The word “legacy” is often applied to well-known individuals—politicians, movement leaders, scholars, and artists—who have left an indelible mark on history and touched the hearts and minds of millions.  

In reality, every person has a legacy, an impact they leave on the people and causes they care about. 

Tom White, the owner and president of construction company J.F. White Contracting Co., helped found PIH with his first significant gift and then systematically gave away his wealth by selling his company and his assets to continue supporting PIH. In his honor, PIH established Tom’s Circle, a legacy society of over 500 supporters dedicated to uplifting this work  beyond their own lifetime.  

CEO Dr. Sheila Davis is among those donors: “PIH has been an important part of my life for many years, and I know firsthand the transformational work happening at PIH sites globally. I can think of no better way to honor the work of our amazing staff around the world than to ensure that PIH is prominently featured in my legacy estate plans to continue this work for decades to come.”  

We sat down with legacy gift planning specialists to discuss the concept of legacy, why more people are engaged in such planning in recent years, and how they have helped those interested make the right choices about their long-term giving. The following answers have been edited and condensed and include responses from Laura Sidla, senior director of gift planning; Paul Michael, development officer; and Kayla Hornback, loyal donor officer.  

What is a legacy? 

Everyone has a legacy. Your legacy is as unique as your fingerprint, a collection of your values, beliefs, life lessons, assets and belongings, loved ones, and causes you aspire to sustain and protect beyond your lifetime.  

Are you confident in what your legacy will be? 

Proactive legacy planning allows you to intentionally cultivate your legacy throughout your life, empowering you to live more fully and joyfully. Proactive legacy planning provides peace, knowing decisions about your values, assets, and loved ones are made, and wishes communicated. 

At PIH, we honor individuals who include PIH in their plans as members of our legacy society, Tom’s Circle, named after PIH co-founder and first supporter, Tom White, and his radical generosity that continues to shape PIH’s work today.  

Why is there an increase in legacy gift planning? 

There is a movement to promote legacy planning to fight inertia (only 4 in 10 American adults have a will or living trust) and reclaim agency, especially among younger folks after the COVID-19 pandemic 

For many PIH supporters, COVID-19 cemented our belief that high-quality health care is a universal human right and that we must fight injustice to provide care, first, to those who need it most. After a life-changing experience like the pandemic, reflecting intentionally on how to spend one’s limited time, energy, and resources feels meaningful to more people. Many desire to support PIH’s critical work beyond regular donations. Many want to give more but cannot today due to market uncertainties or future income needs.  

Post-pandemic, there has been a dramatic increase in charitable estate planning as folks are inspired to reflect on how they can protect the people and causes they care for most beyond their lifetime and what plans they can formally and informally put into place to document their wishes.  

Building on this momentum, PIH hopes to double the size of our legacy society, adding 500 supporters to Tom’s Circle over five years.  

What are the most common ways individuals can include PIH in their legacy planning? 

The most common legacy gifts are: 

• Gifts by will or trust (bequests): You can specify any amount or percentage of your will or trust or even list PIH as a contingent beneficiary, all while putting other provisions in place for other people and causes you care about. Learn more about bequests and FreeWill, which allows you to create a will for free in 20 minutes or less. People of all ages can make these gifts, and they can be revised at any time. We often see folks create their first will when they go through a major life event or experience the loss of a loved one. Early, proactive planning is important so you are not forced to make difficult decisions during particularly stressful periods of life. 

• Gifts by beneficiary designation: Naming PIH as a beneficiary of retirement assets, such as a 401(k) or an IRA, is a terrific way to make a tax-smart gift to PIH. Life insurance policies, donor-advised funds, and other bank/brokerage accounts can also be gifted. These gifts can also be made by anyone at any age for any amount and can be changed at any time. We often see people consider their first beneficiary designation when they open their first retirement account. 

• Gifts that provide income: With a charitable gift annuity, you gift $10,000 or more to PIH and receive income for life through your philanthropy. These gifts are for anyone age 60 or older through a simple contract. Calculate a charitable gift to see how this might work for you.  

Why do some supporters choose this route to support PIH instead of one-time or annual gifts? 

Many people include PIH in their legacy plans and also give annually.  

In the United States, only about 5% of wealth is in cash. So, when people think of the impact of their philanthropy, gifts by check or credit card represent only a fraction of what is possible. We can accomplish much more when we think about our philanthropic impact from total assets. Plus, legacy gifts offer a unique opportunity for impact because many assets like real estate, life insurance, and retirement assets are not available to give until after your lifetime.  

With the passing of PIH Co-founder Dr. Paul Farmer in 2022, many supporters have been inspired by his legacy to make a lifelong commitment to this movement. In PIH’s most recent strategic plan, Paul made a point to note that the transfer of money is the transfer of power. Many PIH supporters create a legacy with PIH to help fuel its social justice-oriented mission and rehabilitate, or repurpose, their privately controlled wealth to help restore communities disproportionately impacted by colonialism, racism, and climate change.  

End-of-life conversations can be emotionally and mentally difficult for families and their loved ones. How is the team prepared for those conversations? What are some best practices?  

PIH’s legacy gift planning team includes people with a wide range of experience and credentials related to legacy planning, charitable estate planning, resource mobilizing, and end-of-life planning, including bereavement counseling, financial planning, philanthropic advising, charitable estate planning fellowship, and death doula training. We understand the extensive web of logistics related to legacy planning, caregiving, and facilitating a legacy after a loved one passes. We approach the process with a balance of attention to detail and compassion. 

Through our blended experiences, we acknowledge that legacy planning is often prompted within financial, estate, and active end-of-life planning. We encourage folks to proactively plan (formally through estate planning and informally through self-reflection, letters to loved ones, and conversations) more holistically and revisit more regularly, regardless of their financial circumstances. 

We are guided by PIH’s principle of accompaniment – walking alongside each other and lending solidarity, a listening ear, a shoulder, a sounding board, a word of counsel or caution, and referring you to professional advisors when appropriate. We are honored to be welcomed into people’s lives in this meaningful way and go out of our way to provide a kind space to listen.  

We encourage our supporters to connect with our team to start your proactive legacy planning. We hope you will share your legacy plans with PIH so we can thank you and ensure your wishes are well-documented and carried out as intended. 

We also encourage sharing your PIH legacy plans with your family as much as you are comfortable. We will happily provide materials for you to give to your loved ones to help share the joy you find in your partnership with PIH.   

When is the best time to consider these gift options? Can donors' choices change over time?  

The best time to proactively plan your legacy is as soon as possible. As soon as you can identify a loved one in your life who will be impacted by your death or you accumulate resources you want to ensure will go to the people and causes you care about, you are ready to start legacy planning. However, many people are overwhelmed by the logistical and emotional complexity of legacy planning and don’t know where to start.  

The good news is that no matter your financial circumstances, there are many different ways to get started and your legacy plan can, and likely will, change over time. Our team hopes to make it easy for PIH supporters to take the first –and often most important—step in planning by offering helpful resources informed by an initial conversation about your goals and wishes.  

PIH Co-Founder and lifelong social justice advocate Ophelia Dahl has received the Radcliffe Medal, a Harvard University honor that recognizes individuals who have had a transformative impact on society.

The medal is awarded each year by Harvard’s Radcliffe Institute, one of the world’s leading centers for interdisciplinary exploration. Past recipients include Melinda French Gates, Dolores Huerta, Hillary Clinton, Ruth Bader Ginsburg, and Toni Morrison.

Dahl’s work in global health began at 18 years old in Mirebalais, Haiti, where she went to volunteer at a school for children with disabilities. During her first year there, she met Dr. Paul Farmer, who was working at a rural clinic in Cange. The seeds of a lifelong friendship—and a movement for global health equity—were planted.

In partnership with Haitian leaders, doctors, and nurses, Dahl and Farmer began to provide free health care to the community, making lifesaving treatment accessible to thousands of patients and advocating for global policy change. This work eventually led to the founding of Partners In Health in 1987, alongside Dr. Jim Yong Kim, Todd McCormack, and Tom White.

In the years since, Dahl has continued her tireless advocacy and leadership in global health. She served as PIH’s executive director for 16 years and now chairs the Board of Directors. She also helps lead the Roald Dahl Literary Estate, which manages the works of her late father, the writer Roald Dahl, and is a trustee at Wellesley College, her alma mater.

Dahl sat down with PIH to share reflections on her life in global health, her experience as a woman in leadership, and some of the greatest challenges—and sources of hope—she sees in the world:

First off, I wanted to congratulate you on receiving this award. So exciting! You're among an amazing group of leaders to have received this: Ruth Bader Ginsburg, Hillary Clinton, Melinda French Gates. They've all had a very deep and lasting impact on human rights. How did you react to learning the news of this award?

I was surprised and extremely honored. It’s an illustrious list of past winners who've dedicated their lives to [service], whether it's law or global health or education. One thing they have in common is that they've all been involved in their fields for a long time and seem to have focused in one area for a long time.

While I feel immensely honored, I also feel as though there are many people who do very difficult work in the same space, and I have been privileged to have found my people and allowed my own career to unfold. It hasn't felt like a career in many ways. It's really felt more like a long and ever-expanding collaboration.

You met Paul Farmer, PIH co-founder, at 18 during your first trip to Haiti and you worked together for more than 30 years. He was often at the forefront of our work as kind of the “face of PIH.” You stayed somewhat out of the spotlight, focused on the work, pushing our mission forward. What does this award mean for you and, perhaps, for all the others who are working behind the scenes?

The thing that became interesting to me early on is the realization that I didn’t need to be an academic, a clinician, a researcher, a supply chain [analyst], or a businessperson…social justice work and “global health” as it has become known, i.e. the work of PIH, is a field that embraces everybody. I applied myself where I was needed. In any job or any movement, it's rare that you get things done on your own. I tried to invite many other people in and to get to know those people and connect others to the work. Anytime I go and visit PIH sites, I'm reminded that, whether it's the people cleaning the hospital or doing malaria testing in a lab, so many people are absolutely integral to this work.

It’s been more than a year since Paul's passing. Your life and career in global health have always been so deeply connected to his, in so many ways. Any reflections you'd like to share, as you remember his life and legacy?

He is woven into every aspect of our work. When I think about the complex weave of what we do, across teaching and research and service provision, building a university and sustaining it…there's really not a day that goes by where I don't think about Paul’s commitment to this mission and how many people he brought in. He invited anyone who was interested, however tangentially, across those fields and more broadly. He brought tons of young people into this through his writing. I also think about his rigorous, boundary-pushing standards and the way that he embraced complexity, never shying away from it. He kept saying, “If it needs to be done, then we must find a way to do it.”

Partnership is in PIH’s name and really key to the work we do and moving it forward. When you and other co-founders wrote the PIH mission statement over 30 years ago, you discussed partnership, specifically this need to draw on the resources of the world's leading academic institutions to fulfill our mission, which is both medical and moral. Can you talk about the role of academia in partnering with implementers such as PIH?

One of the things that Paul and Jim [Kim] realized early on as co-founders and as academics themselves is that there would be a limit to what an NGO could do on its own. We were not in a position to build academic systems and disciplines and if we wanted to create health systems, we would need to have people who were trained to do it. We'd need to create what Paul referred to as a “feedback loop,” so we'd also need to join it to research and teaching.

UGHE is PIH-U[niversity] to some extent, but it’s grounded in academic standards. Throughout PIH’s history, we have been connected with teaching hospitals and academic institutions.

All of us felt strongly that we could not simply have an organization that was supporting research in a country where clearly the health indices were terrible and not do something about it at the same time. These things feel indivisible to us: research, teaching, and service.

Many women look up to you and your life of service. Knowing that everyone is different and there are infinite paths to truly change society, what is your advice for women who are looking at your life and career as an inspiration to get involved?

I would say to absolutely take all of the lessons learned and don't be afraid to put yourself out there. I was really an open book. I had no plans ahead of me, except that I knew I was being affected by all I was seeing in Haiti. I was open to all counsel from many different people, and I had it right there. I had Père Lafontant, Mamito [Yolande Lafontant], Loune [Viaud], and many more examples of good, strong women, including my mother, who had her own career. I also went to a women's college, which I loved. I felt as though all of the people that I was around were women who were forging paths forward and all of that seeped into me from a young age.

I didn’t know it was somewhat unusual. If I was a 30-year-old woman today, if I was trying to muscle my way in and felt endless pushback, minimizing of my efforts, and subjugation, I'd be demoralized. Because of the examples from early on, I didn't hesitate to push my way forward.

I came from artistic and creative parents. My opportunities were broad. As a kid, I was given numerous examples, encouragement, and a great deal of freedom, which was both good and overwhelming at times.

You've helped lead PIH through many crises over the years, from earthquakes to Ebola outbreaks to a global pandemic. What are some of the lessons, whether personal or professional, that you learned from navigating these challenges?

Every time a crisis strikes, the aftershocks and the response will depend on what infrastructure is already in that country. We can see the difference between the aftermath of an earthquake in a country in which there is strong infrastructure, or a medical system, and the aftermath of an earthquake in a country that lacks that infrastructure.

We don't think about ourselves as a crisis response organization, but rather one that builds for the long-term. However, if you're going to do any systems building or improvement of access to health care, you have to also address crises and partner with other organizations doing that work. And our long-term presence in the communities where we work often positions us for effective response to crises, from Ebola to COVID-19.

There is currently a coordinated attack on LGBTQ+ rights in the U.S. and around the world—thinking of the new anti-gay legislation in Uganda, for example. As an inspirational leader who happens to be queer, are there any thoughts or reflections you'd like to share about what is going on or what is truly at stake?

I think a great deal is at stake. And the idea that anybody is persecuted [by] these hate bills, hate crimes, is terrible and outrageous. Places that continue to do this are putting lives at risk. People can't possibly feel safe in the face of legislated hate. We need to find ways to make all spaces safe for everybody and to also continue engaging people in the often longer work of changing policy. We should accompany those people who need help, and at the same time we should be working on changing the hearts and minds of global leaders who are in charge of these laws. Change is possible. Queer people were being chased out of all kinds of countries only a couple of decades ago and are now welcomed. These policies are made by humans, not by monoliths. I've believed all of my adult life that you can change people's minds through long-term accompaniment.

A lot is happening in the world right now, and there's this constant churn of tragedy and heaviness. It has many of us falling into despair, or exhaustion, or cynicism. But you've made a point of remaining optimistic and hopeful, notably saying pessimism is a privilege most cannot afford. So what brings you hope today?

Years ago, I was on a plane coming back from East Africa, and the plane had stopped in Nairobi. Someone got on next to me; they had been on safari in Kenya. They asked me where I was traveling and what I did. I talked about the places where PIH works, and she turned to me and said, “You know, is there really any hope? Is there any reason to do it?” I just was so taken aback by that: the idea that someone's gone to a country on safari but has the ability to relegate an entire country, a people, to a state of hopelessness. That is something I carried with me. I still hear her words and reject them.

I hear this with respect to Haiti all the time—that it's a terrible, terrible mess. It relatively easy for some to write off a country because it is seen as a piece of geography. As soon as you start thinking about the humans forced to live in horrendous circumstances it should become impossible.

We humans came up with this terribleness. We have the ability to address it and stop it. It wasn't an AI system or something in the solar system that just happened upon a people. All of this suffering and all of the awfulness, even to some extent the natural disasters, are caused or exacerbated by us.

You can feel sad and overwhelmed. I sometimes do but not for long. We have the ability to make a difference. I worry about a paralysis that happens with people like us who have access to tools, funding, and extraordinary connections to others. Some of the long-term changes may not happen in our lifetimes but we can set up the circumstances to create change. And there are some things we can address and change right now.

[In my life] I've seen extraordinary change take place. The field of global health, for example, really didn’t exist three decades ago, and now it has become a huge field, for professionals, for students, careers, change-makers. We have multinational funds and political will that have helped to address a pandemic like AIDS very effectively. We have country like Rwanda that might be the first in the world to wipe out cervical cancer. So I feel generally hopeful. How can I not feel hopeful with so much progress already witnessed?

Take Action (Below): Contact U.S. Congress Members

UPDATE (May 15, 2023): May 11 marked the end of the United States Public Health Emergency declaration for COVID-19, which also resulted in the lifting of Title 42, an order used by former President Donald Trump’s and President Joe Biden’s administrations to prevent migrants from seeking asylum at the U.S.-Mexico border.  

Over the past three years, Partners In Health leaders consistently called for the end of this unjust order, which had no basis in public health and increased inhumane conditions for children and families forced to make desperate and dangerous attempts to seek safety in the U.S. Under the misuse of Title 42, children and families seeking asylum were expelled over 2.8 million times, resulting in family separation, a spike in children crossing the border alone—making them increasingly vulnerable to exploitation and illegal child labor, and an overall increase in dangerous conditions for people trying to flee to safety.  

Unfortunately, members of Congress are considering legislation that would extend the inhumane and ineffective Title 42-style expulsions and enshrine this abuse into immigration law. On Thursday, May 11, the U.S. House of Representatives passed H.R. 2. On May 4, U.S. Senators Kyrsten Sinema and Thom Tillis introduced S. 1473. Both bills would effectively end the right to asylum and result in mass expulsions to Mexico and mandatory detention of families, unaccompanied children, and other people fleeing violence and danger. While Title 42 wrongfully used public health as a pretext to expel people seeking refuge, these new policies are now directly threatening a public health crisis based in racism and xenophobia. 

 “For more than three years, the U.S. government has sent the message to millions seeking peace and safety that their lives and families are not worth protecting,” says Cate Oswald, PIH’s chief policy and partnership officer. “Unfortunately, the dangerous conditions forcing people to seek refuge are only increasing. 

“Rather than creating further life-threatening barriers, it is well within the U.S. government’s capacity to address the pressing needs of refugees by building compassionate pathways and real policy solutions to safe migration in this country,” Oswald adds. “PIH urges lawmakers to honor international law and human rights and build policies that create sustainable and prosperous livelihoods for migrants.” 

PIH is urging members of Congress to reject S. 1473 and all attempts to deprive people the right to seek asylum.  

Partners In Health is asking supporters to take action to ensure the U.S. Congress does not advance policies to reinstate Title 42. 

UPDATE (February 10, 2023): On December 27, the United States Supreme Court required President Joseph Biden’s administration to maintain Title 42, an order that uses public health practices to prevent the spread of COVID-19 as a pretext to expel people seeking asylum. In a 5-4 ruling, the Supreme Court put on hold a lower court ruling that would have terminated the order by December 21. Partners In Health (PIH) leaders and advocates have called on the federal government to end Title 42, and this ruling requires the unjustifiable order to continue while the Court hears the appeal. 

On January 5, Biden announced an expansion of Title 42 to expel asylum seekers arriving from Haiti, Cuba, and Nicaragua to Mexico when they are apprehended at the U.S.-Mexico border. The announcement also included plans to institute a narrow parole program for Cubans, Haitians, and Nicaraguans with U.S.-based sponsors to enter the U.S. The Biden administration has argued in a brief to the Supreme Court that the anticipated expiration of the COVID-19 public health emergency on May 11 would terminate Title 42 and render the Supreme Court challenge moot. 

PIH calls on the administration to end Title 42 and restore access to asylum for Haitians and all seeking safety, immediately.  

UPDATE (November 17, 2022): On November 15, a federal judge ruled against Title 42, deeming it illegal for President Joe Biden’s administration to continue using this order to unjustly expel migrants at the United States-Mexico border under the false pretense of preventing the spread of COVID-19, and requiring the government to terminate the order by December 21, 2022.

Partners In Health celebrates this decision and calls on the administration to restore access to asylum for Haitians and all seeking safety, immediately. 

This week’s ruling comes after a different federal judge blocked the Biden administration from terminating Title 42 in May, leaving the inhumane and racist policy in place until now. For over two years, PIH leaders and advocates have called on the federal government to end Title 42 and to respect the human rights of migrants. The November 15 ruling demonstrates that Title 42 has no basis in public health, and we urge the administration to terminate it immediately and respect the rights of migrants.

UPDATE (May 16, 2022): On April 1, Partners In Health (PIH) celebrated the end of Title 42, unjustified for public health reasons, excited that Haitians and others seeking asylum in the United States may soon face a more humane process while trying to enter the country. However, there are now bipartisan bills in both the Senate and House that would keep Title 42 in place indefinitely, and could have lasting, catastrophic impacts on the United States’ asylum system.

On May 12, the White House hosted its second global summit on COVID-19. Despite calls for resolve and funding in our global pandemic response, U.S. lawmakers continue to hold up any further COVID-19 response money by demanding the continuation of the unjustified Title 42 order that has denied asylum to refugees at our southern border.

“It is a shame that lawmakers would rather play politics with the lives of millions seeking asylum than fund vaccines, treatments, and tests for impoverished communities in the U.S. or around the world,” said Cate Oswald, PIH's chief policy and partnership officer. “We are calling on lawmakers to pass COVID-19 funding for domestic and global responses without the Title 42 order, which has already allowed the administration to expel more than 22,000 Haitians from the United States. As an organization that stands in solidarity with the people of Haiti, we urge lawmakers to reverse course immediately.” 

April 1, 2022

Haitians and others seeking asylum in the United States may soon face a more humane process while trying to enter the country. That’s because an unjust order will be terminated in May, the Centers for Disease Control and Prevention announced on April 1. 

The order, known as “Title 42”, has allowed the Trump and Biden administrations to prevent migrants from crossing the U.S.-Mexico border in order to stop the spread of COVID-19. However, those who oppose the order—including Partners In Health (PIH) leaders—argue that there is no public health evidence that the order effectively stops the spread of the virus. 

The Title 42 order is now being lifted, more than two years since it went into effect.

“What a relief,” says Cate Oswald, PIH’s chief policy and partnership officer. “We’re happy that after two years this is finally being recognized by the CDC as unjustified for public health reasons. We’re happy the Biden administration and the CDC  see that.”

For two years, PIH leaders have advocated to end the policy and in March, they co-authored a Perspective piece in The New England Journal of Medicine–published two days after the two-year anniversary of the order. Although the order will soon be overturned, opponents of the measure must not be silent, cautions Oswald. 

“We need to continue our advocacy to ensure that immigration policy and reform continues to move forward. And we need to continue to hold the Biden Administration accountable,” she says. 

The end of the order will hopefully mean a more just process for Haitians and other asylum seekers. In turn, this may also result in fewer people being immediately expelled while giving them more access to representation and an opportunity to be heard. While the order was in place, Haitians in particular have been disproportionately affected. Since February 2021, more than 21,000 Haitians—many of whom were subjected to inhumane treatment—have been deported.

On May 23, the order will officially be terminated. Over the coming weeks, the CDC will work with the Department of Homeland Security to implement COVID-19 vaccination programs for migrants, among other protocols, according to the April 1 announcement. 

“This is a victory in the sense that so many people have been working deeply on a daily basis with Congress to encourage CDC to stop enforcing Title 42 as a public health order justifying turning away asylum seekers” says Oswald.

*Content warning: The following story mentions incidents of sexual violence and attempted suicide. 

The young woman had just turned 17 when she ran out to the supermarket one evening to pick up some candles for her family’s home. On the way back, a group of men surrounded her, pulling her into an abandoned building. They raped her, each taking a turn, while denigrating and taunting her throughout the ordeal. She wasn’t sure if there were eight or nine of them, said Junie Claudie Zamor, a social worker involved in the woman’s case, because “there were too many to count.” 

At least one-third of women across the world experience gender-based violence, according to The World Bank. In Haiti, violence against women has been rising, according to news reports and an analysis by PIH staff, driven by pandemic-era restrictions and the recent proliferation of gang attacks, kidnappings, and political and economic chaos. In Haiti’s Central Plateau and Artibonite regions, over the past year alone, 2 in 10 women experienced physical violence; 3 in 10 suffered sexual violence; and 4 in 10 experienced intimate partner violence. That’s likely an undercount. 

To try to mitigate such violence, Zanmi Lasante (ZL) as Partners In Health is known in Haiti, and PIH Canada launched a program that seeks to help victims of violence through direct care, counseling, and advocating for systemic change to improve their lives so they can be free of violence. 

ZL’s Gender-Based Violence Project started at six of its hospitals and clinics as a pilot program in 2014. High demand from health providers treating survivors, and the Ministry for the Status and Rights of Women, prompted an expansion to an additional five facilities in 2020 and three more in 2021. Overall, the program has reached more than 4,800 survivors of violence.  

Between 2020-2022 alone, the project helped more than 1,900 women and 115 men subjected to violence in the Central Plateau and Artibonite regions.The range of support varied widely, but included medical and psychological care and treatment, financial assistance, and referrals to services, from women’s and adolescents’ empowerment groups to security support.  

Educating Communities About Violence 

Haiti’s male-dominated, patriarchal culture remains powerful, said Eddy Eustache, known as Père Eddy, a Catholic priest and Haitian psychologist who has worked with PIH since 2005 and is now its director of staff wellness and implementation.

“There are still very traditional gender roles in Haiti,” he said. “Men consider themselves the head of the household, so when, for instance, women earn more than the men, they feel diminished, inferior, and sometimes, the way men behave can be destructive.” 

That’s why education is critical to halting gender-based violence, he said.  

As part of the program, ZL staff provide training for police officers and judges, to educate them about violence and power dynamics and how long-standing systems are stacked against women, making it difficult for them to find justice and healing after an attack. To date, 65 people, including 11 female police officers, have participated in the training. But based on reports from a training session with judges, the men (they are all men) are in dire need of such education.  

After one training, for instance, the meeting notes say that the participants had “low levels” of knowledge on gender-based violence and held problematic attitudes. “One notable example is that of judges discussing the drivers of violence,” the notes say. “At the start of the discussion, the judges were clear that they held women responsible for the violence to which they were subjected.”  

ZL staff seeks to dispel these widely held, distorted beliefs. In the same session, the staff pushed back on such anti-women attitudes and helped to reframe the judges' thinking: “Through a series of guided questions, the training facilitators were able to help them shift their understanding of the locus of responsibility for GBV [gender-based violence] from the survivor to the perpetrator.” At the end of the training, the notes say, many participants asked ZL to broaden the project to cover a wider region. 

“The project is great at dealing with the immediate- to short-term consequences, but there are longer-term consequences that fall on the broader health system,” said Dr. Pierre-Noel Sergely, clinical director at Cerca-La-Source. Significant social, political, and cultural barriers remain in the way of supporting survivors, he added.  

For instance, like the judges, many people in the community still blame the survivors of violence, asking, for example, why they are going out after dark and telling them they should know better.

"Abusers set the tone," Sergely said. "Although some abusers are sentenced to prison, they often remain in the community because of loopholes in the justice system. As a result, they continue to harass their victims, exacerbating their trauma."

He said that another unfortunate reality is that abusers sometimes choose to flee Haiti to escape prosecution. Later, they return to the community without being held accountable for their actions. In such cases, victims often find themselves confronted by their abusers. Under the weight of shame, fear and stigma, these victims are often forced to leave the area, while their abusers go unpunished, he said, adding: "This situation highlights the shortcomings of our justice system."

One example he cited was a case in which a 15-year-old girl had been gang raped. The perpetrators wrote a song about the girl, and, as is common in some neighborhoods, gathered on the street to sing together. They sang their song about the young woman. “The girl in question ended up leaving the community,” Sergely said. 

Threats to the Family 

After the 17-year-old’s attack, which occurred in 2021 near the young woman’s home in Cerca-La-Source, the perpetrators forced her to remove her dirty clothes and gave her new ones to put on. Then they pushed her into the street, telling her if she spoke to anyone, they’d kill her family, naming her father and sister. Though she was injured, the social worker said, the woman felt she could not return home. She remained in the street crying until a family friend, who is also a community leader affiliated with ZL, found her and brought her home. The next day, the young woman’s parents took her to the hospital where she was treated and referred to continuing care. Then they went to the police.  

Zamor is one of 17 assistant social workers hired as part of the overall GBV project. She said her job includes home visits to women following a violent attack or incident. The first time she went to the 17-year-old’s home, “her psychological state was frayed,” Zamor said. She had tried to die by suicide, swallowing an entire bottle of pills, and though she was scheduled to go to the hospital for follow-up, “she was too afraid to walk on the streets.” So on that first home visit, Zamor brought one of the team’s psychologists along.  

In general, the goal of these visits is to listen and provide non-judgmental support as needed, guided by the patient.  

“Often victims don’t talk, they cry,” Zamor said. “Our focus is to reassure victims that what happened is not their fault.” 

Zamor conducted two subsequent visits to the young woman’s home. In addition to supportive listening and general empathy, Zamor said one of the “care pathways” is to connect victims to a network of women’s associations supported by ZL, and other groups. Zamor also connected the young woman to an adolescent club led by ZL in which members discuss sexual health and education, rights and consent, and issues related to gender-based violence.  

Supporting Survivors  

The program’s guiding principles include accompaniment and counseling, the right to security and confidentiality, non-discrimination and a right to high-quality care. Social workers and other providers communicate these rights to patients from the outset. 

Indeed, the anti-violence program has had an impact, its leaders said. Specifically, between 2020-2022: 

• 1,793 gender-based violence patients, or 92%, have seen an assistant social worker;  
• 897 patients, or 46%, received a home visit; 
• 1,536 patients, or 79%, received financial support for transportation to a hospital, clinic, or police station;  
• 1,562 patients, or 80%, were referred for legal services.  

And even while stigma around rape and related violence persists and a blame-the-victim attitude remains pervasive, Sergely said ZL’s program is making inroads.  

Before the project began, he said, survivors of violence were reluctant to seek care. When they did seek support, they would often go to the police, where they’d end up waiting for many hours, before, eventually, being directed to a hospital or health facility for follow-up care and treatment.  He added that survivors would, understandably, often take a bath before going to the police station and inadvertently undermine the ability to document evidence that might be used in criminal proceedings.    

“The GBV project aimed to change this behavior,” he said. A key focus of “community sensitization workshops,” which are, essentially, educational gatherings held in health facilities or in neighborhoods where social workers and community members live, has been the need for victims of violence to present to the hospital or health facility before going to a police station. The workshops stress the importance of going to a medical facility within 72 hours after an assault, because it is within this window of time that medication for HIV or sexually transmitted disease exposure or emergency contraception are most effective. Staff has also worked to educate the public about the importance of not bathing or discarding clothes the victim was wearing during an assault. 

Long-Lasting Impacts of Violence 

After three home visits, meetings with her adolescent club, and other interventions, Zamor said, the young woman became more stable. She appeared to stop crying as frequently, her suicidal behavior ceased, and, through ongoing discussions, she was able to talk about her fears and begin to reintegrate into society, Zamor said. The young woman called members of her adolescent club, “family.”  

Still, Zamor said, the attack clearly took a toll, and while several of the perpetrators were arrested, not all of them were prosecuted.  

The young woman and her family eventually left Haiti and moved to the Dominican Republic. 

With so many young victims, Sergely said, it’s difficult to know the long-term effects of such brutal violence.  

“We don’t know what the psychological impacts will be,” he said. “Even if they are able to get back on their feet, we know that there are long-term impacts to this type of trauma.” 

Playing with her 6-month-old son with one arm while supporting her second son with the other as he breastfeeds, Solange Manirumva, 20, has slowly adapted to being a mother of twins.

Just three years ago, she was a high school student.

"I would leave my children alone and just leave," said Manirumva, reflecting on difficult, earlier days of motherhood. "But I now enjoy spending time with them."

Being a mother at a young age, while also supporting her family, was overwhelming.

Manirumva, like many young women in rural villages, faced the responsibilities of adulthood much earlier than planned. She became her family’s primary earner in her teens. When she unexpectedly got pregnant with twins, she found Inshuti Mu Buzima (IMB), as Partners In Health is known in Rwanda, along this path.

Bearing Family Responsibilities

Manirumva’s mother died in 2016 while giving birth to her youngest brother, leaving behind four children and their 74-year-old father.

Her father was too old to work in the fields, which is the main source of income for families like Manirumva's, living in poverty and making a living from cultivating other people’s fields for money. As a result, most of the responsibilities to raise her siblings, like paying for school materials and providing food, fell on her shoulders.

To support her family, she would stop going to school for a couple of weeks to work in the fields for daily wages. Despite this, she performed well and passed the national exam to attend a top boarding high school. A family friend volunteered to support her education, but there was a price paid for that support.

“He would pay for my school fees and other school materials,” said Manirumva. “He would also visit me and [we would] go out together.”  

In 2019, during the second term of her second-to-last year of high school, she felt more emotional than usual and noticed her period was late.

"I immediately knew I was pregnant," said Manirumva. When she shared the news with the family friend who got her pregnant, he stopped talking to her.

She told the school administration that she had a terrible headache and asked to go home for treatment. In anticipation of her baby’s arrival, she applied to be a paid youth volunteer, helping the government's COVID-19 response. She earned enough money to open a vegetable stand in a local market and used the cash to buy clothes and bedding, saving the rest.

A Premature Birth

One late evening, two months before her due date, she started to have unusual contractions. She called a neighbor who took her to the nearest health center, and from there, she was transferred to IMB-supported Kirehe District Hospital.

"I thought I would give birth in two months," said Manirumva. "I had visited a health center once, and they told me I had one baby and my pregnancy was fine."

At Kirehe District Hospital, Manirumva gave birth to not one but two premature infants, weighing 1.3 and 1.1 pounds.

"I was surprised that I had twins," said Manirumva, who was in shock at the news. "I didn't think much of the babies, because I thought they would die. They were very tiny."

In fact, she grappled with depression in the first days, and it took time for her to adjust to the new reality.

The babies were immediately taken to the neonatal intense care unit (NICU). NICUs are crucial resources for newborn care, providing oxygen therapy and other lifesaving services for babies born prematurely or with complications. Luckily for the young family, Inshuti Mu Buzima had recently opened a newly renovated NICU at Kirehe District Hospital, in partnership with the Rwandan Ministry of Health.

Inshuti Mu Buzima supports the Rwandan Ministry of Health to make pregnancy, labor, and birth safer for mothers and newborns by training health care providers, building infrastructure, and strengthening health systems.

Finding Expert Care

In Kirehe’s NICU, Manirumva—like all other mothers—was assisted by a team of doctors, nurses, and expert mothers who guided her through her first days there by teaching her the proper techniques for breastfeeding, how to preserve breast milk, and how to care for herself, among other essential skills.

“I loved chatting with other moms in the NICU,” said Manirumva. “The advice the nurses gave us helped me to overcome fear and get used to my babies.”

Inshuti Mu Buzima practices an integrated form of care to help both new mothers and their children. The twins, like all children born prematurely or with other complications, were enrolled in Kirehe’s Pediatric Development Clinic (PDC), an interdisciplinary program intended to improve health outcomes for babies at risk of death or developmental delays, especially in their first five years of life.

Through the Pediatric Development Clinic, Manirumva met with Cecile Itangishaka, IMB’s psychosocial and community support coordinator, who continued to follow up on the young mother of twins after she was discharged.

Homecoming was difficult for Manirumva and her boys. Many of the resources at the hospital—from baby formula and regular meals to a feeling of safety and comfort provided by other mothers and care providers—weren’t there when she got home.  

“There was not enough food at home,” said Manirumva. “I was concerned about the health of my babies, but Itangishaka and IMB staff continued to visit me and brought food, clothes, and even a mattress.”

The twins, like all children enrolled in the Pediatric Development Clinic, receive regular follow up through clinic appointments and community-based support to ensure that they are thriving. Manirumva receives services that include parenting education, counseling, and social support.

“The babies are much bigger now,” said Manirumva. “The young one especially is very active.”

Joyful, laughing, and playful—this is how María Elena remembers her childhood in Carabayllo. But as a single mother, daily life in the district in northern Lima was full of challenges.

In the summer of 2021, she was working as a cook and caregiver for an elderly person—jobs that enabled her to pay for her two daughters’ education. One day, she felt a flood of symptoms, including dizziness, nausea, and loss of appetite. She decided to take a pregnancy test.

The result was what she had feared: she was pregnant.

"I felt very sad, lonely, down,” she says. “I looked for work and was unsuccessful. No one would hire a pregnant woman."

As she continued the grueling and uncertain job search, she experienced another challenge: a breakup with her partner. The circumstances took a toll on her mental health, worsening her depression and anxiety.

“I didn’t want to get out of bed,” she recalls. “I didn’t even want to cook for my daughters.”

As many as 15.6% of pregnant women in low-income countries experience some type of mental health condition, mainly depression, according to the World Health Organization. The lack of support and stigma around mental health can lead to women suffering in silence.  As women navigate the challenges of pregnancy and mental health conditions, other health issues can arise too.

For María Elena*, these conditions led to her neglecting her diet, which resulted in anemia. She also contracted COVID-19.

Maternal care: a commitment to mothers

María Elena connected with Socios En Salud, as Partners In Health is known in Peru, when she was two months pregnant, during a visit to La Flor Health Center. Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the years since, Socios En Salud has expanded its programs to provide medical care and social support for patients across the country.

For María Elena, the connection to care could not have come fast enough.

Carabayllo, where María Elena lives today, is not only the largest district in Lima, but also has one of the highest maternal mortality rates in the country’s capital. To address this problem, Socios En Salud supports four health centers, including in La Flor, to strengthen maternal and neonatal health in Carabayllo and beyond.

At La Flor Health Center, María Elena accessed maternal care such as prenatal checkups and met Yndira Choque, one of Socios En Salud’s 91 community health workers, who helped her navigate the health system and access medication and additional forms of care, including mental health support.

"They [health center staff] have been very compassionate, supportive and very professional. I felt listened to," she says.

The feelings were mutual.

Choque, who has been a community health worker with Socios En Salud for three years, notes the “affection one feels” for patients. She would check in with María Elena regularly, in person or on the phone.

“It is a beautiful feeling,” she says. “Calling and talking creates bonds of friendship, affection, and trust.”

During the first six months of her pregnancy, María Elena accessed free therapy, four times per week.

In addition to mental and physical health care, she also accessed essential resources, also known as social support, from Socios En Salud, including food baskets.

With medical care, social support, and accompaniment from Socios En Salud, she was able to deliver her child safely and through natural childbirth. Abdiel was born on February 1, 2022, weighing a healthy 7.7 pounds.

Now, more than a year later, María Elena is thankful for the care and support she accessed through Socios En Salud. Abdiel is healthy and up-to-date with his well-baby checkups.

One of the greatest impacts of Socios En Salud’s support was access to mental health care, helping her manage her depression and anxiety.  

"Unlike my previous pregnancies, this time I proved that despite the adversities that came my way, I never fainted. I fell down and got back up,” she says. “And I showed everyone that my greatest strength is my children."

*name changed for privacy reasons

As a child growing up in Salvador Urbina, a small community in the Frailesca region of Chiapas, Mexico, Cecilia Gálvez would walk two hours with her mother to the nearest health center for vaccinations.

During those walks, she would imagine her future. “From that moment on, I grew up with the idea that I wanted to be a nurse," she says.

Over time, Gálvez realized that everyone in her community of 600 people faced similar challenges traveling to town and accessing health care. She pictured herself supporting her community so that they would no longer have to trek for hours elsewhere when they felt sick. 

In 2014, the Mexican Ministry of Health built a clinic in Gálvez’s community, and Compañeros En Salud, as Partners In Health is locally known in Mexico, began working in the community as well. Compañeros En Salud has worked in the state of Chiapas since 2011 in partnership with the Ministry of Health.

Gálvez eagerly applied to become a clinic assistant, where she learned to triage patients, make home visits to chronically ill people, classify medications in the pharmacy, and do sutures. At the same time, she worked as an acompañante for a year.

Acompañantes are community health workers from the communities where Compañeros En Salud works. Since 2012, this program has hired and trained people to provide medications and basic health services, such as screenings, and to conduct home visits to patients with chronic illnesses. Compañeros En Salud currently has nearly 100 acompañantes on staff.

As she worked as a clinic assistant and acompañante, Gálvez was beginning to forge her own path. She decided to start nursing school in Tuxtla Gutiérrez, a city about four hours away from home. It wouldn’t be easy. As a woman from an impoverished community, struggling to make ends meet, Gálvez knew that becoming a nurse would involve immense time, effort and resources.

Each weekend was the same slog: every Friday, she had to travel two hours to Jaltenango de la Paz, where she spent the night, and then drive the next morning, before dawn, to Tuxtla Gutiérrez to take classes. On Sundays, she had to travel back to Salvador Urbina to work Monday through Friday at the clinic. 

This was not the only challenge she had to confront to achieve her dreams, Gálvez says. Because it is customary for women in her community to stay home and care for the family, the decision to attend nursing school was a break with tradition. But, she says, she didn’t mind if neighbors criticized her for attending school.

“Since I was little, I saw machismo and violence against women, and I wasn't going to continue with that," she says.

Machismo, a form of toxic masculinity, is still present in the Frailesca communities of Chiapas, and Gálvez, like many other women, fight every day to break stereotypes, eliminate gender roles, and bring about gender equity. For Gálvez, nursing school was not only a path out of poverty but also a way to forge her own—in spite of traditional gender roles.

After years of intensive study, Gálvez graduated. She then took her skills where she had once envisioned: working as a community nurse for Compañeros En Salud, in the communities where she was once a patient.

Since 2020, she has taken her career a step further, becoming a clinical supervisor. In this role, she mentors nursing and medical interns doing their year of social service at the rural clinics.

"I have been growing professionally and as a leader by supporting my team," she says.

Currently, the clinics are expanding the role of nursing, which includes developing nurses’ clinical skills and encouraging more decision-making and autonomy among nursing staff.

“Before, we depended a lot on the doctors. They were the ones who made the decisions," Gálvez says. “But now, we are validating nurses and acknowledging that we have the tools to make important decisions and care for patients.”

In honor of National Nurses Week, the following essay was co-authored by Partners In Health CEO Dr. Sheila Davis; Cory McMahon, chief nursing officer; and Isaac Mphande, primary health care manager, Abwenzi Pa Za Umoyo (APZU/PIH Malawi) 

Nurses, the backbone of the global health workforce, are facing a crisis. That means patients are bound to suffer.  

Even before COVID-19 struck, nurse and midwife shortages were between 7 million, according to the World Health Organization, and 30 million, based on an analysis for the Global Burden of Disease study, which took into account additional factors to determine need. 

Even with this considerable gap in estimates, the shortfall is significant, and predominantly impacts low and middle-income countries. Now more than three years into the pandemic, there have been widespread departures from the nursing profession, further fracturing already weakened health systems. 

Beyond shortages, the distribution of the existing nursing workforce threatens the equitable and effective delivery of care. More than 80% of the world’s nurses work in countries that contain only half of the global population. The pandemic exacerbated this inequity: high-income countries, also facing high burnout and nursing shortages, increased recruitment of nurses from low- and middle-income countries—further amplifying gaps in nursing supply and demand.  

As nurses make up the majority of global health care personnel and provide almost 80% of hands-on care worldwide, a strong nursing workforce is integral to health system resiliency, pandemic preparedness and response, ongoing essential health care needs, and the ability to deliver on universal health care.  

At Partners In Health, 52% of our clinical staff are nurses, yet nurses provide 75% of our patient care. PIH supports 1,626 nurses—88% of whom are female—across 11 countries. Globally, those most impacted by disparities in nursing availability and accessibility are—as usual—the patients, families, and communities that are most vulnerable. Despite general agreement that the world needs more nurses (and quickly), there are significant structural barriers to entering and remaining in the nursing workforce. Addressing these barriers is essential to improving patient care and outcomes and health systems broadly. 

Case Study: Malawi 

In Malawi, where PIH has worked since 2007, it can take seven years to earn a nursing degree. Even then, there is no promise of a job—despite the national need. Nurses who do secure jobs may find themselves bombarded, expected to see up to 75 or 100 per day at a busy health center. When nurses are unable to obtain employment, this directly impacts the ability to attract nurses to the profession, further contributing to workforce shortages. This understaffing, alongside other dire working conditions, strain nurse retention, recruitment, and the delivery of quality care.  

Despite these obstacles, Malawi has tripled its number of trained nurses and midwives. Each year, hundreds of well-qualified nurses graduate from school, prepared to enter the workforce. Although there is a 54% vacancy rate among nursing and midwifery positions within the public health system, only 70% of trained nurses and midwives are absorbed—there are currently thousands of qualified nurses without jobs in Malawi. However, the public health system is still in dire need of more nurses.    

If there is a global nursing shortage, why then should there be difficulty integrating nurses into health systems? 

This astounding misalignment is due to International Monetary Fund (IMF) imposed austerity measures, which place strict limits on the number of new public sector workers hired and their salaries. These rules impact multiple professions, including teachers and nurses. So, despite an enormous nursing shortage within clinics and hospitals, new nursing graduates are blocked from being hired by the public sector, forcing many to leave the country to find work. Furthermore, the low pay and high workload of the existing workforce means the cost of the austerity is borne by health workers and the health and well-being of the people.  

Recently, Malawi’s National Organization of Nurses and Midwives has been assisting unemployed nurses in seeking jobs outside the country. More than 3,000 nurses matched to jobs elsewhere—including the United States and other high-income countries—but the government blocked visas to prevent their departure. However, this does not prevent nurses from leaving on their own to pursue their careers and livelihoods. 

Nurse-Driven Innovations 

Beyond barriers to entry, a diverse range of challenges prevent the retention and support of nurses in the workforce. These obstacles include under-resourced work environments with high volumes of patients, insufficient supplies, no space or time to take breaks, inadequate access to education and training, and insufficient pay, among others. Achieving a new path forward requires a reimagined future, one in which nurses are recognized as experts and have opportunities to develop their careers while also receiving appropriate pay for their critical work. It will require a paradigm shift built upon the voices of nurses, and others serving on the frontlines, sitting at decision-making tables.  

Across our care delivery sites, PIH is working to formally define specialty areas and advanced practice nursing, enhance professional development opportunities, and establish career pathways that also keep nurses at the bedside. We are developing nursing fellowship programs that bridge the gap between academic and clinical practice, promote nurse-led innovations to care delivery, address burnout through staff wellness programs, provide dignified housing and other social support, and engage in policy change. 

PIH’s nurses are at the forefront of innovative care delivery programs, mentorship and leadership initiatives, and national and global policy efforts to impact broader change. Our integrated maternal child health program in Haiti (J9) is led by an interdisciplinary team of nurses and midwives. From 2018 to 2021, 2,229 women and 1,912 children benefitted from the J9 program. And even during the pandemic and more recent instability, J9 has sustained its enrollment of and services for expectant and new mothers and their babies.  

Nursing Centers of Excellence in Liberia and Haiti serve as hubs for professional development and clinical education and mentorship, bridging the gap from theory to practice. At the University of Global Health Equity’s Center for Nursing and Midwifery, nurses and midwives gain training in leadership, policy, and advocacy, as we make plans for a school of nursing and midwifery in the near future.  

In Liberia, Lesotho, Rwanda, Sierra Leone, and Haiti, we are working closely with national regulatory bodies to support efforts that define scopes of practice and establish national standards and curricula. Furthermore, we are engaging directly—in Malawi and elsewhere—with multilateral organizations to address structural barriers that prevent optimal patient care and to influence equitable resource allocation, workforce distribution and specialization, and strategies to attract, recruit, and retain qualified nurses and other health care professionals to meet present and future needs. 

A Workforce of Experts  

Across PIH and the globe, nurses and midwives deliver care amid difficult circumstances—from natural disasters to violence—and continue to show up as clinical experts, care connectors, educators, innovators, leaders, and compassionate caregivers at the bedside.  

As experts who provide the majority of care, and because of their proximity to patients, nurses should lead the discussion about structural changes needed to fortify the workforce and advance health care as a human right for all. However, health care practice still perpetuates hierarchies that too often minimize nurse leadership. Only 71% of countries have a national nursing leadership position with influence on nursing and health policy. As 90% of the nursing workforce is female, these power dynamics are patterned by gender inequities. Although women hold 70% of health care jobs globally, they only occupy 25% of health leadership roles—and women are, of course, differentially impacted based on social status and other privilege.  

In Rwanda last June, we witnessed the power of nurse leaders coming together through the Global Nurse Executive Fellowship (GNEF) program. Nurses from Haiti, Liberia, Sierra Leone, Malawi, Rwanda, Peru, and Lesotho shared challenges, exchanged ideas, and learned from each other. The innovative solutions that emerged from this collaboration highlight the importance and untapped potential of nurse leadership. Our work across PIH proves what is possible when nurses are engaged in and lead efforts to improve the delivery of expert, dignified, and compassionate patient care.  

Learn More 

People of PIH is a new series highlighting people whose lives have intersected with Partners In Health in some way, whether as patients, staff, or community members, in the 11 countries where PIH works around the world.

From the rural, mountainous Sierra Madre region of Chiapas, Mexico, to the vibrant, bustling city of Freetown, Sierra Leone, people whose lives cross paths with PIH come from a wide range of communities, all of them dynamic, complex, and rich with history and culture.

This series aims to offer a glimpse into people's lives and experiences—in health care and outside of it. Because no one should be defined by their diagnosis or the darkest moments of their life. There is always more to the story.

Follow PIH on Instagram for more.

Leonardo Joaquín Ramos Coutiño | Chiapas, Mexico

“I have a little piece of land and some pigs. My dream was to have more land, to make a big farm. That is how I support my family. But since this happened to me, I didn’t tend it… But that was my goal, to have more land, develop a big farm. I said, 'if God blesses me, if God gives me the opportunity to have more or do more, I will buy a larger piece of land and I’m going to make my farm.' Because I have visited other farms. I love animals. That was my goal, to develop a large farm and to live off of my animals.”

For years, Leonardo Joaquín Ramos Coutiño has dreamed of having a large farm. Coutiño, 58, currently has a small farm with pigs and chickens in Jaltenango, a city in the highlands of Chiapas, Mexico. But that dream was put on hold when he was diagnosed with COVID-19. As he battled the virus, someone else had to watch his animals; some of them passed away. Another illness further complicated his efforts to care for the animals. But Coutiño remains determined. He has since recovered after accessing medical care from Compañeros En Salud, as Partners In Health is known in Mexico. And he still dreams of having a farm one day.

Sinar Caleb Castro Reyes | Chiapas, Mexico

“He likes the rivers and parks [in Jaltenango]. He loves to go out and explore with his family. He loves to go to the park, play games, and go on the swings. At home, he loves to swing in the hammock all day long. He loves to listen to the song 'Lola the Cow'…He [also] loves his birthday. We invite children. We make sweet treats, piñatas, cake. He loves his birthday.”

For Marta Estela Castro Reyes, 27, some of her favorite days with her 5-year-old son Sinar are spent outdoors, enjoying the parks and playgrounds near the family’s home in Jaltenango, a city in the rural highlands of Chiapas, Mexico. Sinar loves swing sets, hammocks, and the family’s small inflatable pool—a welcome relief on Jaltenango’s hottest days, which can top 90° F. And the song he is most likely listening to while relaxing? “La Vaca Lola,” Reyes says. Reyes first connected with Compañeros En Salud, as Partners In Health is known in Mexico, for medical care for Sinar, an autistic child who lives with multiple sclerosis and is receiving support from PIH.

In Haiti, they are known as accompagnateurs. In Peru, they are agentes comunitarios. In Mexico, they are acompañantes. Around the world, they are known as community health workers, and they form the backbone of Partners In Health.

PIH has more than 10,000 community health workers on staff in the 11 countries where it works, with nearly 6,000 in Rwanda alone. Their day-to-day tasks vary, but their mission is the same: accompany patients on their health journeys and beyond.

That accompaniment happens in homes and in hospitals, in community centers and in clinics—wherever patients are, community health workers are by their side, or just a phone call away. As familiar faces, and even neighbors, hired directly from the communities where they work, community health workers care for patients in their houses and neighborhoods and bring linguistic and cultural understanding, cultivating deep bonds and trust.

Here are seven ways CHWs support patients:

1. Accompanying patients to the hospital or clinic

Many patients live in rural communities far from the nearest clinic or hospital—a journey that requires several hours of travel on dirt or poorly paved roads. Community health workers often accompany patients on this journey, helping them safely travel to their medical appointments and navigate the health care system.

2. Visiting patients at home

Each year, community health workers provide more than 800,000 home visits to patients and their families. During these house calls, community health workers remind patients to take their medication, monitor signs like blood sugar levels, and screen for early signs and symptoms of diseases.

3. Helping patients access medication

Finding the nearest pharmacy stocked with their medications is often a challenge for PIH’s patients. Many would have to travel for hours to another town, which would mean taking time off work, losing income, and spending money on bus fares. To address this, community health workers routinely deliver medication to patients at home. This service removes barriers to care and also helps patients take their medications correctly and on time.

4. Helping patients access essential resources

PIH understands it takes more than medicine to make patients well; they must also have access to food, housing, and other essentials often called social support. Community health workers help patients access these essential resources, from food boxes to bus fares to hotel vouchers. Community health workers have also supported patients as they navigate court cases, immigration paperwork, or government benefits programs.

5. Offering mental and emotional support

From unexpected diagnoses to high-risk surgeries, health care can cause mental and emotional distress for patients. Community health workers provide crucial day-to-day support, checking in with patients at home and over the phone. Some specialize in mental health and are trained to provide screenings for depression and anxiety, working closely with psychologists.

6. Educating patients about health issues and how to access care

Many diseases are preventable when detected in time—but early detection is a challenge in communities that lack access to resources, including health education. In communities where diseases like tuberculosis are prevalent, community health workers knock on doors, offer free screenings, and organize health campaigns and workshops to educate the public about health conditions, including testing, treatment, and care.

7. Advocating for patients in the health care system

Patients interact with many staff at PIH sites, from doctors to drivers. But community health workers often spend the most time with them and get to know them on the most personal level. That makes community health workers key advocates for patients at all levels of care, from relaying patient updates and concerns to doctors to translating for patients to providing guidance to clinical staff on patient care.

The team in Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi, is deep into an emergency response after Cyclone Freddy devastated parts of the country, leaving death, injury, and displacement in its wake. 

According to Dr. Chiyembekezo Kachimanga, chief medical officer at APZU, the response team has, for the past two weeks, been providing a range of medical and trauma services for individuals and families staying at camps established for people displaced by the storm. The support services include acute medical care for the injured and ill, HIV and chronic disease care and treatment, mental health assistance, screening and treatment for victims of gender-based violence, water, sanitation and hygiene supplies, and maternal and child health care.  

“We have reached out to 22 camps, all in Chikwawa,” Kachimanga said.  

Psychosocial support is greatly needed, and the two mental health providers on the APZU team have been screening people at the camps for acute stress disorder and providing emergency psychological first aid, Kachimanga added. 

Overall, the team is providing emergency support in the Neno, Chikwawa, and Nsanje districts, and targeting 4,500 households with food packages, household materials, and plastic sheets. The team has also procured medicines, supplies, and fuel to aid in the response, as well as 20 oxygen cylinders refilled from Neno plants to be used for the management of critically ill patients in Chikwawa. 

“To date, APZU has supported with 22 medical outreach visits providing integrated medical care to 2,210 people,” Kachimanga said.  

To enhance emergency service provision, APZU also hired and trained 17 health care workers, including nine nurses, five clinicians and three assistant environmental health workers who will be posted at Makhuwira health center, Chikwawa district hospital, and Ngabu community hospital for the next month, officials said. 

Cyclone Freddy hit Southern Malawi on March 13, after making landfall in Mozambique. The storm was reported as the longest-lasting tropical cyclone ever recorded in the southern hemisphere, leaving more than 670 people dead in Malawi, with 2,171 injured and over 655,000 displaced into 747 camps, according to a March 30 report from the country's Department of Disaster Management Affairs. More than 530 people are missing, the report states, and 2.3 million people lost crops.   

It remains unclear what the longer-term health impacts may be, said Dr. Shada Rouhani, PIH's director of emergency care. "Disease outbreaks are a risk in humanitarian situations," she said. "Overcrowding in camps leads to the spread of disease, so there's a high risk of other outbreaks, such as measles or polio, due to these conditions."

APZU, based in Neno District in southern Malawi, was asked by the national Ministry of Health to support the emergency effort.  

As of early April, the team has assisted in the following ways:  

• Total number of camps reached: 22  
• Total number of people who received medical services: 2,210, including 634 men and 1,576 women  
• Total number of patients screened for acute stress disorder: 624 
• Total number of people who accessed family planning services: 578   
• Total number of children seen in the “under 5” clinic: 471  
• Total number of vaccinations provided: 682

When the national community health worker program launched in Liberia in 2016, the Ministry of Health prioritized patients living more than five kilometers from the nearest health facility–about 29% of the population. 

In an effort to reach more patients and improve the quality of care, Partners In Health (PIH) Liberia ran a pilot program from September 2018 to March 2020 providing services to those living within five kilometers of PIH-supported J.J. Dossen Memorial Hospital in Harper, Maryland County, a largely rural region in the southeast. 

During that time, community health workers visited more than 10,000 households. Those visits helped link 3,177 people with care, of which more than 500 were diagnosed with malaria—a mosquito-borne disease that requires timely linkage to treatment. In a follow-up survey among participating households, nearly all respondents reported that the community health workers treated them respectfully and listened to their challenges and concerns.

The success of the program caught the attention of the government.

“We gave our results to the Ministry of Health and they were so excited about it. They incorporated our ideas into a new, revised policy and strategy plan,” says Lassana Jabateh, PIH Liberia’s community health program director. “We’re making sure that Liberia has a community health program with a strategy covering [all] communities.”

The new strategy, which aims to accelerate progress toward universal health coverage, was announced in late March at the Third International Community Health Workforce Symposium, a global gathering created to share ideas and solutions to sustain community health programs. Key takeaways from the pilot program, including recruitment, remuneration, training processes, and supervisory structure, will serve as a model for future programs across Liberia—and beyond.

An Essential Role 

Community health workers are essential members of the health system in rural Maryland County and Liberia at large. They visit dozens of patients daily; screen them for various diseases, including HIV, tuberculosis, and leprosy; and refer—and often accompany—at-risk and symptomatic patients to the hospital.

Through referrals, patients diagnosed with HIV or tuberculosis receive social support provided by PIH Liberia staff in the form of stipends, housing, transportation, and a food package with rice, beans, sardines, vegetable oil, and more.

“And the reason why we do that is we have to win,” says Jabateh. “We have to weigh the situation of not [offering social support]. If you don’t…they may die.”

There’s currently more than 140 community health workers, peer supervisors, and nurses, who work within the 5-kilometer area surrounding J.J. Dossen Hospital, the largest referral facility in the district. Across the country, there are more than 5,300 community health workers, supervisors, and nurses. Together, they ease the burden on already-strained healthcare facilities and provide patients with more accessible services. 

Looking Back 

The community health worker program in Liberia launched after the Ebola outbreak in 2016, after PIH began working in the country. With guidance from the World Health Organization and other partners, PIH played a key role in initiating the program. When developing the road map with the Ministry of Health, the ministry initially chose to focus on patients in rural areas far away from health facilities where most illnesses and maternal deaths occurred.

In the early stages, the national community health worker program was successful but fragmented. Some initiatives focused on malaria, while others focused on HIV. Some had no clear direction. In some locations, employees were called “general community health workers” and in others, they were called “community health volunteers” or “community health assistants.”

Overall, there wasn’t a standard curriculum or work structure. PIH recognized this and encouraged the ministry to take steps to create a consistent program. Jabateh supported the ministry to develop a road map that led to the development of a five-year policy and strategic plan. Simultaneously, he and others recognized that the success of the program should reach people across the entire country. 

“The Liberian government has recognized [PIH] as one of the strongest partners when it comes to community health,” he says. 

With new strategies and policies, PIH and partners are confident that standardized processes and supervisory structure will support the national scale-up of the already successful community health worker program—providing lifesaving care to thousands of patients every year.

While gang violence and insecurity continue across many parts of Haiti, behind the doors of select hospitals and clinics, life goes on: Babies are born, wounds are tended, chronic illness is treated.

At facilities run by Zanmi Lasante [ZL], as Partners In Health is known in Haiti, teams have had to adjust to the kidnappings, fuel shortages, and general uncertainty through safety precautions such as shifting hours and schedules, relocating staff and patients, and restricting some facilities to basic triage. To avoid risky travel on dangerous roads, some staff have gone months without seeing family to stay closer to work. At certain sites, conversations between patients and doctors are interrupted by gunfire. Still, care continues.

Despite a situation described by one doctor as “practicing war medicine,” and, essentially, the worst violence the ZL team has seen in four decades, these medical professionals remain at work, tending to the sick, offering care, and accompanying their patients. Indeed, this is what solidarity looks like. This is ekip solid--a strong team.

Since October 2022, Haiti has faced escalating violence, gang wars, scarcity of gasoline and political unrest. On top of that, there’s been a nationwide cholera epidemic with more than 26,000 suspected cases of the water-borne illness reported across the country. 

Last month, residents of Borneau, to the east of the capital of Port-au-Prince, faced a particularly perilous situation* when a cholera outbreak emerged, sickening dozens in days. For several months, they had been at the center of a civil war between armed groups fighting over the territories surrounding their small community. Essentially trapped during the conflict, the people of Borneau experienced great difficulty accessing health care. There is a single route to reach the Hôpital Universitaire de Mirebalais (HUM), which is the only area hospital that can provide them with adequate care and is supported by Zanmi Lasante [ZL], as PIH is known in Haiti.

Several people arrived at the hospital in January with symptoms suggesting cholera, including severe diarrhea and vomiting. Shortly after, five deaths occurred in the community. Initially, HUM received 24 patients seriously ill and suffering from dehydration, all from Borneau. The following day, 27 new severely ill patients, also from Borneau, were hospitalized. 

In less than a week, HUM received and treated more than 100 Borneau patients suffering from cholera.  

“In Borneau there is no medical structure. There is only a community network, which includes a few health workers who do not have the materials to treat the population. They only have their knowledge,” says Dr. Jean Joel Manassé, chief internal medicine physician at HUM and the head of ZL’s clinical cholera response. 

A Coordinated Cholera Response

ZL's strategy since the resurgence of cholera includes providing care and support to the sick and public health educations in communities.  Thus, in partnership with others, such as the Ministry of Public Health and Population  and Haiti’s National Water and Sanitation Agency, ZL has been able to quickly set up equipment and personnel to help reduce the burden of cholera in its various sites. According to Manassé, an important aspect of ZL's response has been to work with community leaders and organizations to raise awareness about hygiene and healthy behavior change. 

In Borneau, ZL’s medical staff and community health workers initiated activities to raise awareness among community members and especially community leaders on key issues such as hygiene and sanitation but also on the need to accompany people with symptoms to the hospital.  

“We quickly understood that we had to bring the care closer to the population,” says Manassé. “So, we operated a treatment point on their route to start treating the sick before they arrive at HUM. This has allowed us to reduce the time taken for treatment and also to alleviate transport costs in order to relieve the victims and their families. Thus, they do not wait for a state of total despair in order to seek care.” 

As of last month, ZL had established 13 cholera treatment sites across 11 cities in order to take care of those affected, including the site near Borneau. Thus, 5,581 patients have been treated and 73,348 vaccines were administered since October 2022.  [tk: month/year when response began]. 

However, ZL still needs to strengthen community response with personnel, products, medicines, and materials, administrators said.  

“Today the problem is in Borneau,” Manassé added. “Tomorrow, it could be a completely different locality. I believe that with the strategies we have put in place, we will relieve those who really need it.”  

*This story has been edited and condensed; its original version can be found in English on the Zanmi Lasante website. 

On March 8, PIH-US mobilized partner organizations for a day of advocacy to educate members of Congress and Congressional staff about the critical role of community health workers (CHWs) and promotores/as de salud in the U.S. 

PIH-US worked closely with the National Association of Community Health Workers (NACHW), Visión y Compromiso, Project CHAMPP, and seven other organizations to organize the first-ever Congressional briefing on the community-based workforce. The groups brought over 40 CHWs, promotoras, and allies to Washington, D.C., to attend a panel and advocate on Capitol Hill. CHWs and promotoras are frontline public health workers with a close understanding of the community they serve, and they are the backbone of PIH’s work across the globe and our vision for equity-centered public health systems in the U.S. 

Congressional briefings are a way to inform several members of Congress and staff at once about a particular issue and feature personal stories for policymakers to better understand the impact of policy and funding decisions. This briefing was an opportunity for staff to hear directly from leading CHWs and promotoras, learn about the diverse workforce, and leave with new ideas for how to support the workforce through sustainable financing and comprehensive capacity-building. For PIH-US, the day was also a chance to bring learnings from our longstanding work with CHWs worldwide and our work alongside local public health and community leaders in the U.S. 

Below, we share photos from the advocacy day. 

"We are practicing war medicine."

That’s an analysis of the current situation in Haiti from Dr. Ralph Blondel Charles, a regional director with Zanmi Lasante (ZL), as Partners In Health is known in Haiti.

According to firsthand accounts and news reports, the gang violence, kidnappings, rape, and general terror that began following the 2021 assassination of Haiti’s President Jovenel Moïse have now increased throughout the country, including the Artibonite region where ZL works.  Following a gang-related spree of police killings in January, the dire situation only got worse: officials speculate that up to 90% of Port-au-Prince is controlled by gangs.

Kidnapping has become a daily, almost indiscriminate hazard. Even people who cannot pay ransom are targeted, to say nothing of professionals.

Long-time ZL staff say the current violence and instability in Haiti is some of the worst they’ve seen in four decades. That means sometimes spending the night on the grounds of facilities to stay safe, and falling asleep hearing gunshots around them. 

Blondel said clinics have had to adjust hours and schedules, relocate staff, and temporarily suspend some services for safety, including using certain facilities to provide basic emergency triage before referring to another facility farther from the violence.

If things don't change within a couple of weeks, he said, it will be difficult to continue to deliver care and treatment.

"We are functioning with our nails and teeth."

Blocked Transport

Blondel oversees ZL clinical care in the area of Bas Artibonite, where road access is a major problem. There are often roadblocks in all directions, both into and out of clinic sites. 

Transporting medical supplies has been the most difficult, he said, with patients suffering long delays for essential medicines and staff awaiting critical items. Sometimes, doctors and medical personnel cannot wait and are forced to purchase supplies locally, but in much smaller amounts. Sometimes goods are snuck in vehicles that do not look like ZL trucks or other forms of transportation.  

Located along the western coastline, Saint Marc is the largest ZL medical complex in the Artibonite region and a hub for the other sites. “So, if they can't even make it there, the remaining sites are completely disadvantaged,” he said. “Transports have been nearly impossible for two months now.” Alternate routes, if passable, take far longer than usual, and many routes are impossible due to safety concerns.

All of this while Haiti is also experiencing a widespread cholera outbreak. Blondel said ZL currently has a “dire need” for gloves and other basic supplies that are unable to be delivered. “Now we have a shortage of bandages and gloves at [the hospital in Saint Marc], while we have more than 100,000 pairs stocked and stuck at [Hôpital Universitaire de Mirebalais] waiting to be delivered.”

The heightened danger is weighing on ZL staff, even as they try to persevere.

Their “mental health is highly affected,” he said. “For most of our staff, many who are women, it's very strenuous on them. When they have to go an entire month or more without being able to return home to visit their families, it is hard and it takes a toll.”

Humanitarian Crisis: Help Save Lives in Haiti

RUSH AID

Fuel Shortages

Fabrus Guillaume, ZL’s Divisional Director of Site Support Operations, described a fraught and precarious situation as fuel shortages have worsened over the past few months and gangs take control of greater swaths of the country.

Guillaume said all staff living in in smaller communities in the Artibonite region have been relocated for safety, again spending months away from their families in Port-au-Prince.

“It has been very difficult to transport goods and to supply all our Artibonite sites with fuel,” he said. “Sometimes we've had to use roads that are not accessible to vehicles to send fuel to the sites. No company with whom we have a contract wants to deliver fuel to these areas.”

Guillaume said he has been forced to do some creative problem-solving to work around the many barriers in place. 

One site recently ran out of fuel, he said. “The motorcycle that we use to carry the fuel in gallons couldn’t climb the high mountains to reach the hospital, so we had to borrow a mule from a peasant to carry the fuel and made it to the hospital.” This is not the first time ZL has relied on a mule for transport. 

Several months ago when the country was in lockdown following the fuel crisis, Guillaume said ZL had to purchase fuel at a border town and, again, couldn’t use vehicles or motorcycles to transport due to slippery, unreliable roads. “We had to make several trips using a mule to reach our destination,” he said.

These days, the team cannot reliably provide transportation to all staff, so most employees must use public transportation to get to work, Guillaume said.  “It is almost impossible for the technical team to reach certain areas. Last week, the electro-mechanical team had to use public transport to repair a generator at [the hospital in Saint Marc], because the fleet department could not send a vehicle. It took two months for the medicine to reach [several sites], because our truck carrying the drugs could not pass. “

But, he added, the staff is doing what they can to maintain the highest standards for patients.

“We face many risks every day, especially myself who manages the security and fleet team,” Guillaume said. “But as I have always said, we are ZL. We are warriors. And we will not let the poor die because they cannot access medicine or other resources.”

Globally, tuberculosis [TB] cases and deaths spiked during the COVID-19 pandemic as health systems and medical workers diverted their attention to cope with unprecedented demand for care and treatment for the rapidly spreading infectious disease. COVID-19 surpassed TB as the deadliest infectious disease, but as the pandemic has subsided, TB has regained first place. Indeed, in 2021, there were 1.6 million deaths from TB, according to last year’s WHO Global TB Report .

To better understand the implications for global health of TB’s rise during the pandemic and beyond, we reached out to PIH’s Senior Health and Policy Advisor Dr. KJ Seung, who, for more than two decades, has been working to curb the spread of infectious diseases around the world. In particular, Seung has been shepherding the fight against TB for Partners In Health since 2001, and currently co-leads the Expand New Drug markets for TB partnership, or endTB, which spans 17 countries. Here, Seung explains what drove TB's resurgence, how PIH is fighting back, and what it all means for global health.

Why did TB cases and deaths rise during the pandemic?

The pandemic disrupted health systems all over the world. During COVID-19 surges, hospitals were overrun by severely ill patients. Many services had to be temporarily shut down in order to shift health workers to emergency rooms and makeshift COVID-19 wards. This had a major impact on TB clinics and diagnostic services, which need to be open and accessible to people who are starting to have symptoms of TB.

People were also scared to come to the hospitals and health centers because of COVID-19, leading to delayed diagnosis. When people are coughing at home—instead of being diagnosed and treated for TB— that means that they are infecting more people around them.

Just to be clear, the number of TB cases "found" actually decreased during the pandemic, but we know that the number of TB cases and deaths from TB increased, even if these are not recorded in official statistics.

Three years after the start of the pandemic, what’s happening with TB caseloads?

As the pandemic subsided and health systems returned to normal, the number of people diagnosed with TB has been rising, though in most countries they have not gotten back to 2019 levels. This is because a surge in TB lasts for many years, even after the disruption that triggered it has resolved. We know now that at the beginning of the pandemic, there were a lot of undiagnosed cases of TB. Many of these people died because they couldn't get diagnosed and treated. And they infected many others in their family and community during that time. Those infected people might feel fine now but get sick years later. So, we will still feel the effect of the pandemic on TB diagnoses for years to come. 

Where, globally, have caseloads surged the most?

Probably all regions have been affected, but regions that experienced more severe COVID-19 surges probably had more disruption to TB services and therefore larger TB spikes. So Latin American and Asian countries probably were affected more than African countries.

What is PIH doing at its sites to help?

PIH is working hard to improve TB diagnosis at all our sites. This is important because TB diagnosis was difficult even before the pandemic! One of the more exciting initiatives is to expand X-ray services. X-ray is a great way to look at the lungs, and it's helpful for many other diseases besides TB. But historically, X-ray has only been available at the hospital level in most of the PIH countries. Hospitals have the X-ray machines, the electricity to power them, and the doctors to read them. But that means that patients who need X-ray must travel long distances to get one.

PIH is pushing X-ray out to health centers in rural Lesotho, Peru, Malawi, and Sierra Leone, which is very complicated because it often requires infrastructure upgrades to improve the power supply or internet access. There are exciting new advances in X-ray technology that involve [artificial intelligence] to automatically read chest X-rays, and that is making it more feasible to push X-ray out to more remote health centers. PIH sites are also using small mobile X-ray machines—for instance, staff carry them in backpacks to remote communities in Peru—to reach out to even more remote communities that can't even come to the health center. 

What would you say is something widely misunderstood about TB?

It’s really hard to get diagnosed with TB in most of the countries where PIH works. In the United States, you can go to any clinic and see a nurse or doctor who has access to X-ray and other ways to diagnose TB. In the countries were PIH works, those laboratory tests usually aren't available to the clinicians in primary health centers.

So, diagnosis of TB takes multiple visits and often referral to a nearby hospital. People get diagnosed late when their TB is very advanced and much more difficult to treat. In the meantime, they transmit TB to many more people around them. So the cycle continues. That's one of the reasons TB is the infectious disease that kills the most people every year.

When Manny Montano received his first COVID-19 vaccination, he took a selfie and sent it around to colleagues and friends. He knew that if he was encouraging people to get vaccinated, his actions had to match his words. Manny applies this same strategy to foster collaboration and motivate coworkers: lead by example.

Initially hired as a public health nurse with the Pima County Health Department, a PIH-US anchor partner, Manny was only weeks into his job when the COVID-19 pandemic hit. He quickly pivoted, serving as Public Safety and Tribal Nations Liaison on the frontlines of Arizona’s COVID-19 response. In this role, Manny supported local, regional, state, and federal public safety agencies and the Pascua Yaqui and Tohono O’odham Tribal Nations with interpreting guidance and developing policies. He also served as a COVID-19 expert to communities across southern Arizona, answering questions on exposure response, testing, quarantine, and vaccination.

Below, we talk with Manny about his journey to public health.

What inspired you to get involved in public health?

I think most people end up where they do by chance. I have a bachelor’s degree in political science; at one point, I thought I might be a lawyer. That did not work out, but I ended up in public safety and emergency management for many years.  I serve as a volunteer EMT within the search and rescue community and when I had a chance to go to nursing school, I jumped at the opportunity. I was fortunate enough to be accepted into the accelerated bachelor's of nursing program at the University of Arizona and became a Registered Nurse in 2006. I spent years working in differing specialties: emergency rooms, wound treatment, IV treatment centers, hospice, and procedural sedation centers.  The varied experience gave me a wide range of nursing skills.  After awhile I decided I wanted to have a larger impact, which is why I took a job with the health department. I was originally hired as a public health nurse to support vaccinations, but within weeks of starting, COVID-19 began to spread across the country and then throughout the state. I was pulled in to support with emergency response during the original activation of the emergency operations center at the start of the pandemic and I have been involved ever since. I have also served as a volunteer EMT with search and rescue teams for over 30 years, so emergency response is not only one of my strengths, but one of my passions. 

Working on the frontlines of the COVID-19 response was challenging in so many ways. How did you balance your personal needs with the demands of those you supported? 

Staying focused on the mission helped to get me through. Of course, there were days that I questioned why I was doing the work, but then I reminded myself that it was to keep first responders and Tribes healthy, and to work to minimize the impact that COVID-19 had on both of these communities. The work our team has done has been grueling and difficult. Many times, we made decisions with people's lives in our hands. 

But when someone doesn't have what they need––be it a ventilator, a mask, a test, or even a hug–– and you are able to get it to them, regardless of how big or small, it makes a difference.  Many of the people that I serve have said, ‘Even when COVID-19 goes away, we know you’ll still be here to support us’.  It feels really good to have that kind of support. And it’s true, I’m not going anywhere and still serve in that role.

How has your work pivoted now that we are moving beyond the acute phase of the COVID-19 pandemic?

I remain the Public Safety and Tribal Nations Liaison for the health department. The department is in the process of hiring additional liaisons to support the communities I serve. I still support COVID-19 efforts, including with testing and vaccinations on Tribal Nations, but lately my focus has been on ensuring asylum seekers are supported with testing, medical care, shelter, and transportation to final destinations. Between July 2021 and December 2022, we worked with the Mexican Consulate to provide over 18,000 COVID-19 vaccines to border communities adjacent to the Tohono O’odham Nation. 

I feel proud that, with my role, the health department has established strong relationships with the Tribal Nations in southern Arizona. Prior to this work, communication between the health department and Tribal Nations had room for improvement. Now, the Tribal Nations aren’t just working with the health department, but also with each other. We support each other. We look out for each other and we help each other whenever we can. 

What values guide your approach to relationship building?

I work with a lot of different people who share a commitment to improving their community. There was a period in our country when communities were united. You don’t see much of that anymore, but it would be nice to get back there––to have a common mission and to treat each other well. You don't have to like everybody; you don’t even have to agree with a person’s political or scientific views. Just hear them out.

I apply this same perspective to my work. Basic respect and courtesy can go a long way in making life better for everyone, and as leaders, we must model that. The only way we're going to affect change is by setting an example to treat everyone with dignity, respect, and listening with an open mind to what they have to say, regardless of if we agree with them or not. 

I also try to come from a place of inclusion and gratitude. I've worked with some pretty amazing people, from Tribal chiefs to first responders. I’ve learned something from them every part of the way. And I tell them this! I try and tell everyone I work with how grateful I am for their involvement and input.  

What keeps you hopeful?

The people I work for and the people that I work with. You know, we're family. We don't always agree, we don't always get along, but at the end of the day you all share the same mission. We are all on the same team. That keeps me going every day.

This interview has been edited for length and clarity.

Maya* vividly remembers the day she received her diagnosis.  As a 21-year-old college student in Astana, Kazakhstan, she’d been running persistent fevers and waking up drenched in sweat. Her mother insisted she get checked out. As they waited for test results, the doctor came in to deliver the news: the sputum culture test came back positive for tuberculosis (TB), and Maya would need to start treatment immediately. Hearing the crushing news, Maya’s thoughts began to spiral: “Why me?” she asked herself. “I didn’t deserve this. What’s going to happen to my future?” Maya’s mother broke into tears. Although Maya remained calm on the outside, she was devastated:  “It felt like the end of life.”

That same day, Maya was transported to the TB unit at the City Center for Phthisiopulmonology in Astana. The City Center hospital works with Partners In Health (PIH) on combating drug-resistant TB in Kazakhstan, which has some of the world’s highest rates of TB and multidrug-resistant TB (MDR-TB), a deadlier and more difficult to treat form of the disease.

After being admitted to the hospital, Maya joined the endTB clinical trial—a part of the Expand New Drug Markets for TB (endTB) project launched in 2015. Surrounded by other patients and local clinicians supported by PIH, Maya began the process of accepting her situation. “I realized that there was nothing I could do about my diagnosis, except to move forward with treatment,” she said.

Tuberculosis is the second deadliest infectious disease in the world, making testing, treatment, and care vital—especially for its most drug-resistant forms. In 2017, through a partnership with Kazakhstan's National TB program, PIH started to run the endTB clinical trial in Almaty and Astana as part of the endTB project. The trial, which is funded by Unitaid, has been jointly coordinated by members of the endTB consortium: PIH, Médecins Sans Frontières (MSF), Interactive Research and Development (IRD) and their research partners, Harvard Medical School, Epicentre, and the Institute of Tropical Medicine of Antwerp (ITM). It aims to find safer and shorter treatment regimens for MDR-TB, using the medications bedaquiline and delamanid—the first new TB drugs developed in almost 50 years.  

Since the start of the endTB project in 2015, hundreds of patients have been enrolled in and benefited from the observational study, where MDR-TB patients from 17 countries have received treatment with the new TB drugs and from the endTB and endTB-Q clinical trials. The overall goal of the endTB project is to reduce morbidity and mortality in MDR-TB through the development of MDR-TB treatment regimens that are shorter, more effective, less toxic, and less expensive. EndTB researchers hope that results from the clinical trials, specifically, can be used to advocate for revised international protocols for MDR-TB treatment and improve access to the new drugs.

The endTB clinical trial tests five regimens to show that bedaquiline and delamanid, in combination with other drugs, can offer patients a shorter course of treatment with fewer side effects. In contrast to the standard regimen of 18-20 months of treatment, which includes pills and daily injections, most trial participants receive nine months of daily oral medication. Since 2017, a total of 754 patients across seven countries—including Kazakhstan, Lesotho and Peru—enrolled in the trial.

Maya was among 184 patients who joined the endTB clinical trial in Kazakhstan. In Astana, the PIH team works with local clinicians and is embedded at the City Center of Phthisiopulmonology. After three months at the hospital, Maya transitioned to outpatient treatment, diligently continuing her medication regimen through video-controlled calls and in-person appointments.

But even though Maya’s physical condition continued to improve, feelings of loneliness and doubt about future prospects continued to weigh on her. She was finishing her college degree as a land surveyor online, while her mother and sister worked all day.

“Emotionally, I felt very discouraged,” she said. “I thought, ‘Nobody can understand what I am going through.’ I felt like I was the only one sick in this entire world.”

She opened up about her struggles to Gulrmira Tanatarova, a PIH social worker and outpatient coordinator, whom she met at the hospital. She felt she could confide in Tanatarova, who checked in on her weekly with phone calls. “I can share what’s on my mind and she will immediately support and console me,” Maya said. “Whatever the problem, I know that she can guide me.”

Tanatarova, who currently works with 16 endTB trial participants, tried to boost Maya’s morale. “I explained to her that she’s young and the disease is temporary,” she said. “I tried not to leave her alone.” She felt that Maya could benefit from more professional psychological help, so she connected her with a psychologist at Sanat Alemi Kazakhstan, a non-profit organization that offers social, legal, and mental health services to TB patients.

The sessions catalyzed Maya’s emotional and psychological healing. Within a few sessions, Tanatarova noticed Maya blossoming into a more vibrant and outgoing person. “I started to understand that I could control my own thoughts about how I approach my diagnosis and that I could overcome my fears,” Maya said. Inspired by the care she received from through Sanat Alemi, she applied for a job there working with TB patients to get fully integrated into all aspects of life. “I started feeling like there is a place for me in this world,” Maya said.

She now accompanies patients to plays and museums and coordinates support groups and various social services. The peer-to-peer approach between workers and patients is particularly effective in building relationships of trust, Maya says. “We know exactly what the patients are going through, because we’ve lived through the same moments,” she said.

Reflecting on her journey toward recovery, Maya can point to a shift in her perspective—when she began to see her diagnosis not as a burden, but as an opportunity for growth. A feisty teenager in the past, Maya says she became more gentle toward her friends and family.

“I began to value and enjoy small things in life, like my family and just being healthy,” she said.

The process of learning about TB and how it invades the body inspired Maya to have a new career vision; she switched her studies to nursing and has the dream of becoming a doctor. 

“I began not only to accept, but to love my diagnosis,” Maya said. “Because it gave me an opportunity to change.”

*Patient’s name has been changed

Viola Wleh thought she had a common cold, but her diagnosis was more serious: multidrug-resistant tuberculosis (MDR-TB). 

The infectious disease can be deadly—especially the drug-resistant type—so patients should receive care immediately. Unfortunately, there was no treatment for MDR-TB available at the county public hospital, and Viola’s cough persisted. In an effort to take matters into her own hands, Viola purchased painkillers and cough medication in the hopes that this would improve her condition. 

The cost of these drugs far outweighed her low monthly income of $4,000-5,000 LRD ($25-30 USD). Typically, she used that money to support her eight children; however, her health was in jeopardy. Her situation was gradually becoming a death sentence, she says. 

“I was going to die,” Viola thought.

A few weeks later, a home visit by a Partners In Health (PIH) Liberia community health worker gave Viola hope. She learned about the importance of early treatment and was referred to PIH-supported J.J. Dossen Hospital, the first and only decentralized tuberculosis ward in the country, where she could receive free care. The 15-bed unit opened its doors to patients in 2017.

Viola left her mother’s house, a 3-bedroom dirt home with a zinc roof and no ceiling, where she was living with her children, and headed to the hospital. She traveled 133 kilometers (82.6 miles) via motorbike—the main means of transportation in rural Liberia—from her home in Sinoe County to Maryland County. 

On June 14, 2022, Viola was admitted to the MDR-TB ward at J.J.Dossen Hospital.

Road to Recovery 

Upon her arrival, the 49-year-old mother was given TB medication—at no cost to her, this time. She also received support beyond medical care, including food, housing, and transportation. Guided by social medicine principles, PIH believes it’s important to treat the whole person, not just their disease.

As the days and weeks passed by, Viola became more hopeful. 

“I’m so happy to be alive again,” she says.

After an extensive and consistent nine-month treatment regimen at J.J. Dossen, Viola regained the weight she lost and began to feel healthier. She became well enough to be transferred from the hospital to a PIH-provided home in New Kru Town, a suburb of Harper, Liberia, where she lived for about six months. On March 6, she was reunited with her family in Sinoe County. 

Viola is one of hundreds of patients with tuberculosis who receive PIH support each year. Many low-income countries are burdened by tuberculosis and Liberia is in the top 30 countries worldwide with the highest TB burden. In 2021, Liberia reported 7,446 tuberculosis cases with a treatment success rate of 77%, according to the World Health Organization. 

For the last three decades, PIH has treated patients like Viola and has shown that recovery is possible with the proper treatment plan, social support, and community-based care.

As a record-breaking storm winds down after battering Malawi and neighboring nations, Partners In Health’s emergency response team is tending to patients with medical assistance and other emergency support.

Cyclone Freddy hit Southern Malawi on March 13, after making landfall in Mozambique.  Now, the storm, reported to be the longest-lasting tropical cyclone ever recorded in the southern hemisphere, has left more than 679 people dead in Malawi, with 2,178 injured, according to a March 16 report from the country's Department of Disaster Management Affairs. More than 537 people are missing, the report states, and 659,278 people have been displaced. 

Death Toll Rising

The casualty toll is expected to rise, officials said, as a result of widespread flooding, mudslides, and collapsed buildings. Compounding the devastation, Malawi is grappling with a cholera outbreak that has already killed more than 1,500 people.  

At Abwenzi Pa Za Umoyo (APZU), as Partners in Health is known in Malawi, teams based in Neno District, where storm damage is currently minimal, have been asked by the Ministry of Health to support the emergency response in harder hit areas to the south. That support will initially be directed at the city of Blantyre, the second largest in the country, which to date has the highest number of casualties, and is within 10 districts that have been officially declared disaster zones, according to reports. 

Extending Support to Hard-Hit Regions

APZU is coordinating with Neno District Local Council and the District Health Office to support ongoing assessments and follow-ups where there is a need for support. 

Through the Emergency Operations Center, a unit created to facilitate humanitarian coordination between government, NGOs, and development partners, APZU’s support is being extended to other affected areas beyond Neno District.

The cyclone has compromised infrastructure throughout Malawi, making some roads unnavigable and causing blackouts. APZU is anticipating how this will affect supply chains and is preparing accordingly to ensure patient care remains constant. 

While all of the 14 health centers in Neno remain open, three of them—Matope, Nsambe and Dambe— are largely inaccessible except to foot traffic due to poor road conditions, officials said.  All other facilities remain accessible.

A Potential Cholera Surge

Beyond the potential for more storm-related deaths and damage, officials are worried that Freddy will exacerbate what has been deemed the country’s deadliest cholera outbreak on record, which began in March 2022. To date, the recent outbreak has killed more than 1,500 people in Malawi. APZU team leaders said they are preparing for another surge of the water-borne bacterial disease. Flooding and damaged infrastructure, specifically water and sanitation systems, can contaminate water sources and spread cholera, they added.

To date, over 50,000 cholera cases have been reported in Malawi. While instances of cholera in Neno District have been low compared to the rest of the country, the APZU team is poised to respond to an increase in disease.

Cholera is a deadly disease that can cause severe diarrhea and vomiting. Children, the elderly and patients struggling with other illnesses are often most affected, and can quickly become dehydrated, go into shock, and die within 24 hours if they are not treated. The disease can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between two hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae.   

This summer, a massive cholera vaccination campaign reached a total of 87,352 individuals, or 59% of the district’s target population, who were given both doses of the vaccine, meaning they are fully vaccinated. More than 86% of the population received at least one dose of the oral cholera vaccine during the campaign.

That effort is one possible reason that cholera cases in Neno District were relatively low compared to other regions in Malawi, APZU leaders said.

In the rural community of Rwinkwavu, in eastern Rwanda, Jean Claude “Gatoto” Rutayisire spends his days managing care for patients living with non-communicable diseases—making sure they have a community health worker assigned to their case and access to free medical care and resources offered by Partners In Health. Gatoto can relate to them in ways few others on staff can: he was once a patient.

Gatoto is one of several health workers with PIH who once were patients themselves, enabling them to relate to patients on a deep level and showing how access to health care can transform lives.

For more than 30 years, PIH has provided world-class medical care, strengthened health systems, and advocated for global health equity in impoverished communities worldwide, guided by the belief that health care is a human right. PIH currently works in 11 countries, where we partner with governments to make free, accessible health care a reality.

Many PIH patients have gone on to become health workers themselves, including doctors, nurses, midwives, therapists, and community health workers. Their stories are a testament to the transformational impact of health care that is free and accessible.

Below are three of their stories:

Jean Claude “Gatoto” Rutayisire

Gatoto, 45, remembers a time when no HIV treatment was available in Rwinkwavu, and people were dying at home, alone. It was a terrifying reality. Gatoto, who lives with HIV, began to wonder how many people in his community were also suffering in silence. In the early 2000s, he started a support group for people living with HIV. The group met regularly to offer a supportive space, accompany patients to the hospital, and bury those who died.

When PIH began its work in Rwanda in 2005 and free HIV treatment became available, Gatoto and the support group were instrumental in helping PIH connect with the community and build its HIV/AIDS program—an experience that since inspired him to become a health worker.

Now, Gatoto is a community health worker supervisor, mentoring a group of over 1,000 community health workers in eastern Rwanda and ensuring that patients have access to the care and support that he once had to survive without.

“My experience as a patient helps me connect on a personal level…I understand them in a way someone who didn’t go through the same experience wouldn’t,” he says. “Every patient deserves to be heard.”

Hawa Koroma

As a facility-based peer counselor with PIH Sierra Leone, Hawa Koroma meets with patients and offers care, support, and resources as they navigate their diagnoses—and, for many, their darkest moments.

It was support that, years ago, she needed herself.

Koroma had been sick and living on the streets of Freetown when Partners In Health workers found her and connected her with HIV and tuberculosis screenings, free of charge. She tested positive for both—a diagnosis that put her on the path to medication, care, and recovery and instilled in her the desire to support others.

She first signed up to volunteer with PIH, then joined as staff. Now, Koroma, 39, is a peer counselor at Wellbody Clinic, drawing on her own experiences to support patients and offering reassurance that healing—and hope—is possible.

“PIH has changed my life and my story,” she says.

Rebeca Velasco

Day to day, Rebeca Velasco felt healthy. But when she went in for a check-up at her local clinic in Plan de Libertad, a rural community in Chiapas, Mexico, she received unexpected news: She had a heart murmur, along with other complications. After a series of tests, doctors concluded she would need open heart surgery, or her heart could stop at any minute.

The news terrified Velasco. But fortunately, she was not alone. PIH, known locally as Compañeros En Salud, was there to support her, from testing to surgery to recovery. All expenses were paid through its Right to Health Care program—essential for Velasco, whose family is low-income.

The experience opened Velasco’s eyes and inspired her to work in health care. She is now a community health worker supervisor, using her experience as a patient to guide her work. There’s another inspiration driving her, too. Years earlier, her grandfather passed away due to complications from diabetes, a condition he had lived with for decades.

“When he died, it was very difficult for me, because I felt we could have done more for him. That maybe with the right care, we could have saved him,” she says. “It inspired me to be able to accompany patients in their illnesses, to teach them to take care of themselves, to remind them about their medications…to be a bridge for them, so they are not alone.”

Farmers and families aren’t the only ones keeping an eye on chickens. Global health experts, too, are closely watching the bird.

That’s because of a variant of avian flu, also known as “bird flu” or H5N1, that has spread farther than ever before in recent years. While there is little threat to humans right now, it’s a trend that has global health experts alarmed: if the virus ever mutated to cause human-to-human transmission, it could become the next pandemic.

Avian flu isn’t the only virus raising concerns.

In early February, an outbreak of Marburg virus in Equatorial Guinea prompted a global emergency response. The hemorrhagic fever, which closely resembles Ebola, had never been detected in the country before.

Avian flu and Marburg virus are vastly different diseases. But they have one thing in common: they’re both appearing in locations and populations where they haven’t typically appeared before. And that has global health experts like Dr. Marta Lado, Partners In Health’s cross-site senior health and policy advisor, worried.

“We need to have a clear surveillance system…because viruses can change, can mutate, and if this mutates it can definitely produce big outbreaks,” she says. “These kinds of viruses normally, in humans, produce a lot of mortality. Like people really die.”

PIH has responded to infectious disease outbreaks for more than 30 years, from tuberculosis to Ebola to COVID-19. While avian flu and Marburg virus aren’t currently affecting the 11 countries where we work, PIH experts—along with the global health community—are closely monitoring them as we continue to advocate for pandemic preparedness and stronger health systems worldwide.

Marburg Virus

Historically, outbreaks of Marburg virus have not been large. But the mortality rate is alarming: up to 88%.

First detected in Germany and Serbia in 1967, Marburg has since largely appeared in a handful of African countries, where outbreaks have historically been harder to contain due to a lack of health infrastructure and resources. The current outbreak in Equatorial Guinea began in early February; nine deaths, with one linked to Marburg, have been reported so far.

Much is still unknown about Marburg, but it closely resembles Ebola, spreading through bodily fluids such as blood, vomit, and saliva and living on surfaces for one hour, which puts health workers at highest risk. Symptoms include fever, diarrhea, and vomiting. Ultimately, like Ebola, the virus leads to multi-organ failure.

No vaccines or antiviral treatments have been approved for use, though clinical trials are being designed. The global community mobilized quickly, says Lado, launching rapid emergency response efforts and dispatching health experts and supplies to Equatorial Guinea.

“I think the global community right now is more alert and responds quicker,” she says. “I think COVID has taught us a lot of lessons.”

The global response has been much faster than the early days of Ebola, she adds.

In those days, she recalls, global health experts in high-income countries were saying nothing could be done for Ebola patients and only prevention was possible—despite the fact that when Americans and Europeans became infected with Ebola, they were evacuated to countries with highly-resourced health facilities where their lives were saved, thanks to stronger health systems that lowered the virus’ mortality rate to less than 30%.

The apathy of Western leaders during Ebola was a status quo that PIH refused to accept. Lado and others argued that saving lives was, indeed, possible with the right early detection measures in place and the highest standards of care, including IV fluids, antibiotics, and oxygen.

“I’ve participated in all the outbreaks of Ebola since 2014 until now and these principles are now respected,” she says. “They are the basis of any response to an outbreak of Ebola and Marburg. So I think PIH and other partners made a very strong advocacy at that time.”

Now, Lado is taking her expertise to the World Health Organization, advising on case management for Marburg and drawing from her years of experience responding to Ebola.

What’s especially concerning to her about Marburg is how it has changed over time: the virus is now affecting countries, including Equatorial Guinea, that have never had an outbreak, originating in bats. While not likely to trigger a pandemic, such outbreaks could be devastating for low-income countries with weak health systems—a threat that makes global solidarity, including vaccine equity, crucial in the fight against Marburg.

“The risk of this expanding to other countries is not like COVID or the flu, but the problem is that it happens in places where normally they have weak health care systems,” she says. “It would be complicated in Europe, but in countries where it happens, it’s even worse.”

Bird Flu

Dead minks in Spain. Dead sea lions in Peru. Dead seals in the United States.

All of these animals were killed by avian flu, a virus that has historically affected birds, but in recent years has spread to other mammals. These outbreaks have global health experts worried that the virus could one day mutate to transmit among humans—a change that could trigger a global pandemic.

“If we start seeing clusters of human cases of these avian flus, then that would mean the virus has mutated enough to pass the barrier between animals and humans and that would be definitely worrisome,” says Lado. “That is exactly what happened with COVID.”

Symptoms of avian flu include a fever and coughing, resembling those of other flus. The virus is airborne, enabling it to become a pandemic if it ever transmitted human-to-human.

Humans have caught variants of the flu through contact with infected birds. An 11-year-old girl in Cambodia died of avian flu after coming into contact with poultry. (Her father in the same household was infected, but had no symptoms and survived.)

The mortality rate from avian flu, in humans, is 53%—COVID-19, by contrast, is 1% and the seasonal flu is 0.1%.

Still, says Lado, the general public should not panic. No sustained human-to-human transmission has been reported, and the risk to the public is low. There have been nine cases reported in humans worldwide since early 2022, the start of the current outbreak. But the scientific community is—and should be—worried.

“If this ends up having some mutation and producing more disease in humans, we want to be detecting it as soon as it happens,” she says.

The global health community has already begun pandemic preparedness measures, setting up surveillance groups to identify cases. The U.S., which has a stockpile of avian flu vaccines, is considering mass vaccination of poultry and has reportedly sent viral samples to drug-makers.

A recent report by PIH’s Garrett Wilkinson, government relations and policy officer, and James Krellenstein of the consulting firm Global Health Strategies found that the U.S. could need at least 650 million doses of the H5N1 vaccine for use in humans. It’s unclear how that number could be produced with current manufacturing capacity.

Worldwide, the picture is even more bleak.

As with Marburg virus, Lado is concerned about low-income countries that don’t have strong health systems and infrastructure in place, including the testing and lab capacity to even detect the virus. More outbreaks mean more opportunities for the virus to mutate.

“If some small aspects change, like some mutations happen, this could become the next pandemic,” she says.

Leoncio Carrión was struggling to breathe.

The 78-year-old was battling pulmonary fibrosis, his breaths becoming shorter by the day, and had arrived at the hospital gasping for air.

Had he come just weeks earlier, he may not have survived. But the Rosa Sanchez de Santillan Hospital in Ascope, a town in Trujillo, Peru, had just acquired a lifesaving resource: medical oxygen.

Several tons of it, to be exact, supplied by an oxygen plant newly repaired by engineers with Socios En Salud, as Partners In Health is known in Peru.

Oxygen is essential for patients with a host of respiratory illnesses, including tuberculosis, lung disease, pneumonia, and severe COVID-19. But in many low- and middle-income countries, medical oxygen is in extremely short supply. Even before the pandemic, 9 in 10 hospitals in low- and middle-income countries lacked access to oxygen therapy. And as many as 800,000 children died due to lack of oxygen.

The oxygen shortage only worsened during the spread of COVID-19—a reality that staff at the Ascope hospital saw every day.

“We did not have a separate area, health personnel, [or] medical supplies to care for COVID-19 patients,” says Ana, a nurse at the hospital. “We witnessed the loss of many people’s lives who did not have the chance to receive oxygen.”

Supplying Oxygen, Saving Lives

That’s an issue BRING O2 is trying to address.

BRING O2 is PIH’s initiative  to accelerate access to safe, reliable, and high-quality medical oxygen in five countries: Malawi, Rwanda, Peru, Lesotho, and Madagascar. The initiative, which is funded by Unitaid and completed in partnership with Build Health International and Pivot Madagascar, has facilitated over a dozen oxygen plant repairs, along with training for staff. Through the initiative, Socios En Salud has repaired 20 oxygen plants across Peru and trained staff on how to operate and maintain the equipment.

“Having medical oxygen available 24 hours a day means having the possibility of saving [many] lives,” says Dr. Luis Cáceres, a doctor at Rosa Sanchez. “We all deserve to receive the best health care and delivery, [provided] with quality and equal opportunity.”

Oxygen plants are crucial to delivering that care. Housed in standard-size shipping containers, oxygen plants can run 24/7 and produce thousands of liters of oxygen per day—enough to support patients in the hospital and to refill oxygen tanks for those at home, as well as for health centers and emergency response teams.

Before Socios En Salud’s repair work began, the oxygen plant at the hospital was rundown, leaving Ascope, a town of more than 6,800 in northern Peru, with virtually no access to medical oxygen.

“It is vital to plan for, implement, and follow up on the maintenance of this equipment,” says Jean Franco Bravo, an engineer with Socios En Salud and coordinator of the BRING O2 project.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the decades since, Socios En Salud has expanded its programs to provide medical care and social support for thousands of patients from Lima to Trujillo to Arequipa. That work is part of Partners In Health’s larger mission to strengthen health systems and achieve universal health care in the countries where it works, in partnership with local and national governments.

As Peru has responded to devastating surges of COVID-19 and other respiratory diseases, including tuberculosis, accelerating access to medical oxygen has been crucial to strengthening health systems and care.

Helping Patients Breathe

In November, Socios En Salud’s team of clinicians and engineers arrived in Ascope and carried out an assessment. The oxygen plant had dangerously high voltages and lacked safety features such as fire alarm systems and generators, among others. Hospital staff also weren’t trained on how to operate or maintain the plant.

Over two months of repair work followed, along with training for hospital staff. The Socios En Salud team also performed a simulation of a COVID-19 surge and how it would impact oxygen supply, identifying gaps in care delivery where every second, every breath, counts.

Now, thanks to that work, the hospital has a fully operational oxygen plant—a victory not only for patients in its oxygen therapy beds, but also for those at home and for the 15 health centers and various medic teams who rely on it to refill oxygen tanks.

The relief couldn’t come soon enough. The plant has provided oxygen therapy for more than 200 patients in Ascope and surrounding areas.

Carrión is one of those patients. His family goes to the hospital every week to refill his oxygen tank. Health workers also visit him at home to help him take his medication—part of the accompaniment that is key to Partners In Health’s work worldwide.

That care has sustained Carrión, in more ways than one.

“I feel calmer and safer,” he says. “Thank God, now the Rosa Sanchez de Santillan Hospital has an oxygen plant that allows me to continue living.”

After the devastating 2010 earthquake struck Haiti, health systems were fragile. Hospitals were destroyed. Clinicians lost their lives. And resources were limited.

Then, more than ever, spaces and systems needed to be revitalized to address the immediate and long-term health needs of Haitians. That’s when Hôpital Universitaire de Mirebalais and graduate medical education became a top priority for Zanmi Lasante, as Partners In Health (PIH) is known locally, and the Haitian Ministry of Health. On March 14, 2013, the hospital opened its doors to patients, providing services to more than 185,000 people in the region.

Since then, the hospital and its staff have achieved a long-list of accomplishments, contributing to a much-needed sustainable health system for local communities.

“Public-private partnerships lead to big change in low- and middle-income countries, such as Haiti,” says Dr. Sterman Toussaint, former director of graduate medical education at Hôpital Universitaire de Mirebalais. “This partnership model after the earthquake, in just a decade, has brought so much in terms of access to quality and diversity in health care and medical education.” 

A research paper, published in Academic Medicine and co-authored by Toussaint, who is currently PIH Liberia's director of clinical services and director of medical education, highlights those achievements, challenges, and lessons learned while bolstering graduate medical education and transforming the health system in Haiti after the 2010 earthquake.

Internationally Recognized, Haitian-Led Institution

The vision for Hôpital Universitaire de Mirebalais was always to meet international standards. And in 2020, it officially did when it became the first such facility in the Caribbean, and the first in a low-income country to receive institutional accreditation from an international oversight group. This prestigious milestone indicates that the hospital meets the highest standards for graduate medical education in the world.

“The accreditation highlights a decade of commitment from the leadership team in Haiti to making sure that the standards were put forward and upheld. Those standards are the north star in a lot of ways for the level of quality and commitment the institution strives for,” says Co-author Dr. Michelle Morse, assistant professor at Harvard Medical School and former deputy chief medical officer at PIH, and now chief medical officer for the New York City Health Department.

Like the students, those leading the residency program are all Haitian.

“The program was built by Haitians, led by Haitians, and graduates Haitians,” says Morse.

This significant achievement and model has helped carry Haiti beyond acute relief and toward a more reliable health system. Since 2012, the medical education program has trained 194 clinicians across 11 specialties and subspecialties, including surgery, pediatrics, and emergency medicine. Most graduates (77%) have stayed to work at clinics and hospitals in rural Haiti. And 75% of training programs are now led by alumni, according to Dr. Ornella Sainterant, Zanmi Lasante's director of medical education.

Additionally, all graduates have completed a required social medicine seminar and been evaluated monthly during their mandatory clinical rotation, as social medicine is considered one of the seven core competencies in resident training at HUM. This is a big deal, says Morse, who notes such a requirement doesn’t yet exist in many countries, including the United States. Social medicine brings a social science lens to training to help clinicians understand the full picture of disease, beyond medical symptoms. This includes factors such as education, economic status, nutrition, and structural forces driving poor health. Social medicine training is especially important for those caring for marginalized populations, the authors note in their paper. 

"Our hope for quality health care for all can only be realized through quality training of the future generaion of empathetic, committed, and highly qualified health care professionals," Sainterant says. "Over the past 10 years, we have proven that investing in high-quality of medical education following the ideology of social justice and equity in health care is successful."

Looking Ahead 

As the graduate medical education program continues to expand, leaders are working to strengthen the program through various strategies. Building on the institution’s accreditation, one of the next steps is to earn accreditation for individual specialties, explains Co-author Dr. Mary Clisbee, director of research and administrator for graduate medical education at Hôpital Universitaire de Mirebalais.

Another goal is to maintain retention of graduates in Haiti, especially in the public sector. Though there is a critical need for doctors, nurses, and midwives in Haiti, there are sometimes not enough available roles in the public sector, which drives clinicians to seek work outside of the country or in the private or nongovernmental sectors. Creating additional positions, based on projected population needs, will help create a sustainable work force and health care access for Haitians.

“We remain inspired and feel assured that the sustained commitment and solidarity demonstrated by all stakeholders will continue to flourish and transform health care in Haiti,” the authors wrote in their published paper.

On a sunny Wednesday morning, women of varying ages wait outside of a room tucked in a corner of Butaro Health Center.

Each woman is here for a breast cancer or cervical cancer screening.

Inside the room—dedicated for screening for women’s cancers—is a nurse named Raissa Umutesi, who has worked at the health center for 15 years.

One by one, Umutesi meets with the women and performs breast exams to check for abnormalities or lumps, along with pap smears to examine the cervix. Luckily, none of the patients today have symptoms of breast or cervical cancer—two of the cancers that most often affect women. After each screening, she records the patient information using a tablet.

Just a few years ago, she would have been writing those notes by hand.

Early Detection

Breast and cervical cancer are among the most common forms of cancer affecting women worldwide, making screening and early detection—including for women who appear healthy—critical.  

"Breast and cervical cancer can be cured when detected early," says Umutesi.

Across Rwanda, women can access free cancer screenings from Partners In Health, known locally as Inshuti Mu Buzima, in partnership with other NGOs and the Ministry of Health. These screenings are offered as part of Inshuti Mu Buzima’s Women’s Cancer Early Detection program, a Partners In Health initiative that connects thousands of women with lifesaving treatment. The program typically involves training community health workers and nurses to provide education, screening services, and referral pathways for patients who need further care.

Since the program expanded across five districts in Rwanda in 2018, there has been a significant increase in the number of women seeking cancer screenings. The influx of patients has, however, challenged record-keeping systems—historically, a logbook with hand-written notes about a patient’s personal information, test history and results, and next course of treatment.

For nurses like Umutesi, managing piles of logbooks was overwhelming. But what concerned her most was the risk of losing data and how that would affect a patient’s treatment.

“We receive around 100 women per month,” says Umutesi. “There was a big risk of losing patients’ information. The logbook can easily be lost and extracting information from multiple logbooks is hard.”

In cases where a patient had to be referred to another hospital, their history would often be lost, or key information would be lost in translation, which would hinder the patient’s treatment.

Now, Umutesi and other clinical staff have access to new technology that aims to fix this issue: mUzima.

A New Tool

mUzima is an app allowing health workers to collect and manage patient data on tablets. The app, which can be used offline, securely stores data and is synchronized with a national server on Open Medical Record System (OpenMRS), allowing different hospitals and health centers to access the same data. This ensures that patients with abnormal initial tests can be linked to timely diagnosis and care.

OpenMRS, co-founded by PIH, is tailored for use in developing countries. Today, organizations and governments in 64 countries use this program.

The mUzima app has another important feature: tracking a patient’s appointment history. For instance, if a nurse at a health center schedules an appointment with a specialist at a referral hospital, they will know if the patient attended their appointment, allowing them to follow up.

“Sometimes a patient faces a problem that prevents them from attending their appointment,” says Umutesi. “We get a notification and call them or contact a community health worker near them to know how we can help.”

Since its launch in 2020, the mUzima app has spread to 16 districts across the country. Partners In Health, in collaboration with the Rwanda Biomedical Center, Clinton Health Access Initiative, and Brigham and Women’s Hospital, has trained over 694 clinicians at 273 health centers and 22 hospitals, enabling the tablet-based tool to be routinely used in the cancer early detection program. And Partners In Health has donated 77 tablets to be used by health care providers at PIH-supported districts.

The impact of mUzima has been remarkable. From July 2020 to December 2022, 167,715 women accessed screening for cervical cancer and 89,449 were screened for breast cancer, according to OpenMRS data.

As Partners In Health continues to accompany Rwanda on the journey to enhance data-driven decision-making to improve health services and outcomes, mUzima is an important tool for managing patient data—and saving lives.

“mUzima application has revolutionized how we keep and manage data about patients,” says Umutesi. “It will benefit the patients a lot.”

Partners In Health continues to work with the Ministry of Health and other partners to expand use of this important application to all health centers in the country.

Ana Cecilia Ortega, a psychologist with Compañeros En Salud, as Partners In Health is known in Mexico, helps patients access care and support through the mental health program. Below, she shares a typical afternoon at a women's circle in Matazano, Chiapas, where community members gather to "socialize, share insights, relax, and cultivate a sense of community and belonging." 

It is 5 a.m. and Bernarda Roblero starts her day grinding corn to make tortillas for her three children's breakfast. The electric corn mills sound in unison—evidence that women wake up first in Matazano.

Matazano is a rural community in the highlands of Chiapas, Mexico, surrounded by mountains and trees. Walking down its dirt streets, you can hear the voices of young men sitting on their motorcycles, listening to loud music; they are outside the Ejidal house, where most of the men meet to make community decisions. On the next street corner, a group of men chat on the sidewalk, drinking beer and aguardiente. A few feet ahead, a bouncing basketball echoes across the court as some young men laugh loudly.

A few teenage girls watch the basketball game from the bleachers, and there are mothers walking around the court with their children, but most of the women are at home, doing housework and caregiving—making it difficult for them to connect with women outside of the family.

But there is a group of women in Matazano who are changing this dynamic and are connecting with other women in the public space.  

In a classroom at the local elementary school, more than 15 women arrive punctually to a group known as “the women's circle.” This time, they have to rearrange the space because the room where they usually meet is busy. However, they seem to adapt quickly; the younger ones help the older ones by pulling the desks into a circle so they can all look at each other. In the center is Bernarda, who works as a community mental health worker with Compañeros En Salud, as Partners in Health is known in Mexico.

Compañeros En Salud has worked in Chiapas, Mexico since 2011, providing health care and social support to thousands of patients in the rural, mountainous Sierra Madre region. Community health workers have been integral to that work, accompanying patients to medical appointments, helping them access medications, and checking in with them at home.

Since 2019, Compañeros en Salud has trained nine community health workers known as cuidadoras (Spanish for “caregivers”) in mental health interventions. The cuidadoras support patients as they navigate common mental health conditions, such as depression and anxiety, and help prevent these conditions in general by offering the women a source of community and support.

The women’s circle, which began last year, is crucial to that work, especially as women in Chiapas are disproportionately affected by mental health conditions due to poverty, gender inequity, and gender-based violence. 

Compañeros En Salud organized its first women’s circle in 2022 to provide a safe space for women to connect with each other. The women’s circles are facilitated by the cuidadoras, and all women interested in the community are invited to participate every two weeks. The circles offer a space for the women to socialize, share insights, relax, and cultivate a sense of community and belonging.

At the women’s circle in Matazano, the activity of the day is embroidery. Everyone receives a set of materials: colored yarn, cotton fabric, and wooden hoops. Bernarda begins the session by inviting the women to give a round of applause and then reminds them of the importance of respecting confidentiality in the group to ensure it is a safe space.

As the women start embroidering they begin to talk about how they have been doing. Bernarda asks questions to prompt conversation, such as “What is the most beautiful gift you have been given?” Some of the women remember gifts from loved ones who passed away. Others remember other types of loss, such as when a family member had to leave to work in the United States. Some participants share memories of gifts that remind them of when they felt loved by their spouses or children. During the sharing, some women smile wistfully; others let the tears flow.

After the women share their personal stories, Bernarda serves small cups of rice pudding. As everyone eats and mingles, she asks, "What things that we talked about today made you reflect or connect with your own story?" This question encourages the women to learn from each other. Many are surprised by the things they learn in the circle.

"We see each other on the street, but we don't know what's going on in each other's lives," says one participant.

Another one adds, “I now know that I am not the only one going through this.”

Most importantly, the circle offers a space in the community where women’s voices matter. Or, as a participant put it: "For me, the women's circle means friendship, unity, and trust."

When health worker Alicia Cortez set out to evaluate community needs in New Bedford, Mass., she was resolute that her own community should be heard. 

So, Cortez, working with a team of 11 other community health workers, known as the promotoras victoriosas, showed up at the fisheries and markets, shopping areas and public spaces where she knew people of Guatemalan descent gathered. This new effort, backed with training by the New Bedford Health Department and the U.S. division of Partners In Health, worked.

“We know where people walk around and at what times, so we would just stop them and ask them,” said Cortez, who was born in Guatemala and has lived in the U.S. since she was 8 years old. “We’d tell them we want to know how they feel about the health department, and ask if they know all the services available. … We said if they’d answer a few questions, it would open up doors to their health.” 

Barriers to Care

And open up they did. People cited an array of barriers to getting quality health care: inadequate transportation; no time off from work to see a doctor; a dearth of dental care; a lack of understanding from health officials when they had trouble understanding English-only materials; no insurance; fear of deportation; and cultural stigma surrounding illness. 

In the end, the PIH-trained promotoras, working with SouthCoast Health and the local health department, gathered over 800 of the more than 1,200 surveys collected from people detailing their health needs, challenges, and concerns about the system. Two years earlier, a different health assessment team, that didn’t lean on the expertise of the promotoras, collected only 430 surveys.  

Two-thirds of the recent survey respondents were Hispanic, women, and living with a median household income below $25,000. By comparison, in 2019, the vast majority of respondents were white, female, and highly educated. 

Marlene Cerritos-Rivas, PIH’s health equity program manager in New Bedford, said it was meaningful that the latest survey included communities that were previously overlooked. “To have their voices included, that was very important, “ she said.

“For the health department, but also for the community to know that the government wanted their input, wanted to know about the barriers. It was a very empowering experience.” 

The new data, which will be analyzed, verified, and ultimately used to inform future regional public health planning strategies, offers a deeper understanding of the demographic evolution of New Bedford.  

A City of Immigrants

Located in southeastern Massachusetts, New Bedford is home to about 105,000 residents, including approximately 5,000-10,000 undocumented immigrants. Like many other cities with comparable demographics, New Bedford has been hit hard by health crises, including the COVID-19 pandemic, the opioid epidemic, and homelessness, among others. As a result, according to the health department, New Bedford’s Hispanic population and other marginalized groups suffer from disproportionately poor health outcomes. 

To begin to address this, the health department hired three full-time outreach workers who provide services to community members in English, Spanish, Portuguese, and Cape Verdean Creole. And, in collaboration with PIH-US, the department provided training and employment to the promotoras in order to reach out to communities that had never before been asked for their opinion. This practice of hiring local community health workers to strengthen and broaden care is modeled off of PIH's work globally, where CHWs are a central component of every health care team.

The PIH-New Bedford partnership started in late 2020, as PIH began responding to requests for technical support from regions across the United States slammed by COVID-19. In early 2021, PIH-US recruited, hired, and trained a five-person team embedded in the New Bedford Health Department. The team’s full-time epidemiologist, contact tracer, community liaison, health equity specialist, and senior team leader began supporting all aspects of the city’s COVID response, but are now pivoting to support the development of a stronger, more equitable regional health system. 

“Our emergency response work in New Bedford has evolved into a longer term commitment to improving health equity,” said Katie Bollbach, executive director of PIH-US. “As we now work to address the underlying systemic issues that drove deeply inequitable COVID-19 outcomes, we’re deepening our partnerships in the city to ensure local expertise and experience are driving identification of new solutions to these long-standing challenges.”

A significant element of this strengthening involves gathering more input from people who are most affected by various health care policies and structures.  

Gaining Trust

So, Cerritos-Rivas said, in the summer of 2022, the promotora training began. “They practiced with friends and family and then began reaching out to the broader community, going to public areas, festivals, church, and then to the streets, to places with heavy foot traffic by the Hispanic community.” The promotoras, she said, reflect that community: they are predominantly from Central America, notably Guatemala and El Salvador. Four of the health workers speak K’iche, a language indigenous to Guatemala. “We’d had a hard time reaching out to the K’iche community,” she said. “There was a lack of trust.” 

Luisa Carina Raymundo, another promotora from Guatemala, said community members were motivated to speak to people familiar with their struggles and lived experience. “They do this because they believe that together we will be able to make changes and because they are tired of living in an oppressive system.” 

Raymundo, who was raised by a single mother, and has lived in New Bedford for the past four years, said there is significant fear in these immigrant communities. “One of the things that worries me is knowing that there are families that experience domestic violence and knowing that there are many children who are growing up in an unsafe family environment,” she said. “Many people are scared because they do not feel safe on the streets, and others cannot feel safe at home because of alcohol abuse or other problems.” 

Overall, the promotoras said, their goal is essentially to help people use the health care system to improve their daily lives. 

All of the information from the surveys will inform a comprehensive health disparities data analysis, documenting the impact of race and ethnicity on health outcomes in New Bedford.  

Based on this information, officials said, new recommendations on health policy and programming will emerge, “providing a blueprint to reduce, and ultimately eliminate, racially- and ethnically-driven health inequities.” 

The vision, added Alicia Cortez, is “to send a powerful message…this job, the work is very powerful and we can save lives.” 

As Partners In Health marks one year since the passing of Dr. Paul Farmer, we remember our beloved co-founder’s life and legacy—a force that planted the seeds of our community decades ago and continues to grow and guide us today.

From treating our first patients in Haiti in the 1980s, to urging global leaders to act in solidarity with the poor, to accompanying doctors on rounds, Paul put his values into practice every day. Those values—including a preferential option for the poor—inspired generations of doctors, nurses, patients, students, and more, creating a global community united by the belief that health care is a human right.

Paul held many titles and received numerous accolades throughout his life. But he accompanied patients and presidents alike, remembering faces, names, and details few others would. No one was a stranger to Paul—or, at least, no one was a stranger for long.

Paul may have left us in 2022, but his legacy lives on in every person, policy, and program he touched. His teachings—captured in books, speeches, and interviews—offer a reminder of our past and a roadmap for our future. Paul left an indelible mark not only on global health, but on our hearts and the hearts of everyone he healed and held, comforted and challenged, taught and tended to.

Below are excerpts from reflections written last year by those who knew Paul:

A Practice of Accompaniment 

Sheila Davis, Partners In Health CEO: 

“What inspired me most about Paul was his practice of accompaniment. He had a unique ability to meet people exactly where they were – no matter where that was – and sit beside them, with them, accompanying them. From community health workers, who are our true heroes and teachers as Paul would always say, to patients to colleagues – Paul would show up, listen, and make the person in front of him feel special.”

Bill Clinton, 42nd president of the United States, wrote a tribute to Paul. The following is an excerpt from TIME:

“But his voice still rings in our ears. All our lives are passing, but the purpose of living endures: to lift others and empower them to live and work just as he did—with love, gratitude, and joy.”

Claudine Humure, among Paul’s first patients in Rwanda in the early 2000s, who later worked at PIH’s University of Global Health Equity in Butaro:

“I was grateful to have been blessed to know him. He was truly a blessing. He first became my doctor, then he became my friend, then he became my colleague, and then he became a father. Our relationship was profound, and it is truly the definition of what he always taught his staff: accompaniment. The power of walking with those you serve and those you serve with. We walked the walk together.”

A Visionary with Moral Clarity

Matthew Bonds, associate professor of global health and social medicine at Harvard Medical School and cofounder of PIVOT:

"Paul’s genius was that he not only saw how each part of the system was connected—from frontline care providers to global funders to drivers, scientists, cleaners, and everyone in between—he knew how to fortify and grow those connections around a common moral clarity on behalf of patients everywhere."

Joseph Rhatigan, Jr., associate professor of medicine and global health and social medicine, and associate chief of the Division of Global Health Equity at Harvard Medical School:

“Hope, for Paul, was a moral decision.  He often told me that it was irresponsible for us, the privileged, to give into the temptations of cynicism and despair because there was so much we needed to do to address the situation of those suffering from poverty and disease.”

Regan Marsh, senior strategic advisor at Brigham and Women's Hospital and former director of clinical systems at PIH:

“He was ambitious about what must—and can—be done. He refused to be constrained by people’s lack of imagination. In making everyone a bit nervous with his vision, we achieved things that we were told weren’t possible. He told all of us to do what was needed, and that we would sort out the details later.”

Gregg Gonsalves, co-director of the Global Health Justice Partnership and an associate professor of epidemiology at the Yale School of Public Health, wrote a tribute to Paul published in The Nation. The following is an excerpt:

 “Gone now, I hope, is the idea of Paul as the good doctor, who is—was—there to make us feel like he was one of the better angels of our nature, a humanitarian who tended to the poor and sick, without making any claims on us.”

Jacklin Saint Fleur, chief of operations at PIH’s Hôpital Universitaire de Mirebalais in Haiti:

“Paul was a great father taking care of his family, a passionate physician who treated his patients with compassion, respect, and dignity, a great professor who helped his students mastermind the most complex concepts, and a loving friend with a great soul. A global health visionary  who dedicated his life to improving human health and advocating for health equity and social justice worldwide.”

Alicia Ely Yamin, PIH's senior advisor on human rights, wrote a reflection about Paul, published in English and Spanish on OpenGlobalRights. The following is an excerpt: 

“Paul had an extraordinary impact on everyone he touched in every corner of the globe, whether through his healing hands, his mentorship and friendship, or his inspirational writing. He literally connected the world through his work and his life, and continually showed us our common destiny and shared humanity. At a time when the world seems so broken, it could not be more urgent to carry forward Paul’s vision for human rights.”
 

Mark Brender, national director of PIH Canada, wrote a reflection about Paul Farmer, published on PIH Canada's website: 

“The tributes from philanthropists and colleagues and those who considered him a mentor all speak to a once-in-a-generation life cut far too short, a momentous global loss. But I don’t worry for PIH’s future without him. . .The movement will continue to grow and blossom, building on successes to show the world what is possible. That was always Paul’s plan.”

An Advocate for Patient-Centered Care

Tracy Kidder, bestselling author of Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, wrote a tribute to Paul in The New York Times. The following is an excerpt:

"Paul’s basic belief was that all human beings deserve equal respect and care, especially when they are sick. His dream, he once told me, was to start a movement that would refuse to accept, and would strive to repair, the grotesque health inequities among and within the countries of the world. When I first met him — in Haiti, in 1994 — he had already created a growing health care system in a desperately impoverished area. I thought he’d done a lot already. Now, looking back, I realize that he was just getting started."

Dan Palazuelos, PIH’s director of community health systems and assistant professor at Harvard Medical School:

"I lost my captain, my mentor, my trickster uncle, my great friend. I didn't think there would be much utility in grieving publicly, but I'm looking up from my grief to remember that what Paul wanted was incredible in its simplicity. His message was radical but straightforward: national borders, price points, patents, policy — everything is mutable if we focus first on how we treat one another.”

Cate Oswald, PIH’s chief policy and partnership officer:

“When I was going through the act of completing this work over the past many years I had not realized—until stepping into my current role dedicated to advancing our policy and advocacy efforts—that each and every action I was taking—that Paul had demonstrated to me first hand—was in and of itself advocacy. Patient advocacy. Leading with the patient at the center.”

Aaron Berkowitz, neurology advisor for PIH:

“His writings, the organization he built, and the community of practice he created will continue to inspire generations to serve those less fortunate than them, fight for health equity, and do what is good and just. But for those of us who had the chance to meet him even briefly, he will also inspire us to do as he did: lock eyes with everyone we meet, slow down the handshake, truly see the person in front of us, listen to them, and thank them for the work they do.”

Joia Mukherjee, PIH's chief medical officer:

“Everyone who knew Paul, knew how he lived in this space between sorrow and joy. For when we truly feel the pain of others—in our chest, in our bones—it is because we love; because our connection is rooted in the undeniable humanity of one another.”

Andy Wilson, PIH's chief development officer, wrote a reflection about Paul, published in Interfaith America. The following is an excerpt:

“Paul’s last text to me from Rwanda was a reminder of why we had to save this patient: “This is such a big part of our mission. You know, an antidote to despair.”

Alex Coutinho, former executive director of Inshuti Mu Buzima, as PIH is known in Rwanda:

“Paul died like he lived his life, at the frontline serving patients and always teaching and mentoring. The greatest lesson you could learn was to observe Paul’s interaction with the sick and poor and hungry. The love, compassion, care and reassurance he gave his patients was like a spiritual experience reminding us of how our patients and their many needs should always come first.”

A Revolutionary Caregiver

Jim Ansara, co-founder and executive director of Build Health International, wrote a tribute to Paul for WBUR's Cognoscenti. The following is an excerpt:

"Dr. Paul Farmer’s unreasonable vision about what was possible, and what could be accomplished has led to great advancements in the global health community, time and time again. From proving against conventional wisdom, and the scientific community, that multidrug-resistant tuberculosis could be treated successfully through a low-cost community health model, a program in Haiti to treat HIV/AIDS patients, building a hospital, cancer center, and then medical school in rural Rwanda, to leading PIH into an emergency Ebola response and then permanent programs in West Africa."

Gunisha Kaur, assistant professor of medicine at Weill Cornell Medicine and medical director at the Weill Cornell Center for Human Rights, wrote a tribute to Paul in TIME. The following is an excerpt:

"With his radical approach and generosity of spirit, he trailblazed a pathway for global health to be a social justice movement. Through his own work, and through the continued work of his students, he improved the life and wellbeing of countless patients across the world.”

Ashish K. Jha, physician and dean of Brown University's School of Public Health, wrote a tribute to Paul in The Atlantic. The following is an excerpt:

"He was unconstrained by small thinking. He rejected the artificial limitations we put on caring for the world’s poor—limits we would never put on ourselves or our families. He refused to accept the soft bigotry of low expectations. When HIV was devastating Haiti, the standard response in public health was to write off people, saying HIV therapies were too expensive and difficult to deliver to the world’s poor. So Paul set out to prove everyone wrong. He set up clinics and hospitals with a simple goal: deliver the same quality care that he provided when he was caring for patients in Harvard’s teaching hospitals. It wasn’t an easy task, but it worked. Tens of thousands of people received the latest HIV care. So many lives were saved."

Arachu Castro, a public health professor at Tulane University and former PIH volunteer and Harvard Medical School faculty:

"Paul was inspired by many but followed no one’s path. He treasured his family, friends, students, and, above all, his patients. Despite his premature death, Paul did manage to change the world, and his vast legacy will live on through generations."

John Green, bestselling author and longtime supporter of PIH:

"I don’t really believe in heroizing individuals, but Paul was, for me and for many, a hero. As a medical anthropologist and physician, he was deeply committed to the belief that all human lives had dignity and that every person deserves access to high-quality health care. He lived this belief for his entire career."

Michael Murphy, founding principal and executive director of MASS Design Group, wrote about Paul. The following is an excerpt from MASS Design’s newsletter:

“But the other lesson of why we were there—to ‘beautify’ the grounds of a rural clinic—is equally important. We have to remember that the person we lost on February 21st was not only a father figure and leader, a humanitarian, and a voice for change. Paul Farmer was also one of the greatest designers of our built world, one of the greatest systems thinkers to have ever lived. He was the kind of architect I aspire to be.”

Michelle Williams, dean of the faculty at Harvard T.H. Chan School of Public Health, wrote about Paul in The Boston Globe. The following is an excerpt:

"Paul Farmer never accepted the status quo. … Inequality is status quo. Racism is status quo. The notion that the poor will live in misery and die from diseases that are eminently treatable — that’s status quo too. And Paul would have none of it."

Hugo Flores, former executive director of Compañeros En Salud, as PIH is known in Mexico:

“Those of us who had the opportunity to know him saw that he never rested. He was always traveling, carrying the message, inspiring, seeking funds, envisioning what was impossible for many to achieve, a 3rd level hospital in the middle of Haiti, a world class university in Rwanda. I never saw him refuse his attention to anyone who wanted to talk to him, even if it was 2 o'clock in the morning. He always saw patients wherever he went.”

An Inspiring Teacher

Bill Gates, co-founder of Microsoft and co-chair of the Bill & Melinda Gates Foundation, wrote a tribute to Paul in The Atlantic. The following is an excerpt:

"There will never be another Paul Farmer. I will miss him deeply. I am comforted by the knowledge that his influence will be felt for decades to come. His work will continue through Partners in Health, and it will be carried on by the many people he trained and inspired."

Steve Reifenberg, a teaching professor at the Keough School of Global Affairs at the University of Notre Dame and a member of PIH’s Board of Trustees:

"His work in global health was transformative. He gave many of us working in the field a new vocabulary that overcomes ‘failures of imagination’ by seeing what is possible if we work together in partnership. His life and work embraced proximity to the poor and pragmatic solidarity. ‘It isn’t just signing a petition or voicing one’s displeasure or anxiety,’ he’d say, ‘but actually doing something with solidarity.’”

Katie Kralievits, Paul’s chief of staff:

“Paul taught us many things, but understanding what it takes to be a caring and loyal friend will be one of the most important lessons for me. In these last few weeks, while Paul was in Butaro, doing what he loved so deeply, he didn’t give me much to worry about. I could tell it in his voice during our daily calls. “Free for a quick hi?” we’d ask each other before dialing. (Paul wasn’t a fan of “cold calls.”) He was so at peace in Butaro, and so in his element. He was surrounded by cohorts of loving students, patients who needed his attention and care, and dozens if not hundreds of redwoods and rose bushes. The time he spent there was a gift he wholeheartedly deserved.”

Sriram Shamasunder, physician, associate professor of medicine at the University of California San Francisco, and co-founder and faculty director of the HEAL Initiative—wrote a tribute to Paul. The following is an excerpt from NPR's Goats And Soda:

"When I finished my residency, like so many physicians in my generation, I attempted to follow his example. I wanted to work in Haiti, where he started his organization Partners in Health in 1987. On a brief phone call, he instead enrolled me to work over the next year in rural Burundi, a place with even fewer physicians. Like so many before me, so early in my career, he made me feel as if I were making the only career decision that made sense—choosing what he called 'pragmatic solidarity' alongside the poor."

Vikram Patel, the Pershing Square Professor of Global Health in the Blavatnik Institute's Department of Global Health and Social Medicine at Harvard Medical School, wrote a tribute to Paul. The following is an excerpt from the Indian Journal of Medical Ethics:

“It was watching and learning, how you had transformed global health from a highly academic subject, typically taught in wealthy countries about the less fortunate peoples of the world, by scholars whose lives are disconnected from those peoples, into a subject suffused with rights, equity, dignity, inclusion, compassion, and most of all, outrage… .”

Junaid Nabi, a physician and senior researcher in health care strategy, wrote a tribute to Paul in STAT. The following is an excerpt:

"Farmer taught an entire generation of physicians to reimagine the practice of medicine and work toward treating the systems that surround patients, and not just the diseases they had."

Cameron Nutt, infectious disease fellow at Massachusetts General Hospital and Brigham and Women's Hospital and Paul's former research assistant, wrote a tribute to his mentor. The following is an excerpt:

“Those who stuck around, though, often learned remarkable things. More than simple facts about verdure, his lessons included metaphors for our own lives and shared work. Paul’s beloved giant sequoia, for instance, slowly grows its seeds in clusters of resin-covered cones high above the forest floor and holds fast to them for years. Through a property called serotiny, the tree releases these seeds, suddenly and all at once, only after exposure to fire.”

In November, the American Public Health Association (APHA)––the largest member-based public health organization in the United States––passed the policy statement A Strategy to Address Racism and Violence as Public Health Priorities: Community Health Workers Advancing Equity & Violence Prevention, acknowledging community health workers as a critical tool for addressing violence prevention and improving health equity. This comes on the heels of the APHA’s 2020 declaration that racism is a public health crisis.  

Public health advocates have long understood the link between structural violence in the United States and broader public health drivers like access to food, shelter, or employment. Beyond naming racism and violence as detrimental to public health, the new policy statement, written and prepared by the Community Health Worker section of APHA and endorsed by many organizations––including PIH-US––recognizes community health workers as a part of the solution to addressing these problems.  

Below, we summarize this statement and explain why it is important and what happens next.   

What does this new policy propose? 

The new APHA policy statement lays out a pathway to address violence and racism through a public health lens by partnering with community health workers. Community health workers, also known as promotoras de salud, as well as other members of the community-based workforce are frontline public health workers who are trusted members of and/or have a close understanding of the community that they serve. The authors of the policy statement recognize these community experts as integral to helping break through barriers left by systemic racism and structural violence in the United States.   

What gaps do the authors of the policy statement hope to address? 

The APHA’s new policy identifies gaps in past public health policies that have failed to address structural violence and have contributed to inequities in our public health and health care systems, including:  

• Partnerships that have prioritized (through funding, coordinated messaging, and staffing) large health care institutions over community-based organizations and trusted messengers in the community.  

• An over-emphasis on medical care, rather than addressing social drivers of health rooted in structural racism and structural violence.  

• Inequities in access to health care and financial resources.  

• Inequitable research practices that perpetuate racial biases through the research conducted, authors of that research, and, ultimately, programs funded and implemented. 

The new policy statement recognizes that although community health workers are equipped to respond to the social determinants of health, bring cost-savings to the health care system, and intervene both on structural racism and violence, as a workforce they face many barriers to success, including:  

• Lack of recognition or support from public health, health care, and other sectors addressing social determinants of health.  

• Lack of consistent, sustainable funding for community health worker programs and activities. 

• Chronically low salaries and inequitable pay.  

• Over-medicalized community health worker training, rather than training that emphasizes community knowledge. 

Why did PIH-US endorse this policy? 

The new policy statement from APHA acknowledges structural violence and identifies community health workers as a core part of the work to combat structural violence and deliver on health equity. Since 2020, PIH-US has applied lessons from our global work to lift up this critical workforce throughout the COVID-19 response and beyond.  

The statement directly supports the efforts PIH-US has been engaged in to expand the community health workforce across the country. Now, we plan to leverage the recommendations within the policy and to continue to advocate for sustainable investments in community health workers.  

In addition, some of PIH-US’s experts contributed to the author’s work. 

Why is the APHA’s passage of this policy significant?  

Though statements like this don’t change governmental policy, they do offer recommendations for policymakers, public health departments, and other actors. As one of the most influential organizations in public health in the United States, the APHA’s stance matters: when the organization takes a decisive policy position, it broadens the opportunity for research, advocacy, and more on the topic. This statement, voted on through the APHA’s democratic processes, added a new perspective to the conversation about community health workers, focusing on this workforce as a way to address structural racism, community violence, and health inequity in the United States.  

Now that this policy has been adopted by the APHA, what impact can it have on health?  

Now that this statement has been recognized by the APHA, it is on the shoulders of public health practitioners at the community, state, and federal level to put this plan into action.  

The APHA policy recommends that Congress pass legislation to support community-based organizations to hire community health workers and strengthen efforts to address racism and violence in communities across the country. APHA also recommends that state legislators follow suit. It calls for community health worker associations to implement trainings on violence prevention and structural racism, for philanthropic entities to help fund those trainings, and for higher education institutions to integrate into curriculums the importance of community health workers in addressing structural racism and violence prevention. 

PIH-US urges recipients of CDC funding for public health infrastructure to consider the importance of investing in community health workers, via partnership with community-based organizations, for long-term health equity.  

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Authors, contributors, and endorsers of A Strategy to Address Racism and Violence as Public Health Priorities: Community Health Workers Advancing Equity & Violence Prevention:

• Authors: Rumana Shams Rabbani, CHW-VPP, MHA, PhD Student, RWJF HPRS; Abdul Hafeedh bin Abdullah, CHW-VPP; Dannie Ritchie, MPH, MD; Cynthia Williams, PhD; Keila Marlin, MPH; Noelle Wiggins (Advisor), EdD, MSPH
• Contributors:  Angie Kuzma, MPH, CHW; Evan Richardson, RN, MSN, CNM; Dina Ferrenti, RN, PhD; Charlie Bruner, PhD; Honey Estrada, MPH, CHW; Marcia Morales Villavicencio, CHW, MPH;  Jamie Santana, CHW; Maria Lemus, Promotora; Ashley Rodriguez, CHW; Justin Mendoza, MPH; Devin Worster, MD, MPH; Ali Bloomgarden, MA; Brenda Galloway, CHW-VPP; Vance Williams, CHW-VPP, Keshana Owens-Cody, HRM; Dwight Myrick, CHW-VPP; Juliette Jenkins, PhD, MSN; Teresa Campos-Dominguez, CHW; Jennifer Norville, BS; Mae-Gilene Begay, MSW, CHR; Maria Velasco, MA, CHW
• Governing Councilors: Mae-Gilene Begay, CHR; Maria Hererra, Promotora
• Special Acknowledgements: Betsy Rodriguez, RN, BSN, MSN, DCES and Refilwe Moeti, MA; Center for Disease Control & Prevention
• APHA Endorsements: Maternal Child Health Section, Public Health Social Work Section, Oral Health Section, Family Violence Prevention Caucus, Women’s Caucus, Men’s Caucus, Law Section
• External Endorsements (prior to policy being passed): Community Healing through Activism + Strategic Mobilization, NC Area Health Education Center, NC CHW Association, Partners In Health, Common Indicators Project, The University of Wisconsin Population Health Institute

For years, the Pleebo Health Center laboratory consisted of a single room. In that room, limited medical testing occurred for more than 50,000 Liberians. Although the laboratory was functional, it faced many obstacles. 

For example, specimens couldn’t be processed there. Instead, they were taken to Partners In Health (PIH)-supported J.J. Dossen Memorial Hospital in Harper—about 16 miles away. There were often delays, which meant the samples had to be recollected. And, clinicians were unable to test patients on-site for tuberculosis or HIV (both common in the region). The necessary machines weren’t available. The lack of space and limited diagnostic equipment were major challenges for both clinicians and patients.

In 2022, significant improvements were made: more space and stuff were added—two of the five S’s essential to strengthen health systems. Now four rooms, the laboratory is also equipped to test blood, urine, and hemoglobin A; and diagnose tuberculosis and HIV—which wasn’t possible before the expansion. 

Often overlooked, labs are critical for diagnosing a patient’s condition, explains Isaac David, Jr., officer in charge at Pleebo Health Center. 

“The lab is now closer to those who cannot afford to travel to far places to do their tests. The tests are also free…and treatment is provided 24/7,” says David, Jr.

Laboratories run tests related to disease prevention, diagnosis, and treatment. With the expanded space, the center is able to hire enough laboratory personnel to quickly assess and identify potential health problems. Notably, the lab can now test viral loads—the amount of virus detected in patients with HIV. The optimized space is also newly equipped with machines such as the GeneXpert machine, which is used to diagnose and monitor the treatment of tuberculosis; and a complete blood count machine to measure red blood cells, white blood cells, and platelets. 

With these improvements, staff are encouraging community members to use the free health services. 

“Our goal is to give preferential diagnostics to marginalized [people]. Pleebo Health Center has a high patient load, which means they are not getting the ideal patient care. For us, we are improving diagnostics. It means the patient gets the right treatment and care because of the right diagnostics,” says Arnold Ayebare, PIH Liberia’s laboratory manager, who oversaw the expansion project.

Dr. Shada Rouhani thinks about emergencies often: How to prevent them, manage them, and better equip doctors and hospitals to handle them. 

As Partners In Health’s director of emergency care, Rouhani has, for many years, been deeply involved in developing innovative ways to deliver high-quality emergency care within resource-limited settings. 

From 2013-2018, she was the co-director of the department of emergency medicine at Hôpital Universitaire de Mirebalais [HUM] in Haiti, a national teaching hospital run by Zanmi Lasante, PIH’s sister organization. There, Rouhani helped establish the first emergency medicine residency program in Haiti, at HUM, and continues to research the burden, epidemiology, and costs of emergency care globally. Since 2018, she’s helped PIH sites around the world strengthen their emergency care programs. 

Rouhani recently returned to Boston from Sierra Leone, where PIH is rolling out an emergency medicine certificate for local health workers. We spoke to her about the importance of emergency medicine and how it’s evolving around the world. 

Why Does Emergency Care Matter? 

Emergencies happen everywhere and they happen to all of us. But where you are in the world when an emergency happens disproportionately determines your outcome.  No matter if we are talking about trauma, or acute exacerbations of a non-communicable disease like asthma or heart problems–when it comes to emergencies, the outcomes for patients in middle- and low-income countries are worse.  

How Much Worse? 

Much worse.

The overall burden of emergency disease is estimated to be four-to-five times higher in low-income countries compared to high-income countries. But the availability and quality of emergency care is very limited. One study found that the death rate in emergency departments in low-income countries was 45 times higher than in the U.S.

Over half of the entire, worldwide burden of disease could be treated with emergency care. That translates into over 28 million deaths annually from emergency medical disease. 

There is a tremendous unmet need.   

What tends to contribute to this higher mortality in countries with fewer resources? 

Simply put, people don’t have access to high-quality emergency care, or any emergency care at all. Despite the higher burden of emergency disease, emergency medicine is much less developed in lower income countries.  

It starts with the spaces: many hospitals don’t have emergency rooms at all, or people may have to travel great distances to reach care.  

Even where there is an emergency room, it often lacks the key components needed to deliver care. There are typically fewer staff, who are usually not trained to deliver emergency care. Facilities lack supplies—and we’re not talking about fancy machines here. Facilities don’t have the basics, like IV fluids, antibiotics, and oxygen. In many ERs, when these supplies are not available and you come in for a crisis, the doctor has to hand you a prescription to go buy IV fluids, antibiotics or basic supplies like gloves so the doctor can examine you. Even if a family member has money to go and buy those supplies for you, by the time they come back it may be too late. The supplies need to be in the emergency department so they can be used immediately when needed. And they can’t be dependent on someone’s ability to pay.  

Finally, emergency care systems are often less developed. Simple procedures that help you quickly assess and diagnose a patient can make the difference between starting a treatment right away or not. And though it sounds cliché, in emergencies, minutes matter. So those systems, those delays, can be the difference between life and death.  

How does this two-tier system play out? 

Take the example of triage. In the U.S., when you’re in the ER, when you get seen is based on how sick you are. This makes sure the sickest people get immediate treatment. That’s a system we take for granted. In most low-income countries that doesn’t happen. You come and you wait in line. People die waiting in line. You need a triage system and the relative cost of that is minimal.

Is emergency care all about trauma?  

Trauma is one part of emergency care, but only a small part. In Haiti, for instance, only 20% of emergency patients are suffering from traumatic injuries. Most often it’s heart failure, hypertension, pneumonia, tuberculosis, cancer, and other issues that bring people to the ER. Often, it’s exacerbations of chronic conditions.  

Think of asthma. Asthma can often be controlled with medications you take at home, but if you have a severe asthma attack, that’s an emergency and you need emergency treatment. During acute exacerbations like this, patients need emergency care to stay alive, and whether that’s available heavily influences your mortality.  

How does the ER fit into the overall health system? 

We generally think of emergency care for accidents, heart attacks, and acute health events. But its role is so much bigger. The ER is a plug-in to the health system. In many parts of the world, people are unable to seek routine preventative care. It costs money to get to a hospital and it means time away from work. So, they just go in when something’s wrong, and that generally means when something is acute, so they end up in the ER. The ER fixes the acute problem, but it can also help people to plug into more routine care to reduce future crises. We diagnose many chronic conditions like diabetes, heart disease, high blood pressure, and TB/HIV for the first time in the ER. Strong emergency care can educate these patients and connect them to long-term preventive care, which can transform and improve their lives. 

In addition, the ER department touches every part of the hospital—the lab, radiology, in-patient, and other systems. Strengthening emergency care works to strengthen reciprocal operations and tends to elevate the rest of the hospital. 

You oversaw the development of an improved ER system in Haiti after the 2010 earthquake. Talk about the before and after there. 

Haiti is a great example of what is possible–so much has improved in terms of capacity there. When the devastating 2010 earthquake happened, there were no Haitian emergency physicians in the country. Hundreds of thousands of people died, and who knows how many of those people might have been saved if immediate high-quality emergency care was available.  

The ER residency began at HUM in 2014 and has been graduating Haitian emergency physicians since 2017. It is fully self-sustaining and entirely Haitian-run since 2018. The HUM graduates now work throughout the country, strengthening care in many emergency departments.  

As many people know, Haiti unfortunately was struck by another earthquake [in 2021]. But the difference in access to emergency care in 2021 compared to 2010 was like night and day. Haitian emergency physicians—all of whom graduated from HUM since 2017— were involved in the response in so many ways, from working at a major referral hospital near the earthquake to receiving patients at other hospitals around the country to accompanying them in the air ambulance in between.

And they provided high-quality, top-notch emergency care in every one of those roles.   

For people in the U.S. and other wealthy countries, what do we need to understand about ER care in lower- and middle-income countries?   

First, you need to understand that the space and the staffing are very different, which translates into different care. When people in the U.S. think about emergency rooms, they think of arriving first in an area where cases are triaged to determine who needs to be treated first, then eventually going to a private treatment room to be seen by a provider. In the US, the vast majority of emergency patients are seen by emergency physicians, with specialized training in the diagnosis and management of emergent conditions.  

Compare that to many low-income countries. In many hospitals, the emergency room is just that: a room, usually a small room with three or four beds crammed in; there may be a nurse assigned there, but the doctor or provider is probably responsible for other parts of the hospital and occasionally stops in the ER. They probably don’t have any specific emergency training. This leads to people being misdiagnosed, because people come in with symptoms rather than a label saying what their problem is. For instance, if someone comes to the hospital because they can’t breathe it could be pneumonia, heart failure or even a car accident leading to a collapsed lung. You need someone trained to discern between these because the treatment for each one is incredibly different. You also need someone trained to start treatments right away before all the test results come back— in the ER you need to be diagnosing while you are intervening.  

Is there anything currently underway to improve ER care at PIH sites? 

Lots. The emergency medicine residency continues to train new providers at HUM in Haiti, and we have a new emergency ultrasound fellowship there that is training Haitian emergency physicians in advanced diagnostic skills. PIH-Sierra Leone just launched a certificate in emergency care—a 12-week course focusing on the most essential emergency care. It’s training the frontline ER providers at Koidu Government Hospital as well as students who will go on to practice in different locations. The team there also just finished a national survey of emergency care capacity around the country that will help guide future national planning. And those are just some of the activities–our teams in Liberia and Mexico also have ongoing trainings as well.  

All of that,  is only the tip of the iceberg of what is needed. Within the next five years, we hope to find the resources to expand trainings and systems even further and make PIH facilities national training hubs for emergency care.  

At Partners In Health, 88% of doctors, nurses, and other clinicians are from the countries where we work. In Haiti, our staff is 99% local.

Local staff are essential to what we do and the care we deliver at PIH: They speak patients’ language. They understand patients’ cultures. Often, they grew up in patients’ communities themselves, making them familiar faces and more readily trusted.

A deep understanding of language and culture is crucial to delivering health care that is respectful and effective. For example, handing out flyers with health information is ineffective if not written in a language patients can understand or if they are illiterate. Even opening a hospital or clinic is insufficient in communities where distrust of health care runs deep, due to histories of violence and discrimination at medical facilities.

Hiring locally is also important from an economic perspective, providing job opportunities in communities that have little to no formal economy. Income generation helps lift families out of poverty, enabling them to buy food and other necessities, pay for school fees, and improve their quality of life.

From Haiti to Peru to Rwanda, local staff are the lifeblood of PIH and enable us to provide care that is culturally relevant and effective.

Here are three ways we hire locally:

1. Clinical staff

In the 11 countries where we work, the vast majority of our doctors, nurses, psychiatrists, and other clinical staff are hired locally, enabling them to deliver care in patients’ languages and with deep cultural understanding. Our clinical teams partner directly with ministries of health, supporting governments as they work toward universal health care coverage. Our teams also meet regularly with local leaders and community organizations to understand communities’ needs.

Drawing on their shared cultural identities and our ethos of accompaniment, our clinicians build trust with patients and communities, leading to culturally relevant models for care delivery. In Mexico, Haiti, Liberia, and Sierra Leone, our clinical staff includes traditional midwives, whose healing and birthing practices have shaped maternal care there for centuries. In Chiapas, Mexico, our traditional midwives assist with facility-based births and help patients feel more comfortable giving birth in Sierra Madre communities scarred by histories of patient abuse and forced sterilization at hospitals.

2. Community health workers

At PIH, we don’t just care for patients in clinics and hospitals—we knock on their doors. This outreach is carried out by our 10,000 community health workers. Known in Mexico as acompañantes, in Peru as agentes comunitarios, and in Haiti as accompagnateurs, these workers are hired directly from the communities where we work and trained to provide basic health services, such as delivering medication, accompanying patients to appointments, or visiting patients at home to check on their mental and emotional health.

Community health workers have been central to our work since it began in Haiti in the 1980s. They are trusted neighbors, enabling them to build relationships with patients in ways no other staff can. And they bring deep cultural and community expertise to their work, delivering care in ways that patients can most easily receive it.

3. Support staff

Health workers aren’t the only local staff who make our work possible. Drivers, cooks, janitors, and other support staff enable lifesaving care and resources to reach our patients, wherever they are—and these staff members, like community health workers, are 100% local.

PIH has always provided more than medical care. In all communities where we work, we offer food, housing, transportation, and other essentials, which we call social support, tackling the systemic barriers to health care. Our support staff make this work possible. From cooks serving culturally appropriate food in our hospital cafeterias to drivers accompanying patients during doctor’s visits in communities far from home, support staff work tirelessly to create an environment where patients feel safe, welcomed, and respected.

Content warning: This story relates to suicide.

As the clock struck midnight, Brenda Mijahuanca ate 12 grapes while sitting under the table, celebrating the new year and reflecting on her resolutions—a tradition in Spain and several Latin American countries.

She once didn’t know if she would make it this far.

2022 had been a year of struggle—as a transgender woman, as a sex worker, as a daughter disowned by family. And she was used to struggling alone. No one to call. No one to check on her. No one to care for her.

The struggles had compounded over the years, too. First, it was a nasty case of COVID-19. Then, debt and bouts of homelessness. Then, what felt like the unthinkable—an HIV diagnosis.

Month after month, Mijahuanca fell deeper into depression. Some days she didn’t want to take her pills, prescribed for HIV, tachycardia, and hypertension. Every day became a battle—and she felt like she was losing. The dark thoughts grew louder and all-consuming. She began to think about ending her life.

“At any moment, I could get very sad,” she recalls. “I felt like not existing and not living anymore.”

In August, she heard about a mobile health clinic run by Socios En Salud, as Partners In Health is known in Peru, where tuberculosis (TB) and HIV screenings were being offered free-of-charge. And these diseases weren’t the only ones addressed at the mobile clinic. There, Mijahuanca received a screening that revealed another health condition: depression.

A Silent Crisis

Depression affects 280 million people worldwide, including more than 1.7 million in Peru. It can cause a loss of interest in activities, poor concentration, feelings of low self-worth, hopelessness, and, in its most severe form, can lead to suicide. Although treatment exists for depression and other mental health conditions, 80% of Peruvians lack access to it.

Mental health conditions are especially prevalent among people who identify as transgender due to stigma, discrimination, and violence. On the streets of Lima, 86% of transgender women report having faced discrimination. And more than half have experienced domestic violence, according to a survey conducted by Socios En Salud and Féminas Peru in 2020.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant TB in Carabayllo. For decades, its mental health team has delivered care to patients—including transgender women—in Lima and beyond. Mental health care is integrated into care for maternal health, tuberculosis, chronic diseases, and more.

In 2021, the mental health team provided more than 146,000 screenings in Lima and Trujillo and more than 41,400 mental health consultations. The team also works closely with other programs at Socios En Salud, including JunTrans, formerly known as Féminas, which supports transgender women.

Mijahuanca was one of thousands of patients who accessed a mental health screening from Socios En Salud last year—opening the door for life-changing care.

A Care Plan

Just days later, Mijahuanca received a phone call from Socios En Salud Psychologist Dr. Maria Fernanda Amézquita Olivares, who wanted to learn more about her experience with depression as well as provide basic education about the condition.

Mijahuanca was anxious at first; but as Olivares continued speaking, she felt more at ease.

“Maria gave me a lot of confidence every minute that passed,” Mijahuanca recalls, “because she provided me a lot of security and support and I felt that she really wanted me to keep going.”

They set up a time for a weekly therapy session. Each session would be an hour; the therapy would last two months.

Socios En Salud also helped Mijahuanca access other forms of support, including a support group for transgender women, home visits by a community health worker, and essential resources such as food, which is one of several ways in which PIH provides social support.

Over the weeks, Mijahuanca’s progress was notable.

“The first time I talked to Brenda, she was showing signs of depression and a deep sadness,” says Olivares. “But in the last session, she was totally different—a more recovered personality, more animated, with a more hopeful vision… I feel very proud of Brenda.”

Mijahuanca feels proud of herself, too. The depression is still there, but it is more manageable. And things are looking up.

She finished paying off her debts. She has her own apartment, where she lives with her dog and cat. For emotional support, she leans on friends and her partner. And she turned 35 this year—a birthday that is beating the odds. Across Latin America, most transgender women don’t live past their 35th birthday.

As for new year’s resolutions, Mijahuanca has a few dreams she’s working towards, including one day opening her own bar.

“There were days where I only thought about no longer existing, I had no energy, and I didn’t feel like myself,” she says. “Now, I see myself. I am a girl who wants to get ahead by herself. I am an encouraging person. I like to motivate the people that I appreciate and love. I like to set goals and projects for my life.”

Accessing mental health care was critical to turning things around.

“I no longer lack energy, feel crestfallen, and I am no longer thinking about negative things,” she says. “If anyone is going through the same thing or something similar, without a doubt, I would tell them to seek help.”

If you or a loved one are experiencing suicidal thoughts or a mental health crisis, help is available. In Peru, call 113 (option 5). In the United States, call 988 for the Suicide & Crisis Lifeline.

In November, when Dr. Marie Djenane José arrived for her first day on the job as director of the pathology lab at Hôpital Universitaire de Mirebalais (HUM), she was surprised to find a fairly well-equipped laboratory that met international standards.

The problem wasn’t the equipment, she said, but the lack of sufficient training for the technicians operating that equipment. This training gap, and other issues, led to a backlog of more than 500 specimens awaiting macroscopy, the slicing and processing of tissue samples so they can be examined on a slide for cancer or other diseases.  The backlog was exacerbated by the resignation of a previous pathologist months earlier and a chaotic system for identifying tissue samples awaiting analysis.

José sprung to action.

Her first move was to triage the specimens, prioritizing which, among the oncology, gynecology, and surgery cases, were possible cancers or other diseases requiring immediate attention. 

Then, she developed a plan to improve the technicians’ training so they could take on some of the critical work of the pathology lab, including a more in-depth study of human anatomy, tissue analysis, and the art of slicing and dicing, called “grossing.”

A Dearth of Pathologists

Her vision, José said, is to lay the groundwork for a residency program in pathology at HUM. With about six pathologists in all of Haiti, a country of 13 million people, “the country needs it,” she said. Indeed, delays in cancer diagnoses can mean the difference between lifesaving treatment or death, if tumors grow or cancer spreads while patients await medical interventions.  

A future pathology residency would add to a number of residency programs at HUM, the teaching hospital run by Zanmi Lasante, Partners In Health’s sister organization in Haiti, including in emergency medicine, surgery, internal and family medicine and obstetrics and gynecology.

Prior to José’s arrival, HUM was relying on a patchwork system of pathology that, as one doctor put it, “wasn’t perfect or permanent…but a mini-miracle in the context of everything happening in Haiti,” including escalating chaos, violence, kidnappings, and a lack of resources from fuel to electricity that impacted all departments.  

HUM’s pathology lab, which opened in 2016 within the Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory, helped accelerate cancer diagnoses by allowing many tissue samples to be analyzed locally, rather than mailed to hospitals in Boston, where volunteer pathologists reviewed and diagnosed the biopsied samples.  

A Telepathology Fix

Expectations among doctors and technicians rose when a tissue scanning machine was donated and delivered in 2019 to the pathology lab by the American Society for Clinical Pathology, arranged by its former chief medical officer, Dr. Dan Milner, who, with others, had consulted on the original pathology lab design. Milner said the scanner couldn’t be installed until 2021, when a visitor was able to travel to Haiti to support the process.

The problem, yet again, was training: no one knew how to operate the machine.

Frustrated that patients were waiting far too long for diagnoses, Rebecca Henderson, a University of Florida medical student, anthropologist, and long-time volunteer at HUM, taught herself how to operate the scanner and then trained several HUM staff in the basics. Henderson relied on 24/7 technical support from the scanner’s manufacturer when it broke or bewildered staff, she said. That support allowed the establishment of a rudimentary, but functional, telepathology system, anchored by the Haitian team.

"The technicians took on the challenge of mastering a difficult new piece of technology, made more difficult by Haiti's fragile electric grid and difficult internet infrastructure,” Henderson said.

HUM technicians started preparing and scanning tissue sample so that pathologists at Brigham and Women’s Hospital in Boston, which has a long-standing collaboration with PIH as part of the Global Health Delivery Partnership, could read and analyze them. Last year, for instance, more than 1,000 tissue samples were viewed by the Boston pathologists, said Dr. Jane E. Brock, chief of breast pathology division at Brigham and Women’s, who leads the team assisting HUM. Nearly half the tissue samples were cancerous, Brock said, most of them breast cancer, or cervical cancer, which are by far the most prevalent cancers for women in Haiti, according to the WHO’s International Agency for Research on Cancer.

The current system still involves mailing certain tissue samples to Boston. That’s because breast cancer requires more complex evaluation, what’s known as immunohistochemistry, a special process of staining that shows whether the cancer cells have certain hormone receptors, which can be crucial in determining a treatment plan. That means every breast tissue sample must be shipped to Boston for analysis in order to determine what treatment options to pursue. This can take several weeks for a complete diagnosis.

Still, Brock said, telepathology means that what used to take months, now takes weeks.

“Without the Boston pathologists,” said José, “I believe the [HUM] lab would have been totally dysfunctional.” Ultimately, with their additional training, HUM technicians will be handling the tissue samples while José and future Haitian residents will be able to analyze more routine cases, and only the very complex cases will need the Boston pathologists.

Top-Notch Training

José has seen up close the difference that top-notch training can make. She completed her medical studies at the Université Notre Dame d'Haïti  and pursued a residency program in pathological anatomy at the Hospital of the State University of Haiti, which, she said, “has serious problems of equipment, infrastructure, supply.”

Subsequently, José won scholarships in Martinique and Lille, France, at university hospitals equipped with state-of-the-art laboratories with immunohistochemistry and genetics.

“I was able to see the world of difference between these laboratories and those we had at the time in terms of infrastructure,” she said. “The HUM laboratory has at least a standard basis but requires more equipment and trained personnel. I dream that Haiti can have a pathology laboratory worthy of the name to conduct cancer research with a Haitian tumor bank.”

This dream aligns with PIH’s mission to offer “a preferential option for the poor.” But sometimes it takes time to get there. For people with cancer in Haiti, for example, there is no radiation treatment, and some of the newest, most effective chemotherapy drugs are financially out of reach. Still, cancer care at HUM has radically improved over the years, said Dr. Joarly Lormil, HUM’s chief of oncology, who recalls when he was a resident, and whole specimens, indeed every specimen, had to be sent by mail to Boston. “But hopefully,” he said, “with this new team and the current momentum, things will improve considerably.”

One thing that has already improved is the training and communications. Chantale Bellevue and Myrlene Mompremier worked for HUM in various capacities before entering the field of pathology; Taina Saint Jean, a medical assistant, is also studying to become a pathology technician.

In November 2022, Bellevue traveled to Boston for additional training, working with pathologists, including two who spoke Haitian Kreyol, to learn the latest techniques. This training, Bellevue said, “taught me how to do my job better…[and] bring those skills back and make our lab stronger.”

More training came by way of physicians at the University of Pennsylvania’s Perelman School of Medicine, who developed simple visual guides for macroscopy for the HUM technicians.

Still, said Marcellus: “Our training isn’t finished. It’s always continuing…and with telepathology, the patients can get their results so much more quickly.”

Faster Diagnoses

More support is needed. Lormil said in addition to faster turnaround time for specimens in oncology, a systematic method of entering pathology reports onto the digital electronic medical record is critical. And, he said, he’s eager to start using available technology, such as a GeneXpert platform cartridge that can perform all of the immunohistochemistry tests needed for a personalized breast cancer diagnosis on site.

Arranging for the distribution of these cartridges to HUM is underway.

“I'm really excited about the momentum we have in pathology,” Lormil said.  “And I hope that we will push it further. There are fewer and fewer pathologists in Port-au-Prince, and access for patients is increasingly difficult. It imposes on us, I believe, a moral duty to provide these services, with the highest possible standard.”

The following photos and story are by Thomas Patterson, PIH photo editor.

"The government needs the helicopter," Partners In Health (PIH) Lesotho Communications Officer Mpho Marole said, "so we're driving there instead."

For cross-country journeys, sometimes there's a spare seat or two on a government helicopter heading over the Maloti Mountains to the remote villages of eastern Lesotho, but during the week in August when I was there, it was being used for training.

More often, PIH drivers take clinicians and other staff members on this trek. So, dark-and-early one morning, Marole, PIH Lesotho Chief Medical Officer Dr. Afom Andom, PIH Lesotho Director of Policy and Partnerships Danielle Sharp, Videographer Caitlin Kleiboer, Driver Matlosa Phakisi, and I piled into a PIH truck and headed east out of the capital, Maseru, up into the mountains on one of the country's few paved highways. 

Lesotho is a small, landlocked country surrounded by South Africa, with a population of about 2.2 million. Our destination, PIH-supported Lebakeng Health Center, is only 130 or so miles away as the crow flies. But due to winding, washed out, boulder-strewn mountain roads, and the unpredictable nature of waiting for a hand-rowed ferry across the Senqu River, we expected the journey to take four or five hours. Lebakeng Health Center is one of seven small but vital sites offering comprehensive health care in a joint program with Lesotho's Ministry of Health called the Rural Health Initiative. 

Our first pit stop was at a lodge in Semonkong, in the center of the country, high in the mountains. Semonkong means "site of smoke" in Sesotho, the local language, deriving its name from the mist of the famous Maletsunyane Falls nearby. Unfortunately, viewing the waterfall itself requires a half-hour hike from the lodge, and we were in such a hurry to cross the country with enough light left in the day that we had no time for tourism. As Lesotho is in the Southern Hemisphere, August days are rather short.

After an hours-long final stretch over rock-strewn, deeply rutted roads, we reached the Senqu River. On the shore we met Mahase, a PIH employee, who helped us into his boat and rowed us to the other side, as he did all travelers who sought health care at Lebakeng Health Center.

​​​​​​From there, a steep hike up out of the canyon and onto a narrow ridge where the health center and adjoining airstrip lay.

All told, our journey from Maseru to Lebakeng Health Center took more than seven-and-a-half hours. Whereas we had (mostly) motorized transportation to take us to Lebakeng, many of the patients we met there were mothers who had also spent hours traveling that morning, but on their own two feet, babies on backs, to get pediatric checkups for their children.

Other people had traveled a long way to access health care at Lebakeng as well, for a variety of needs. In an area of rural Lesotho that truly feels like a medical desert, Lebakeng Health Center provides an oasis, a small community of accompaniment, with services from obstetrics to radiology, all in one place.

After a long afternoon meeting with patients and the clinicians serving them, we hiked down the hill, rowed back over the river and drove to the border town of Qacha's Nek to spend the night. The next day we drove a few hours to Nkau Health Center, another clinic in the Rural Health Initiative.

Day after day Johnson Doe and Saturday Wesseh prayed for a cure. They hoped to ease the pain of their chronic conditions and live healthy lives outside of the hospital. Their friendship grew stronger as the days and weeks passed. 

There was a natural connection between them, given their many similarities. They are both in their 50s, fathers, with the same diagnosis: a dangerous infection. Upon being discharged from Partners In Health (PIH)-supported J.J. Dossen Memorial Hospital, they got to know each other on a more personal level. 

“[We] do almost everything together,” says Wesseh, who considers Doe to be his brother. From playing games and running errands to checking-in and giving advice, they’re inseparable.

Wesseh and Doe are roommates living in rural southeast Liberia. After they showed consistent signs of improvement, they were transferred from the hospital to temporary PIH-supported housing. Wesseh moved in first, then to his surprise, Doe joined about a year later.

“When I saw him I was happy for him to come and join me,” says Wesseh.

Healing Together 

Doe and Wesseh understand each other. They both went through the challenges of buruli ulcer, a tissue-destroying infection that affects various body parts. For Doe, his foot and for Wesseh, his leg. Similar to a third-degree burn, buruli ulcer eats through skin, nerves, and blood vessels, making its way to bone. For many people, movement is restricted and only regained through physical therapy. Doe requires a wheelchair because of the condition. It is unknown how the disease spreads and there is no prevention, according to the World Health Organization, but there are treatment options. 

Both of their illnesses were originally attributed to witchcraft—a common belief among families in this region. In fact, Doe himself believed the sharp pains in his right foot were the result of witchcraft hunting by members of his community. And Wesseh’s wife and neighbors believed his unbearable pain and discomfort were due to witchcraft. Afterall, the medicines from local clinics weren’t helping and bumps began to appear on Wesseh’s leg, so what else could it be, they thought. 

Eventually, both men were referred to J.J. Dossen Memorial Hospital. Doe was referred by his younger brother after he wasn’t satisfied with the care at another facility. And Wesseh was referred to the hospital during a local PIH community outreach event. They were given buruli ulcer diagnoses and received standard medical treatment, including antibiotics.  

Although they are now out of the hospital, they still receive care. A nurse visits the men daily to care for their wounds; and a community health worker visits regularly to provide social assistance, including food, supplements, and transportation money for family members to visit them, among other things. And together, the men provide each other with emotional, social, and practical support.

“Sometimes when he doesn’t have soap, I can go and buy it for him,” says Wesseh. “And each time he needs anything, I can help.”

Treating the Whole Patient

At PIH sites around the world, care is focused on treating the whole patient, not just their illness. Quality care includes the five S’s: staff, stuff, space, systems, and social support. The fifth is just as important as the first four.  

Although social support comes in many different forms, it generally involves basic necessities including food, transportation, and housing. Safe, PIH-supported housing is provided at no cost, which is essential considering the men are currently unable to work due to their conditions. Previously, Doe worked in a gold mine and Wesseh was a sheriff in the judiciary court. 

The men are eager to fully heal and reunite with family and friends. Until that day comes, they’re glad to have each other.

“What I will forever remember and be grateful about is the social assistance that PIH is giving us,” says Wesseh.

Itumeleng Nkhabu, a 48-year-old widow, contracted tuberculosis (TB) in 2003. Then again in 2011. That was not the last time she got sick. 

In 2018, she was diagnosed with multidrug-resistant tuberculosis (MDR-TB), a severe form of the respiratory disease.

She soon began standard TB treatment, which typically includes up to two years of daily injections with a long list of side effects including acute psychosis and permanent deafness. The treatment is costly and often ineffective.

But there was more effective treatment on the horizon.

A few days later Nkhabu was admitted to Partners In Health (PIH)-supported Botšabelo Hospital in Maseru, Lesotho—the country’s only hospital for people with MDR-TB. About three weeks later, she enrolled in the endTB study.

endTB: a novel approach

The goal of Expanding New Drug Market for Tuberculosis (endTB) is to improve treatment for patients with the deadly disease. UNITAID funds the collaborative effort, which is a partnership among PIH, Médecins Sans Frontières (Doctors Without Borders), and Interactive Research and Development. 

Nkhabu is one of 81 patients who enrolled in the endTB study in Lesotho since 2018. Hundreds of additional patients are enrolled in 17 countries, including Kazakhstan and Peru—where PIH works.  

While on the standard treatment plan, Nkhabu recalls taking 27 pills per day. In the endTB trial, she takes fewer pills with less side effects. She continued treatment for a year and 10 months. 

Medication wasn’t the only form of support Nkhabu received.

Providing support beyond medical care is a key component of PIH’s work. It’s called “social support” and includes essentials such as food, housing, and transportation.

Upon being discharged from the hospital, Nkhabu continued with monthly check-ups. PIH provided free transportation to and from the hospital because she was too sick to drive herself. In between check-ups, nurses regularly visited Nkahbu at her home and provided food to take with her medications. Nurses would call her too.

“When I would receive a call, it gave me hope to continue to push and work together with the hospital staff to get well,” says Nkhabu. “They believed that I could recover even when I had no hope.”

Nkhabu recovered and is now leading a happy, healthy life again. 

Ts’eliso Pakeng, a 36-year-old patient co-infected with HIV and TB, is another one of the many patients who received TB care and social support. For several years, Pakeng was in and out of various hospitals. In 2021 he was admitted to Botšabelo Hospital and finally began to show signs of improvement. 

He says the hospital staff and social support played a vital role in his speedy recovery.

“Although my family supports me with a lot of things, they would have struggled to feed me,” says Pakeng. “I am very grateful…for the food. I do not know what I would have done without [it].”

Pakeng, who is enrolled in the endTB study, no longer relies on medication and has recovered from TB.

Since the introduction of oral medicines—namely bedaquiline and delamanid—TB treatment has greatly improved for many patients. endTB is leading the way in finding new treatment regimens. As the effort expands access and exposes demand, more patients will hopefully find relief from the disease in the coming years. 

“When patients are valued, respected, and [heard], the results become outstanding,” says Dr. Kunda Kwabisha Mikanda, DR -TB senior medical officer and site principal clinical investigator, who oversees endTB work in Lesotho.

From Rwanda to Peru, Partners In Health provides more than medical care: We cook meals for our patients. We give them a place to stay. We pay for their bus fares.

In communities where we work, where many live on $1 per day, health care often ends up on the back burner as people put their money toward essentials like food and housing—a struggle tied to poverty and systemic injustice.

At PIH, we understand it takes more than medical care to make patients well. In all 11 countries where we work, we offer social support—basic resources like food, housing, and transportation that make it possible for patients to access and benefit from health care.

Here are five ways that PIH provides social support:

1. Food

Healthy food is essential to staying well, but difficult for many of our patients to access, as they often spend what little they have on medical costs. At hospitals and clinics where we work, PIH makes sure patients and their families have food to eat.

When patients come to PIH-supported hospitals such as Butaro District Hospital in Rwanda, they are served three free meals a day, cooked with fresh, locally-sourced ingredients. Our food support extends beyond the hospital and clinic. In Peru, we deliver boxes of food and support community soup kitchens that provide daily hot meals to residents in Carabayllo, where thousands of our patients live.

2. Housing

Without safe and stable housing, it is nearly impossible for patients to stay healthy, whether recovering from an injury or managing a chronic condition. Around the world, PIH helps patients access short- and long-term housing.

During medical procedures such as surgeries or childbirth, we ensure patients and their families have a place to stay, hosting them at our guest houses or maternal homes onsite or providing vouchers for nearby hotels. We also help patients access long-term housing. In Malawi, PIH has built 137 homes and renovated 268 more in rural Neno District, serving more than 2,000 people. In Peru, PIH opened the first-ever safe house for people living with schizophrenia—a home that has since served as a model for 50 more across the country.

3. Transportation

For patients living on $1 per day, a bus ticket to the closest hospital or clinic can be too costly, resulting in missed doctors’ appointments and unfilled prescriptions. And for those with severe injuries or illnesses, travel on crowded public transit isn’t realistic; but private transportation is out of reach financially.

PIH recognizes that transportation is critical to a patient’s care, from diagnosis to recovery. In all countries where we work, we provide stipends for transportation, paying for bus tickets and taxi fares to ensure patients can reach the hospital or clinic. In Mexico and Rwanda, we deliver this and other social support through the Right to Health Care program. In these and other countries, we operate fleets of our own cars, staffed by our experienced drivers, who transport patients to and from appointments.

4. Education

Education equips people with the tools to make informed decisions about their lives, including their health and well-being. But in the communities where PIH works, this basic human right is inaccessible for many students, whose families must choose between school fees and other expenses, or send sons, but not daughters, to school.

PIH is determined to challenge those realities. In Malawi and other countries, we pay for school fees, uniforms, notebooks, and other supplies—expenses that total about $2 per child but are unaffordable for many families. Since 2007, PIH has covered school fees and other supplies for more than 1,100 students in secondary school and more than 2,000 in primary school in Neno District, widening access to education that can change lives.

5. Employment

In communities where PIH works, people often rely on jobs that are low-paying, seasonal, or otherwise unpredictable. In Peru, for example, 68% of workers are part of the informal economy. Paid work is essential to staying well, and a medical issue can take a devastating toll on health and finances, as patients miss work and accrue costs, fueling a cycle of poverty and sickness.

PIH supports patients as they seek job opportunities. In Kazakhstan, we’ve helped patients in our tuberculosis program access employment, along with residency papers. In Peru, PIH has distributed small business loans and helped patients start economic cooperatives. Our patients have joined our ranks too, becoming doctors, nurses, drivers, and more—evidence that care can change lives and improve outcomes.

Partners In Health is excited to announce the establishment of the Paul Farmer Collaborative of the University of Global Health (UGHE) and Harvard Medical School. This initiative, made possible by a $50 million gift from Cummings Foundation, will expand and deepen a long-standing partnership between the two institutions. The ten-year grant will be divided equally between the two institutions to support joint activities.

Building on Paul Farmer’s legacy, the collaborative will catalyze the development of sustainable, equitable health systems that improve health care delivery to underserved populations, helping to strengthen and influence the medical training ecosystem in Rwanda and across Africa. The work of the collaborative will involve the exchange of students, postdoctoral trainees, and faculty between UGHE and HMS; support for research, education, and teaching; an annual global health conference focused on health equity, global health delivery, research, education, and social medicine; and clinical training opportunities for medical students and residents at both institutions.

The collaborative will complement efforts we have underway to establish the Paul E. Farmer Scholarship Fund for UGHE. Although this grant will not be a part of the scholarship fund, it will enhance opportunities for both faculty and students supported by the scholarship fund. The visibility from this collaborative – as well as early commitments to the scholarship fund – will help us build momentum as we continue to fundraise toward the scholarship fund’s goal over the next three years. So far, we have raised just over $70 million toward the $200 million goal.

In addition to the $50 million gift to launch the collaborative, Cummings Foundation has contributed $2 million to Partners In Health to construct a residential facility to house and support faculty visiting UGHE’s campus in rural Butaro, Rwanda.

An initiative of Partners In Health, UGHE launched in 2015 with catalytic support from Cummings Foundation, the Bill & Melinda Gates Foundation, and the Republic of Rwanda. Its academic programs include a bachelor’s level medical degree and Master of Science in Global Health Delivery. UGHE also offers executive education programs with a focus on strengthening health care delivery systems.

It has been nearly a year since Paul’s sudden and unexpected passing, which occurred in Rwanda while he was working and teaching at UGHE. Paul fundamentally believed that universities should be critical agents of social change and active drivers of solutions to society’s most urgent needs. This gift, and the establishment of the collaborative, is the embodiment of this belief and his values.

Read the full press release.