malawi

Two-year-old Rachel Namazongo only recently began growing her first strands of hair. Her eyes twinkle and her lips curve into a grin as she toddles over and climbs onto the lap of Blessings Banda, the HIV and Nutrition Manager for PIH’s sister organization in Malawi, Abwenzi Pa Za Umoyo (APZU).

Just three months ago, Rachel didn’t have the energy to walk. Listless and with sunken eyes, the toddler was dehydrated and severely malnourished, recalls Banda. The circumference of her upper arm, measured to assess the nutritional status of children, was less than 9 centimeters — about the circumference of a plastic bottle cap. At this acute stage of malnutrition, she was so sick that she didn't want to eat, said Banda. Her frightened mother brought her to a nearby children’s clinic in the rural southwestern corner of Malawi.

Sadly, Rachel’s poor health is not an unusual story. Many Malawian children suffer from malnutrition, which is the single biggest contributor to child death in the country, according to UNICEF. Girls, in particular, carry the heaviest burden of malnutrition worldwide – they are twice as likely as boys to die from malnutrition as boys, according to the Food and Agriculture Organization. But Banda and his team of clinicians from PIH/APZU and the Malawian Ministry of Health were determined that Rachel would not become a statistic—and they had the resources to act.  

Seeing that Rachel needed immediate medical care, Banda’s team quickly transported her to Neno District Hospital for admission into the new Nutritional Rehabilitation Unit (NRU).

A complex battery of health issues most likely contributed to the young girl’s malnutrition. She was treated for parasites and given antibiotics to help fight other possible infections. Doctors also diagnosed her with HIV, and quickly began a course of lifesaving antiretroviral therapy. The medication soon helped spark her appetite, and the NRU staff was well-equipped to provide her with food especially formulated to combat her condition.

	Rachel with her mother, shortly after being admitted to the Nutritional Rehabilitation Unit in Neno, Malawi.
	Rachel one week after being discharged from the Nutritional Rehabilitation Unit, with Blessings Banda, HIV and Nutrition Manager for APZU.

Every day, she ate packets of a special calorie-rich therapeutic food. Thanks to partnerships with UNICEF and Two Degrees Food, APZU has access to a peanut-based therapeutic formula for treating severely malnourished children. The special calorie-rich product quickly helped put weight onto her small frame. After just two weeks of the intensive therapy, which also included drinking a daily concoction of nutrients, Rachel was well enough to return home.

Rachel is one of the dozens children who are now enjoying healthy childhoods thanks to the lifesaving care provided by the NRU since it opened in May 2011. The space — with its walls of colorful, hand-painted cartoon animals and hanging dioramas of repurposed plastic — allows clinicians at PIH to provide a full spectrum of care for acutely malnourished children, from treatment of underlying infections like HIV and malaria to a balanced food regimen that allows rapid recovery. Because of the NRU, a child like Rachel can quickly recover from a critical state and begin living a healthy childhood in just weeks.

Lifesaving care does not end at the NRU's doors, however. As a patient in APZU’s outpatient nutrition program, Rachel receives food packets from our partners and other food supplies to help prevent malnutrition from returning, including Likuni Phala, an enriched corn-soya blend that can easily be cooked in the home. She will also continue to receive antiretroviral therapy for the rest of her life.

Today, Rachel has the contagious energy of a healthy toddler. “Rachel’s progress has been a tremendous improvement,” Banda says, as Rachel grabs his pen and scribbles on his notebook. “I am really thanking the family for making sure Rachel adheres to her medication and nutrition support, as these things go together.”

“However, there is still much more to be done for a child like Rachel,” he adds. Rachel’s mother has no source of income, for example, and because she was in the hospital with Rachel during the planting season, she has no crops to harvest. In addition, like other HIV patients on antiretroviral therapy, Rachel faces heightened nutritional needs that must be met. To address these complex issues, Blessings alerted PIH/APZU’s Program On Social And Economic Rights, who conducted a needs assessment and will support Rachel and her family to help her stay in good health.

Learn more about PIH's work in Malawi.

Adolescence is a difficult time for girls everywhere, but coming of age in a developing country carries even greater risk. Teenage girls living with HIV struggle to come to terms with their condition. As girls mature, they face contracting sexually transmitted infections such as HIV and human papillomavirus.

ADOLESCENT SUCCESS STORIES

Gardasil Vaccination: In Haiti, thousands of girls are vaccinated against HPV, the disease that can lead to cervical cancer

Carmen's Story (VIDEO): After losing her legs as a result of Haiti's 2010 earthquake, a young woman devotes herself to helping others

Marie's Story: In Rwanda, a young woman gains access to an education

Pulane's Story (VIDEO): In Lesotho, a young girl receives treatment for multidrug-resistant tuberculosis

MARIE'S STORY:
The Women and Girls Initiative Scholarship Program sends young women and girls back to school in rural Rwanda.

Some of the recipients of a new scholarship for adolescent girls in Rwanda.

By Grace K. Ryan, Department of Community Health and Social Development, Partners In Health/Inshuti Mu Buzima, Rwanda

The “New Life” club is starting to live up to its name, according to Marie*, an 18-year-old orphan from the Nyamirama sector of Eastern Rwanda. In January 2012, she and 40 other at-risk girls aged 12 to 19 started school for the first time in years, formally launching the Women and Girls Initiative Scholarship Program.

The Women and Girls Initiative was founded in 2009 by Didi Bertrand-Farmer, Director of Community Health and Social Development at Partners In Health’s Rwandan sister organization, Inshuti Mu Buzima (IMB). “The objective,” Ms. Bertrand-Farmer says, “is to produce girls who are independent, who have access to information so that they can make healthy decisions about their lives.”

With the help of local authorities, health center staff, and representatives from IMB, more than 120 out-of-school girls in Nyamirama sector were organized into six clubs, including “New Life.” These clubs meet weekly to discuss health and reproductive issues, offering peer-to-peer psychosocial support and a platform for health outreach programs organized through the health center.

"We want to eliminate barriers to education for these girls"

“But this is only the beginning,” says Ms. Bertrand-Farmer. “We want to eliminate barriers to education for these girls and ensure their economic independence.” IMB is currently seeking partnerships with local and international organizations experienced in vocational training, microfinance, and women’s cooperatives, in order to empower the girls economically. In the meantime, the clubs have identified 41 members who are ready to complete their education. These girls will receive school-fee support, uniforms, sanitary products, and other necessary materials to continue their schooling.

“Educating a girl is important,” explains Marie, “because a girl who can go to school can find work and money for her future. Otherwise she will look to a man to give her money.”

After a traffic accident killed both of her parents ten years ago, Marie was adopted by a single mother of seven, named Therèse. Now in her fifties and often in poor health, Therèse struggles to provide for her family as a farmer. Two years ago, she realized she could no longer afford her children’s school fees. Marie dropped out of secondary school and became pregnant not long after. 

Linking health, poverty, and education

The connection between health, poverty, and education are palpable in the stories of girls like Marie, who show not only remarkable resilience but also creativity in the face of adversity. Another 18-year-old scholarship beneficiary, Lucille, describes a special support system her club has developed. Each of the 20 members tries to bring 100 Rwandan Francs (about 17 US cents) to their meetings, to be pooled together and donated to a different girl each week. With the 2,000 francs ($3.30) collected, she can buy hygiene and sanitary products. “So we don’t rely on men,” Lucille explains.

PIH/IMB staff and partners from Nyamirama Health Center and local government, with scholarship recipients and their parents.

In the Rwandan health system, community health workers are responsible for pregnant women, infants, and children up to age five, but adolescents must rely on school programs for health education. Girls who cannot afford school fees are economically vulnerable and lost to the health system until they become pregnant—which is often all too soon. With limited access to the cash economy, girls struggling to make ends meet in rural communities may leverage their romantic relationships in order to survive. They may not fully understand the potential consequences—a teenage pregnancy or sexually transmitted infection—or how to protect themselves.

Girls in Nyamirama are particularly vulnerable. The sector was hard hit by Rwanda’s 1994 genocide, leaving a HIV infections and child-headed households in its wake. Of the girls who returned to school in January, 10 percent are orphans and 68 percent have only one living parent. Of the girls who do have two living parents, 33 percent have at least one parent who is incapacitated by illness or disability. Many of the girls themselves bear the scars of conflict, including Lucille, who was wounded in the leg as an infant during the genocide.

Marie said that she wouldn't have become pregnant even if she had been enrolled in school over the past two years, adding, “It’s time to change ideas.” She plans to take advantage of her education to pursue a career as a deputy in local government, so that she can help develop her sector, even as she helps herself, her baby daughter, and her adoptive family.

As Partners In Health Co-Founder Dr. Paul Farmer has written, “You will never break the cycle of poverty and disease without educating girls.” For the girls of the Nyamirama Women and Girls Initiative, scholarships are a humble first step.

*The names of the participants have been changed to protect their privacy.

About 70 percent of deaths of children under five happen in the first year of their lives. Exposed to dangers such as HIV, poor nutrition, and the loss of a mother, baby girls need health and social services to help them grow strong.

INFANCY SUCCESS STORIES

Diana's Story: Supporting orphans and preventing maternal deaths in Malawi

From Birth to Toddlerhood: Butaro Hospital in Rwanda continues to serve quadruplet sisters

FROM BIRTH TO TODDLERHOOD:
Butaro Hospital in Rwanda continues to serve quadruplet sisters.

Quadruplet sisters at their home in northern Rwanda.

In July 2009, a crowd of curious and jubilant villagers gathered outside Butaro Hospital in northern Rwanda. News of a seeming miracle had drawn them to the facility—the birth of healthy identical quadruplet girls.

“The chances of a woman giving birth to quadruplets are in the region of one in 800,000; the odds of them sharing a single placenta run into tens of millions,” said Dr. Mickey Sexton, a PIH doctor who was working at Butaro that day.  

Their birth became a day of surprises, especially for their mother—she had come to the hospital to seek treatment for a slight cough. Minutes after arriving, and about eight months into her pregnancy, she went into labor. However, more surprises were to come. Her 20 week prenatal check-up had revealed two babies. While she was in labor, PIH's Dr. Juvenal Musavuli noticed that the mother’s abdomen was enormous—measuring 49 cm (more than 36 cm is generally considered abnormal), so decided to perform another ultrasound scan. He was shocked to find three babies. The first two were delivered without difficulty, but the third was born in the breach position—she was so small that he was able to ease her out by her feet. And then came another surprise—Dr. Musavuli discovered that there was still one more baby waiting to be born!

Knowing the babies would be very premature, Dr. Musavuli knew that they should ideally be delivered somewhere with a neonatal intensive care unit. However, there wasn’t time to transport their mother to Kigali, Rwanda’s capital city, before she gave birth. Luckily, all four babies were healthy enough to survive the trip to Kigali after being born.

Today, Butaro District Hospital boasts a modern neonatal special care nursery, as well as a full array of prenatal, post-natal, and emergency obstetric services to care for other babies born prematurely and for their mothers. Even in 2009, the very existence of Butaro Hospital likely saved the lives of the four girls and their mother—before PIH and its Rwandan sister organization Inshuti Mu Buzima (IMB) arrived in the Burera district in 2007, the district did not have a functional hospital. Women in labor would have to risk crossing Lake Burera by boat in order to reach the nearest medical facility.

The quadruplets and their mother eventually returned to Butaro hospital, where they were carefully monitored by doctors, nurses and nutritionists until they were strong enough to go home. However, PIH/IMB made sure that their services wouldn’t end with their discharge, said Léonce Byimana, a program coordinator for PIH/IMB.

Ministry of Health and IMB/PIH worked together provide assistance to the parents, who would otherwise not have been able to support their family, which included five children in addition to the four babies. A nutrition technician and social worker have kept in close touch with the family to follow up with any nutritional and social issues faced by the family. The family was also provided with a monthly package of milk and food supplements, as well as a dairy cow. In addition, PIH has helped build the family a bigger house with four rooms, a kitchen, and bathroom—they had previously been crammed into a small one-room hut.

Today the quadruplets are happy, healthy toddlers, doted upon by their parents and five older siblings.

Learn more about PIH's work in Rwanda.

About 70 percent of deaths of children under five happen in the first year of their lives. Exposed to dangers such as HIV, poor nutrition, and the loss of a mother, baby girls need health and social services to help them grow strong.

INFANCY SUCCESS STORIES

Diana's Story: Supporting orphans and preventing maternal deaths in Malawi

From Birth to Toddlerhood: Butaro Hospital in Rwanda continues to serve quadruplet sisters

DIANA'S STORY:
Supporting orphans—and preventing maternal deaths—in Malawi.

Diana's mother died in childbirth. Abwenzi Pa Za Umoyo (APZU), PIH's sister organization in Malawi, is working to make sure Diana will not face the same struggle as her mother.

“If you want to understand what APZU has done,” said Veronica Kanyenda, a nurse at Neno District Hospital in Malawi, “you should know the story of the baby Diana.” She pointed out a small child sitting on a young woman’s lap in the shade of the health center’s metal roof. 

Veronica, affectionately called masiteni (mother) by junior staff, first met Diana the day after her birth. Diana’s mother, Madalitso, was just 15 years old. Afraid to tell anyone of her pregnancy, she hid it, and delivered Diana behind her home. She suffered a post-partum hemorrhage—heavy bleeding that usually requires emergency medical care. Her family and neighbors administered traditional medicines, but Madalitso died at home, leaving Diana an orphan. 

Wondering how she would feed and support the tiny baby, Diana’s young aunt brought her to Neno District Hospital, where staff from the Ministry of Health and APZU provided the newborn with medical care and gave her family infant formula, clothes, and the on-going social support of a community health worker. 

“Without APZU, Diana would have been another statistic,” said Veronica. “She would have been an orphan in a family that lacked the means to support her. She would have died."

However, Veronica acknowledges that the best way to ensure that other girls like Diana have a chance to grow up healthy is to ensure that their mothers survive to care for them. The tragic fate of Diana’s mother is commonplace in Malawi. Malawi’s maternal mortality rate—a measure of deaths from pregnancy-related causes—is among the highest for all developing countries at one maternal deaths for every 148 live births.

The average woman in Malawi has five children, and almost half of these children are delivered at home. Home deliveries in rural Malawi are risky. When complications requiring emergency obstetric care—such as Caesarean sections—occur, health facilities may be hours or even a day’s journey away.

To prevent maternal deaths, APZU employs a community-based model that supports women in their reproductive health choices and links them to a strong clinic- and hospital-based women’s health program. The maternal health program focuses on prenatal care (as is standard in most public health programs) and on emergency obstetric care. Other program priorities include providing access to transport to a facility for women in labor, skilled attendants to perform deliveries, and blood and surgical services for when complications occur.

When Veronica first met Diana, she knew APZU could help because of the Program on Social and Economic Rights (POSER), which enabled her to provide social support as well as clinical care.  POSER embodies PIH’s efforts to treat not just the symptoms of disease but the extreme poverty that causes illness by providing the poorest patients with support such as food, transportation, jobs and agricultural supplies. Since Diana’s birth, the POSER team has routinely supplied her family with baby formula, food, fertilizer, soap, and charcoal to cook with. 

“APZU saved this child’s life,” Veronica said. Today, she is a lively young girl who plays with her cousins and chatters with her neighbors.

Working closely with the government of Malawi—in particular new President Joyce Banda's Safe Motherhood Initiative, Veronica and her APZU colleagues hope that Diana will never face her mother’s fate. And the day may come when Veronica will no longer have to tell the story of a small child orphaned because her mother died during childbirth.

Learn more about PIH's work in Malawi.

As women age, they battle chronic diseases while playing an important role in the care of their families. Partners In Health is working to address chronic diseases through regular visits and accompaniment of community health workers.

OLDER ADULT SUCCESS STORIES

New Stoves Curb Disease: Reducing kitchen smoke in rural Guatemala

Non-communicable Diseases (VIDEO): Controlling asthma and diabetes in rural Rwanda.

Gulmira's Story: In Kazakhstan, a family survives MDR-TB

NON-COMMUNICABLE DISEASES:
Controlling asthma and diabetes in rural Rwanda.

Medical conditions like asthma and diabetes, readily controlled in wealthy countries, are debilitating and often life-threatening in poor communities where the basics are hard to come by.

Learn more about PIH's work treating non-communicable diseases. 

Around the world, nearly 800 women die every day in childbirth—and 99% of these deaths occur in developing countries. Delivering a baby can be dangerous where women must hike hours in labor to reach a health facility, if one even exists.

PREGNANCY & CHILDBIRTH SUCCESS STORIES

Peruth's Story: A mother in Rwanda receives an emergency cesarean section

Gertrude's Story: In Malawi, a woman living with HIV dedicates her life to helping new mothers after losing her infant to that disease

Maternal Health (VIDEO): In Lesotho, women with HIV learn to care for themselves and their newborns

Maternal Health (VIDEO): Providing emergency obstetric care in post-earthquake Haiti

GERTRUDE'S STORY:
A woman living with HIV fights for better care in Malawi.  

Gertrude (sitting, far left) meets with women as they enter PIH's clinic in Neno, Malawi.

In Malawi, a mother living with HIV helps other young women break the cycle of disease.

Gertrude has a strong build that she carries with extraordinary grace at the weekly gatherings of HIV-positive patients where she dances and sings public health messages to crowds that grow larger by the week. 

She embodies a comforting maternal presence that calms women living with HIV, many of whom feel overwhelmed by the stigma of living with the disease. For over 10 years, she has been leading the community to help fight the disease that has affected her so personally.

In 2002, Gertrude gave birth to a baby boy. He failed to put on weight, grew sick, and died before his second birthday. Distraught and searching for answers, Gertrude got tested for HIV and was found to have the virus. At a time when there was no district hospital or access to antiretroviral therapy (ART) in Neno, Malawi, this was a grim diagnosis. Even worse, with the odds already stacked against her, her husband left her when he discovered her status.

Gertrude speaking at a women's health event.

Where many women might have given up, Gertrude harnessed her natural charisma and leadership skills to mobilize fellow community members. Together, they launched an organization, the first of its kind in the region, dedicated to advocating for the rights of people living with HIV and raising awareness about the disease. To combat stigma and isolation, they revealed their own status and held community mobilization events that sought to encourage people to get tested and promote safe practices, despite the serious consequences this kind of exposure often carries. 

“People said lots of things about me,” Gertrude explains. “When I went to gather water, people would run away. Children would sing songs, mocking me because I had HIV.”

When asked how she kept working, Gertrude answered, “A problem shared is already half solved. I needed to show people that if you have HIV, you are as strong as anyone else. That it’s important to get tested, because HIV does not mean you will die.”

Gertrude fought on, winning funds for her organization and attending conferences around Malawi.  

In 2004, ART drugs were finally available at Queens Hospital, the major public hospital in Blantyre, capital of Malawi’s southern region. Every month, Gertrude walked through 60 kilometers (37 miles) of mountainous jungle terrain just to get to the closest paved road where she could hail a minibus to Blantyre. There, she waited in line all day and all night, often sleeping in line to get her ART. At several points over the years, she has contracted TB and has been forced to spend up to six months in the hospital for treatment.

Gertrude singing at a tuberculosis advocacy event on World TB Day, which falls on March 24 each year.

Unbelievably, none of this seemed to slow her down.  

In 2006, she founded and led the Neno AIDS Support Organization and provided critical mentorship and training to four other organizations around Neno, helping them flourish and join the fight against HIV. And Gertrude’s community-based efforts to fight stigma paved the way for PIH’s future success in rapidly scaling up HIV testing and antiretroviral therapy in Neno district, which began in 2007. 

Gertrude has been accessing ART in Neno for five years now, in the same hospital where she now works as an attendant, keeping her viral load undetectable and helping her stay healthy. It came as little surprise when she was elected overwhelmingly to become vice president of the Neno Community Support Initiative at APZU, a position that allows her to leverage her experience in community mobilization to hold massive community outreach events. 

Now, with over 4,000 individuals able to receive lifesaving ART in 13 health facilities across Neno, and over 1,000 on pre-ART, Gertrude is happy.

“It’s so much better now,” she says, “Not only is treatment available everywhere, but people get food support also. I can go to ART clinic any time now.” 

Looking to the future, she wants to make sure the nine children she is raising—eight adopted from siblings who died of HIV—find happiness and success. “I have a vision of Malawi and the entire world free of HIV,” she said, a vision she works towards every day and invites us all to contribute to.

Learn more about PIH’s work in Malawi.

Adolescence is a difficult time for girls everywhere, but coming of age in a developing country carries even greater risk. Teenage girls living with HIV struggle to come to terms with their condition. As girls mature, they face contracting sexually transmitted infections such as HIV and human papillomavirus.

ADOLESCENT SUCCESS STORIES

Gardasil Vaccination: In Haiti, thousands of girls are vaccinated against HPV, the disease that can lead to cervical cancer

Carmen's Story (VIDEO): After losing her legs as a result of Haiti's 2010 earthquake, a young woman devotes herself to helping others

Marie's Story: In Rwanda, a young woman gains access to an education

Pulane's Story (VIDEO): In Lesotho, a young girl receives treatment for multidrug-resistant tuberculosis

Angelique's Story: In Rwanda, young girl affected by HIV enrolls in a mental health support group

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ANGELIQUE'S STORY:
A support group for HIV patients in Rwanda helps teens overcome their fears.

Support groups for adolescents and children affected by HIV include time to relax and socialize with their peers.

When she was 16 years old, Angelique* tested positive for HIV. She had already lost both her mother and stepmother to AIDS. Scared and angry, the teenager from the rural Rwinkwavu community in eastern Rwanda blamed her father for infecting her family.

Adolescence can be a time of emotional and psychological stress for many girls. For those living with a stigmatized disease like HIV/AIDS, having emotional support can be crucial. In Rwanda, Partners In Health is working to target these teens with a number of mental health and social support programs and services.

After an initial grieving period, Angelique finally came to terms with her status. She began antiretroviral therapy (ART) and started attending the adolescent counseling group at Rwinkwavu Hospital.

When Angelique first joined the adolescent counseling and support group, she harbored a lot of insecurities. She was uncomfortable with the realities of her diagnosis and was afraid of facing stigma and having others find out about her status. But thanks in large part to the holistic bio-psycho-social curriculum and the support of an HIV-positive peer group, she overcame her fears and is now the leader of the adolescent girls’ Saturday counseling group.

	Inshuti Mu Buzima, PIH's partner organization in Rwanda, holds support groups for children (pictured above), as well as for adults and adolescents.

Now 20 years old, Angelique leads the group in song and drumming and assists the nurse and social worker in educating her peers as well as in directing field trips. Her confidence and willingness to share her experiences with the group has inspired other young women to talk about living with HIV and coping with stigma. She now presents herself as an example of how to take care of oneself and often shares her struggles with opportunistic infections with her peers to teach them how to stay healthy and manage their HIV.

Angelique is currently in her second year of a secondary school at a boarding school in Kigali, where her teachers support both her health and her learning.

She remains more comfortable with peers in her counseling group than others her age; she is anxious about relatives and members of her community at her school or elsewhere finding out her status. Even so, she has come a long way.

Once she completes secondary school, Angelique will transition into an Adult HIV support group, where the nurses are confident that she will flourish. She has already exhibited the capacity to manage her own health and has been a valuable resource to other HIV-positive adolescents learning to care for themselves.

*Name has been changed to protect the privacy of the patient.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

JELEN'S STORY:
In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family.

	Jelen and her two children walk through the Gamarra district in Lima, Peru.

Jelen is a fighter. As a street vendor, she fights every day against the authorities, the competition, and the street. As a single mother, she fights to give her children the best life she can.

With the help of PIH’s sister organization in Peru, Socios En Salud (SES), she recently fought—and won—one of the most difficult fights of her life: the fight against multidrug-resistant tuberculosis (MDR-TB). In doing so, Jelen (pronounced Helen) closed a difficult chapter in her life.

After completing 18 months of treatment, Jelen’s life has begun to return to normal. With help from SES, she has launched her own small business. Every afternoon, she goes out with more motivation than ever to sell her homemade curtains.

“It’s made me stronger,” says Jelen. “To be sick isn’t just about taking medicines. It’s a really long, hard fight, both the treatment and the side effects from the medication. But finally I won.”

With SES microfinance, Jelen starts a new life

Jelen is part of a large group of vendors in Gamarra, a district of Lima that is home to roughly 90,000 people who sell homemade products. The streets are their storefronts. 

	Sewing curtains at home and selling them in Lima's shopping district has allowed Jelen to become her own boss.
	A now healthy Jelen stands in front of the hills of Lima.

“Now I am happy every day,” says Jelen. “When I’d go out to work while I was in treatment, I didn’t like getting there. I took some of my medications in the mornings and then the other half in the afternoon, which made me feel sick. And that’s how I’d go out to work. All the sounds and background noise were unbearable, but that’s how I’d have to go around offering my products so people would buy from me.”

Now Jelen is motivated to sell curtains, and she has developed tools to improve her family’s financial situation.

“Before I’d sell about 40 to 60 soles a day (US $14 to $20), and now I sell between 80 and 100 ($28-35),” says Jelen. “I’ve gotten better. Now with my sewing machine I can be making things at any time I want and can take orders.”

Her improved health and income have enabled Jelen to live in a more comfortable home and focus on making sure she and her kids are able to buy nutritious food.

Jelen is just one of tens of thousands of Peruvians who sell wares on the street. Almost always, these workers make inadequate incomes, work long hours, and lack access to medical insurance.

Stitching together a small business 

“I’d been working before for a sewing shop,” recounts Jelen. “They’d give me 1,000 shirts to stitch and they’d pay me 1 sol (US $0.35) per shirt. But that would take me a long time. In just four days I’d have to hand back all those shirts. So I’d be up all night sewing, resting only four or five hours, and I wasn’t eating well. All of that made me weak and I think that’s why I got sick.”

Since then, with the loans from SES, she has become independent. And her business is expanding. “My goal this year is to buy a couple more machines, rent a stand, and sell wholesale.” 

Though business was a little slow in late 2011, Jelen recently obtained a third loan for her business, this time with Mi Banco. While SES provided the the first two loans Jelen used to start her business, she is now financially stable enough to obtain a loan from a bank, with SES serving as an intermediary.

Making a long-term investment

After saving up money for the past few years, Jelen has broken a long cycle of poverty. In January 2012, her son began attending a local vocational college with the goal of becoming a police officer.

“I’ve told him we’ll have to save up a lot of money for that. And we’re going to do it,” said Jelen. “One of my goals is to give 100 percent to my son, so that he becomes someone great.”

After a year of coursework, Jelen’s son plans to apply to the Academy of the National Police Force of Peru.

Though Jelen has completed treatment and is increasingly financially stable, SES continues to check in with her every month to see how her business is going and provide technical assistance when needed. 

Learn more about PIH’s work in Peru.

As women age, they battle chronic diseases while playing an important role in the care of their families. Partners In Health is working to address chronic diseases through regular visits and accompaniment of community health workers.

OLDER ADULT SUCCESS STORIES

New Stoves Curb Disease: Reducing kitchen smoke in rural Guatemala

Non-communicable Diseases (VIDEO): Controlling asthma and diabetes in rural Rwanda.

Gulmira's Story: In Kazakhstan, a family survives MDR-TB

WORKING TOGETHER:
Women's groups come together to reducing the threat of respiratory disease in Guatemala.

“After nearly one year of use, the results are nothing less than dramatic,” said Lindsay Palazuelos, PIH’s project coordinator in Guatemala. A project has sharply reduced the wood smoke that causes lung disease by introducing improved cooking stoves in the rural village of Jacaltenango, Guatemala. 

Women from various small communities came together and learned how to assemble and care for their new stoves.

In July 2011, PIH and the PIH-supported Equipo Tecnico en Educación y Salud Comunitaria (ETESC) partnered with women’s groups from dozens of communities to organize and implement this project, largely led by family matriarchs, women who run their families' homes and care for children and often grandchildren. In total, 175 families learned to install, use, and maintain improved wood-burning ONIL stoves, manufactured by HELPS International.

In a region where wood is the main source of cooking fuel, harmful smoke fills kitchens and forests steadily shrink as people chop down trees for fuel. 

Less than a year after receiving new stoves, families saw a 90 percent decrease in kitchen smoke, significantly reducing both wood consumption and the smoke-related diseases – asthma, chronic respiratory disease, and lung cancer – affecting people in rural communities like Jacaltenango.

Only 6 percent of women in participating households reported coughing during or immediately after cooking, a steep decline from the 46 percent of women who reported coughing prior to receiving new stoves.

On average, the 24-hour carbon monoxide exposure readings in homes outfitted with the new stoves fell by 77 percent. 

Families also decreased the amount of wood they used by 50 to 70 percent.

Read “Improved stoves replace indoor cooking fires, ‘silent killer’ of women.”

A "hidden" health crisis

"Visitors to rural Guatemalan homes are often astounded by the thick smoke filling people’s homes,” Palazuelos said. Families spend a significant amount of time and money buying, chopping, and hauling wood to cook meals and heat water, all of which has to happen multiple times a day.

A home before the introduction of the new OLIN stoves.

New stoves reduce floating particles by 90 percent.

“Because of this, it’s not uncommon to meet middle-aged women suffering from emphysema or chronic bronchitis, as if they were lifetime smokers,” Palazuelos said. “But instead of a two-pack-a-day habit, they’ve simply been making beans and tortillas in a smoky kitchen.”

Roughly 90 percent of rural households worldwide still use solid fuels such as wood and charcoal for cooking. As a result, an estimated 1.5 million people die prematurely from smoke-related diseases each year, making this the eighth most dangerous contributor to the global burden of disease.

In response to high rates of respiratory illness, ETESC invited five communities to form environmental health committees – each consisting of 35 families.

Over 90 percent of representatives are family matriarchs, adult and older women who run not just the family kitchen, but the home generally.

Once the committees had been established, ETESC's local Environmental Health Promoters presented each of them with five environmental health projects that could be introduced into their community to improve their quality of life.

After receiving training on environmental health themes and analyzing their own communities, all five communities chose to introduce high-energy, low-smoke stoves. 

A significant environmental effect

ETESC’s team of local Environmental Health Promoters travelled by foot to participants’ homes several times before and after the stoves’ introduction to weigh woodpiles, survey participants, and measure carbon monoxide. 

On average, the improved stoves have reduced the amount of wood that participating families use for cooking fuel by more than half, from 17 kg (37.4 lbs) to 8 kg (17.6 lbs) per day. Over the course of one year, each family will save on average over three tons of wood, while the group as a whole will save over 400 tons. This saves trees and slows deforestation. 

The old, open-fire stoves (left) posed a greater risk of injury than the new OLIN stoves (right).

Decreased wood consumption also makes an economic difference to families. Local families either spend hours hauling wood, typically on their backs over long distances or buy it with their limited income. The reduced fuel consumption significantly lessens the amount of time and money spent procuring wood.

Next steps

Installation of the stoves represents the first part of a three-year campaign in which communities will participate in regular environmental health workshops and choose projects to implement. The before-and-after data will be presented back to the participants, many of whom are not literate, through interactive games and demonstrations, to help inform their future planning.

PIH and ETESC’s three-year environmental health initiative is funded by Green Mountain Coffee Roasters.  

Addressing non-communicable diseases is an integral part of PIH's work.
Learn more about PIH’s work in Guatemala.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

LOMILE'S STORY:
A mother adopts five orphans after raising her own children. 

Lomile September raised 3 children to adulthood, then started over with five more who had lost their parents to HIV and MDR-TB.

Learn more about Lomile September's adopted family.
Learn more about PIH's work with orphans and vulnerable children. 

Around the world, nearly 800 women die every day in childbirth – and 99% of these deaths occur in developing countries. Delivering a baby can be dangerous where women must hike hours in labor to reach a health facility, if one even exists.

PREGNANCY & CHILDBIRTH SUCCESS STORIES

Peruth's Story: A mother in Rwanda receives an emergency cesarean section

Gertrude's Story: In Malawi, a woman living with HIV dedicates her life to helping new mothers after losing her infant to that disease

Maternal Health (VIDEO): In Lesotho, women with HIV learn to care for themselves and their newborns

Maternal Health (VIDEO): Providing emergency obstetric care in post-earthquake Haiti

PERUTH'S STORY:
An expecting mother is rushed to the hospital where she receives an emergency cesarean section.  

Early one morning this year, before the sun had risen, Peruth, 36, set out for the health center nearest to her home. She was in labor with her fifth child. The health center isn’t very far away. But Peruth’s home is perched on top of a steep mountain, and she had to descend a rocky footpath in the dark, as labor pains wracked her body.

She wasn’t too worried. Peruth had attended all four of her recommended prenatal visits at the health center, and all signs pointed to a normal, albeit demanding, birth. Plus, she’d had four healthy, normal pregnancies and births before. But neither she nor her nurses could have predicted that the baby would become distressed and need to be delivered via emergency C-section.

The nurses knew that she would need to be transferred to the nearby district hospital—the PIH-supported Butaro Hospital.

When she arrived, the surgical team flew into action. The operating room was prepped and a team assembled. Dr. Theophile and Dr. Emily, the anesthesiologists, joined Dr. Sierra, an obstetrician, and Dr. Illuminee, a general practitioner at Butaro who specializes in maternal health. They immediately set to the task, and within minutes, Dr. Sierra and Dr. Illuminee skillfully extracted the baby.

The baby was breathing, but barely. Dr. Emily and two midwives worked to clear the airway and stimulate breathing, and after some time, the infant regained color and vital signs. The babywould need to be watched overnight in Butaro’s Neonatal Special Care Nursery, but the team’s swift action had saved a new life.

Back on the operating table, Peruth was not faring as well. She was bleeding profusely. Her blood was not clotting. Dr. Sierra called for Dr. Robert, a Boston-based trauma surgeon, and Dr. Eric, another Rwandan general practitioner, to discuss the case. Despite receiving large amounts of blood and fluids, it became clear that in order to save her life, Peruth would need not only platelets and frozen plasma to help with clotting, but also an emergency hysterectomy. 

Despite their efforts, Peruth was still bleeding. 

The medical team called the Rwandan Blood Bank in Kigali. They would send platelets and plasma if the team could find a car to transport the products. The 2.5 hr ride from Kigali to Butaro is rocky in dry, daylight conditions. At night, it can be treacherous.  Fortunately, there happened to be a Partners In Health truck and an experienced driver in Kigali who could pick up the products and rush them to Butaro. 

If all went according to plan, Peruth would have plasma and platelets within the next three hours. 

Once they arrived, the platelets and plasma slowed and eventually stopped the bleeding. Doctors closed Peruth’s abdomen. But she was not free from peril just yet. She was in critical condition, and the anesthesia team had to take shifts monitoring her vital signs through the night.

In the morning, her condition had stabilized. After a day, her condition was stable enough for her to begin breastfeeding. After a few days, she was released with her new infant, Chirac.

Surviving was only a part of the story

Peruth is a subsistence farmer, and her husband, Theophile, drives a motorcycle taxi, paying rent weekly to be able to use an acquaintance’s motorcycle.

Peruth, her newborn Chirac, and two of her older children. Photos by Aubrey Davis.

After they had their fourth child, they knew they could not afford more. A community health worker (CHW) had taught them about birth control and how it could help them keep their family size to four. Peruth began taking oral birth control pills, with the full support of her husband. But as sometimes happens, Peruth later received a shock: she was pregnant with her fifth child.

As she recovers from a major medical procedure, Peruth worries. They don’t have anyone to work their fields, and they worry they may have to pay someone to cultivate them. Peruth also doesn’t have anyone to fetch water for her—a twice-daily task that requires she and the children walk 30 minutes to a nearby spring, and on the return trip, straining under the weight of the yellow jerry cans they carry on their heads back up the mountain. 

When asked what her biggest challenge is each day, she says it’s dealing with their poverty. They are perpetually struggling to keep enough francs in their pockets to buy the beans, potatoes, and porridge that constitute their two daily meals.

Asking “what if?”

Recalling the birth, Peruth prefers brevity. She doesn’t like to think about the night when she and Chirac almost died. She does remember that as the reality of the situation began to grip her, she envisioned her death. Her family would suffer without her—she knew that well.

Theophile admits, too, that during the ordeal, he was terrified at the thought of telling their children their mother had died.

The family is grateful to PIH/IMB. Peruth doesn’t have to think long when asked what if there weren't a hospital like Butaro nearby. “I would have died,” she says frankly, in steady, rapid Kinyarwanda.

Many Rwandan women aren't so fortunate. In 2010, 340 of every 100,000 Rwandan women died in childbirth. In the U.S., that number was 21.

But things are improving. An aggressive government campaign has resulted in 71 percent of women traveling to a clinic or hospital to give birth. As a result, the maternal mortality rate has fallen. In 2000, roughly 1,051 of every 100,000 women died while giving birth—a number that has dropped threefold in ten years.

“Buhoro buhoro” 

The kind of care that Peruth received that day in the Butaro operating room was exceptional for poor, rural communities. But it doesn’t have to be. With continued accompaniment at all levels of a healthcare system, improvements are made “buhoro buhoro,” little by little. And sometimes, the accumulation of those small changes makes a huge difference.

Before PIH/IMB began working in Butaro, there was no hospital in the entire district, and the closest health center provided poor care. Women with complications in labor often died in a health center. Worse, some women, desperate to get to a hospital, tried to make the trip to the closest facility in Musanze by being rowed across Lake Burera in a boat. Many women died in those boats before they even got across.

We’ve come far in obstetric care at PIH/IMB, but we don’t want to stop at better than before. We won’t be satisfied until all Rwandan women like Peruth have access to the kind of quality lifesaving obstetric care that she got at Butaro Hospital that day.

Read about PIH’s work in Rwanda.
Learn more about Butaro Hospital.

By Andrew Johnston

This past week, old but sturdy solid oak pews were installed in the waiting room of PIH's National Teaching Hospital at Mirebalais. The pews, which will soon support Haiti's sick while they wait to receive world-class health care, were salvaged from Saint Cecilia, a venerable Roman Catholic Church in downtown Boston.

The windows behind the pews open onto the green hills of Haiti's Central Plateau.

The 60-year-old pews were slated to be removed from the church and demolished during a recent renovation. Brian Scott, an employee of Shawmut, the Boston-based construction company directing construction of Haiti's newest hospital, saw an opportunity. He knew from the Mirebalais Hospital plans that a large number of benches were needed, so he notified Jim Ansara, the founder of Shawmut, that there were pews that could be re-used as benches in the patient waiting rooms. 

“I know that your plans calls for a bunch of waiting benches, would you like to use these?” asked Brian, who is now based in Haiti and working as the Site Supervisor at Mirebalais Hospital.

Father John Unni of Saint Cecilia, a longtime Haiti advocate, supported the idea from the start.

The benches were carefully dismantled and shipped from Boston (above). Crews are beginning to place the benches in waiting rooms as the hospital takes shape (below).

Jim immediately said “Yes!” and found funds to pay local carpenters to disassemble the benches. Due to the large amount of patient seating in the hospital, procuring all new benches would have been prohibitively expensive. To avoid interfering with the renovation schedule, the carpenters arrived on a Saturday in January 2011 and worked for 20 hours straight to complete the job.

Shawmut employees then donated their time to help organize and pack the pews.

“On a cold day in January, Shawmut office employees and supervisors in business casual khakis and dress shirts packed up the pews and loaded them onto a truck for onward shipment to Haiti,” said Brian. 

It was a labor-intensive process, and Shawmut employees Dan Bagnall, Luke Grady, Shawn Cavarallo, Andy Felix, and Chett Walsh were particularly instrumental in salvaging the pews and getting them down to Haiti.

The pews were shipped via container and arrived on-site in Mirebalais in late October. Since then, a total of 65 pews of various sizes have been re-assembled onsite by experienced volunteer carpenters from the US working closely with Haitian colleagues. So far 13 pews have been installed in the waiting area of Community Health – where children will receive malnutrition screening and vaccinations, 22 pews in the Women’s Health Outpatient waiting room for use by women seeking prenatal visits, and 21 pews for the Ambulatory Care waiting room for use by patients seeking general outpatient services.

The pews have been well received by staff and community members. Indeed, PIH emphasizes that patients should receive care in dignified, aesthetically pleasing environments, and the well-crafted pews conform to this principle. 

Learn more about Mirebalais Hospital.

IHSJ Reader     December 2011     Issue 14         

Note: Triple asterisk (***) indicates subscription-only sources.

FOREIGN AID REFORM

The Politics of Partnership: Why Taking a Risk May Actually Be the Smartest Thing US Foreign Aid Can Do (Gregory Adam, Oxfam America, December 13, 2011)
Oxfam America released a new report this week, with research from Haiti, Malawi, Ethiopia, Guatemala, and Tanzania, outlining nine ways the United States can be a better foreign assistance partner. From encouraging commitments of long-term support, to showing trust for local leaders while improving transparency, this report calls on US policy makers to accept and manage risk as a necessary part of true partnership for aid effectiveness.

Busan Partnership for Effective Development Co-operation (4^th High Level Forum on Aid Effectiveness Outcome Document, December 1, 2011)
After arduous negotiations, government representatives at the Fourth High Level Forum on Aid Effectiveness (HLF4) finalized common goals and principles for effective development. Though emerging economies such as China and India are not bound to agreements in this outcomes document, they did ultimately endorse the document under the premise of voluntary, South-South cooperation. Some established donors sought to weaken the outcomes documents in the final days of negotiation. A common set of monitoring standards that apply to everyone – new and traditional donors, as well as countries receiving aid – will be developed over the next six months to measure action towards improving local, institutional capacity for effective development. 

HIV/AIDS 

ICASA 2011: Stephen Lewis Warns “Reckless” Donors: How Dare You Decide Whether Africans Live or Die? (Stephen Lewis, Southern Africa HIV and AIDS Information Dissemination Service, December 7, 2011) In a speech delivered at the International Conference on AIDS and STIs in Africa last week, Stephen Lewis called on African political leaders to demand that funding for the Global Fund for AIDS, TB and Malaria (GFATM) be increased and restored. Lewis cites the cancellation of Round 11 by the GFATM as betrayal, and asserts that donor countries should not be able to decide whether Africans live or die. He concludes with the observation that the Millennium Development Goals are not attainable for Africa without controlling the AIDS epidemic, for which continued funding is necessary.

UN Launches Plan to Accelerate Male Circumcision for AIDS Prevention in Africa (Press Release, December 5, 2011) The  Joint UN Program on HIV/AIDS (UNAIDS) recently unveiled  a partnership with the President’s Emergency Plan for AIDS Relief (PEPFAR) to scale up voluntary medical male circumcision in Africa over the next five years as one measure of  preventing HIV  transmission. The expansion and rollout will focus on scaling up services in 14 priority countries in eastern and southern Africa, including Lesotho and Malawi. Voluntary medical male circumcision has been found to reduce the risk of HIV transmission from women to men by 60%. Focusing on national ownership, implementation of these strategies will serve as a high impact step in reaching an HIV-free generation.

Voluntary Medical Male Circumcision for HIV Prevention: The Cost, Impact, and Challenges of Accelerated Scale-Up in Southern and Eastern Africa (UNAIDS and PEPFAR Collection, PLoS, November 29, 2011) PEPFAR and UNAIDS released this collection of articles highlighting how scale up of voluntary medical male circumcision in eastern and southern African can help prevent HIV at an individual, community, and population level.

Reducing AIDS funding will deal a devastating blow (Joyce Kamwana, The Hill, December 2, 2011) 
In this piece Minister Binagwaho credits the government of Rwanda for their success in promoting an integrated, community-driven development process. By emphasizing the importance of empowering citizens through nationwide economic initiatives like using community cooperative savings mechanisms, nationwide programs have encouraged a spirit of independence. This spirit is the result of an unwavering commitment to the participatory process and the health and wealth of all Rwandan citizens.

RWANDA

HPV Vaccine in Rwanda: Different Disease, Same Double Standard (Agnes Binagwaho, Claire Wagner, Cameron Nutt, The Lancet, December 3, 2011)
In response to doubts about Rwanda’s national human papillomavirus (HPV) vaccine rollout, Rwanda’s Minister of Health, Dr. Agnes Binagwaho, cites research that directly refutes arguments against Rwanda’s progressive health policies. Given Rwanda’s successful vaccination coverage rates (upwards of 95%) and the known effectiveness of the HPV vaccine, the authors write that refusing to support strategies solely because of where women are born is a violation of human rights.

Health, Human Rights, and Democracy In Rwanda (Agnes Binagwaho, The Rwanda New Times, December 11, 2011)
In this piece Minister Binagwaho credits the government of Rwanda for their success in promoting an integrated, community-driven development process. By emphasizing the importance of empowering citizens through nationwide economic initiatives like using community cooperative savings mechanisms, nationwide programs have encouraged a spirit of independence. This spirit is the result of an unwavering commitment to the participatory process and the health and wealth of all Rwandan citizens.

MULTIMEDIA

The Beginning of the End of AIDS (World AIDS Day broadcast, ONE Campaign and (RED), December 1, 2011)  
Tune into this World AIDS Day broadcast, hosted by the ONE Campaign and (RED), to hear President Obama (at 0:38:10), George W. Bush (at 0:33:05), Bill Clinton (at 1:48:00), Bono, and others discuss the progress that has been made in the HIV/AIDS epidemic over the past thirty years and why evidence that treatment can prevent transmission could be the beginning of the end of AIDS.