Rampant flooding and mudslides in the wake of the storms destroyed buildings, crops, and belongings in low-lying areas throughout Hinche, Mirebalais, Petite Riviere de l'Artibonite, and Saint-Marc. Moreover, the true scale of the damage is still unknown, as the ZL team is still finding isolated, remote pockets of severely devastated villages throughout the region.

PIH’s partners in Haiti, Zanmi Lasante (ZL), are currently working overtime to help care for those who lost nearly everything—including about 1,000 patients and ZL staff. Meanwhile the PIH Boston staff is working to quickly find and ship the most desperately needed supplies. Although PIH had never intended to be an emergency relief organization, the team quickly discovered that they were one of the only organizations able to quickly access, assess, and begin delivering relief to the flooded areas.

“Our team is able to [assess the situation and immediate needs] because of the strong community network of social workers and community health workers, who are living in the situation so we can get the kind of information that others have no access to,” said PIH Medical Director Joia Mukherjee.

Unfortunately, these assessments have been grim (see sidebar). “The overall numbers for affected people in our sites are daunting,” wrote Mukherjee in an email from Haiti. She estimates that about 10,000 people across four communities were forced to flee their homes (about 1 million have been displaced throughout the country—about 12% of the total population of Haiti). Almost 7,000 people are now living in 25 makeshift shelters supported by ZL. Supplying these shelters with food, clean water, basic medical care, and basic living essentials (clothing, beds, etc.) has become a key priority.

	A shelter in Hinche providing a hot meal
	A school classroom was converted into a mobile clinic in Mirebalais

Thanks to generous emergency donations from PIH supporters, the ZL team has been able to begin providing these needs. Most supplies thus far have been procured quickly and locally, but within days of the flooding the PIH Boston team was also able to procure and ship a 40-foot long container loaded with almost 9 tons of medical supplies, mattresses, water jugs, and other supplies. An air shipment will rush medical supplies, clothing, water jugs, and water filters down to the ZL team within the next few days, and several more 40-foot-long containers will soon be packed with medical supplies and equipment, water, clothing, sheets and blankets. ZL is also partnering with the Haitian Government and other organizations such as the Haitian Red Cross, the Clinton Foundation, World Vision to bring in needed food and supplies.

The ZL team also quickly began organizing mobile clinics to provide medical care and treat malnourished children. The clinics will deliver selected public health interventions to prevent the spread of disease in the densely-packed shelters, targeting vaccinations for communicable diseases such as measles. The team is also targeting strategies for treating and preventing the spread of HIV/AIDS and other sexually-transmitted diseases, as ZL anticipates and increase of risky coping strategies in the wake of the storms’ destruction. The mobile clinics will reach out to those who sought refuge on higher ground, those living in remote regions of the flooded sites, as well as those living in the shelters. Earlier this week, a mobile clinic in Petite Riviere saw hundreds of patients, and continued to treat patients by candlelight well into the night.  

Additionally, ZL’s team of social workers are also on the ground and on the lookout for individuals and families who are suffering or at risk of falling ill, households in need of clean water and children who may be malnourished. They are aided by the local network of ajan sante (health agents who provide basic health education including hygiene, childhood vaccination, and nutrition) and other community health workers. The accompagnateurs are also busy tracking down all of ZL's HIV and TB patients in the flooded areas, to ensure that those who need daily medications do not miss a dose. 

The team is now looking ahead to longer-term relief plans, such as housing for the displaced (many of the current shelters are school buildings that will be needed for classes come October). They have also begun creating and distributing “resettlement packages” to help those who lost nearly everything. These packages include food supplies, cooking pots, stoves, water containers and purification systems, clothes, shoes, and school fees and supplies for children. Strengthening the medical facilities in these areas is also a priority, as the coming months will likely bring an influx of patients with flood-related illnesses (particularly water-borne diseases), as well as patients from neighboring communities that had their own health centers destroyed by the floods.

The team is also working to bulk up microfinance, agricultural and food production projects, as well as local infrastructure to give the devastated communities a real opportunity to flourish. “The work has just begun,” says PIH Executive Director Ophelia Dahl.  

[posted September 2008]

ACTION ALERT: Malaria Net Challenge
The floodwaters from four hurricanes have receded in Haiti, but countless pools of stagnant water still remain—the perfect breeding ground for mosquitoes and an imminent public health disaster—a massive outbreak of malaria. To prevent this, Partners In Health kicked off the Malaria Net Challenge to raise money to distribute 10,000 bednets to the families in most need. Please consider joining this challenge and helping us buy bednets! Each net only costs $5. Find out more 

Heroes in Hinche
In crises like the recent storms, it is the reaction that defines individuals and organizations. Many Zanmi Lasante (PIH's partners in Haiti) staff members sprang into action when the floodwaters came. Two in particular embodied PIH's "whatever it takes" philosophy by commandeering a car, rescuing flood victims, finding supplies, distributing food, bringing order to shelters, and that was just the first day. 

Social workers help HIV patients cope with flood destruction
It was 4 in the morning when Ermaze, a social worker in Haiti, received an urgent phone call, telling her that the city of Hinche was flooded. The first thing that ran through her mind was to get up and go rescue Zanmi Lasante's HIV patients. "When arriving, all we could see were the roofs of homes under all of the water," she said. "With water levels reaching our chests, we began searching for all of our HIV patients and their families."   Read more.  

Recent storms add to tragedy in Haiti
"Working for the past decade in Haiti has required a constant eye to the weather – to the political climate inside Haiti, toward the shifting tides of international politics and global finance, and, of course, a nervous eye to the Atlantic Ocean during hurricane season," says PIH physician Evan Lyon. Read his account of a dire situation made only worse by recent storms. 

Bringing emergency relief and a plan for recovery to flooded communities
The aftermath of four severe storms in rapid succession left thousands of Haitians unable to return home in many of the communities that PIH's partners currently work in. The Zanmi Lasante team is currently working overtime to help care for those who lost nearly everything.

"The work has just begun," writes PIH Executive Director Ophelia Dahl
Thanks to the generosity of PIH supporters, mobile clinics are operating, and food and water are being delivered, but the work has just begun, writes Ophelia Dahl in a recent letter. Read more about the what PIH and its partners in Haiti are currently doing, and their plans for the coming months.

Inside Gonaives: A photo essay of the hurricanes' destruction
"Everywhere, people were walking in the flooded streets," says PIH physician Evan Lyon, who recently visited the devastated city of Gonaïves. "Tens of thousands residents remain in the city and outside organized shelters, trying to protect their damaged home and trying to survive." View his photos of the shocking conditions he found there.

Ghost town left behind as floodwaters recede in central Haiti
Gran Plas is empty, swept away by the floods that followed Hurricane Ike. The scope of this un-natural disaster and of the inadequate humanitarian response in the hardest-hit areas in the Artibonite Valley, literally downstream from the Central Plateau, is finally becoming recognized.  Estimates of deaths in the past month range from 500 to 1000 and perhaps as many as one million people have been left homeless. Read more

I have never seen anything as painful," writes Paul Farmer from flood-ravaged Haiti
PIH co-founder Paul Farmer recently sent an email to colleagues describing the devastation caused by the recent hurricanes in Haiti after driving through the flooded coastal city of Gonaïves. With more storms on the way, tens of thousands of people have been driven from their homes and thousands more are living on rooftops without any access to food, water or shelter. Read his letter

Hurricanes' one-two punch inundates Haiti: Donations needed to support relief efforts
Torrential rains from Hurricanes Gustav and Hanna swept through Haiti earlier this week, leaving behind dangerous flood waters and devastated communities.

”The situation is very dire and catastrophic and sad and frustrating,” writes Loune Viaud of Zanmi Lasante (ZL), PIH’s partner organization in Haiti. She estimates that around 10,000 people have been displaced due to floodwaters in the Artibonite Valley, where PIH recently expanded operations to six facilities. Read more about this emergency situation, and how you can help.

A call to action
PIH Executive Director Ophelia Dahl wrote a letter to PIH supporters about the dire situation in Haiti. "There is a clear and desperate need both for emergency relief and for long-term assistance to address the vicious cycle of poverty, environmental degradation and disease, which is guaranteed to intensify in the aftermath of this crisis," she writes. Read her letter

Reflections on past hurricane tragedies
PIH co-founder Paul Farmer reflects on poverty, disease, and Hurricanes Katrina and Jeanne. "The great vulnerability to which we expose all those who lack fundamental social and economic rights, including the right to be protected from foreseeable and, indeed, predicted disasters, is a cause worth fighting for," writes Farmer.

[published September 2008]

"I have never seen anything as painful":
Paul Farmer writes from flood ravaged Haiti

On Saturday, September 6, PIH co-founder Paul Farmer wrote to colleagues and supporters of Partners In Health describing the devastation caused by flooding from Hurricanes Gustav and Hanna in Haiti. The previous day Paul and colleagues from Zanmi Lasante had driven to and through the coastal city of Gonaïves, where tens of thousands of people have been driven from their homes and thousands more are living on rooftops without any access to food, water or shelter. Hurricane Ike arrived the next day with more torrential rains and deadly floods.

6 September 2008

Dear PIHers:

	On the main street of Gonaïve

I am writing from Mirebalais, the place where our organization was born, having just returned from Gonaïves—perhaps the city hit hardest by Hurricane Hanna, which, hard on the heels of Fay and Gustav, drenched the deforested mountains of Haiti and led to massive flooding and mudslides in northern and central Haiti. A friend of mine said this morning: “I am 61 years old, born and raised in Hinche. I have never seen it under water.” Gonaïves, with 300,000 souls, is in far worse shape, as you’ll see from the other pictures I append. The floodwaters in Hinche are dropping, but as of 5 p.m. last night, when we left Gonaïves, the city was still under water. And hurricanes Ike and Josephine are heading this way as I write.

Everyone copied on this note has already heard, most probably directly from PIH, about these storms and their impact on Haiti. I apologize for writing again and for asking my own colleagues and friends to consider sending more resources—we need food, water, clothes, and, especially, cash (which can be converted into all of the above)—so that Zanmi Lasante, and thus all of us, can do our part to save lives and preserve human dignity.

The need is of course enormous. After 25 years spent working in Haiti and having grown up in Florida, I can honestly say that I have never seen anything as painful as what I just witnessed in Gonaïves—except in that very same city, four years ago. Again, you know that 2004 was an especially brutal year, and those who work with PIH know why: the coup in Haiti and what would become Hurricane Jeanne. Everyone knows that Katrina killed 1500 in New Orleans and on the Gulf Coast, but very few outside of our circles know that what was then Tropical Storm Jeanne, which did not even make landfall in Haiti, killed an estimated 2000 in Gonaïves alone. Logging on this morning from Mirebalais, I see that Ophelia has circulated the essay I wrote about what are, essentially, unnatural disasters.

	People fleeing Gonaïve with what few possessions they could carry

We’re faced with another round of death and obliteration. Haiti’s naked mountains promise many more unnatural disasters. We know that a massive reforestation program and public works to keep cities safer are what’s needed in the medium and long term. But there’s a lot we can do in the short term to help out with disaster relief.

None of us regard PIH as a disaster-relief organization. Together, we’ve built PIH—meaning the network of locally directed organizations working in 10 countries—to serve a different cause. We wanted to attack poverty and inequality and bring the fruits of modernity—health care, education, et cetera—to people marginalized by adverse social forces. It seemed likely, as reports came in this week, that many other institutions and organizations would be far better able to respond to the after-effects of storms and floods. I’d been told, as the American Airlines flight passed over flooded Gonaïves, that the city was cut off from outside help, but even as I heard this, I knew that our own colleagues were there, volunteering what meager resources we had on hand, and a few hours later I was there too. I was hoping that we’d find that the city was receiving the expert attention of organizations trained to do disaster relief. So imagine my surprise, yesterday, when I discovered that very little in the way of help had reached Gonaïves or the other flooded towns along the coast.

Although it’s not true that Gonaïves cannot be reached by vehicle, it is true that the city center is still under water, and that the road into the city is well and truly flooded. Between Pont Sonde—the only way to the coast, since the major bridge between Port-au-Prince and Gonaïves is out, as is that to the north—and the flooded city, we saw not a single first-aid station or proper temporary shelter. We saw, rather, people stranded on the tops of their houses or wading through waist-deep water; we saw thousands in an on-foot exodus south towards Saint-Marc.

	A boy we met on the road to Gonaïves carries a goat. He said he was thirsty so we gave him our last bottle of water.

We saw a couple of U.N. tanks rolling through the muddy water over these streets, some Cuban doctors, and two Red Cross vehicles (one of them stuck in mud at least 10 miles from the city), and heard and saw helicopters overhead. But for the most part the streets were full of debris, upside-down vehicles, and dazed residents looking to get out before the next rains. Our friend Deo from Burundi was there and said it reminded him of nothing so much as what he’d seen there, and in Rwanda, at the time of the genocide in 1994—long lines of people carrying little more than their children, goats, and balancing sodden bags and suitcases on their heads.

A speedy, determined relief effort could save the lives of tens of thousands of Haitians in Gonaïves and all along the flooded coast. The people of that city and others have been stranded without food or water or shelter for three days and it’s simply not true that they cannot be reached. When I called to say as much to friends working with the U.S. government and with disaster-relief organizations based in Port-au-Prince, it became clear that, as of yesterday, there’s not a lot of accurate information leaving Gonaïves, although estimates of hundreds of deaths are not hyperbolic. We had no cell phone coverage there and had to wait until last night to call people in Port-au-Prince. One sympathetic American friend, following up on our distress calls about a lack of relief, told me this morning the retort she’d heard from an expert employed by a U.N.-affiliated health organization: “Three days without water is nothing. People in southern Haiti affected by Gustave went ten days without water.”

	People living on rooftops on Gonaïve's main street, Rue Christophe

No human can go ten days without water. Food, perhaps. But not water. So we can expect that the people you see in these photographs, which I took by borrowing the digital camera of a ZL employee from Gonaïves (whose family, like all those you see, lost everything), are at great risk of falling ill with water-borne illnesses. There is also a lot of dead livestock floating down the streets of the city. The stench is overwhelming.

We are familiar with a lot of the Haitian officials charged with responding to this tragedy, which is, agreed, widespread. They showed up in Gonaïves: the district health commissioner, who is from the city and felt lucky to have avoided drowning; the coordinator of the government’s disaster response; nurses and doctors we’ve known over the years. They are doing the best they can with scant supplies. They are tired, thirsty themselves, hoarse-throated. Even Haiti’s newly-appointed Prime Minister, on her first day on the job, showed up this morning in Mirebalais, keeping a promise she made many months ago, long before she was directly involved in politics. She now has to install a new government, perhaps this afternoon, and respond to multiple disasters at once. These people, who are trying to help their fellow Haitians, deserve our help.

This is an internal appeal to staff, family, and friends. Our co-workers in Haiti are already contributing what services and supplies they can. We will withdraw from Gonaïves (as soon as we get the information we need regarding urgent supplies and as soon as we see more evidence of the mainstream disaster-relief organizations) to Saint-Marc and Petite Rivière de l’Artibonite, where we will run the hospitals and health centers with our colleagues in the Ministry of Health; we will help organized food and some clothing for people in Gonaïves and refugees being brought in today from Gonaïves.

	Animal carcasses litter the flooded streets of Gonaïves and threaten the health of people with no access to clean water

p>Mirebalais is going to be under a good deal of stress. As many of you know, the city’s hospital is not really functioning (in January, local protests about the hospital led to its closing, with patients evacuated to Cange, Boucan Carre, and LaColline). To my knowledge, at least 15,000 are expected to arrive here today—and they will come with nothing. They’ll need water, food, and shelter immediately, and the Mayor of Mirebalais, with whom we met this morning, is looking for dry spaces for them (maybe schools, etc) but there’s no bedding or mosquito nets or cots, that I know of.

A U.S. Coast Guard cutter is to arrive in Gonaïve tomorrow with water and supplies, but by report last night’s attempt to dock a U.N. vessel and distribute food was not successful because of “fear of crowd control” (this was from an American friend in Port-au-Prince, so I can’t confirm anything other than what I saw: no widespread distribution of water or food or tents or tarps or anything).

Since ZL is, like all the PIH sister organizations, nimble, we can do a lot by pooling small donations from friends and family members and helping ZL respond in real time to requests from those coordinating the relief efforts. We’ll need to source things like tetanus vaccine (withdrawn from Gonaïves some months ago because of concerns over quality of a certain batch; I don’t know the details), first-aid supplies, oral-rehydration packs, and of course food, cooking oil, and fuel. Again, I know that conventional disaster-relief organizations have greater experience in logistics, and am expecting they’ll have kits prepared for precisely these needs, but as of today these supplies are conspicuous by their absence. Problems with “crowd control,” refugees, and short tempers will only increase as the days go by—especially if more rain falls, as is predicted, tomorrow and Monday.

	The site where the bridge connecting Mirebalais to Pont Sonde and Gonaïves was washed away by floodwaters

Over 20 years ago, someone explained to me that “wet poverty is worse than dry poverty.” I wasn’t then sure what that meant, but had a pretty good idea of the misery endured by those living through the rainy season in houses that, as the Haitians say, “can fool the sun but not the rain.” I’ve repeated the maxim often enough to merit teasing from my students, but the Haitians find it neither amusing nor over-used. Trying to sleep in wet clothes, on a muddy floor, is high on the list of degradingly uncomfortable activities. It’s better to simply give up and wait until daylight.

Surveying the devastation in Gonaïves, and the wretched population on roofs or wading through the streets or carrying bundles out of the city, we knew that these floods and the lack of effective response are not so much about the unruly forces of nature. Many of you on the Haiti team recall that we’ve long been based in a squatter settlement formed by the floodwaters of the Artibonite; that we spent years rebuilding lean-tos and shacks that didn’t even fool the sun; you’ll remember our co-worker’s mother swept away in a flash flood; or you’ve been part of a team of health workers watching helplessly as an ambulance is swept downstream before their eyes.

Paul Farmer

[published September 2008]

	Youth health promoters at a recent training workshop in Carabayllo, Peru
	Youth health promoter tutoring a younger student

By Elaine Weisman

The group of promotores juveniles (youth health promoters) is composed of local adolescents between the ages of 13 and 20 who receive special training from SES’s Child Health team to mentor young children. The teens, many of whom participated in SES programs in primary school, help supervise SES-crafted education programs in participating public schools as well as in after school activities and homework help at the Lois and Thomas White Community Center.

In addition to their time with the children, the youth promoters attend meetings to debrief the week, help organize community fund-raising activities, and bring up other issues of concern within the community or among peers. As teenagers in situations of poverty are often faced with the responsibilities of adulthood at an early age—feeding and supporting their families, taking care of younger family members, etc.—they are also exposed to adult pressures of drug and alcohol use, sexual exploration, and gang membership.  By arming youth promoters with the information and support networks they need to confront these kinds of situations, SES hopes to foster a sense of social responsibility that will sculpt their role in the community.

Once a month SES staff also runs workshops designed to build trust and communication skills between youth health promoters and their parents. As support and relations are a major indicator of the overall health of the family, especially for communities battling poverty and disease, these workshops were designed to help create a dialogue between parents and children, and to give participants the skills to resolve problems verbally instead of physically. Lighthearted skits, often caricatures of home life, consistently lead to both boisterous laughter and heated debates.

Keeping the lines of communication open between teens and their families, peers and community builds confidence and self esteem among youth health promoters in Carabayllo and leads to higher academic achievement as well as a strong sense of collectivity. Though materially they have very little, the promotores juveniles are prepared to offer plenty.

[posted September 2008]

GRAN PLAS, Haiti, Sept. 11, 2008 — Gran Plas is empty, swept away by the floods that followed Hurricane Ike.

Three storms had already ravaged Haiti before Ike brought heavy rains again to swollen rivers and saturated ground on Saturday. Last week, Hanna caused terrible flooding in Hinche, the capital of Haiti's Central Department. Zanmi Lasante’s staff has been working around the clock alongside local officials and other NGOs to provide shelter, food, water, and medical care in the upper plateau. More than 2000 people have been sheltered temporarily in Hinche. 

The scope of this un-natural disaster and of the inadequate humanitarian response in the hardest-hit areas in the Artibonite Valley, literally downstream from the Central Plateau, is finally becoming recognized.  Estimates of deaths in the past month range from 500 to 1000 and perhaps as many as one million people have been left homeless.

The lower plateau had largely been spared of damage from the first three hurricanes to hit Haiti in recent weeks.  But Ike proved too much.

Sometime around 3 am on Sunday morning, September 7, the bridge connecting Mirebalais to St. Marc, Gonaïves and the rest of the Artibonite Valley washed out.  This not only separated the city of Mirebalais from its hospital on the other side of the river, but it cut the last road connecting the Artibonite with Port-au-Prince. It seems likely that shipping containers from the Nepalese Battalion UN base – near Gran Plas – were swept downstream by the waters and contributed to the bridge collapse.  Haitian President René Préval called Monday for a “flood of helicopters” to help move aid from the capital to where it is needed most. 

The people of Mirebalais have been forced to cross the Latombe River in canoes.  Local officials have informed us that 32 homes were completely destroyed near the bridge, with another 38 homes flooded.  We know of another 61 homes destroyed in the area but this assessment is incomplete.

Zanmi Lasante is helping coordinate emergency shelter for over 300 people in Mirebalais with the local government, the Ministry of Public Health and Population, the Haitian Red Cross, World Vision, and the Rotary Club.  These homeless include 45 children under the age of five.  We are providing food, water, shelter, and medical care. 

Displaced and vulnerable people continue to arrive seeking assistance several days after the worst flooding.  Which brings us again to Gran Plas, up stream from Mirebalais along the same Latombe River that destroyed the bridge.

Yesterday, a number of people arrived from Gran Plas, bringing with them stories of the floods that destroyed their homes and their crops.  Most had not eaten in several days.  The local magistrate from Gran Plas and I went to survey the damage earlier today.  While the area was small when compared to a large city like Gonaïves, the devastation was complete. It was not possible on a first assessment to know how many homes were lost.  Some were completely swept away. Others were wracked together, pushed into the trees.

Recovery from these floods will take a long time.  But perhaps what was most troubling about visiting Gran Plas today was witnessing the lost crops.  In a region where subsistence farming is the often the only means of survival and where food insecurity and malnutrition are chronic problems, the loss of crops will be a problem for months to come. 

A peasant farmer we met in Gran Plas told us, “I had very little before and now I have nothing.  My house was spared, but my garden is completely destroyed.  The millet was not ready to be cut and the corn was not ripe.  Now its all gone, along with everything else that was in the ground.”

There are hundreds of places like Gran Plas in Haiti.  Many still without assistance of any kind.

A Zanmi Lasante health worker wades through floodwaters to find missing HIV patients.

Torrential rains from Hurricanes Gustav and Hanna swept through Haiti earlier this week, leaving behind dangerous flood waters and devastated communities.

”The situation is very dire and catastrophic and sad and frustrating,” writes Loune Viaud of Zanmi Lasante (ZL), PIH’s partner organization in Haiti. She estimates that around 10,000 people have been displaced due to floodwaters in the Artibonite Valley, where PIH recently expanded operations to six facilities earlier this year.

Full reports of the one-two punch left by both storms to the battered island of Dominica are currently hard to find, as news and media outlets had little time to focus attention from Gustav before Hanna roared through; and many instead turned their attention to Hanna’s path towards southern Florida.

Communications with Viaud and other PIH/ZL staff have painted a stark picture of desperation and destruction. Some patients and health workers were stranded on the roof of a submerged hospital. One doctor was forced to take refuge on the roof of his house, calling for ZL to help evacuate his patients.

On Wednesday morning, members of Zanmi Lasante’s team trudged through swollen rivers and muddy embankments in search of patients living in the flooded areas. About 45 patients in ZL’s HIV program had homes underwater—fortunately, all have been accounted for, and are housed with neighbors and friends living on higher ground. But ZL fears that the situation may deteriorate even further, as Tropical Storm Ike approaches Haiti.

	Flooded houses in the Artibonite Valley

Although these storms have contributed to the current disaster in Haiti, the rampant poverty and lack of infrastructure throughout the region have also played a role in both these hurricanes, and past storms. Unlike New Orleans, there are no levees to hold back the water in many of the low-lying communities served by ZL. Mud huts without solid foundations, walls, or roofs are easily swept away; unpaved streets quickly degrade into muddy holes, hampering evacuation and relief efforts. Hospitals and health clinics lacked the infrastructure to safely evacuate patients, and ZL staff are worried about the looming public health problems in the wake of the storms—the spread of water-borne illness, access to clean water, malaria. The six facilities partnered with ZL in the Artibonite region are now frantically preparing to handle a flood of patients in the coming months.

[published September 2008]

By Max Bearak

	Dumanel Luxama a few days after surgery to repair a hole in the front of his skull

In a cozy, sunny room on the ninth floor of Children’s Hospital in Boston, 11-month-old Dumanel Luxama happily coos and chortles as his father Almane stands beside him. Just a few days earlier, the little Haitian boy had undergone major surgery to prevent brain tissue from bulging through a hole in his skull.

Dumanel was born with a frontal encephalocele, a rare neurological defect. An irregular hole in the calvarium, or “skull cap,” allows brain tissue to protrude, resulting in an abnormally shaped head. Dumanel’s condition can be repaired in developed countries. But the operation cannot be performed in Haiti due to lack of funds, equipment and proper training.

When Dumanel was born last fall, Almane sold a piece of land and used the proceeds to buy a bus ticket to take his baby to Zanmi Lasante’s hospital in Cange, more than half a day’s journey from their home in Ti Riviere. Almane left behind his wife and his home in hopes of saving his boy.

“I am a proud father and he is my son," he said. "It is my duty to take care of him."

	Dumanel Luxama with his father Almane and Dr, John Meara before surgery

On a visit to Haiti in March, Children’s Hospital's Plastic Surgeon-in-Chief, Dr. John Meara, noticed Dumanel in the Zanmi Lasante hospital. Dr. Meara and other doctors donated their time and worked with PIH to organize free care for Dumanel at Children’s Hospital.

Through its Right to Health Care program, PIH has a history of bringing patients who cannot be treated at local sites to larger, better-equipped hospitals in the U.S. and elsewhere. The program demonstrates PIH’s commitment to the human right to health care and embodies the organization’s mission statement: “When a person in Peru, or Siberia, or rural Haiti falls ill, PIH uses all of the means at our disposal to make them well...Whatever it takes. Just as we would do if a member of our own family—or we ourselves—were ill.”

When Dumanel reached Boston, doctors discovered that he had another serious medical complication—an arachnoid cyst in his brain. The cyst, a collection of the fluid that bathes the brain, was about the size of an apple and would have to be drained during Dumanel’s surgery in Boston.

“It was good that we brought him up to Boston in time," Meara said. "The cyst could have caused dangerous pressure on the brain."

Over almost ten painstaking hours, Meara, a reconstructive surgeon, and Dr. Ed Smith, a neurosurgeon, operated on both the cyst and the encephalocele. Meara described the procedures as “extremely successful, yet very difficult.”

Dumanel stayed in the hospital for about two weeks after his surgery. He and his father will probably remain in Boston for several more months in case any complications arise.

For now, the Luxamas’ medical journey continues. Almane will continue to sleep on the cot beside Dumanel’s crib and Dumanel’s mother will keep waiting eagerly for her husband’s daily call so she can listen to the reassuring and joyful laughter of her baby.

[published September 2008]

By Tom Spoth

Deo escaped the civil war in his native country of Burundi, but he couldn't leave it behind. He came to the United States and built a new life-learning English, finding work in nursing homes, and enrolling in graduate school. But still he was consumed by thoughts of death and despair back in Burundi, distraught because he didn't know whether his family was alive or dead.

“You feel so lonely even though everyone is really nice, you feel like you are a stranger even in public space,” Deo says of his years in the US. “I was carrying my tragedies like luggage all the time.”

While at the Harvard School of Public Health, Deo met Partners In Health co-founder Dr. Paul Farmer and became involved in PIH’s work. “It was such a great relief to get involved with PIH,” Deo says. “I felt at home here. It’s amazing how far Haiti is from Burundi, and yet how similar these two countries are in terms of misery. Finding a group of dedicated and talented people in the USA doing such great work in Haiti, a country with a history of tragedy like my own country, brought my dream back to life.” This dream of developing a free medical clinic in his native village turned into the birth of  Village Health Works (VHW), a 501(c)(3) charitable organization based in the US.

Deo and his family were forced to flee their home when Burundi’s civil war broke out in 1993. When he returned in 2005, Deo found that his home village had turned into “hell on earth.”  He describes seeing a picture of extreme poverty, hunger, disease, and misery. Children going naked and eating garbage. Women dying in childbirth. No clean water. With the complete devastation of health infrastructure, Burundians were being incarcerated because they could not afford medical care. Diseases such as tuberculosis, malaria and AIDS, went untreated, along with conditions well known in the West like chronic arthritis, cardiac disease, and diabetes.

In 2006, the World Bank rated Burundi the poorest country in the world. Life expectancy in the country is 39 years. More than 25 percent of children don’t attend primary school and 18 percent die before the age of 5.

People in Burundi are by and large uneducated, and many don’t even know when they were born, Deo says: “People here are preoccupied with how to survive each day… where they might get their next meal. They don’t celebrate birthdays or keep a calendar; they mark time by their own suffering. That’s the kind of life we are talking about in Burundi.” But Village Health Works is now providing health services and hope where there was none before.

	The future site of the VHW health clinic
	The VHW health clinic today

Deo returned to to his home village on Christmas Day, 2005, and encountered great skepticism about developing his dream here. The people were so embittered by years of oppression from their leaders, and indifference from the international community, that they had a hard time believing Deo was there to help. In time, he convinced the residents that he was for real. Once hope was restored, hard work soon followed. The community pitched in as best they could, gathering and hauling stones to build a health clinic, rebuilding roads, and injecting new life into the moribund village. Today, the VHW staff meets regularly with a “community committee” of 22 women and 5 men to discuss health issues and community participation.

“Without the help of the community, it would’ve been very difficult,” says Deo’s younger brother. “It’s theirs, it’s their clinic.”

Now 20, Deo's brother is following in his footsteps, having spent more than a year studying at Deerfield Academy in the US. and matriculating at Williams College this fall. He had a difficult childhood – he was often on the run with his parents because of the civil war – but he hopes to return to Burundi after school, perhaps to work on education initiatives. “I know education is important, that’s what we lack,” he asserts. But after a moment’s thought, he adds, “We lack a lot of things.”

Deo's brother says it took 90 minutes to walk to the nearest health clinic before Village Health Works was operational, and most people wouldn’t go anyway because they couldn’t afford to pay. Village Health Works provides medical care without charge, relying on donations to sustain itself and following the PIH model of providing a preferential option for the poor. “It’s going to involve a lot of fundraising events and begging for the poor,” Deo says.

The community and government of Burundi provided 26 acres as a site for the VHW clinic, and Burundi officials have visited the village and met with Deo several times. While the government is unable to provide financial assistance, it’s important to have the moral support, Deo says.

	A crowded waiting room at the VHW health clinic

Since opening in 2006, Village Health Works has welcomed two doctors, six nurses, 33 community health workers, and many volunteers into the fold. The outpatient clinic opened in late 2007, and served over 16,000 patients in its first eight months of operation. Deo, colleagues and friends are also working on bringing reliable supplies of food, water, and electricity to the village.

VHW has formed close bonds with Partners In Health’s Rwanda project, Inshuti Mu Buzima. IMB employees have come to VHW to offer technical support and training; PIH medical director Joia Mukherjee and PIH co-founder Paul Farmer have also visited the Burundi clinic. Workers from VHW have also traveled to IMB to see the PIH model in action. While PIH does provide assistance to VHW, all funding has been secured directly by Deo and his team.

Because the services and quality of care VHW provides are not available elsewhere in the country, people are flooding into the health clinic from far and wide looking for medical care. “It’s going to be very difficult in terms of how we can handle this huge operation [but] we are not going to turn people away,” Deo says.

	Deo's home village in Burundi was not always this peaceful

The impact of Village Health Works goes beyond treating the sick, Deo explains. “People ask me, ‘What is the most gratifying thing about this work?’” he says. “Burundi is a country where people have been living in fear of each other for more than a decade, many of them displaced by the war. We now have Hutus and Tutsis being brought together because of this project… they’re doing something constructive instead of something destructive. While the government and the international community talk about reconciliation, it’s hard to expect any positive outcomes when people who lost their homes get sick, and instead of getting medicine, they get detained; when parents can’t send their children to school. Now we have former enemies volunteering to work together to help build their clinic, and getting health care in the process.” Indeed, they know better than anyone else how important the VHW clinic is for them.
  
To donate to Village Health Works, visit http://villagehealthworks.org.

[posted August 2008]

Extensively drug-resistant tuberculosis (XDR-TB) is curable with intensive and specialized care conclude two recent studies published in the New England Journal of Medicine (NEJM) and The Lancet. Both studies were conducted by researchers from the Department of Global Health and Social Medicine at Harvard Medical School, the Division of Global Health Equity at Brigham and Women's Hospital, Socios En Salud (PIH’s partner organization in Peru) and PIH, in cooperation with other organizations.

When XDR-TB burst into the headlines in 2006, it was widely portrayed as a new and virtually incurable disease. An outbreak of XDR-TB in South Africa in 2006, in which 52 out of the 53 patients infected died, lent credence to fears that being diagnosed with XDR-TB was an effective death sentence. 

Multidrug-resistant or MDR-TB strains are those with resistance to at least the two main first-line drugs, isoniazid and rifampin. XDR-TB strains are resistant not only to isoniazid and rifampin but also to at least three of the six classes of second-line drugs. 

	MDR-TB patient in Peru

In Peru, between 1999 and 2002, patients with MDR-TB (some of whom also met the definition of XDR-TB) were treated with an aggressive treatment protocol.  The authors of the NEJM study demonstrated that XDR-TB had appeared well before 2006 and that it can be treated using this protocol. Of 651 patients entering the treatment program, 48 already suffered from what would now be classified as XDR-TB. The other 603 patients had MDR-TB that was not also XDR-TB. Fully 60 percent of the patients with XDR-TB were successfully treated and cured, a cure rate only slightly lower than the 66 percent achieved with the other MDR-TB patients.

The study adds urgency and hope to the debate about drug-resistant strains of tuberculosis, said Carole Mitnick, the study’s lead author and a PIH research associate. She added that she hoped this report would help doctors move away from using the treatment protocol that has been used for 15 years to treat MDR-TB unsuccessfully.

That protocol calls for a standard six-month regimen, known as DOTS (Directly Observed Treatment, Short Course), of first-line TB drugs. If this regimen is unsuccessful the first time, then it is repeated. The regimen is highly effective when used on TB strains that are susceptible to the drugs included. But in those patients who already have drug-resistant TB, the first-line drugs are ineffective from the start, and can only make the problem worse.

When asked what needed to change in order to see more widespread success in treating drug-resistant TB globally, Mitnick said, “The mentality needs to change. A one-size-fits-all method doesn’t work for some groups of TB patients. Specialized interventions need to be adopted.”

Mitnick suggests that in places where drug-resistant strains of TB are widespread, at the first diagnosis of TB, patient strains should be tested to determine whether they are susceptible or resistant to the most important drugs. Policies mandating such an approach could make it possible to start effective treatment with second-line drugs immediately.  This would increase the chance of curing patients and reduce both fatalities and transmission of resistant strains, including XDR-TB.

Mitnick also pointed out that, when necessary, patients in the study received nutritional and financial support, psychosocial counseling and surgery. Community health workers were instrumental in providing daily supervision of patients’ doses. She said that the study indicated that comprehensive, community-based treatment of this sort may amplify the benefits of the drug regimens.

Same treatment, similar results in Russia

	Doctor and MDR-TB patient in a Russian prison

The same treatment protocol was applied by PIH and collaborators in a rather different setting, in the Siberian province of Tomsk in the Russian Federation. The study published in the Lancet looked at 608 patients with MDR-TB who received treatment in civilian or prison health services between 2000 and 2004. Of these patients,  29 had XDR-TB. Treatment programmes were designed for each patient based on the results of drug-sensitivity testing and previous treatments they had received, with the aim of providing at least five drugs to which that particular patient’s strain of TB was susceptible. If five effective drugs were not available, doctors considered using drugs to which resistance was known, especially if patients had no previous exposure to them.

The researchers found that using this aggressive regimen, 48% of the patients diagnosed with XDR-TB were cured (compared to 67% of non-XDR TB patients).  Interestingly, adverse events due to medications were similar in both sets of patients.
Although this program was implemented in a setting with a high level of alcoholism, the study reported outcomes similar to those achieved in Peru. 

"Our study is novel because it shows that XDRTB can be treated under regular
program conditions as part of an integrated TB program,"  said Salmaan Keshavjee, the report’s lead author. "Although the Russian system has a hospital-based component during the intensive phase of treatment (generally the first 6 months), the remainder of the treatment occurred on an ambulatory basis.  This is very important, in the setting of some countries wanting to keep patients with MDR-TB and XDR-TB under quarantine….

"The fact that our findings are similar to Mitnick and colleagues’ contribution in the NEJM supports the fact that aggressive treatment regimens, aggressive adverse-events management, and community-based delivery of care are part of a package that works for MDR-TB and XDR-TB.  This doesn't mean that we don't need new drugs as soon as possible -- instead it means that with the existing drug regimens, delivered appropriately, we can save many more lives now."

From Peru and Russia to Lesotho, raising the bar

Although the Peru and Russia reports showed that XDR-TB can be treated, they also highlighted one additional factor that contributed to the lethal outbreak in Kwazulu-Natal – co-infection with HIV. None of the XDR-TB patients treated in Peru or Russia tested positive for HIV. All of the South African victims of XDR-TB were also infected with HIV.

"The new twist is one that we predicted, and many others did as well," PIH co-founder Paul Farmer said last year at the launch of a PIH program to tackle the epidemic of drug-resistant TB in Lesotho, just across the border from Kwazulu-Natal. "When HIV and drug-resistant tuberculosis collide, there is going to be an even more urgent need to intervene effectively because HIV really speeds up the process and makes these epidemics faster and more lethal."

In Lesotho, where as many as three quarters of XDR-TB patients are co-infected with HIV, PIH has taken a groundbreaking treatment approach modeled on what proved so successful in Peru. Patients are not quarantined, as they have been in other countries like South Africa, but are visited twice a day by community health workers at their homes or at rented houses near the hospital, allowing them to remain with their families during treatment. Up to 300 patients are expected to be enrolled in PIH’s XDR-TB program in Lesotho by the end of this year.

As in Peru and Russia, the Lesotho program follows the same treatment protocol proposed by PIH in a 2004 Lancet report led by Joia Mukherjee, PIH’s Medical Director.  XDR-TB patients in Lesotho are enrolled in a two-year treatment program using drugs selected after sensitivity testing to determine resistance for their particular strain of TB. Although none of the patients have yet completed the course of treatment, indications suggest that unlike in Kwazulu-Natal, a significant proportion of these patients can be treated successfully. 

Keshavjee, who has worked with both the Russia and Lesotho programs and is the chair of the WHO’s Green Light Committee on MDR-TB treatment, notes that “part of the challenge is to diagnose patients early, get them on appropriate MDR-TB and HIV treatment, address their often profound malnutrition, and deliver care to them for the two years that it will take for them to be cured. It isn’t an easy task, but it’s something that, given appropriate human and financial resources, we know we are able to do.”

Unfortunately, many XDR-TB cases are discovered and treated too late, especially for those with HIV. To see better outcomes in the treatment of XDR-TB, Paul Farmer, Carole Mitnick, Salmaan Keshavjee, and Hind Satti (PIH Lesotho’s MDR-TB program director), all agree on the need to expand resources for both research and treatment, as called for at a recent Workshop on Clinical Trials for DR-TB of which Mitnick and Keshavjee were principal organizers. In Satti’s words, “increased investment in research that will give rise to evidence-based policies and procedures is key to fighting the epidemic.”

[published August 2008]

By Elana Hayasaka, PIH Communications Specialist

“It’s not so bad,” Edwin told me, surveying the property. I was dubious. One solid push probably would have toppled the dingy walls of the small house. It was flanked by a small brick house without a fourth wall, and a mud structure without a roof. Several dogs lay sunning themselves in the dusty shade of a small tree while a flock of black hens and a lone white turkey pecked around the yard. “There are so many more people even more poor than this family. We have to help them first.”

	Chimfuka Felesiano

So we climbed back into the truck and bumped back up the dirt road towards the village of Magaleta in the southern corner of Malawi, one of the poorest areas of one of the Africa’s poorest countries.

Edwin, the coordinator of Malawi’s Program on Social and Economic Rights (POSER), was right. Unfortunately, this family was actually relatively well off for the area, I reflected as our driver turned down a small, rocky path (which quickly grew smaller and more rocky). Soon, the truck’s wheels began mowing through tall reeds, grasses, and small shrubs as we made our way to visit the Felesiano family. Chimfuka Felesiano shuffled towards us as we climbed out of the truck.

I soon realized why he moved so slowly — a hollow-sounding rattle wracked his lungs with each breath he took. He had a severe, debilitating cardiovascular condition. As Edwin translated the family’s story to me, Chimfuka struggled to recover from the exertion of walking to greet us.

Over the years, Chimfuka’s breathing problems rendered him unable to work, unable to support his family, and unable to maintain their small hut. His condition was exacerbated by living in the damp, drafty mud structure, and as his house deteriorated, so did his health. It was a catch-22 situation: If he were in better health, he would be able to build and maintain a decent house; but his health would never improve without better housing to start with.

	Chimfuka’s old house after the rainy season.
	The straw house Chimfuka's family was forced to move into.
	Chimfuka’s new house.

One night last December, Chimfuka and his wife, Noulifa, and their young son were sound asleep during a rainstorm, when the wall and roof of their hut crashed down on them. With his medical condition, there wasn’t much Chimfuka could do to rebuild the house. So Noulifa and her son did the best they could to cobble together a shelter to help the family endure the torrential downpours of Malawi’s rainy season. They constructed a small lean-to out of a pile of straw and reeds leaned up against a tree. No floor but the muddy ground, and no walls or roof but a straw stack that looked like it would collapse if anyone other than Chimfuka puffed at it. In this “house,” Chimfuka’s condition only grew worse.

As part of PIH’s communications team, my job regularly includes interviewing our program staff and patients and sharing their stories with our supporters (often through this e-Bulletin). So I know only too well that Chimfuka’s story isn’t unusual for our patients. One of the guiding beliefs at PIH is that most of the poor health and diseases our partners face are rooted in poverty, a reason for the formation of POSER in the first place. However, because most of PIH’s Boston-based staff rarely get an opportunity to visit program sites, my visit to meet Chimfuka was actually one of the first opportunities I’ve had to see a POSER team in action.

Although PIH’s partner organization in Malawi is only a year old, Edwin and his POSER team are already making a difference for people like Chimfuka. After visiting his family for the first time this spring, the team immediately decided that a new house was desperately needed. Construction of a modest two room house with a metal roof, brick walls, and cement floor quickly began on a small plot of land a few feet away from both the crumbling hut and the makeshift straw lean-to.

Edwin and I soon returned to visit the family again, but this time in their new home. Although still wheezing, Chimfuka was all smiles that day, and a small crowd of neighbors had gathered to admire the shiny, solid (and warm and dry) house. But we didn’t stay long. We couldn’t. After inspecting and approving the sturdy structure, Edwin quickly herded us back into our truck and we began the bumpy journey to help another patient in need.

By Sadie Richards

Strains of tuberculosis that cannot be treated with traditional approaches and drug regimens pose an ever-growing threat to global health. Just one year ago, patients in Lesotho infected with multi-drug resistant tuberculosis (MDR-TB) faced almost certain death. Today they and their families have reason to hope for a better prognosis.

Partners In Health Lesotho’s (PIHL’s) MDR-TB Program Director, Dr. Hind Satti, recently reflected on the accomplishments of - and challenges still facing - the national program she helped spearhead last July.

	A treatment supporter, PIHL record book in hand, descends into a village to visit one of her patients.

PIHL worked hand-in-hand with the Ministry of Health and Social Welfare (MOHSW) and other partners (including the Foundation for Innovative New Diagnostics and the World Health Organization) over the past 12 months to build up the basic infrastructure, expertise and technical support needed to test and treat patients for MDR-TB. The national program now encompasses a state of the art MDR-TB hospital, laboratory and pharmacy, all of which are fully staffed and complemented by a team of treatment supporters who provide personalized, in-home patient care.

Satti attributes PIHL’s achievements largely to the organization’s community-based model of care and its collaboration with the MOHSW from the start. PIHL’s approach involves building local capacity from the ground up, within a framework that offers staff financial incentives, personal protective equipment, and continual training. High staff and patient retention has also resulted.

PIHL’s MDR-TB program currently treats 155 patients living in all ten districts of the country. This number is growing rapidly and is expected to reach 280 by the end of the year, and 450 by the end of 2009. Most of these patients receive treatment in their homes. Community health workers (a.k.a. treatment supporters) visit each patient twice daily to administer medication, provide psychosocial support, screen and counsel family members and/or accompany extremely sick patients to the hospital in Botsabelo.

	Dr. Hind Satti with five young MDR-TB patients, most of whom are orphans.

The youngest of nine children who are part of the program is only three years old. Of these young patients, three are sick enough to be in-patients at the 20-bed hospital. One young boy, however, is well enough to attend school. With the comprehensive PIHL package of medical care, food supplementation and financial support, the others may soon join him.

PIHL also trains “expert patients” who become an integral part of the community-based model. These are out-patients who have often returned to health from the brink of death to take on roles similar to those of the treatment supporters. They identify new potential patients, combat stigma associated with the disease and seeking treatment, visit patients at home, provide health education on TB, HIV and sexually transmitted infections, and provide psychosocial support to other patients and their families. As Satti attests, they are “the living, breathing example of the success that can be reached in treating MDR-TB” through community-based programs.

To stave off the spread of drug resistant strains of the disease, and for effective programmatic scale up to continue successfully, more funding – for treatment, prevention and research – will be necessary. Satti specifically calls for increased investment in research that will give rise to evidence-based policies and procedures. Since more than three quarters of Lesotho’s MDR TB patients also have HIV, Satti is convinced that lessons from Lesotho can inform disease treatment and prevention in other resource-poor countries struggling with a high burden of MDR-TB and HIV co-infection.

[published July 2008]

Lack of access to clean water in Haiti has devastating health consequences and constitutes a clear violation of Haitians’ right to water according to both domestic and international legal obligations, claims a new report released on June 23 by the Center for Human Rights and Global Justice (CHRGJ), Partners In Health (PIH), the Robert F. Kennedy Memorial Center (RFK Center), and Zanmi Lasante.  The release of the report, “Wòch nan Soley: The Denial of the Right to Water in Haiti,” comes just months after public outrage over rising food prices led to a full-blown political crisis in Haiti. 

The 87-page report—which combines health and water data gathered on the ground in Haiti, legal analysis, and discussion of the historical context—presents the findings of a joint project conducted by the groups, who worked together to research, author, and release it.  The groups used human rights and public health methodologies to assess the right to water in Haiti by surveying community members, testing water sources, and meeting with community leaders and government officials.

One of the report’s main findings is of an undeniable link between the international community’s political interference and the intolerably poor state of potable water in Haiti.  Using documents obtained by the RFK Center through a Freedom of Information Act lawsuit against the U.S. Treasury Department, the report exposes the U.S. government’s role in blocking the disbursal of millions of dollars in loans that would have had life-saving consequences for the Haitian people.  The loans, which the Inter-American Development Bank (IDB) approved in 1998 for urgently needed water and sanitation projects in Haiti, were derailed in 2001 by politically-motivated, behind-the-scenes interventions on behalf of the United States and other members of the international community. 

“When an institution takes on the responsibility to improve water and health conditions, it cannot turn around and undermine the rights of the people it was established to serve, regardless of pressure from one of its most powerful members,” said Monika Kalra Varma, Director of the RFK Center.  “To keep history from repeating itself, the IDB and the U.S. government must take responsibility for their actions and put in place transparency and oversight mechanisms to guarantee that the human rights of the people of Haiti and other IDB member states will not be violated by an institution mandated to support their economic and social development.”

When the Bank halted disbursement, it violated its own charter, which strictly prohibits it from allowing politics to influence its decisions.  This has been common practice, according to Loune Viaud, Director of Operations for Zanmi Lasante and recipient of the 2002 RFK Human Rights Award.  “The international community is able to turn a blind eye to the impact of its policies because it is not forced to confront the human faces of those who die or become ill through its action or inaction. This report shows the devastating human rights impacts of its policies.”

While exposing the link between violations of Haitians’ human rights and the international community’s actions, the report also provides a clear framework of concrete rights and duties that should be followed by all actors involved in Haiti.  Such actions include strengthening the Haitian government’s ability to regulate the private water sector; ensuring that all water projects respond to the needs of the very poorest Haitians; and obtaining informed consent from community members concerning improvements in the water systems that are meant to serve them.

“Although the Haitian government is the primary guarantor of rights in Haiti, the international community is not without obligations,” said Prof. Margaret Satterthwaite, Faculty Director of the CHRGJ.  “The states that make up the international community have a duty not to harm or undermine human rights—including through their actions as members of international financial institutions.  In this case, the international community effectively crippled the Haitian government’s ability to fulfill one of the most basic subsistence rights due to all people—the right to water.”
  
Haiti is not only the most impoverished country in the Western Hemisphere, it also has some of the worst water in the world, ranking 147th out of 147 countries in the Water Poverty Index.  The report, which contains detailed data obtained through an in-depth scientific study of water in the coastal city of Port-de-Paix, shows the devastating consequences that the lack of access to clean and safe water has on the population studied.  Like the majority of the Haitian people, the population of Port-de-Paix lacks accessible, affordable, and safe potable water.

“In my years as a doctor in rural Haiti, I have witnessed the tragic relationship between lack of access to clean water and preventable disease,” said Dr. Evan Lyon, one of the project’s primary investigators from PIH.  “This survey opened my eyes to how essential clean water is to all facets of life, from cooking and washing, to growing food and the ability of children to attend school. When even water at the local hospital—which is meant to treat people who have fallen ill with water-related diseases—comes from the very same contaminated sources that first made those patients ill, one begins to grasp the dangerous relationship dirty water has with all aspects of survival.”

The four organizations that authored the report are committed to working together to find ways to transform the findings into action.  The report’s title,“Wòch nan Soley” comes from a proverb in Haitian Kreyol lamenting that, “the rocks in the water don’t know the suffering of the rocks in the sun.” In other words, the wealthy do not know the suffering of the poor.  According to Viaud, this is precisely what needs to change. “We must strive to hold our governments, and the institutions to which they belong, accountable.  And we must commit to ensuring that the right to water is realized in rich and poor countries alike.  It is time for all actors in Haiti to put the rights of the Haitian people first.”

The organizations involved hope that the report will contribute to real policy changes by compelling international financial institutions, national governments, and other entities to understand that respect for human rights is inextricably linked to resource and development issues and, crucially, that they are legally obligated to respect, protect, and fulfill those rights. 

[published June 2008]

Academic collaboration brings Haitian nurses to Boston and skills to Zanmi Lasante

By Melissa King

	(Right to left) Zanmi Zante nurses Lydie Presnar, Jeanne Myrléne Astrémond Taveús, Marie Myrléne St. Vil Marius and Sanon Marie Mylande (in back) gather with Joyce Granara, RN, director of surgical services, before a laboratory session at Lawrence Memorial Hospital.

That commitment carried Marie through nursing school, and later, motivated her to leave the relative comfort of a hospital in the capital city to work at PIH’s partner organization Zanmi Lasante (ZL) in Haiti’s isolated and impoverished Central Plateau. Most recently, it brought Marie and three colleagues to Boston to receive formal training for operating room nurses that is not offered anywhere in Haiti.

In late June, she and Sanon Marie Mylande, Lydie Presnar and Jeanne Myrléne Astrémind Taveús became the first international students to complete the Introduction to Perioperative Nursing Course at Regis College in Weston, Massachusetts.

Known in Haiti as instrumantistes, perioperative nurses are critical members of the operating room team who prepare patients for surgery, maintain a sterile operating room environment and to monitor patients carefully during surgery.

Partners In Health and Regis College pooled resources to provide this formal training to the nurses, who will use their new skills to enhance patient care, to help review surgical equipment needs and to improve the flow of operating procedures at two ZL sites in Haiti – Cange and Belladère.

"Our hope is that the nurses will work with operating room teams to develop and implement updated standards of care,” said PIH Advocacy and Policy Director Donna Barry.

The beginning of an academic collaboration

In a country that only spends about US$2 per person on health care each year, limited resources present a challenge for health professionals like Marie who are providing health care to the nation’s poor.

This is compounded by the fact that their jobs are socially challenging. Marie and the other nurses report to work for 14 consecutive days, followed by a three-day weekend; they are home with their families only a few days per month. It is this kind of dedication that defines PIH staff and their commitment to solidarity with those living in impoverished settings.

In the autumn of 2007, PIH staff—together with Regis College's Dean of Nursing Toni Hays and faculty member Nancy Street—met with leaders of nursing schools in Cap-Haïtien and Port-au-Prince to learn how they could help improve education for nurses in Haiti. This was the formal beginning of what all institutions hope will be a long, fruitful partnership.

When Ophelia Dahl, PIH’s CEO, went to Haiti earlier this year, ZL’s chief surgeon mentioned that it would be very helpful if some nurses had specialized operating room training. Upon her return, she and Donna Barry met with Dr. Hays and mentioned this priority need.

Regis College stepped up to help fill the gap, offering to provide free tuition and housing if PIH could bring students from Haiti to Boston to take part in the perioperative nursing program, find clinical placements and cover the other costs. PIH took them up on the offer and found another willing collaborator in Boston Medical Center, where the nurses were paired with preceptors to take part in clinical observation.

The perioperative nursing program, which is now in its fifth year, provides registered nurses with a solid understanding of the theories, principles, skills and best practices of perioperative nursing. It is a collaboration among Regis College Nursing Program, Lawrence Memorial Hospital, Hallmark Health’s Center for Professional Development and several Boston-area hospitals.

From the classroom to the operating room

Marie eyed her “87.” An hour before class, she and the other Haitian nurses had already convened to go over their tests from the previous week.

While she had scored far above the mean, Marie reviewed each question carefully to see how her answers could have been better. “The [Haitian] students have been very motivated,” observed Laurie A. Hillson, RN, MSN, who developed the course. “They are always asking for more resources and information.”

	Zanmi Lasante nurse Sanon Marie Mylande lays out surgical toolsas colleague Jeanne Myrléne Astrémind Taveús and Joyce Granara, RN, director of surgical services, look on.

Hillson, who is the coordinator of continuing studies at Regis, said that the nurses were motivating the rest of the class, as well. “They are getting us to think more globally,” she said. “We are learning more about how much waste we have, and how we can better conserve.” Colleagues at Lawrence Memorial and its clinical affiliates are now collecting medical supplies to send to Haiti—materials like suction tubing and gowns that are unused and have not expired, but that they are required to dispose of if a surgery is canceled.

When the nurses were not in class at Regis College, they were either taking part in laboratory sessions at Lawrence Memorial Hospital, or in clinical observation at Boston Medical Center (BMC).

Unlike many of their fellow classmates, the nurses had seen some of the technologies at BMC only in books. Sanon said they were impressed not only by the sheer variety of tools, but by the fact that there are so many types of operating room nurses in the United States. “It is interesting to see that in nursing teams here, every person has a specific job and there are more people to provide the same care,” she said.

The nurses say they were also pleasantly surprised that some of the hospital staff they met in Boston are of Haitian decent. The irony is that Haitian nurses have long been part of the fabric of New England hospitals. There are currently more people from Haiti taking up residence in Boston than in Cap-Haïtien, Haiti’s second largest city.

The Road Ahead

Now that the nurses have completed the program, they face the added challenge of applying their skills and practices in a very different environment. As Lydie Presnar, one of the four nurses, pointed out, “In order to enable us to use all that we have learned here, we will need more materials and more resources than we currently have in Haiti.”

The nurses from Cange should soon have these, as PIH and ZL will be renovating a building that holds the two operating rooms at Hopital Bon Sauveur in Cange in the coming year. ZL is also hoping to raise funds to build a larger operating room, complete with more of the most modern equipment.

The success of Marie and her classmates is a good sign for the future of an academic collaboration that is creating a means for health professionals in Haiti to bring much-needed expertise and resources from Boston to patients in the Central Plateau.

Jeanne said that the nurses plan to continue collaborating, wherever the road ahead leads them. The prospect of helping those in need, she said, is well worth the bumpy two-hour stretch between Belladère and Cange that they will travel to meet each other every couple weeks.

PIH Note: Enormous thanks to our partners at Regis College, Lawrence Memorial Hospital, Boston Medical Center and all the individuals who worked on translation, transportation and other logistics. This was an amazing collaboration and shows how well institutions can work together to improve patients’ lives in far-away places.

[posted June 2008]

	Participants at the Tomsk training, June 2008

The training seminar was entitled “Treatment of Patients with MDR-TB,” and was part of the global struggle against multidrug-resistant tuberculosis (MDR-TB). It brought together TB doctors employed in Russia and 10 countries of the former Soviet Union. The training was carried out jointly with Partners In Health, the Tuberculosis Office of Tomsk Oblast, UFSIN the Tomsk Oblast State Penitentiary System, and with financial support from the Eli Lilly Foundation.

Forty-eight tuberculosis specialists took part in the training, representing Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan, Uzbekistan, Ukraine, as well as several regions of the Russian Federation.

As for lecturers, specialists were invited from the non-profit organization Partners In Health, Harvard Medical School, and local clinical project staff in Tomsk.

During the seminars, participants were instructed by Russian and international experts on proper treatment of patients with MDR-TB. Participants also took part in case-based clinical discussions and shared best practices. Additionally, there were organized visits to TB hospitals including LIU-1, UFSIN, Tomsk Oblast Clinical Tuberculosis Hospitals, and Tomsk Oblast civilian tuberculosis clinics, where participants of the seminar familiarized themselves with the work of local experts.

On completion of the training course Dr. Edward Nardell, a professor at Harvard Medical School and Albert Tigranovich Adamyan, Director of the Department of Public Health of Tomsk Oblast, presented certificates to all the participants, as well as training materials on CDs and guidelines for the treatment of patients with MDR-TB, so that all participants can easily access this crucial information to aid them in their fight against MDR-TB.

[posted June 2008]

	A child helps paint a colorful mural on the wall of the Lois and Thomas J . White Community Center

Children make their artistic mark on local community cetner.

Colorful posters, perfectly completed homework assignments, and popsicle-stick picture frames fill the inside walls of the Lois and Tomas J. White Community Center in Carabayllo, Peru. The community's children lovingly provided these works of art, so when it came time for the center to get a facelift, the kids eagerly moved their creativity to the outside walls.

Staff of PIH's partner organization in Peru, Socios En Salud (SES) and members of the Carabayllo community recruited the help of three professional local graffiti artists to transform the artwork and imagination of the neighborhood children into a vibrant mural along the center’s exterior. The three artists visited the center and gathered drawings from the children by posing the question “How do you imagine your community in the future?” They used the drawings as a basis for the design of the mural, then began painting a general outline of the mural on the walls while listening to instructions and excited commands of the true artists—the kids themselves. Participants of the SES afterschool education programs then grabbed smocks and paintbrushes, eager to finish filling in the outline and put their own mark on the wall – filling in a landscape of smiles, friendship and messages of peace to welcome visitors.

Professional artists were recruited to help translate the children's vision onto the walls of the community center.
Children painted the outline sketched by the professional artists, adding in their own artistic flair.

The mural, completed in the beginning of December, is the latest addition to the Lois and Thomas White center, following the 2008 inauguration of the community library. The center serves the surrounding community as a small rural health center and pharmacy, afterschool learning center, and general community space operated by SES staff and local health promoters.

SES’s commitment to comprehensive health care includes a strong children’s health program, Salud Infantil, which provides consistent medical check-ups and home visits, educational support and socio-economic assistance to families. All too often in poverty-stricken communities like this shantytown in Carabayllo, childhood is abandoned early for meager wages made on the street or in other informal work. The educational programs sponsored by SES attempt to return the creativity and energy to the community’s children while reinforcing high achievement in school.

Walking past the mural and through the doors of “Lois and Thomas,” as it’s affectionately known, kids can proudly point to their individual contributions. Seeing their artwork valued and hard work acknowledged the kids learn to feel confidence in themselves, inside and out.

[posted June 2008]

My name is Loune Viaud and I work in Haiti with Zanmi Lasante for the right to health.

One morning in November 2002, I met Monika Kalra Varma, from the RFK Memorial Center. I made her toast to a long-time commitment to Haiti. Little did she know it was going to be that serious.

Later on, I asked her to look into the reasons behind the blocking of the loan to a life-saving water project in Port-de-Paix. Little did I know it would take us six years to produce this painful report on what we found about this project.

This study was very difficult to do. First of all, none of us had any idea it would take that long and would be that devastating.

I wanted to launch the report in Haiti, in Port-de-Paix to be exact. But, given the political situation after Prime Minister Alexis was force to resign, we thought it was better not to wait for a new government. So we are releasing the report here [in New York City] with the hope of having another launch in Haiti, in the near future.

Why a study on access to water? The right to water? I bet most of the people in this city do not think about this as a right. It is taken for granted every day, several times a day. One needs water to drink, for sanitation, for hygiene, cooking, etc.  Just imagine one day without water, here in New York City. It would be a disaster – in the news around the world. It would be outrageous.

Because people go without water in Haiti, we said, why not prepare a report on the IDB [Inter-American Development Bank] and the water project in Port-de-Paix?

It is not because we are against the IDB or the international community; it is not because we have nothing better to do; it is not because we're very angry people and want to take on the US government.

Believe me, I wish I did not have to worry about access to health, to water, to food, to housing, to education: to human rights.

It is because that is what we stand for. We have to stand up for what's right. What is right is for the IDB and the international community to stop playing with the lives of innocent people.

It is because we want the IDB and the international community to make it right. For too long the rights of the Haitian people have been compromised. It is time we take action.

If not us, then who? We did this study and prepared this report to prevent it from ever happening again.

We can't afford not to care. When you and I are not watching, bad things happen to innocent people.

Thank you for your attention and your solidarity.

[published June 2008]

Woch nan Soley: The Denial of the Right to Water in Haiti

[Download the report as a PDF]

A recent New York Times article also features the report.

	A water source in need of an intervention in Haiti.

By Tom Spoth

In 1998, the Inter-American Development Bank (IDB) awarded $54 million in loans to the Haitian government to improve the country’s patchwork, crumbling public-water system. The money was intended to bring clean water to people who for many years had been denied this basic human right, with devastating consequences for public health. Ten years later, however, this desperately needed money has not produced a single improvement to Haiti’s water supply in the city designated to be one of the first recipients.

A new report from Partners In Health and three other groups reveals the United States government’s clandestine efforts to ensure that political considerations (namely the desire to destabilize Haiti’s elected government at that time, led by President Jean-Bertrand Aristide) took precedence over the rights of some of the planet’s poorest and most vulnerable people.

In the 10 years since the loans were approved, the Haitian water system has actually gotten worse. In 2002, a water-poverty index released by the British-based Centre for Ecology and Hydrology ranked Haiti dead last out of 147 countries surveyed.

On June 23, Partners In Health – along with its Haitian sister organization Zanmi Lasante, the Center for Human Rights and Global Justice, and the Robert F. Kennedy Memorial Center – released the 87-page report “Wòch nan Soley: The Denial of the Right to Water in Haiti” in New York City.

“We have to stand up for what's right,” Loune Viaud, director of operations at Zanmi Lasante, said at the press conference. “What is right is for the IDB and the international community to stop playing with the lives of innocent people.”

Viaud and the rest of the investigative team worked for six years to bring the story of the IDB loans to light. During that time, Haiti’s water system continued to deteriorate. The report states that:

• Public water systems are rarely available throughout the year and close to 70 percent of the population lacks direct access to potable water at all times
• The percentage of the population without access to safe drinking water has increased by at least seven percent from 1990 to 2005
• Infectious diarrhea was the second leading cause of death in Haiti in 1999, and gastrointestinal infection was the leading cause of mortality for young children. These preventable diseases result primarily from unsafe drinking water and poor sanitation.

The failure to address Haiti’s crippling public-health problems is the latest in a long line of oppressive policies toward the country. Haiti, the only nation to be born from a successful slave revolution, has been hamstrung by crushing foreign debt for virtually its entire existence. It took Haiti more than 100 years to pay off a debt of 150 million francs (equivalent to $21 billion today) imposed by France in 1825 to “compensate” for the value of lost property, including the former slaves themselves. More recently, impoverished Haiti has been forced to pay $1 million a week toward settling a $1.54 billion debt piled up mainly by the dictatorial Duvalier regime, which did nothing to improve the lives of average Haitians.

Massive debt has precluded spending on desperately needed infrastructure projects. In 2003, for example, Haiti’s debt service was $57.4 million; the Haitian government’s combined budget for education, health care, environment, and transportation was $39.21 million. Meanwhile, the Haitian people continued to endure crushing poverty, which has been exacerbated by the failure to disburse the IDB loans. The report contains a telling comparison: In order to purchase the World Health Organization’s minimum standard of 20 liters of water per day, a Haitian family of four would have to spend approximately 12 percent of its annual income – the equivalent of asking a U.S. family living at the poverty level ($20,444 per year) to pay nearly $2,500 per year for water.

In Port-de-Paix, the Haitian city that was supposed to be one of the first beneficiaries of IDB loans, the private sector provides 80 percent of drinking water, and 86.7 percent of residents surveyed reported that they are “always” or “sometimes” unable to pay for water. Eighty percent indicated that water quantity had either declined or stayed the same in the five years before the survey was conducted, and 88.9 percent said water quality had gotten worse or not improved.

A household survey conducted by PIH documented the devastating impact on public health. Fifteen percent of the surveyed households reported probable recent cases of typhoid. One-third of respondents suffered from symptoms of gastrointestinal infection, the leading cause of death for Haitian children under the age of five.

“I’ve been working in Haiti for more than a decade,” commented Evan Lyon of PIH, “so I have long been aware of the connection between lack of access to clean water and preventable disease. But surveying households in Port-de-Paix opened my eyes to how essential clean water is to all facets of life, from cooking and washing, to growing food and the ability of children to attend school. At one household, we perched on rickety chairs in front of the house, ankle-deep in water, and the family was literally bailing filthy water out of their yard while I asked them questions. When we tested water at the local hospital we discovered it was just as contaminated as the water that makes people sick in the first place. The hospital's water comes from the same dirty sources.”

Although initial bids have been taken for the Port-de-Paix project, as of May 2008, no ground had been broken. Several attempts to obtain updates from the IDB’s Public Information Center were unsuccessful. (In an article about the report, The Miami Herald quoted an IDB spokesman as saying that in Port-de-Paix, funds are being disbursed to contractors and work should be completed by 2009.)

By failing to distribute loans and grants to Haiti, the IDB violated its own charter, which strictly prohibits the bank from letting politics influence its decisions. Internal documents from the U.S. Treasury Department and the office of the U.S. Executive Director at the IDB, obtained through Freedom of Information Act requests, show that officials actively used American influence to block the loans in an attempt to destabilize the government led by President Aristide, who was ultimately overthrown in 2004.

International law also protects the human right to water, according to the United Nations’ Committee on Economic, Social and Cultural Rights, as well as other international covenants and declarations. If one accepts the notion of water as a fundamental right, then the U.S. government’s actions can be construed as a direct violation of its international human-rights obligations.

“I bet most of the people in this city do not think about this as a right,” Viaud said. “It is taken for granted every day. Just imagine one day without water, here in New York City. It would be a disaster -- in the news around the world. It would be outrageous.”

The report’s authors recommend a “rights-based” approach to water projects in Haiti going forward: All initiatives should focus on accountability and sustainability, and should involve Haitians living in the communities where projects will be implemented in the process.

“Wòch nan Soley: The Denial of the Right to Water in Haiti” will be launched in Port-de-Paix at a later date. French and Kreyol versions will be available soon.
 
 

[posted June 2008]

	A Haitian girl styles her new shoes

They’re bright. They’re sturdy. They’re trendy. They’re Crocs – the often gaudily colored plastic shoes worn on playgrounds, hospital floors, beaches and hiking trails all across the United States. And as of this month, they’re on the feet of thousands of children, women and men on the central plateau of Haiti.

The sudden popularity of Crocs in poor Haitian communities wasn’t dictated by fashion. It was prescribed by doctors. Going barefoot in the rocky hills and muddy valleys of Haiti isn’t just uncomfortable. It leads to a major public health problem – an epidemic of tungiasis, an infestation of sand fleas that can cause pain, itching, swelling, open sores and, if left untreated, sepsis, tetanus or gangrene.

So when they learned that 40,000 pairs of Crocs were available, Zanmi Lasante (ZL, PIH’s partner organization in Haiti) and the Haitian Ministry of Health jumped at the offer.

	A Zanmi Lasante doctor examines a patients' feet for signs of sand flea infestation

The donation included not only the value of the shoes contributed by Crocs Footwear but all the costs of shipping them from the factory in China to the docks in Port-au-Prince.

The initiative was orchestrated by Kageno Worldwide, a non-profit dedicated to “transform[ing] communities suffering from inhumane poverty into places of opportunity and hope.” Kageno solicited the shoes from Soles United, Crocs’ program for donating shoes made from recycled material. They also negotiated steeply discounted shipping terms with Cargo Services and arranged to split the costs of the shipping with Pearson Publishing. Brothers Brother, another nonprofit, took charge of getting the shoes into a container and onto the dock. ZL and the Ministry of Health assumed responsibility for distributing the shoes through mobile clinics.

Frank Andolino of Kageno traveled to Haiti to witness the beginning of distribution first-hand. In an email to other contributors, he reported: “I wish you all could be here! It has been amazing. 10,000 pairs of CROCS have safely made it from China to Haiti and 4,000 individuals have already benefited from your generosity.”

[posted June 2008]

By Betty Rigodon and Dr. Jonas Rigodon

	Patients picking up food on horseback at Nohana

In August 2007, the staff at PIH's clinic in Nohana confronted an alarming increase in the number of malnourished children arriving from the surrounding mountain villages. Within a single week, more than 100 children were diagnosed as malnourished in Nohana. Most were suffering from moderate malnutrition and several exhibited symptoms of wasting (marasmus) and swelling (kwashiorkor) associated with severe lack of calories and protein. Months before headlines and television reports announced a global food crisis, these children alerted PIH to a spike in the hunger and malnutrition that chronically afflict poor communities in Lesotho and other countries where we work.

Statistics reveal the scale of the persistent "silent tsunami" of hunger that only captured the attention of the media and the world when people took to the streets to protest soaring food prices. More than 800 million people suffer from chronic hunger. Nearly 10 million of the world's children die each year before reaching the age of five. Sadly, two out of three of these children die from easily preventable and treatable diseases such as diarrhea, pneumonia and malaria, and most would survive if they had not been weakened by hunger and malnutrition.

Conditions in Lesotho reflect these global trends. It is estimated that 40 percent of children under five are stunted and 20 percent are underweight, which are respectively signs of chronic and acute undernourishment.

Even before the recent upsurge of hunger in Lesotho and around the world, PIH-Lesotho had teamed up with the World Food Program to provide monthly food rations to all tuberculosis and HIV patients. This program reflects our belief that prevention and treatment of HIV are impossible without adequate nutrition. Numerous studies have confirmed what our experience tells us every day – that HIV patients are more likely to contract severe illnesses due to the weakness of their immune systems if they are not well-nourished.

When cases of severe malnutrition shot up last year, PIH launched a supplementary feeding program to provide nutritional support to all malnourished children in the mountains. Every child enrolled in the program receives a package containing 60 kilograms of maize meal, 9 kilograms of beans, 4 liters of cooking oil, and 6 kilograms of a nutritious corn-soy blend to help them gain weight. In addition, all severely or moderately malnourished children older than six months receive a special high-protein, high-energy peanut butter fortified with vitamins and sugar. This “Ready-to-Use Therapeutic Food” requires no preparation or special supervision and can be delivered to malnourished children at home by their parents or any other untrained adult.

Each child’s file at the clinic includes an intake form that records his or her weight, height, and upper arm circumference—all of which are used to measure nutritional status. Progress is monitored on a follow-up form that requires children to come back to the clinic both for a regular assessment and to pick up their monthly food rations.

The benefits of the program extend far beyond what can be gauged by measuring upper arm circumference. The regular visits also provide opportunities to:

• vaccinate many children who have never been immunized
• test a large number of children and their parents for HIV (in a country where nearly a quarter of the adult population is HIV positive)
• distribute vitamin A to improve eyesight and reduce child mortality exacerbated by the high incidence of vitamin A deficiency
• supply iron supplements for a population where more than half of all children under five suffer from iron deficiency anemia

	Malipho before and after receiving food and treatment

For a child like Malipho Ramahapa, the Plumpy’nut and food packages are just as essential as the other medicines that spell the difference between life and death. Malipho, a 19-month-old boy, weighed only 5.2 kilograms (11.5 pounds) in October 2007, when he was brought to the clinic at Nohana. According to his mother, little Malipho was suffering from a daunting array of symptoms – a very high fever, oral thrush (a fungal infection in his mouth), chronic diarrhea, vomiting, loss of appetite and weight loss. An examination confirmed the symptoms and a diagnosis of both severe malnutrition (marasmus) and pulmonary tuberculosis. Results of an HIV test revealed that he was also suffering from advanced HIV progressing to AIDS.

Just two months after starting treatment and a diet of Plumpy’nut, Malipho was barely recognizable. Gone was the child so weak and wasted that he could barely sit up, replaced by a robust boy with an engaged look and a ready smile.

Malipho’s mother was so overjoyed by her son’s recovery that she chose to speak out and urge other parents to bring their children to the clinic. Just 20 years old and HIV positive, she had been reluctant to undertake the long trip to the clinic herself. But with her only child on the brink of death, she finally decided to come. “I took the decision to come to this clinic just because my child was so sick,” she recalled. “And also because the village health worker forced me to. I remember that it took me two days to get to the clinic, for a trip that would normally take about eight hours for a health person on horseback.”

Now, she says, “I really appreciate all the help that I got from this clinic, which keeps my child from dying today. It may be difficult for patients to come to the clinic, but all of them should do so in order to save their children’s lives. Saving lives is more important than worrying about the two-day trip.”

[posted June 2008]

By Peter Drobac

A young, widowed mother of five named Patricie was recently admitted to the Burera District Hospital. She suffered from both advanced HIV/AIDS and disseminated tuberculosis. Though there are an estimated 600 new cases of tuberculosis in the district annually, Patricie was only the second person to receive treatment this year. Just a few months ago, there was only one physician to serve a population of nearly 400,000. Many faced limited access to health care, and despite the fertile volcanic soil, childhood malnutrition was rife.

We have seen this before. Three years ago, Partners In Health, in partnership with the Clinton Foundation, arrived in Rwanda to help the government rebuild health systems in two rural districts—Kayonza (Rwinkwavu) and Kirehe. Two hospitals and seven health centers later, hundreds of thousands of Rwandans have gained access to high-quality health care; more than 2,000 HIV-infected individuals are thriving with antiretroviral therapy, village-based accompaniment, and nutritional support; thousands of jobs have been created, many of them for our recovering patients. In Rwinkwavu, the contrast between the post-conflict desolation of 2005 and the lush gardens and bustling activity in the government-run facility of 2008 is striking—even for those of us who have seen this before in places like central Haiti.

So when the Government of Rwanda proposed an ambitious program to strengthen rural health systems throughout the country utilizing many of the core elements of the PIH/CHAI model, we were both humbled and delighted. The resulting framework, developed by the GOR in close collaboration with bilateral and multilateral funders, PIH/CHAI, and other NGOs working in the country, will require years of work, new partnerships, and significant funding.

The first step was to replicate the successes of the Rwinkwavu collaboration, and other health delivery approaches in use in the country, in one of the two remaining Rwandan health districts without a district hospital — Burera. Nestled in the volcanic hills of northwest Rwanda, Burera happens to be the prettiest corner of what just may be the prettiest country in Africa. Yet it is a large district, physical and communications infrastructure are among the nation’s poorest, and the GOR aims to accomplish the Burera scale-up more quickly — and more effectively — than ever before.

To help support such a daunting and critical project, as the implementing partner in the district, PIH needed to identify someone special.  Did we look to Harvard or another elite American university? No. Perhaps a respected international consultant? Hardly. Instead, we turned to rural Haiti.

Patrick Almazor joined PIH's Haitian partner organization, Zanmi Lasante, seven years ago as a newly minted young physician from Port-au-Prince. After several years of serving and training in Cange, Patrick helped to transform the delivery of health care at several facilities in Haiti’s central plateau.  He gained formal training as a public health practitioner, and then crossed the Atlantic to become PIH’s Burera District Director.

	Patrick Almazor visiting Patricie and her family at their home

Those familiar with the philosophy of PIH know that home visits are an integral part of our work. There is no substitute for the opportunity to sit with a patient in his or her home in an effort to understand the social, economic, and structural forces that shape lives and contribute to illness. For this reason, the first home visit in Burera felt like an inauguration of sorts. Dr. Patrick had met Patricie just a few weeks earlier during her initial hospitalization. Though gravely ill, she had survived that hospital stay and begun treatment for both HIV and tuberculosis—starting eight new medications, in all.  Patrick decided to see how she was faring at home.

The walk to her home involved about two hours of steady climbing, and brought us within a stone’s throw of the Ugandan border. Upon arriving, I quickly understood how it is that a child can starve in such a fertile region. Patricie and her five children live in a two-room shack with a thatched roof and a mud floor. Their home is nestled near a picturesque hilltop surrounded by lush fields of sorghum, corn, beans, and vegetables. Yet Patricie’s land is hardly bigger than the poor little house itself—none of those crops are hers. She has scraped out a living by working her neighbors’ land in return for a small share of the crop yield. Due to her illness, Patricie was unable to work at all for several months. Her husband had died years earlier of AIDS. As a result, her five children (though blessedly HIV-negative) clearly suffered from malnutrition and parasitic infection.

The GOR framework provides Patricie with more than medicines alone. She is visited daily by a trained accompagnateur from her own village, who provides a critical link to the health center. Patricie and her family receive both medical and nutritional support. We hope to someday help rebuild her house and help get her children to school, as has been done for hundreds of other destitute families near Rwinkwavu (and thousands in Haiti). Agricultural projects and other income-generating activities are planned, as the support becomes available.

Peter Drobac, M.D., is a clinician who works with PIH, predominantly in Rwanda, and aa Research Fellow in the Division of Infectious Disease and Social Medicine at Brigham and Women's Hospital in Boston.

[published June 2008]

By Melissa King

	(Right to left) Zanmi Zante nurses Lydie Presnar, Jeanne Myrléne Astrémond Taveús, Marie Myrléne St. Vil Marius and Sanon Marie Mylande (in back) gather with Joyce Granara, RN, director of surgical services, before a laboratory session at Lawrence Memorial Hospital.

Every since she was a child growing up in Haiti, Marie Myrléne St. Vil Marius has wanted to dedicate her life “to people who have nothing and are in need.”

That commitment carried Marie through nursing school, and later, motivated her to leave the relative comfort of a hospital in the capital city to work at PIH’s partner organization Zanmi Lasante (ZL) in Haiti’s isolated and impoverished Central Plateau. Most recently, it brought Marie and three colleagues to Boston to receive formal training for operating room nurses that is not offered anywhere in Haiti.

In late June, she and Sanon Marie Mylande, Lydie Presnar and Jeanne Myrléne Astrémind Taveús became the first international students to complete the Introduction to Perioperative Nursing Course at Regis College in Weston, Massachusetts.

Known in Haiti as instrumantistes, perioperative nurses are critical members of the operating room team who prepare patients for surgery, maintain a sterile operating room environment and to monitor patients carefully during surgery.

Partners In Health and Regis College pooled resources to provide this formal training to the nurses, who will use their new skills to enhance patient care, to help review surgical equipment needs and to improve the flow of operating procedures at two ZL sites in Haiti – Cange and Belladère.

"Our hope is that the nurses will work with operating room teams to develop and implement updated standards of care,” said PIH Advocacy and Policy Director Donna Barry.

The beginning of an academic collaboration

In a country that only spends about US$2 per person on health care each year, limited resources present a challenge for health professionals like Marie who are providing health care to the nation’s poor.

This is compounded by the fact that their jobs are socially challenging. Marie and the other nurses report to work for 14 consecutive days, followed by a three-day weekend; they are home with their families only a few days per month. It is this kind of dedication that defines PIH staff and their commitment to solidarity with those living in impoverished settings.

In the autumn of 2007, PIH staff—together with Regis College's Dean of Nursing Toni Hays and faculty member Nancy Street—met with leaders of nursing schools in Cap-Haïtien and Port-au-Prince to learn how they could help improve education for nurses in Haiti. This was the formal beginning of what all institutions hope will be a long, fruitful partnership.

When Ophelia Dahl, PIH’s CEO, went to Haiti earlier this year, ZL’s chief surgeon mentioned that it would be very helpful if some nurses had specialized operating room training. Upon her return, she and Donna Barry met with Dr. Hays and mentioned this priority need.

Regis College stepped up to help fill the gap, offering to provide free tuition and housing if PIH could bring students from Haiti to Boston to take part in the perioperative nursing program, find clinical placements and cover the other costs. PIH took them up on the offer and found another willing collaborator in Boston Medical Center, where the nurses were paired with preceptors to take part in clinical observation.

The perioperative nursing program, which is now in its fifth year, provides registered nurses with a solid understanding of the theories, principles, skills and best practices of perioperative nursing. It is a collaboration among Regis College Nursing Program, Lawrence Memorial Hospital, Hallmark Health’s Center for Professional Development and several Boston-area hospitals.

From the classroom to the operating room

Marie eyed her “87.” An hour before class, she and the other Haitian nurses had already convened to go over their tests from the previous week.

While she had scored far above the mean, Marie reviewed each question carefully to see how her answers could have been better. “The [Haitian] students have been very motivated,” observed Laurie A. Hillson, RN, MSN, who developed the course. “They are always asking for more resources and information.”

	Zanmi Lasante nurse Sanon Marie Mylande lays out surgical toolsas colleague Jeanne Myrléne Astrémind Taveús and Joyce Granara, RN, director of surgical services, look on.

Hillson, who is the coordinator of continuing studies at Regis, said that the nurses were motivating the rest of the class, as well. “They are getting us to think more globally,” she said. “We are learning more about how much waste we have, and how we can better conserve.” Colleagues at Lawrence Memorial and its clinical affiliates are now collecting medical supplies to send to Haiti—materials like suction tubing and gowns that are unused and have not expired, but that they are required to dispose of if a surgery is canceled.

When the nurses were not in class at Regis College, they were either taking part in laboratory sessions at Lawrence Memorial Hospital, or in clinical observation at Boston Medical Center (BMC).

Unlike many of their fellow classmates, the nurses had seen some of the technologies at BMC only in books. Sanon said they were impressed not only by the sheer variety of tools, but by the fact that there are so many types of operating room nurses in the United States. “It is interesting to see that in nursing teams here, every person has a specific job and there are more people to provide the same care,” she said.

The nurses say they were also pleasantly surprised that some of the hospital staff they met in Boston are of Haitian decent. The irony is that Haitian nurses have long been part of the fabric of New England hospitals. There are currently more people from Haiti taking up residence in Boston than in Cap-Haïtien, Haiti’s second largest city.

The Road Ahead

Now that the nurses have completed the program, they face the added challenge of applying their skills and practices in a very different environment. As Lydie Presnar, one of the four nurses, pointed out, “In order to enable us to use all that we have learned here, we will need more materials and more resources than we currently have in Haiti.”

The nurses from Cange should soon have these, as PIH and ZL will be renovating a building that holds the two operating rooms at Hopital Bon Sauveur in Cange in the coming year. ZL is also hoping to raise funds to build a larger operating room, complete with more of the most modern equipment.

The success of Marie and her classmates is a good sign for the future of an academic collaboration that is creating a means for health professionals in Haiti to bring much-needed expertise and resources from Boston to patients in the Central Plateau.

Jeanne said that the nurses plan to continue collaborating, wherever the road ahead leads them. The prospect of helping those in need, she said, is well worth the bumpy two-hour stretch between Belladère and Cange that they will travel to meet each other every couple weeks.

PIH Note: Enormous thanks to our partners at Regis College, Lawrence Memorial Hospital, Boston Medical Center and all the individuals who worked on translation, transportation and other logistics. This was an amazing collaboration and shows how well institutions can work together to improve patients’ lives in far-away places.

[posted June 2008]

Visiting 16 patients scattered among the rural hills of Malawi not once but twice a day, every day? "No problem!" says one village health worker.

	Briston and his trusty bike

Every day, Briston Threemunthu rises before the crack of dawn, climbs onto his trusty bicycle, and pedals down a narrow dirt path to visit his first patient.

As a village health worker with Abwenzi Pa Za Umoyo (APZU, PIH's partner organization in Malawi), his job is to visit HIV patients twice each day to monitor their health and help support the intensive regimens needed to treat the disease. But the visits often call for more than just monitoring medical needs. "I visit them, chat, share ideas, remove stress, encourage them that [even if they] are sick, it doesn't mean the end of life."

Briston's route currently includes 16 patients in the rural, mountainous district of Neno. "Other [CHWs] may have only six patients. But it is no problem. [My patients] all know me well. They all chose me to be their village health worker. I cannot deny them. That's why I have so many," grins Briston. "It is no problem," he repeats, smiling at the black mountain bike that is one of the keys to his ability to care for so many patients, some who live as far as five or six kilometers away from each other. Although APZU currently employs a cadre of nearly 300 village health workers, Briston is unfortunately one of the few with access to a bike.

But the bike is only part of the equation. The other part is Briston's own dedication. The path he travels down is full of rocks and potholes that fill with water and mud, requiring him to get off and carry the bike on his shoulders for part of his route. In the rainy season, he sometimes must leave the bike at home and do his rounds on foot, which takes about twice as long. Every evening, he repeats his route, checking in on each patient one more time before returning home to his wife and their two-month-old baby. Even though it sometimes means returning home well after dark, he is careful to give all of his patients the attention they need. "Every round should be exemplary," he insists. Plus, each patient is more than just a patient-they are his neighbors. "I am assisting my brothers and my sisters," he says. "As long as I'm assisting them, there's no problem and they are getting well, and I am happy," he smiles. "No problem."

[posted June 2008]

By Melissa King

HIV/AIDS knows no borders. This was obvious from the start of the recent FACE AIDS Spring Conference, which brought together student leaders and speakers from across the nation and the world to build alliances in addressing the HIV/AIDS pandemic.

	(From left to right) Sheri Fink, MD, PhD; David Ryan; Henry Epino, MD; FACE AIDS Managing Director Annie Kalt; and Emmanuel Ahishakiye stayed after the keynote address to speak with students. Annie left for Rwanda on May 1 to help coordinate the FACE AIDS pin-making program.

“The discussion we need to start today is how to battle skepticism,” said FACE AIDS Executive Director David Ryan in his opening remarks on April 11, referring to those “who disagree that they can make a difference.” This set a tone of action and creativity for the three-day event at the University of Texas at Austin, which featured workshops, speakers from the field of health and social justice, and a concert to show attendees a true welcome to “the music capital of the world.”

FACE AIDS was founded in 2005 with the mission of “mobilizing and inspiring students to fight AIDS in Africa.” The organization centers around a microfinance program, where HIV-affected individuals in Africa are hired to craft beaded awareness pins that are in turn sold by students in the United States. Each sale is then matched dollar for dollar by private donations. After program costs (supplies and pin-maker wages), all proceeds go to benefit PIH programs in Africa.

Since 2005, FACE AIDS has recruited 150 high school and university chapters, supported 170 individuals in Zambia and Rwanda, and distributed roughly 70,000 pins. Earlier this spring, the organization passed a major milestone by reaching its goal of raising $1 million for PIH.

FACE AIDS began a formal collaboration with Partners In Health in 2007 to operate the pin-making program at Inshuti Mu Buzima in Rwanda. Emmanuel Ahishakiye, who helps coordinate this project, attended the conference. A talented filmmaker whose work has been featured at the Cannes Film Festival, Emmanuel shared a documentary on the program that he had written and directed. Through his camera, students caught a glimpse of how the pin-making project is impacting lives, from a young woman who for the first time had career options, to a mother who could send her son to school.

Keynote presentations were delivered by award-winning journalist Sheri Fink, MD, PhD, and Henry Epino, MD, PIH medical director for IMB Rwanda. Dr. Fink spoke about her experiences reporting on the treatment of HIV in war and conflict zones, while Dr. Epino discussed the challenges of caring for patients in rural and impoverished settings.

The speakers emphasized that infectious disease knows no borders, a fact that they encouraged student leaders to use in battling skepticism. Quoting a recent adage, Dr. Epino challenged the students to help break cycles of poverty that exacerbate the spread of HIV: “You are the change, you are the people you’ve been waiting for,” he said.

Help build a student movement! Anyone interested in starting a new FACE AIDS chapter should contact Cristin Weekley at cristin@faceaids.org.

[published May 2008]

We hope you enjoyed the 60 Minutes segment featuring the work of Partners In Health. If you missed any part of the broadcast, you can view it below. Photos and text can be viewed on the CBS News website.

Learn more about Partners In Health

We hope that the images you've seen and the voices you've heard will inspire you to find out more about PIH's work in Haiti and around the world. Here are a just a few resources to learn more:

• Read PIH's Annual Reports
• Subscribe to the PIH e-Bulletin to receive monthly updates on our work
• Read past issues of our e-bulletin and print newsletter
• Learn about the work done by the Institute for Health and Social Justice, PIH's advocacy and policy arm
• Check out our events calendar to see if a PIH event is happening near you

Interested in taking action to support Partners In Health?

Becoming an activist for social justice, health care, and poverty relief can be one of the most powerful ways to help PIH. One person at a time, one community at a time, we can build a movement together. Here are some places to start:

• Learn more and teach others about social justice, health care, and poverty issues. Click here for a list of books and films we recommend.
• Organize an event to promote social justice and/or fundraise for PIH.
• Invite a speaker from PIH to share our work and the issues we focus on with your school, organization, or conference. To do this, please contact the appropriate program manager here.
• Consider applying for one of the employment and volunteer opportunities at PIH.
• Support or volunteer for other organizations that are also working on social justice causes. A few of them are listed below. We also recommend looking at www.idealist.org, a great resource for finding jobs, internships, and volunteer positions (including those at PIH) at thousands of nonprofit organizations.
  • Equal Justice Initiative: EJI provides legal representation to indigent defendants and prisoners who have been denied fair and just treatment in the legal system. The organization litigates on behalf of condemned prisoners, juvenile offenders, people wrongly convicted or charged with violent crimes, poor people denied effective representation, and others whose trials are marked by racial bias or prosecutorial misconduct. Learn more at www.eji.org.
  • FACE AIDS: This organization works to mobilize and inspire students to fight AIDS in Africa and provide a means of income generation for HIV patients. Please visit www.faceaids.org for more information about how to join a chapter near you.
  • GlobeMed: A non-profit organization that mobilizes university students in a movement to improve global health. Its student-driven network includes over 300 members at 13 university chapters. Learn more at www.globemed.org.
  • Health GAP (Global Access Project): This organization is dedicated to eliminating barriers to global access to affordable life-sustaining medicines for people living with HIV/AIDS. Learn more at www.healthgap.org.
  • Institute for Justice and Democracy in Haiti: IJDH's mission is to work with the people of Haiti for the return and consolidation of constitutional democracy, justice and human rights. The work focuses on distributing objective and accurate information on human rights conditions in Haiti, pursuing legal cases, and cooperating with human rights and solidarity groups in Haiti and abroad. Find out more at www.ijdh.org.
  • Jubilee USA Network: This network brings together people to turn a disparate reality around by active solidarity with partners worldwide, targeted and timely advocacy strategies and educational outreach. Find out how you can help at www.jubileeusa.org.
  • Médecins Sans Frontières (Doctors Without Borders): MSF is an international humanitarian aid organization that provides emergency medical assistance to populations in danger in more than 70 countries. Learn more at www.msf.org.
  • Physicians for Human Rights: PHR mobilizes health professionals to advance health, dignity, and justice and promotes the right to health for all. Harnessing the specialized skills, rigor, and passion of doctors, nurses, public health specialists, and scientists, PHR investigates human rights abuses and works to stop them. Learn more at www.physiciansforhumanrights.org.
  • RESULTS: This grassroots advocacy organization is committed to creating the political will to end hunger and the worst aspects of poverty. RESULTS is committed to individuals exercising their personal and political power by lobbying elected officials for effective solutions and key policies that affect hunger and poverty. Find out more at www.results.org.
  • Student Global AIDS Campaign: SGAC is a national movement with more than 85 chapters at high schools, colleges, and universities across the United States committed to bringing an end to HIV and AIDS in the U.S. and around the world through education, informed advocacy, media work, and direct action. Visit this organization at www.fightglobalaids.org.
  • Universities Allied for Essential Medicines: UAEM works to determine how universities can help ensure that biomedical end products, such as drugs, are made more accessible in poor countries; and works to increase the amount of research conducted on neglected diseases, or those diseases predominantly affecting people who are too poor to constitute a market attractive to private-sector R&D investment. Visit www.essentialmedicine.org for more information.

[published May 2008]

Socios En Salud, PIH's partner organization in Peru, has published a simple, illustrated guide for participants in their Peer Mentorship program. The participants are former MDR-TB Patients who provide education, advice and treatment support to help current patients through the two long years of treatment. The SES Accompaniment Guide is now available for download (in Spanish).

[Download PDF, 9MB]

By Bill Quigley

Riots in Haiti over explosive rises in food costs have claimed the lives of six people. There have also been food riots world-wide in Burkina Faso, Cameroon, Côte d’Ivoire, Egypt, Guinea, Mauritania, Mexico, Morocco, Senegal, Uzbekistan and Yemen.

The Economist, which calls the current crisis "the silent tsunami," reports that last year wheat prices rose 77 percent and rice 16 percent, but since January rice prices have risen 141 percent. The reasons include rising fuel costs, weather problems, increased demand in China and India, as well as the push to create biofuels from cereal crops.

Hermite Joseph, a mother working in the markets of Port-au-Prince, told journalist Nick Whalen that her two kids are “like toothpicks” because they’re not getting enough nourishment. "Before, if you had $1.25, you could buy vegetables, some rice, 10 cents worth of charcoal and a little cooking oil. Right now, a little can of rice alone costs 65 cents, and is not good rice at all. Oil is 25 cents. Charcoal is 25 cents. With $1.25, you can’t even make a plate of rice for one child.”

The St. Claire’s Church Food program, in the Tiplas Kazo neighborhood of Port-au-Prince, serves 1000 free meals a day, almost all to hungry children – five times a week in partnership with the What If Foundation. Children from Cité Soleil have been known to walk the five miles to the church for a meal. The cost of rice, beans, vegetables, a little meat, spices, cooking oil, propane for the stoves, have gone up dramatically. Because of the rise in the cost of food, the portions are now smaller. But hunger is on the rise and more and more children come for the free meal. Hungry adults used to be allowed to eat the leftovers once all the children were fed, but now there are few leftovers.

The New York Times lectured Haiti on April 18 that “Haiti, its agriculture industry in shambles, needs to better feed itself.” Unfortunately, the article did not talk at all about one of the main causes of the shortages -- the fact that the U.S. and other international financial bodies destroyed Haitian rice farmers to create a major market for the heavily subsidized rice from U.S. farmers. This is not the only cause of hunger in Haiti and other
poor countries, but it is a major force.

Thirty years ago, Haiti raised nearly all the rice it needed. What happened?

In 1986, after the expulsion of Haitian dictator Jean Claude “Baby Doc” Duvalier the International Monetary Fund (IMF) loaned Haiti $24.6 million in desperately needed funds (Baby Doc had raided the treasury on the way out). But, in order to get the IMF loan, Haiti was required to reduce tariff protections for their Haitian rice and other agricultural products and some industries to open up the country’s markets to competition from outside countries. The U.S. has by far the largest voice in decisions of the IMF.

Doctor Paul Farmer was in Haiti then and saw what happened. “Within less than two years, it became impossible for Haitian farmers to compete with what they called ‘Miami rice.’ The whole local rice market in Haiti fell apart as cheap, U.S. subsidized rice, some of it in the form of ‘food aid,’ flooded the market. There was violence, ‘rice wars,’ and lives were lost.”

“American rice invaded the country,” recalled Charles Suffrard, a leading rice grower in Haiti in an interview with the Washington Post in 2000. By 1987 and 1988, there was so much rice coming into the country that many stopped working the land.

Fr. Gerard Jean-Juste, a Haitian priest who has been the pastor at St. Claire and an outspoken human rights advocate, agrees. “In the 1980s, imported rice poured into Haiti, below the cost of what our farmers could produce it. Farmers lost their businesses. People from the countryside started losing their jobs and moving to the cities. After a few years of cheap imported rice, local production went way down.”

Still the international business community was not satisfied. In 1994, as a condition for U.S. assistance in returning to Haiti to resume his elected Presidency, Jean-Bertrand Aristide was forced by the U.S., the IMF, and the World Bank to open up the markets in Haiti even more.

But, Haiti is the poorest country in the Western Hemisphere, what reason could the U.S. have in destroying the rice market of this tiny country?

Haiti is definitely poor. The U.S. Agency for International Development reports the annual per capita income is less than $400. The United Nations reports life expectancy in Haiti is 59, while in the US it is 78. Over 78% of Haitians live on less than $2 a day, more than half live on less than $1 a day.

Yet Haiti has become one of the very top importers of rice from the U.S. The U.S. Department of Agriculture 2008 numbers show Haiti is the third largest importer of US rice - at over 240,000 metric tons of rice. (One metric ton is 2200 pounds).

Rice is a heavily subsidized business in the U.S. Rice subsidies in the U.S. totaled $11 billion from 1995 to 2006. One producer alone, Riceland Foods Inc. of Stuttgart, Arkansas, received over $500 million dollars in rice subsidies between 1995 and 2006.

The Cato Institute recently reported that rice is one of the most heavily supported commodities in the U.S. -- with three different subsidies together averaging over $1 billion a year since 1998 and projected to average over $700 million a year through 2015. The result? “Tens of millions of rice farmers in poor countries find it hard to lift their families out of poverty because of the lower, more volatile prices caused by the interventionist policies of other countries.”

In addition to three different subsidies for rice farmers in the U.S., there are also direct tariff barriers of 3 to 24 percent, reports Daniel Griswold of the Cato Institute -- the exact same type of protections, though much higher, that the U.S. and the IMF required Haiti to eliminate in the 1980s and 1990s.

U.S. protection for rice farmers goes even further. A 2006 story in the Washington Post found that the federal government has paid at least $1.3 billion in subsidies for rice and other crops since 2000 to individuals who do no farming at all; including $490,000 to a Houston surgeon who owned land near Houston that once grew rice.

And it is not only the Haitian rice farmers who have been hurt.

Paul Farmer saw it happen to the sugar growers as well. “Haiti, once the world's largest exporter of sugar and other tropical produce to Europe, began importing even sugar-- from U.S. controlled sugar production in the Dominican Republic and Florida. It was terrible to see Haitian farmers put out of work. All this sped up the downward spiral that led to this month's food riots.”

After the riots and protests, President Rene Preval of Haiti agreed to reduce the price of rice, which was selling for $51 for a 110 pound bag, to $43 dollars for the next month. No one thinks a one month fix will do anything but delay the severe hunger pains a few weeks.

Haiti is far from alone in this crisis. The Economist reports a billion people worldwide live on $1 a day. The US-backed Voice of America reports about 850 million people were suffering from hunger worldwide before the latest round of price increases.

Thirty three countries are at risk of social upheaval because of rising food prices, World Bank President Robert Zoellick told the Wall Street Journal. When countries have many people who spend half to three-quarters of their daily income on food, “there is no margin of survival.”

In the U.S., people are feeling the world-wide problems at the gas pump and in the grocery. Middle class people may cut back on extra trips or on high price cuts of meat. The number of people on food stamps in the US is at an all-time high. But in poor countries, where malnutrition and hunger were widespread before the rise in prices, there is nothing to cut back on except eating. That leads to hunger riots.

In the short term, the world community is sending bags of rice to Haiti. Venezuela sent 350 tons of food. The US just pledged $200 million extra for worldwide hunger relief. The UN is committed to distributing more food.

What can be done in the medium term? The US provides much of the world’s food aid, but does it in such a way that only half of the dollars spent actually reach hungry people. US law requires that food aid be purchased from US farmers, processed and bagged in the US and shipped on US vessels -- which cost 50% of the money allocated. A simple change in US law to allow some local purchase of commodities would feed many more people and support local farm markets.

In the long run, what is to be done? The President of Brazil, Luiz Inacio Lula da Silva, who visited Haiti last week, said “Rich countries need to reduce farms subsidies and trade barriers to allow poor countries to generate income with food exports. Either the world solves the unfair trade system, or every time there's unrest like in Haiti, we adopt emergency measures and send a little bit of food to temporarily ease hunger."

Citizens of the USA know very little about the role of their government in helping create the hunger problems in Haiti or other countries. But there is much that individuals can do. People can donate to help feed individual hungry people and participate with advocacy organizations like Bread for the World or Oxfam to help change the U.S. and global rules which favor the rich countries. This advocacy can help countries have a better chance to feed themselves.

Meanwhile, Merisma Jean-Claudel, a young high school graduate in Port-au-Prince told journalist Wadner Pierre "...people can’t buy food. Gasoline prices are going up. It is very hard for us over here. The cost of living is the biggest worry for us, no peace in stomach means no peace in the mind. I wonder if others will be able to survive the days ahead because things are very, very hard."

“On the ground, people are very hungry,” reported Fr. Jean-Juste. “Our country must immediately open emergency canteens to feed the hungry until we can get them jobs. For the long run, we need to invest in irrigation, transportation, and other assistance for our farmers and workers.”

In Port-au-Prince, some rice arrived in the last few days. A school in Fr. Jean-Juste’s parish received several bags of rice. They had raw rice for 1000 children, but the principal still had to come to Father Jean-Juste asking for help. There was no money for charcoal, or oil.

Jervais Rodman, an unemployed carpenter with three children, stood in a long line Saturday in Port-au-Prince to get UN donated rice and beans. When Rodman got the small bags, he told Ben Fox of the Associated Press, “The beans might last four days. The rice will be gone as soon as I get home.”

Bill Quigley is a human rights lawyer and law professor at Loyola University New Orleans. He can be reached at quigley77@gmail.com People interested in donating to feed children in Haiti should go to http://www.whatiffoundation.org/

People who want to help change U.S. policy on agriculture to help combat world-wide hunger should go to: http://www.oxfamamerica.org/ or http://www.bread.org/.

[published April 2008]

Families crowded around the sidelines of the basketball court in front of the community center as children of all ages competed in soccer and volleyball tournaments, relay races, dance competitions and balloon toss games, all organized and led by the team of youth health promoters. The celebration came as the culmination of two and a half months of summer camp activities including dance, sports, arts and crafts, swimming lessons, and math and grammar reinforcement workshops.

The highlight of the afternoon for many was the presentation of Carnival de Qatakamara, a traditional dance from Cuzco, performed by 16 kids and teen promoters twirling and bowing in their vibrantly ornamented outfits. “¡SEÑORITA! ¡Tómame una FOTO!” As the show ended I was bombarded by frantic waves and persistent tugs by the performers eager to see their images reappear on the digital screen, confirming their eternal presence in the excitement of the day. The ceremonies concluded as the inaugural ribbon was cut, officially opening the library doors to all.

Now with the academic year in full swing, the kids come bounding into the center with the same energy for after school homework help. In years past, the youth health promoters (who also serve as after-school tutors) had been charged with the often near impossible task of settling the kids down to their studies. They had also faced the additional challenge of doing so with very limited resources. The proposal for the library came as a response to the lack of books and references needed to continue bringing meaningful support to the community’s children.   

	Teen helping younger students in the new children's library
	Children enjoying books at the new library

Beginning with a 5 soles (about $2) donation from each household in the surrounding communities, the Socios en Salud staff, in collaboration with community leaders, bought books and children’s stories for the library. These, along with donations from personnel and friends of Socios, made up the initial 150 books on inauguration day.

In the month since opening day, I have seen the library blossom to over 400 books, not including the previous collection or the reference books for teens and adults. I now climb the hill every day to find kids leaning over encyclopedias with pencils scribbling in notebooks, as the promoters twist between long division lessons and spelling tests.

Shortly after the inauguration, I asked the group of teens what would be most important for further progress. The immediate first response was “More books for the library!” Through self-organized book drives and door-to-door solicitations, the teens have procured not only more books, but more children to attend the after school library hours. Committed to expanding the library, they are in the process of planning more fundraisers. Motivated by the success of the dance performance, the teen promoters are also continuing the dance workshops, now open to all kids and teens in the community.

The library only occupies a small corner of the community center. However through advocacy efforts of the teen health promoters and the community members who continue to utilize the space and donate supplies, the new library has embodied the essence of community.

If you have would like to donate Spanish language encyclopedias or children’s books, please contact Rachel Ross (rross@pih.org).

[published April 2008]

PIH helps bring quality care to the only district in Rwanda without a hospital

	The inauguration was attended by the local mayor, officials from the local police and military, PIH co-founder Paul Farmer, and members of the community and new hospital staff.

For years, the 360,000 residents of the Rwandan district of Burera relied on a single doctor and a hospital that existed only in name. But no longer. On March 20, a beautiful new 24-bed ward officially opened its doors to the people of the impoverished community, complete with a staff of 43 skilled health professionals, including five doctors, plus a team of over 50 trained community health workers. The inauguration of the new ward also marked a major milestone for the effort by the Rwandan government, PIH and the Clinton Foundation to bring quality health care coupled with initiatives to alleviate extreme poverty to every corner of rural Rwanda. 

“The new ward that is now hosting patients was an abandoned building where goats were hanging out,” writes Charles-Patrick Almazor, a Haitian physician who brings experience acquired working with Zanmi Lasante to his new job as the head of PIH operations in Burera. Goats notwithstanding, the new facility provides a welcome relief for the community, as patients used to walk for miles to seek care in a neighboring district or even across the border in Uganda. Several have died while attempting to cross the lake separating Burera from the closest district hospital.

Built through a strong partnership that united the government, the Clinton Foundation and Partners In Health, the new ward complies with modern hospital standards. It features an infection control system that includes good ventilation with huge windows, sinks in the ward where health providers can wash their hands, modern toilets and showers available for the patients. And of course, adds Dr. Almazor, it has other essentials that were previously lacking, like electricity.

The new ward before (above) and after (below) renovation

Although it represents a vast improvement, the new ward is only a first step. Over the next few months, the partners plan to open a new operating room equipped to perform Caesarean sections and to deploy a fleet of ambulances. And plans have already been set in motion to construct a new main hospital with over 100 beds, to be completed by the middle of 2009.

With this new base of operations in Burera, PIH is now working in three districts of the country: Kayonza and Kirehe in the east and Burera in the north. These hospitals in turn are part of the partnership’s plans to bring comprehensive community-based care to all 27 districts and nine million residents of rural Rwanda.

“The opening of this ward truly tells how the government is moving toward the vision,” writes Dr. Almazor.

[published April 2008]

Since beginning work in Lebakeng last September, PIH Lesotho has begun working in the community of Tlhanyaku in January, with Methalaneng to follow before the end of March.

In recent months, PIH has accelerated its expansion to remote clinics high in the mountains of Lesotho. The logistical challenges faced by the Lesotho team have multiplied even more rapidly, given Lesotho's rugged mountain terrain, as PIH Country Director Jen Furin and her colleagues quickly discovered in Lebakeng.

Literally translated, Lebakeng means “the middle of nowhere,” which perfectly describes the location of the site where PIH Lesotho started working last September. Without access by road, or even a rutted path, the only way PIH staff could get to Lebakeng was on a single-engine plane flown by Mission Aviation Fellowship.

About one-third of Lesotho’s adult population is infected with HIV (the third highest seroprevalence of the disease in the world), so one of the main purposes of this initial visit was to assess what would be needed to initiate HIV therapy in the remote community. 

“We had been warned by many that Lebakeng would pose more challenges than the other sites,” Jen Furin recalled. “I must confess part of me was hoping we would not see as much disease in Lebakeng and that we could start things a little more slowly there as we got more on our feet. Those hopes were dashed almost immediately.”

In a single afternoon in the clinic on this “site visit,” Furin and other PIH staff tested 13 women for HIV; six were found to be positive. Of these six, all were in their third trimester of pregnancy and in desperate need of antiretroviral therapy (ART) for themselves and to prevent transmission to their children either in utero or during childbirth. The team was faced with a dilemma: start providing treatment in Lebakeng right away or wait until they were more “ready,” potentially sacrificing these women and their children. “It is the type of decision we have to make all too often, but it felt very acute with Lebakeng,” said Furin. After much discussion, they decided they could not wait. They soon began training village health workers and treating patients.

From the very first weekend of working in Lebakeng, the team faced a relentless stream of challenges. “We were all sleeping on the floor of a tiny house in a violent hail and snow storm. The roof leaked,” said Furin. And because of the site’s remote location and lack of infrastructure, just about everything required fancier logistical gymnastics than anything PIH Lesotho has performed to date (which is saying a lot, as described by Rural Initiative Project Coordinator Archie Ayeh in the November 2007 e-Bulletin). All supplies had to be flown in, or ferried on the backs of donkeys.

Moreover, the site was overwhelmed with incredibly sick patients. “And as is always the case, once we showed up more and more of them started arriving,” said Furin. “Clinically, Lebakeng pushes us all to the limit, as the patients are so acutely ill with so many various diseases.”

In a few short months, the Lebakeng clinic documented more than 1,200 patient encounters, diagnosed over 190 people with HIV (of whom about 80 are now on ART), and provided training to more than 47 community members.

	Woman carrying a stone for the new health clinic in Lebakeng

It quickly became clear that the tiny facility would very soon be unable to cope with the steady influx of patients, so the staff and community began building a new clinic. “This is harder than it sounds, given our inability to get building materials that will fit into the small single-engine Cessna planes flown by our dear friends at Mission Aviation Fellowship,” said Furin. “So we are using local stone. By 5:30 this morning, the sound of rocks being dug from the quarry echoed across the clinic compound, as did the voices of the women who are carrying the rocks, one by one, on their heads down a long, steep path. These rocks will be used to make the clinic. It is a labor of love on everyone’s part, tiresome and tedious at times, but buoyed by knowing that the clinic will stand strong and proud for all the work that has gone into it.”

Lebakeng was the fourth site for PIH and its partners in Lesotho. Ambitious plans to begin work in six more sites in 2008 (a new site every other month) are already underway. At least one or two of the planned future sites are about as remote as Lebakeng. But with the PIH Lesotho team's experience "in the middle of nowhere," they are prepared to tackle these new challenges, even if it means carrying one stone at a time.

published March 2008

Faced with a major global shortage of healthcare workers which may prevent the world from achieving several of the Millennium Development Goals and providing universal access to HIV/AIDS services, the World Health Organization (WHO) launched a major initiative called “Treat Train, Retain” (TTR) in August 2006. This initiative aims to address the human resource crisis by creating policies that call for treatment of health workers living with HIV, training of new and existing staff, and the creation of environments in which staff retention is improved.

As part of the TTR project, WHO wanted to understand how existing human resources could be used in a way that allows for a “rational redistribution of tasks among health workforce teams…a process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications.” The model was called “task shifting.”

	A community health worker distributes medicine to an HIV patient in Haiti

Based on Partners In Health’s (PIH) experience in community-based delivery of HIV and TB care, we were invited to join a technical consulting team for the development of international guidelines entitled Task Shifting: Global Recommendations and Guidelines. The project is funded by UNAIDS, the Italian Ministry of Foreign Affairs, the Norwegian Agency for Development Cooperation and the US Office of the Global AIDS Coordinator.  Representatives from several other non-profit organizations, universities and WHO collaborated in the development of these guidelines. 

For our contribution to the task-shifting project, PIH conducted a bi-national study mapping the distribution of HIV-related clinical tasks among different cadres of healthcare workers in our programs and also participated in the development and writing of the guidelines. We found the study process itself to be quite informative, and we were pleased that we were able to play a significant role in the shaping of the guidelines on key points of interest to us, such as the role of trained and paid community health workers and the importance of comprehensive services.  Below are a few descriptions and direct quotes from the guidelines illustrating how key parts of PIH’s model have been integrated into them.

Fair Compensation

“Task shifting” is a process that naturally evolved at our sites through our local partners’ wisdom to utilize the talents and skills of local community members in caring for their neighbors and relatives.  As our medical work has expanded, it has become a cornerstone of our healthcare model.  Other healthcare staff and community health workers (CHWs) are routinely assigned tasks in HIV and TB care that traditionally were considered “doctor” tasks.  One issue that we and our partners have continuously is an “old school” perspective that local residents should be willing to volunteer their time for health and development projects that benefit the community at large.  However, PIH has consistently made it a priority to provide monetary compensation to all staff members, including community health workers, which is beneficial for the employees, communities, local economies and our projects’ acceptability. 

After working with the other stakeholders in this project, we now have the WHO, PEPFAR and UNAIDS agreeing on the following statement: 

“Countries should recognize that essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable.  While volunteers can make a valuable contribution on a short-term or part-time basis, trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives.”

Community health workers are integral parts of health care
and enhance the quality of care
At clinics, but most often in the community, CHWs are performing critical tasks to bring care to patients in their homes. Examples of services provided by CHWs in the community include:  HIV counseling and testing; HIV test interpretation; identifying and referring HIV and TB patients to clinics for care; following stable patients on first-line antiretroviral (ARV) therapy; and adherence support.  In addition, in the clinics many CHWs are recruited as X-ray technicians, laboratory and pharmacy assistants and data clerks.

Research performed by PIH in Haiti for the WHO study shows that patients in our HIV program are very satisfied with the healthcare they receive. At all PIH sites we strive for the highest quality of care and CHWs are a key part of that.  Task-shifting should never lead to a decline in quality, but instead should improve quality for all patients.

“…people living with HIV/AIDS reported a high level of satisfaction with the health care they were receiving from community health workers. In a survey of 200 people living with HIV/AIDS, the great majority were satisfied or extremely satisfied with their assigned community health worker.” 

The fundamental role of the CHW is highlighted:

“…delegation to cadres of health workers with no formal clinical training can increase access to health care and improve quality of care.”

Increasing the total number of health workers
PIH has advocated strongly that involving CHWs and other health workers in health systems is not a “cheap solution” to the healthcare worker crisis, and should not be viewed as such. Task shifting is not a substitute for training an increased number of highly trained health workers such as physicians and nurses and as mentioned above, CHWs must be paid for their work. This is emphasized by the WHO and highlighted throughout the guidelines.  Community health workers are essential members of our teams but are not expected to replace more highly-paid, highly trained members.  PIH was pleased to see this belief outlined in the WHO guidelines:

“Task shifting should not be viewed as a cost-cutting strategy. In fact, a successful task shifting programme which decentralizes and expands access to HIV services at the community level is likely to increase the total number of health-service users, including increasing the demand for other health services.”

Increasing access to comprehensive health care
The guideline authors propose that “successful task shifting should increase access to health services and increase utilization of the health system generally.” This has proven to be the case at every site PIH has helped open in every country that we are working in.  Increasing outreach to communities, in most cases with initial funding for HIV-specific services, brings crowds to clinics for all health problems.  Therefore, clinics and health systems should be strengthened and outfitted to provide comprehensive services.  

The Task Shifting Guidelines were launched at a conference in January 2008 which was attended by health ministers, other senior government officials, opinion leaders and representatives of several NGOs and UN agencies.  Many countries are now changing regulatory codes, instituting new training courses and shifting tasks from overburdened doctors and nurses to other cadres of health workers in order to remediate the crushing health care worker shortages. PIH looks forward to sharing our model with these countries and ensuring that paid community health workers become integral parts of many more projects around the world so that everyone has access to the highest standard of healthcare, even those in the poorest places on earth.

[published February 2008]

A volunteer surgical team from Brigham and Women's Hospital in Boston recently began a mission to help Rwandans suffering from heart failure (often caused by Rheumatic Heart Disease, or RHD). This condition leaves thousands of Rwandans gasping for breath in a process of slow suffocation that can only be treated with surgery, which medical facilities in Rwanda currently cannot provide. Enter Team Heart. This spring, the team began began performing life-saving surgeries while working with PIH, a local hospital, and the Rwandan Ministry of Health to establish a self-sustained cardiac surgery program in the country. Team Heart has started a blog to document their innaugural trip. PIH co-founder Paul Farmer was one of the first to post.

The Harvard News Office recently produced a multimedia website featuring Zanmi Lasante, PIH's partners in Haiti. The site is part of a project to document the global involvement of Harvard affiliated organizations (including PIH) in helping to improve health around the world. Videos and articles follow the work of PIH co-founders Paul Farmer, Jim Yong Kim, and PIH doctors Louise Ivers and David Walton

After conducting a national-level MDR-TB training session in St. Petersburg in September, PIH has now trained representatives from all 88 regions of the Russian Federation over the past two years.

	MDR-TB training in St. Petersburg

The St. Petersburg session provided training for 52 doctors from throughout the European region of the Russian Federation. Participants were instructed by Russian and international experts on the treatment of MDR-TB in line with international consensus and guidelines. The course emphasized practical implementation of MDR-TB programs in the Russian setting. The training was strengthened by robust debate and discussion, particularly on aspects of TB infection among pediatric, diabetic, and elderly populations.

PIH is encouraged by the successful conclusion of the ambitious training program, carried out with support from the Eli Lilly and Company Foundation, and is currently planning the next steps to ensure that those territories have adequate follow-up and resources.

[published January 2008]

One world, one hope, a multitude of voices

In 1988 there was little to celebrate—antiretroviral therapy was still years away, and the epidemic was already sweeping through Africa and other poor areas of the world.  Life for those with HIV could be prolonged a little by treating the opportunistic infections (such as pneumonia and herpes), but the prognosis was grim, indeed terminal. Nearly two decades ago, the first World AIDS Day originated at the World Summit of Ministers of Health on Programs for AIDS Prevention. It began as an occasion to remember the dead, to mourn the untreatable epidemic that was before us, and to focus on preventing its further spread.  

The world has changed.

Within 10 years, AIDS became a treatable disease with the advent of highly active antiretroviral therapy (ART). Suddenly, people literally on death’s doorstep became well. Clinicians saw Lazarus. And World AIDS Day became an occasion to celebrate. In 1996, the theme of World AIDS Day was “One World, One Hope,” with the vision that all would have access to this lifesaving and miraculous therapy. Yet, globalization’s geopolitics would not let one world be one world… but rather two or three or four: those who had access to free ART, those who had to pay for ART and in some way were able, and those—fully 90% of the epidemic—who had no chance of obtaining ART. People living with HIV in poor countries (who already numbered 26 million) were told that ART wasn’t possible, wasn’t affordable, wasn’t feasible.  AIDS remained a death sentence. In Cange, Haiti, a handful of patients began receiving ART in 1998, and improved just as remarkably as the patients in the United States and Europe that had access to ART. NGOs followed suit with providing the therapy. Brazil began manufacturing ART to provide its citizens treatment for AIDS as part of their constitutional right to health.  However, few countries followed Brazil’s lead, and “One World” had a tragic disparity in hope.

But in 2000, fully four years after the miracle of HIV therapy became the standard in rich countries, activists began fighting. At the International AIDS Society Conference in Durban, South Africa, the conference’s theme “Break the Silence” gave voice to the millions of people living with HIV who had no access to treatment.  Nelson Mandela, the former president of South Africa, gave the closing address, saying, “If 27 years in prison have done anything to us, it was to use the silence of solitude to make us understand how precious words are and how real speech is in its impact upon the way people live or die." He called upon the collective leadership in Africa to face the HIV/AIDS epidemic. “We have to rise above our differences and combine our efforts to save our people,” he added. “History will judge us harshly if we fail to do so now, and right now."

A seminal year followed the Durban conference. During 2001, our group worked with faculty members from Harvard to publish the “Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries.” Partners In Health and Zanmi Lasante published the first report of The HIV Equity Initiative in the Lancet and the Bulletin of the World Health Organization.  In these articles, we described 60 and then 150 patients in Haiti on antiretroviral therapy.  We reported on the general outcomes: the patients were doing well and had gained weight; the price of ART had dropped considerably with the entry of generic drugs on the market (thanks to activism by Doctors Without Borders (MSF) and others); and community health workers accompanying patients on ART were the backbone of the program addressing adherence and social support.

Activists cheered the “Haiti Model,” although many public health experts were skeptical (link to the editorials).

In that same year, Secretary General of the United Nations Kofi Annan called the UN General Assembly together for a special session on AIDS.  At this meeting, heads of the world’s heavily HIV burdened countries sounded a clarion call for assistance.  For the first time, a massive mobilization of international aid began for an epidemic which was at that time already 20 years old. The assembly called for the creation of an empty coffer for donor governments to put billions of dollars in order to actually bring ART to the people in the world’s poorest countries. This coffer became known as the Global Fund to Fight AIDS, TB and Malaria.

	2003 World AIDS Day celebration in Lascahobas, Haiti

In Haiti, we received the money in the first round of the Global Fund, and our project, the HIV Equity Initiative, suddenly went from 250 patients to more than 1,000 in just one year.  The advent of the Global Fund brought a new opportunity to Zanmi Lasante—scaling up the access to ART not just in Cange and our charity hospital Clinique Bon Sauveur, but in the long neglected public sector.  In short, interest in and money for AIDS allowed us to rehabilitate basic health infrastructure in Haiti’s central department. Our philosophy was that we could not find AIDS cases or treat them if clinics stood understaffed, empty and without essential medicines.  Thus, the investment in AIDS became our Chwal Batay, or battle horse—a tool to bring us into a larger battle against poverty, inequality and poor health.

This Chwal Batay of AIDS funding eventually lead us to Rwanda, and then Lesotho and Malawi—other places stricken by HIV/AIDS, but also in need of health infrastructure and primary care. In partnership with the governments of these countries, the Clinton Foundation, Irish Aid, and Mission Aviation Fellowship, PIH used the newfound attention on AIDS to open, revitalize, and renovate 21 public clinics in just 5 years.

The AIDS movement has become the movement for health care, and today, almost 20 years after the first World AIDS Day, we can stand on the mountain that we have climbed and reflect on the lives of the people living with AIDS who are now healthy human beings. World AIDS Day is now a day to celebrate the lives and dignity of those affected, wherever they live, so that they won’t remain closeted in fear and shame.  World AIDS day is about solidarity and what the voices of communities can accomplish when raised together.

Click here to read how PIH's partners around the world celebrated World AIDS Day 2007.

[posted January 2008]

	A dance performance at the World AIDS Day celebration in Lascahobas, Haiti

The HIV/AIDS epidemic threatens countries around the world, and currently infects about 33 million people. Although the international fight against the disease often seems difficult and endless, there are also countless victories each year. World AIDS Day on December 1 was the occasion for celebrations by PIH partner organizations around the world – detailed below – and for reflections by PIH Medical Director Joia Mukherjee on the progress that has been made over the past two decades.

From Haiti:
"Abstinans, fidelite, kapot!" shouted a crowd of dancing people at the World AIDS Day celebration in Hinche. With eating contests and other games interspersed with dancing and singing, the festive atmosphere did not detract from the event's more sober messages of HIV prevention and care, as well as the role of poverty and human rights in the history of the disease.

A crowd gathered to commemorate World AIDS Day in Lascahobas

The day was marked by similar events at all of Zanmi Lasante’s sites in Haiti. In Lascahobas, hundreds of people wearing “Stop AIDS” t-shirts packed a church courtyard festooned with banners and posters. On the stage, vibrant dances and songs alternated with inspiring speeches and testimonials from Zanmi Lasante staff and HIV patients whose lives have been revived and transformed by access to treatment.

“The highlight for me was seeing all the young faces from babies to adolescents soaking up our messages about HIV/STIs [sexually transmitted infections], and of course their right to access to care,” wrote Chloe Gans-Rugebregt, Data Manager for PIH projects in Haiti. “I felt proud to know that although many of them are already affected by HIV, we are actively working to empower youth so that they will not be touched by this disease any more.”

As soon as patients are healthy enough, we arrange for them and their families to return to their country of origin. But “whatever it takes” doesn’t end when we put them on the plane. We make certain that the family’s housing situation is secure and appropriate for a recuperating patient. When need be, we pay school fees (a modest $300 a year, but out of reach for nearly all the residents in Haiti’s Central Plateau) as part of our economic and social rights mission.

From Lesotho:
More than 1,000 people gathered to commemorate World AIDS Day at Bobete health center, high in the mountains of Lesotho. For the past year, the tiny health center has been providing HIV testing and treatment to local villages. Since January, nearly 3,000 people have been tested. All of the 918 who tested positive are either receiving antiretroviral drugs or are being closely monitored by the center’s dedicated medical staff.

Bobete community members performed traditional dances and sang songs about HIV to celebrate World AIDS Day

“None of these people were receiving treatment or follow-up prior to the PIH rural initiative,” said Dr. Jen Furin, PIH’s Country Director in Lesotho. These achievements helped to make this year’s World AIDS Day a cause for celebration.

The day also focused on raising community awareness of HIV/AIDS—encouraging more people to know their status and fighting the stigma associated with the disease. The theme for the day was “Stop AIDS and Keep the Promise,” referring to the community’s commitment to work together to fight the epidemic. Community members living with HIV, village health workers, and village leaders all shared moving testimonials while vowing to keep working towards their goal of stopping the disease. The celebration culminated with a short hike to a mountain near the clinic to plant a tree and create a sign for HIV with painted stones.

“Several of the local participants stated that the event was the biggest thing ever to happen in Bobete,” writes Dr. Furin. “It will surely go a long way in raising awareness of HIV/AIDS in the community.”

On another rocky hillside to the west, 1,500 villagers also celebrated World AIDS Day at the health center in Nohana. “It was a big, first-ever event for the patients, village health workers, treatment supporters and all the community in general,” said Dr. Jonas Rigodon, Nohana’s Chief Physician.

One of the highlights of the event was a play put on by local village health workers, which emphasized the importance of HIV patients adhering to the strict antiretroviral drug regimens needed to treat the disease. The opportunity of life only comes once, they stressed, so patients need to remain faithful to themselves by adhering to their medications.

While this celebration focused on the same goals as other events around the world, the organizers placed a special emphasis on leadership.“The good answer to the AIDS pandemic has been accomplished under the auspice of strong leadership,” asserted Dr. Jonas. “A good leader will be the one who will help and encourage the sick to get help from the clinicians,” he added. “Are you a leader?” he asked the crowd. “If not, start today.”

	Over 400 people lined up to find out their HIV status in Burera
	Government officials, local leaders, and the military all joined in the World AIDS Day festivities
	Dancing, poetry reading, and musical performances all added to the celebratory atmosphere

From Rwanda:
“We started [in the morning] under a beautiful shiny sun on a green soccer field; it was the ideal place,” writes Dr. Patrick Almazor, describing World AIDS Day in Burera, Rwanda. A crowd quickly gathered as a team from Inshuti Mu Buzima (IMB), PIH’s Rwandan partner organization, set up stations to test people for HIV and counsel them about the disease and other sexually transmitted infections.

“It was amazing to observe how people want to know about their HIV status,” said Dr. Almazor, a PIH physician. Even a mid-afternoon thunderstorm didn’t dissolve the crowd. “It was already dark when we decided to stop for the day, but people were still in line, and we promised to test them first thing [the next morning].”

The community members in line had a reason to be excited about the free IMB voluntary testing and counseling (VCT) event on World AIDS Day—their district is the only one in Rwanda that lacks a hospital, and IMB staff had traveled all the way from their health centers in Rwinkwavu and Kirehe to celebrate the day with them.

The community soon had another reason to celebrate. IMB used the occasion to announce that they are teaming up with the Rwandan Ministry of Health and the Clinton Foundation to begin serving the 350,000 people who currently have no access to a district hospital.

Plans to begin construction of the new hospital are already underway in Butaro, the selected site for the facility. The new hospital will be part of the effort to expand the rural health model throughout the country. In addition to VCT, the event included musical performances, dancing, games, and many speeches, which all focused on different aspects of battling HIV, including fighting stigma, addressing rape, the importance of adhering to antiretroviral regimens to treat the disease, and the national theme of the day—protecting children against HIV.

“These events announced the coming health activities that we [PIH and its partners] will initiate in the district to improve health conditions of thousands of poor people living in this very remote area,” said Dr. Almazor.

	SES staff member educates children

From Peru:
Socios En Salud (SES), PIH’s partner organization in Peru, celebrated World AIDS Day by participating in an educational fair in Carabayllo, a shantytown on the outskirts of Lima.

SES staff members helped to teach local children about HIV infection and its consequences, among other activities.

From Malawi:
"In a project less than 1 year old, our World AIDS day was a big success," wrote Dr. Keith Joseph, PIH's County Director in Malawi. "Unlike the usual fanfare geared toward big shots, a party to celebrate life was lead by one of the most popular music groups in Malawi," he added. 

“Thinking of the movement that we are involved in is beautiful and humbling,” writes Dr. Joia Mukherjee, PIH’s Medical Director, who was in Malawi for World AIDS Day. “It is so much bigger than any one of us, so much bigger than AIDS and so much bigger than the individual projects in which we work."

Thousands enjoyed speeches and musical performances on World AIDS Day in Neno
Traditional dancing at the Neno World AIDS Day event

“World AIDS Day is the day, more than all other commemorative days in health—TB Day, Women’s Health Day etc.—that does indeed mark collective action. It was started by activists and patients, not by health bureaucrats. It celebrates the lives and dignity of those affected, wherever they live, so that they won’t remain closeted in fear and shame."

"World AIDS Day is about solidarity and what communities’ voices can achieve when raised together. The day is celebrated and recognized from Haiti to Lesotho, from Boston to Rwanda, from Peru to Russia and Burundi to Chiapas... and in many parts of the world that PIH has never touched yet share the vision that all should live with dignity and have the basic right to health and life."

“I had the pleasure of taking call at the Neno Hospital in Malawi so that the staff of APZU (PIH’s partner organization in Malawi) could enjoy the festivities of the day here,” said Dr. Mukherjee. “And was reminded as I cared for sick children with malaria and men with tuberculosis and women with complications of pregnancy, that the solidarity around AIDS, the outcry of the affected and the collective action for treatment, have allowed us the privilege of acting together with communities all over the world.”

Read Dr. Mukherjee's reflections on the evolution of World AIDS Day over the past two decades here.

[posted January 2008]

A new hospital has opened in the Central Plateau of Haiti. Built through a partnership between the Haitian Ministry of Health and Zanmi Lasante, the new facility will help serve the communities of Lascahobas and Lacolline. Before the construction of the hospital, patients had literally flooded into a tiny under-staffed, poorly-equipped health center.

A throng of people gathered to inaugurate the hospital, including Haitian President René Préval and Haiti’s Minister of Health, Dr. Gabriel Timothé.

“The people of Lascahobas and Lacolline, like all the people of Haiti, deserve modern health infrastructure,” said PIH Co-founder Dr. Paul Farmer, who also attended the event. “This facility was built by our team--which includes hundreds of people from this area--to keep a promise made in 2002: that PIH and Zanmi Lasante would work with the Ministry of Health to improve public infrastructure at the same time that we take care of the sick, prevent illness, and train people to provide modern health care to the underserved.”

“This hospital includes a number of features that we believe are important innovations: it’s well ventilated, has outside waiting areas, and private rooms for people with active pulmonary TB, an airborne disease,” said Dr. Farmer. “It even has ultraviolet lights to kill the bacillus that causes TB.”

“We are grateful not only to our partners in the Ministry of Health, but to AmeriCares, the HHCF, friends from Chicago and the other groups that helped us to build this modern, safe hospital for the valiant people of this area,” said Dr. Farmer.

Advocating at the APHA Annual Conference

PIH Advocacy and Policy Manager Donna Barry recently attended the American Public Health Association (APHA) annual meeting in Washington, DC, and reported back about her experience:

Earlier this month I had the opportunity to attend the American Public Health Association’s (APHA) annual meeting in Washington, DC.  APHA is a membership-organization of individuals working in public health, from environmental workers in Kansas to midwives in Uganda. Their annual 4-day conference brings together representatives from far and wide and gives them a platform to present their work to peers and learn from others. As PIH’s advocacy and policy manager, attending these meetings is an important part of the work that I and PIH engage in.

This year I gave a presentation on how NGOs can help strengthen public sector health services, using Haiti as a case.  As part of a panel organized by colleagues at Health Alliances International, this talk focused on how NGOs can positively engage the public sector to help alleviate the health care worker crisis and provide comprehensive health care to those who need it most.

I also organized a panel on reducing maternal mortality to try and expose why the past twenty years of effort to reduce maternal deaths have not been successful.  The panelists included Ann Starrs from Family Care International, who discussed the larger efforts to confront the tragedy of over 500,000 deaths per year related to pregnancy; Patricia Bailey from Family Health International, who presented specific interventions that have worked to save women’s lives; and Alicia Yamin formerly of Physicians for Human Rights, who discussed a human rights framework for assessing how countries and health systems can be judged relative to their efforts to reduce maternal deaths. Finally, Dr. Maxi Raymonville, Zanmi Lasante’s Women’s Health Director discussed the structural barriers to reducing maternal mortality, such as limited phone coverage and lack of transportation for obstetrical emergencies. He also focused on how ZL has tried to overcome these barriers, including the use of email and satellites when regular phones are scarce. For more details about the presentations, please click here.

In addition to these panels, PIH work was presented in a poster session and in a round table discussion. The poster presentation was based on research by Mary Kay Smith Fawzi, an Epidemiologist at PIH, and colleagues who interviewed youth in Boston's public high schools in resource-limited settings. Their study examined the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant youth. Although other studies have focused on “externalizing” behaviors, such as substance abuse and high risk sexual behavior, few have examined “internalizing” symptoms like PTSD or depression. Conclusions included calculating a prevalence estimate of PTSD and depression of 14 percent and 12 percent. The study also examines the factors associated with these conditions and ways to intervene to improve the psychosocial health of immigrant youth from Haiti living in the U.S.  The poster was presented by Cate Oswald, a research coordinator with Harvard’s Program in Infectious Disease and Social change who works with several PIH projects in Haiti. For more details about the study, please click here
.
PACT staff members, Joya Lonsdale and Soridania Santana hosted the roundtable discussion on community health promoters. Their presentation was entitled, “Community health promoters’ role in improving health outcomes by focusing on HIV medication adherence in underserved communities in the U.S. using the Partners In Health accompagnateur model.” The discussion focused on how PACT’s community and home-based program helps HIV patients adhere to their antiretroviral medication regimen, despite having previous histories of adherence problems. The presentation was part of a lively session on community health workers as integral members of the health care delivery team. To learn more about PACT’s program, click here.

On the last day of this year’s conference, I attended the APHA Action Board meeting.  The Action Board is an arm of APHA that reviews policies that are passed by elected members during each annual meeting, and advocates for those policies on many different levels from city to national to international.  I was nominated to be a member of this committee for the next few years, and I look forward to the opportunity to infuse APHA policy and advocacy efforts with some preferential options for the poor. 

For some, large bureaucratic organizations like APHA seem like impenetrable bastions of old thinking which exist only to serve as conference organizers, and where mundane discussions of the same public health issues occur year after year. I confess to thinking just that for a long time, but after getting more involved, as a presenter and now Action Board member, I see the potential of engaging with like-minded public health workers and advocates to begin changing policy and programs that could have a large impact for those whom we serve. 

[published November 2007]

	Children in Rwanda replicate the PIH logo

Inshuti Mu Buzima (IMB), PIH’s partner organization in Rwanda, has accomplished a great deal during its first two years of work in two destitute rural health dis­tricts. It has enrolled more than 2,500 HIV patients on antiretroviral therapy, trained and hired more than 800 villagers as community health workers, and recorded nearly 100,000 patient visits in 2006.

Not content to stop there, IMB and their partners in the Rwandan Ministry of Health and the Clinton Foundation have now committed them­selves to an even more daunting and inspiring challenge—to make IMB’s approach to delivering comprehensive, community-based care the model for Rwanda’s national Rural Health system. Plans have already been drafted to extend the model first into the districts most in need of services and then to all 27 districts and 9 million residents of rural Rwanda.

PIH’s model has already been replicated around the world, says Dr. Michael Rich, PIH’s country director in Rwanda. “However, there’s a difference between replication and scaling up a model in an entire country,” he says. The difference is not only in sheer magnitude, but also in the close coordination needed with all government ministries and providers of health care. “So how do we go from replication to a countrywide scale-up?”

Instead of PIH finding and training staff and procuring equipment and facilities, the focus will be on training Rwandans to replicate the model, and then creating a “critical mass” of people who can teach the model to other areas, says Dr. Rich. The goal is for PIH to work mainly as facilitators, helping the Rwandan government meet its own national health goals, which are addressed as part of this rural health scale-up.

“What’s especially exciting about this is that the Ministry of Health is committed not just to scaling up treatment for HIV, which would be great, but to our entire comprehensive, holistic approach that considers the dignity of the patient,” said Dr. Blaise Bucyibaruta, who heads up pediatric HIV programs for IMB. “We do whatever it may take,” he added. “That includes ensuring that poor people have access to care, training community health workers well and paying them fairly, and making sure that patients and their families have enough food to eat, access to education, and a means to generate income.”

All of these dimensions of the PIH model are included in a set of 10 principles that PIH and their partners in the Ministry of Health have established for the national scale-up (see box to the right). These principles commit the partners to provide:

• Comprehensive health care, available to all;
  Relentless focus on the patient and quality of care, regardless of the challenges of the environment;
• A community-based model, decentralized where possible from hospital to health center and from health center to patients’ homes;
• Holistic care for the community beyond the purely clinical, including food, education, clean water, and income generation projects.

The plan will be launched in four of the neediest districts in 2008 and will then be rolled out to all 27 rural districts across the entire country. Work in each district will include four levels of involvement: at the district hospital, health centers, health posts, and with the community health workers.

Finding the resources—both human and financial—remains a huge challenge for the scale-up, says Dr. Rich. For example, there are currently only about 3,000 nurses in all of Rwanda. “That’s one limitation,” he says. “It would really take about 6,000 nurses” to staff the scale-up, backed by all the funding needed to train and pay them.

“Right now in Rwanda, very little money gets spent on health, maybe only a couple of dollars per year [for each person living in a rural area],” Dr Rich continued. “We want to increase that almost ten-fold, to about $23 to be spent on that person for health care.”

Although that would represent a steep increase in spending, it pales in comparison to current U.S. health spending of about $6,700 per person. More importantly it fits within the plans and commitments of the Rwandan government and in the first few years of the plan, it still falls below the targets endorsed by the African Union of spending 15 percent of national budgets to provide essential health services.

Dr. Agnes Binagwaho, who heads Rwanda’s National Commission to Fight AIDS, emphasizes that the scale-up is a necessary and affordable com­ponent of “a development process that includes the most vulnerable.”

“Our institutions seek to trans­form Rwanda from a poor country to a middle-income country,” she explained. “This transformation takes place by developing high-quality care that is available equitably across our country. That’s why the model called ‘Rwandan rural health care’ is seen as a necessary step towards rapid development, fair and shared by all. I also support this effort because it has already been implemented in two districts and has shown us that it is possible, a sound investment, efficient, and necessary for sustainable development."

	World AIDS Day at Rwinkwavu Hospital in Rwanda

Some of the money is already in the country, from the government’s existing $100 million national budget for health care, and from NGOs and other funding sources. Some of these resources can be directed towards the scale-up strategy, says Dr. Rich. “But we will still have a ways to go.”

As for medical workers, many locals can be trained and employed as community health workers to ease the workload for nurses, which will also contribute to the goals of providing income-generating opportunities and strengthening local economies. But this form of task-shifting will only stretch so far. In all, estimates put the cost of the providing a comprehensive model of health care at about $280 million per year nationwide.

Scaling up resources to that level and extending comprehensive, community-based care throughout rural Rwanda will not happen overnight. But hope abounds. Manzi Anatole, a Rwandan nurse working with IMB radiates his excitement over the planned scale-up, “We have many challenges,” he says, “But we want to show the people of the village, the province, the country, the world, that such things are possible.”

Partners In Health is calling on friends and supporters of Haiti to join Paul Farmer and other PIH staff in skipping meals and taking action to help build pressure to cancel Haiti's crippling debt.

Evan Lyon, a PIH doctor who has worked in Haiti for the past 10 years, explained to a reporter for the Boston Globe why he has chosen to fast for three days. "Hunger is the most important issue that we see" in Haiti, Lyon said. "It's not uncommon for the people I take care of to come into the clinic not having eaten for one or two days. I chose to take this fast on with the understanding that for me it's a pretty modest thing to do."

Jubilee USA Network has organized a 40-day rolling fast to educate about debt and mobilize grassroots pressure on Congress for debt cancellation for Haiti and every other country requiring immediate debt cancellation to address extreme poverty. Find out more and sign up to fast for a day (or more!) at www.jubileeusa.org/
canceldebtfast.html.
 
We are at a crucial time for Haiti debt cancellation.  Since last year, the World Bank, International Monetary Fund and the Inter-American Development Bank have each decided that Haiti’s debts should be cancelled.  But they are demanding that Haiti wait until the completion of a three-year process (at a minimum) before the debt is actually written off.  In the meantime Haiti will pay millions more in debt service to these institutions, when the money could be used for health and education funding, infrastructure and many other immediate needs.
 
In March of this year, seven members of Congress introduced a resolution calling for Haiti’s debt to be cancelled immediately.  This resolution now has 63 co-sponsors.  This October we will make a final push to get the resolution to a vote with one week of intense grassroots lobbying. 
 
Take part. A few minutes of your time can make a big difference for millions of people. On October 2, 3 or 4th make a call to your member of Congress asking him/her to co-sponsor House Resolution 241.  If your member of Congress has already co-sponsored the resolution give them a call anyway.  Thank them for co-sponsoring the resolution and ask him/her when we can expect a vote on the resolution.  Find out if your congressperson has signed on by searching for the bill (H Res 241) on www.thomas.loc.gov .  
 
Also, let your member of Congress know about the briefing on October 4. Let him or her know that this is an important issue for you and you expect a representative from that office to be at the briefing. Come to the briefing if you can! The briefing will run from 3:30-5:00 in room 2105 of the Rayburn House office building.  Dr. Paul Piere from Zanmi Lasante/Partners In Health will be a panelist at the briefing. For more information on debt cancellation and how you can help, please visit www.jubileeusa.org/canceldebtfast.html.

[published September 2007]

Report from the Cange forum

By Monika Kaira Varma

A few days ago, I attended Zanmi Lasante's 13th Annual Health and Human Rights Forum in Cange, Haiti.

I first came to Cange almost five years ago, after Loune Viaud received the Robert F. Kennedy Human Rights Award for her groundbreaking work with Zanmi Lasante to realize the right to health for all Haitians. Since then, the RFK Memorial Center for Human Rights has partnered with Loune and Zanmi Lasante and we have learned many lessons from Haiti.

Despite being a country with very limited resources, Haiti has emerged as a leader in the global movement for health and human rights. Even a child in Haiti will tell you that we have a right to health, water, education, housing and food, and that these rights are just as important as our civil and political rights. In terms of defining a government's obligations toward its people, Haiti's Ministry of Health is a particular leader: as Dr. Gabriel Timothee, the Ministry's Director General, stated, the right to health is not simply about care, but includes ensuring that everyone can lead a healthy life, and the government has the primary responsibility to fulfill this right in its totality.

As a human rights advocate, there should be little work to do in a country that recognizes its obligations and wants wholeheartedly to fulfill them. But sadly, this is not the situation in Haiti. Instead, international institutions often undermine and violate Haitians' human rights.

The international community has shown its lack of respect for human rights in Haiti far too many times. To take just one example, in the most impoverished country in the hemisphere, ranked 147th out of 147 nations by the Water Poverty Index, where one out of every three deaths is a child, the Inter-American Development Bank (IDB) stopped lifesaving loans for potable water, health, education and rural roads because of international pressure. The IDB and the Haitian government approved the loans and signed a contract, but just before money started to flow to these vital projects, the United States government intervened to stop any funds from reaching Haiti. Seven years later, a part of these loans has been "released," but countless Haitians die every year because of the failure to implement the approved water and sanitization projects.

No one has been held accountable for these deaths.

The human rights community has long debated whether and how to advocate for economic and social rights. The critical question now is not "whether," but "how"? Traditional legal and human rights frameworks are not working in the places where they are most needed. Every day, international donors, the United Nations, international financial institutions and member states undermine and violate human rights in countries like Haiti.

We have a duty to hold the perpetrators accountable. As Dr. Timothee rightly asserted, the Haitian government is the primary guarantor of human rights for Haitian citizens, but those individuals and institutions that undermine the government's ability to do its job must be held accountable too.

We at the RFK Center for Human Rights have spent the last five years trying to do just that. We have been investigating the US government and IDB's actions and examining the devastating health impacts of withholding the loans. We are calling these actions what they are, human rights violations, and exploring accountability mechanisms. There have been many obstacles and a few mistakes made along the way. We've had to rethink our old tools and find new ones, but we have been led by great leaders. I was privileged to spend time with them this past week in Cange.

The broader human rights community can join these efforts by recognizing that the right to health is as fundamental as the right to vote and that human rights violators, no matter where they act must face the consequences of their actions. Together we can find innovative ways to hold these international actors accountable for undermining and violating human rights in places like Haiti.

Monika Kaira Varma is Director of the Center for Human Rights at the Robert F. Kennedy Memorial

[published September 2007]