Henry Domingo Vilca used to be “cold and distant,” not expressing his feelings or connecting with his children emotionally. Now, the sight of his daughter running toward him, shouting “Papa!,” often brings him to tears.

“She is my everything,” he says. “She is my world.”

He didn’t experience moments like that growing up.

“My father was quite firm and had a traditional upbringing,” Vilca says. “He didn’t hug me or tell me how he felt. He even hit me.”

In Peru, machismo still runs deep. This set of ideals and beliefs associates masculinity with traits like dominance and aggression and has fueled decades of violence against women and girls, including femicide, and promoted traditional gender roles. At the same time, machismo has also pressured men to suppress their emotions, masking their struggles with mental health and discouraging them from seeking help.

When Vilca’s son was born, he followed traditional gender roles, acting as the breadwinner while his wife managed the home and caregiving responsibilities. He also didn’t show affection or take much interest in his son’s feelings.

But when his daughter Cayetana was born, all that began to change.

For one, the girl had a hemangioma, a vascular tumor that is usually benign, on her back. Fortunately, the condition went away on its own. But it worried Vilca. He made sure to take her to the local clinic in Carabayllo for her 12-month check-up.

At the clinic, staff evaluated her psychomotor development and found that she was showing signs of risk for developmental delays in her social, language, and motor skills, prompting them to connect Vilca and his family with Socios En Salud, as Partners In Health is known in Peru.

Fathers As Caregivers

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis in Carabayllo. In the years since, Socios En Salud has expanded its work to provide medical care and social support for thousands of people nationwide.

One of those programs is CASITA, a three-month intervention for caregivers and children ranging from 6 months to 2 years old. Based in Carabayllo, the program identifies children at risk of developmental delays and enrolls them and their caregivers in free sessions to learn social-emotional, motor, language, and cognitive skills through play. Since 2013, CASITA has enrolled more than 3,648 children and screened more than 6,795, with 85% showing improvement during its pilot period.

Early detection of developmental delays is critical in helping children access the care and support they need to become healthy, independent adults. This is especially true in Carabayllo, where daily challenges include poverty, malnutrition, and domestic violence and where only 34% of children under 3 are up-to-date on their growth and development checks.

Vilca began CASITA in February, attending weekly classes with Cayetana and 10 other caregivers and their children. The sessions were taught by a community health worker, one of nearly 100 local residents hired and trained by Socios En Salud to provide basic health care at the community level.

Over the next three months, Vilca and other caregivers sang songs, read books, and built pyramids of toys with their children. With each session, Cayetana began to show signs of growth, including taking her first steps, improving her foot-eye coordination, and memorizing and pronouncing words. And she wasn’t the only one learning new skills.

“Socios En Salud was there at a key moment for our family,” says Vilca. “It has really helped my daughter and me as her father.”

Learning To Play

Vilca was the only father in the group—a fact that, at first, made him self-conscious.

In traditional Peruvian households, the mother is responsible for caregiving, raising the children, and taking care of the house, while the father is the breadwinner, bringing in income. Throughout history, caregiving has been a role assigned to women, attributed to “maternal instinct” instead of viewed as a learned behavior. This stereotype has harmed women, creating a widely-documented gender gap in caregiving, has led to the devaluation of caring professions such as nursing, and has also reinforced the myth that men are less capable of caregiving.

In reality, caring has no gender.

As the weeks went by, Vilca grew his own confidence as a caregiver. He learned how to show affection and respond to Cayetana’s emotional needs.

Those changes went beyond the classroom.

“I see that she’s happy when she’s with me and that makes me feel like the best dad,” he says. “Now I suddenly have the desire to spend time with her, as well as with my son. I really enjoy going out to play and have time with them outside of [CASITA] sessions.”

He used to barely acknowledge his children when he came home from work each night, exhausted and depleted. But since CASITA, his evening routine has changed.

“I love holding my children when I arrive [at my house] and hugging them,” he says. “I won’t deny that it was strange at first.”

He and Cayetana have now completed the CASITA program. But he keeps in touch with Socios En Salud staff and the other caregivers.

“I am grateful to Socios En Salud for our lives,” he says. “Some may think that SES only helped my daughter, but they also cared about our family and counseled me on my relationship with my partner. It has strengthened everyone’s bond and left us with great lessons on how to face challenges in the future.”

The greatest lesson, for Vilca, is feeling more connected with his children.

“They have completely changed me,” he says. “My greatest wish is to see [them] achieve their dreams...I want them to know that I will always be there to listen, guide, and support [them].”

Health promotoras, health educators, community ambassadors––though known by many different names, community health workers are frontline public health workers who leverage their unique understanding of local language and culture to connect communities to health care and social support.   

Our experiences have shown that a robust community health workforce is crucial for achieving better health equity, empowering communities, and building a stronger public health system. Across the globe, community health workers play a vital role in reducing health burdens while significantly improving the health and lives of people in their communities. In the U.S., community health workers serve as essential connectors between communities and medical services by accompanying individuals on their health care journey, advocating for their community’s health needs, and matching individuals to essential social support, all of which are integral activities to ensure the right to health for everyone. 

Communities of color and people living in low-income and rural areas face countless challenges such as documentation status, access to transportation, and translation support that make not only accessing, but navigating the health system difficult. Community health workers are crucial to mitigating these barriers by supporting their own communities in identifying culturally relevant resources, navigating complex health and social service systems, and advocating for the design of more accessible health services. A robust community health workforce is vital for achieving better health equity, empowering communities, and building a stronger public health system. 

Here are some ways PIH-US partners with community health workers across the country: 

Chicago, Illinois 

Four Community Health Organizers from local community-based organizations in Chicago are enhancing their capacity to address public health needs by attending PIH-US-led trainings in advocacy, organizing, public health skill-building, and resource navigation. Each organizer has identified projects within their organization that they would like to introduce–from creating wraparound services for a growing immigrant community and advocacy campaigns for Medicaid expansion, to improving staff wellness services–to mobilize their neighbors in the fight for environmental justice and health equity. 

Immokalee, Florida 

PIH-US and our partners at HealthCare Network hired and trained community health workers in Immokalee to go door-to-door to connect community members to health and social services. In doing so, they help the primarily migrant community overcome barriers to health care like travel times, costs, and stigma. Throughout 2022, 15 community health workers completed over 8,600 engagements with community members including conducting COVID-19 mobile testing, facilitating transportation to vaccine events, and serving as resource navigators. When Hurricane Ian hit parts of southeastern Florida, community health workers launched vaccination outreach events for TDaP (tetanus, diphtheria, and pertussis) and influenza in hard-hit neighborhoods.  

New Bedford, Massachusetts  

In Massachusetts, PIH-US partnered with the New Bedford Health Department to train promotoras from New Bedford’s Community Economic Development Center, an advocacy organization that supports a large Central American immigrant population, to conduct surveys and outreach for the local community health needs assessment. They gathered over 800 surveys from historically excluded communities detailing their health needs, challenges, and concerns about the system. By providing the health department and local health system with a deeper understanding of community concerns, the surveys collected by this workforce will ensure future public health planning and strategies are designed to meet local needs. 

North Carolina 

PIH-US is working with the North Carolina Community Health Worker Association, North Carolina Department of Health and Human Services, and others to develop both a formal training and certification process, as well as a community, public health, and clinical integration model which are designed to provide career development and employment opportunities for community health workers across the state. To further uplift community health worker voices, PIH-US partnered with North Carolina Community Health Worker Association to host a series of trainings on legislative advocacy to ensure that community health workers participating in a state-wide Advocacy Day felt comfortable and confident sharing their stories and championing their communities to policymakers. In April, community health worker advocates met with over 50 elected officials to elevate the impact of the community-based workforce on communities across the state and urge legislators to support plans to sustainably integrate community health workers into North Carolina’s public health infrastructure. 

Now more than ever, it is critical that decision-makers recognize community health workers as an essential frontline workforce whose knowledge and skills are indispensable. PIH-US is working closely with the National Association of Community Health Workers to promote recognition and funding for this workforce nationwide. We believe that investing in community health workers is imperative to the fight for health and racial justice in America. 

Cholera is often thought of as a 19th-century disease that spread around the world through travel and trade. But in low- and middle-income countries, especially in the wake of natural disasters, cholera continues to kill tens of thousands of people—even though a simple, effective treatment exists.

A similar narrative emerges with other diseases. Health conditions that have known treatments and cures continue to claim millions of lives worldwide, disproportionately in the Global South. This inequity is due to the enduring injustices of poverty and colonialism that have led to weak health systems and a lack of access to testing, treatment, and care.

These issues bring to light the urgent need for global health equity, a mission that has been the cornerstone of Partners In Health’s efforts around the world for more than 30 years—from our work fighting HIV/AIDS and multidrug-resistant tuberculosis in the 1990s to our response to Ebola, COVID-19, and several other health conditions, including non-communicable diseases.

From Haiti to Lesotho, our work is driven by a simple yet radical idea: health care is a human right, and it should be free and accessible for all people, everywhere. 19th-century diseases should not be a death sentence, anywhere, in the 21st century.

Below are five diseases that are fully treatable but continue to devastate much of the world:

1. Tuberculosis

A cure has existed for tuberculosis for decades. But millions of people continue to be infected and die of the disease, despite diagnosis and treatment being available in wealthy countries. The WHO estimates that 1.6 million people died of TB and 10.6 million fell ill in 2021. Over 80% of these cases and deaths occur in low- and middle-income countries.

2. HIV/AIDS

While no cure exists for HIV/AIDS, the disease is treatable and it is fully possible for people to live long, healthy lives with access to the proper medication and care. Over the past decade, massive strides have been made in widening access to antiretroviral therapy, with 76% of all people living with HIV accessing treatment. Still, 630,000 people died of HIV-related causes and 1.3 million acquired the disease in 2022, highlighting the need for continued efforts to improve access to treatment and care.

3. Malaria

Malaria is curable and can be prevented through measures like mosquito nets, medication, and vaccination. But despite the existence of a cure, 619,000 people died of malaria and 247 million became infected in 2021 due to lack of access to care. And the disease has a disproportionate impact: 96% of deaths and 95% of cases happen in the WHO African Region, with children under 5 accounting for 80% of all malaria deaths in the region.

4. COVID-19

Vaccines and treatments have been developed for COVID-19, the virus that has led to nearly 7 million deaths worldwide since its emergence. Despite the world’s fastest-ever vaccine development—with the first vaccines produced in less than 12 months, without compromising safety—vaccines remained unavailable for most of the global population, as wealthy nations bought up the world’s supply. In 2022, 1.3 million people died of COVID-19—a total that is likely much higher, given that many deaths were not officially reported. Only 23% of people in low-income countries had at least one vaccine dose by November 2022, compared to 80% of people in high-income countries.

5. Cholera

Cholera, which can cause death within 24 hours, is easily treatable: less than 1% of patients die when they’re rehydrated quickly, through oral rehydration solution, a mixture of water, salt, and sugar. But each year, anywhere from 21,000 to 143,000 people die of cholera, due to lack of access to treatment. The disease is especially deadly in countries with weak health systems in the wake of flooding, earthquakes, and other natural disasters, including in Haiti and Malawi.

In March, a woman was killed every three days in Peru. Since January, the country has seen at least 51 cases of femicide.

Gender-based violence is just one of the daily realities that women and girls face in Peru. They must also make their way, personally and professionally, in a society that is still sexist and patriarchal in many respects. More than 50% of Peruvians believe that women should put their role as mothers and wives first, ahead of their own dreams, according to Peru’s National Institute of Statistics and Informatics.

And then, for women who live in impoverished areas, there are challenges such as a lack of clean drinking water, a lack of sewage services, and overcrowding. In Lima alone, according to the National Superintendence of Sanitation Services, more than 635,000 people do not have access to clean drinking water, which can cause health issues such as parasitosis and chronic diarrhea.

Delia Lunasco has seen these problems first-hand.

In her role as a community health worker with Socios En Salud, as Partners In Health is known in Peru, she is not only dedicated to promoting health care and accompanying patients in their recovery—she has also become an advocate for women’s empowerment in her community.

A commitment to community

Socios En Salud has worked in Peru for more than 25 years, providing medical care and social support to thousands of patients in Lima and beyond. To provide this care, Socios En Salud enlists the help of 90 community health workers—local residents trained to provide basic health services in their communities, such as delivering medications and checking on patients at home.

Over 90% of these community health workers are women.

Lunasco, 54, has been a community health worker with Socios En Salud for more than a decade. But her commitment to the health of her community, El Progreso of Carabayllo district, began more than 20 years ago.

In Lima, the vast majority of settlements are on the slopes of hills on the outskirts of the city, where more than half of residents do not have title deeds or access to basic utilities, such as electricity, drinking water, or sewage, according to the NGO Techo Peru. Thousands of people live in the settlements, many of them migrants and refugees, and make a living by working informal jobs such as street vending.

It was in El Progreso that Lunasco became a leader of the neighborhood committee, and her passion for community health was born.

"In the hills, there is always filth and diseases that especially affect the children," she says.

Lunasco would have liked to become a nurse. But as a mother of six children, with limited financial resources, she was forced to set that dream aside.

It’s a reality all too common for women in El Progreso.

A survey by the Institute of Peruvian Studies estimates that, in 82% of Peruvian households, women do most of the housework, spending twice as many hours per week as men on tasks such as cooking, washing, or cleaning. The burden of unpaid domestic labor often means that women have less time and energy for education, work, or other pursuits.

Still, Lunasco was determined to find a way to strengthen her community and address the health issues she saw day-to-day.

In 2013, she learned about a new opportunity: community health worker with Socios En Salud. Not having higher education was not an obstacle—all residents were welcome to apply. Through a one-week orientation and recurring training, she could learn how to provide basic health care and prevention and eventually be dispatched to homes and clinics to care for patients.

Lunasco was thrilled at the news. Her husband was not.

After joining Socios En Salud, she started leaving her home in the mornings and afternoons to attend trainings and visit patients. One day, her husband, a bus driver, suggested that she should work for him instead as an assistant.

To this day, Lunasco remembers her answer vividly: "And me, what am I going to do sitting around? I'm not going to produce anything. Instead, by leaving [home] I'm helping [other people], because there are patients who can't get up and we have to go find them."

It took time, but her husband eventually began to support her. In a few weeks, her training was complete, marking the start of a decade-long career.

Facing challenges

Over the years, Lunasco has cared for dozens of patients, helping them access testing, treatment, and care for tuberculosis and other health conditions. She has accompanied them to appointments, visited them at home, and helped them navigate the local health system. She has also delivered a crucial message to the women in her community.

"I tell all of them that we are unique, that they should go forward and not be stuck at home,” she says. “We are women leaders—empowered."

In June, Lunasco was recognized by Socios En Salud during its annual Community Health Worker Day, for her tireless work in the tuberculosis program and her years of service to the community.

For her, this recognition is a reflection of her commitment to the health of the most vulnerable people, as well as the value of community health workers—a role that is often overlooked, misunderstood, or unknown to people, even within health care.

Throughout her career, Lunasco has witnessed how some health centers downplay the importance of community health workers, even though they often have the strongest bonds and most frequent contact with patients. She also believes that machismo is still a problem in the health sector, making women’s empowerment and education ever more crucial.

Along the way, Lunasco has helped dozens of young women find work in health care, from becoming health promoters at the health center in El Progreso to community health workers with Socios En Salud.

"We want to rise and move forward," she says.

Tuberculosis (TB) is preventable and treatable. Despite this, 1.6 million people died from the infectious disease in 2021—a majority of whom live in low- and middle-income countries. 

In an effort to reduce deaths and find safer, shorter treatments, Partners In Health (PIH), in collaboration with Médecins Sans Frontières and Interactive Research & Development, launched the endTB project in 2016. A key part of the Unitaid-funded partnership is research, including the endTB clinical trial that concluded in Lesotho and 6 other countries in late June. A second trial, endTB-Q, will be completed in 2024.  

We spoke to three researchers involved with the endTB clinical trial in Lesotho: Dr. Llang Maama, Ministry of Health TB and leprosy manager; Dr. Kunda Kwabisha Mikanda, drug resistant-TB senior medical officer and site principal investigator; and Carole Mitnick, co-principal investigator of the endTB trial and professor of global health and social medicine at Harvard Medical School.  

Below, edited and condensed, are their responses to questions exploring the challenges of this clinical trial, preliminary results, and what this means for global TB care: 

What challenges did you face before the endTB trial began in Lesotho, in treating patients with multidrug-resistant tuberculosis (MDR-TB)? 

Kunda: Before we started the endTB trial, patients were receiving treatment that involved taking daily pills and injectables for 24 months. Many patients stopped their treatment along the way because it was too long with too many pills—about 14,600 throughout treatment. In addition, there were lots of irreversible side effects like psychosis, renal failure, and permanent deafness. It was a big challenge and we didn’t have another treatment option at the time.    

Can you give a big picture overview of the endTB clinical trial? What did you examine and who was enrolled? 

Mitnick: The endTB clinical trial was set up to examine five experimental regimens for treatment of a type of TB caused by bacteria resistant to the most important first-line drug, rifampin. 

Participants were randomized to six different arms: five experimental and one standard of care or “control.” All the experimental arms included nine months of treatment using all-oral regimens. The control arm was 24 months and could contain an injectable agent, according to World Health Organization guidance at the time. We used a fancy system for randomization called Bayesian response-adaptive randomization. Most trials pre-define the number of people in each arm, and that number is often identical across arms. In endTB,  we used the information coming out of the trial as the trial was running to randomize more people to the arms that were performing better. We did this because it allowed us to efficiently  test a whole bunch of regimens at the same time.  

There were 754 participants from seven countries, including three where PIH works, enrolled in the trial. Participants were pretty young. The median age was 32 years old. About 20% of the people enrolled have comorbidities, such as HIV and diabetes. We also included people with substance use disorders or mental illness. We wanted our trial population to be similar to the population in the world that gets drug-resistant TB, so that the results would be relevant. 

Why is this trial unique? 

Mitnick: There are a few reasons. First, this was the first time Bayesian response-adaptive randomization was used in a TB trial. It has been used in cancer trials in high-income countries, but never for TB.  

Second, it was a trial carried out by three major service-based non-governmental organizations, who don’t normally get involved in trials: PIH, Médecins Sans Frontières, and Interactive Research & Development. All three of these organizations thought this was important because nobody else was going to do it. The pharmaceutical companies that developed two of the newer drugs used in the regimens did not finish the job; they got their drugs approved by the U.S. Food and Drug Administration and other regulatory authorities and stopped short of really understanding how best to use the drugs. 

Lastly, because PIH led the project, it had a strong influence on the design of the trial and used an accompaniment model to support study participants to complete their treatment and trial participation.  

Acknowledging that the team is still sorting through the data (which will be publicly available later this year), what is the biggest takeaway so far? 

Mitnick: Our very preliminary analysis of some patients shows 84% favorable outcomes across the board. In comparison, the standard of care when we started the trial was around 60%. That's a massive improvement. We don't know how that will shake out among the arms. It’s really encouraging that overall the results are good. I think some of the other takeaways are that there is a space for organizations like PIH and its service partners, its social justice- oriented, human rights-oriented peer organizations to be involved in clinical research.  

We relearned that accompaniment is really helpful for people with complex diseases or social conditions to help them through care. And COVID-19 amplified all of this because the trial was running during the pandemic, which reinforced the importance of nimbleness in doing both service work and research. 

What does the conclusion of the study mean locally in Lesotho, where the TB incidence is the highest in the world? 

Maama: This is a very exciting experience. I remember in the beginning we were doubtful whether we were a suitable country to implement the trial, considering our limitations especially in monitoring patients. Capacity was built here. We are happy to be part of the evidence.  

Kunda: The conclusion of the trial will be tremendous to the country in terms of policy changes and guidelines implementation to improve lives in Basotho. When the results are published, they'll help the government and stakeholders to adopt better treatment regimens which are shorter with less side effects. 

Do you think these results will have an impact on global TB care? And if so, how? 

Maama: I think the impact has already been felt because we started with injectables, but because of the ongoing trials we have transitioned to all oral regimens. And that has really reduced that burden on patients who were losing their hearing to treatment, and becoming incapacitated in terms of their work, and their inability to sustain their families. So yes, the impact of this is visible now that we have improved the regimens and compliance. Even our treatment outcomes have improved because of the endTB evidence. 

What happens next for enrolled patients? How will they continue care and treatment? 

Mitnick: All of the participants in the trial have completed their TB treatment. Thankfully, TB can be cured. It does not require continuous treatment in the same way HIV does. Unfortunately, people who get TB once are at higher risk for getting TB a second time than somebody who has never had TB. And there's increasing awareness that people who have TB are also at risk of chronic lung damage, cardiac disease, and other complications. You can think of this as “long TB” like long COVID. In other efforts, PIH is working to follow people who have completed treatment and make sure they get the care they need for any of these long-term effects.  

We will also be sharing the results with the study participants. Oftentimes, the results only get shared at professional society meetings, conferences, or in peer-reviewed publications; the people who volunteered their time and gave us their trust to be in this trial don't hear the results. We're looking for ways to reach this population and engage with them in a meaningful way when the results become available. 

University Hospital of Mirebalais (HUM) in Haiti recorded 40 cases of extreme fever over the weekend, with 11 confirmed cases of dengue fever so far, according to Dr. Christophe Millien, HUM’s chief medical officer. Dengue fever is a mosquito-borne viral disease occurring in tropical and subtropical areas. Symptoms can include high fever, rash, and muscle and joint pain. In severe cases there is serious internal bleeding and shock, which can be life threatening. Preventing mosquito bites is the best way to avoid getting dengue fever. Treatment includes providing patients with hydration and pain relievers. Severe cases require hospital care.

Millien has started working closely with his team to prepare an action plan for community intervention. “Considering there is currently an epidemic of dengue fever in the Dominican Republic, it has probably already spread throughout our territory,” he says. The viral disease has already spread through many rural areas of the Dominican Republic, which shares a border with Haiti. Communities in the Dominican province of Elias Pina, which neighbors Mirebalais, are at greatest risk.  

“We are planning to go into the communities in Mirebalais and raise awareness through the radio and television stations,” explains Millien. The team will also distribute mosquito nets to help with prevention.

“We are currently monitoring all cases of fever at HUM and have set out rapid tests to be able to diagnose the symptoms very quickly,” he says. “I have also started training the staff at HUM on the proper ways to tackle this.”

It’s been over four years since multiple cases of dengue fever were recorded throughout most of Haiti, while 3,500 cases were identified in the Dominican Republic at the time. The difference may also indicate a difference in the two countries’ abilities to systematically screen for the disease.

HUM is a 205,000 square-foot, 330-bed teaching hospital, which opened its doors in March 2013, in partnership with the Haitian Ministry of Health (MSPP) and filled a void for people with limited access to quality health care. HUM receives over 1,250 outpatient visits per day and serves a population of 1.3 million people. Ten years since its opening, with a highly skilled staff of medical practitioners like Millien and his team, HUM remains committed to bringing the benefits of modern medical science to those who need it most and to serve as an antidote to despair.

Tuberculosis (TB) is a common, and in many cases fatal, infectious disease that attacks the lungs, and can affect other parts of the body. The incidence of TB, like many infectious diseases, reveals glaring health care inequities where more than 95% of deaths occur in developing countries.  

Partners In Health (PIH) has been battling this injustice for more than three decades by treating and preventing the spread of TB while working with partners to dramatically improve treatment of multidrug-resistant tuberculosis (MDR-TB) in some of the most vulnerable communities in the world. 

Although the World Health Organization has labeled TB as the deadliest infectious disease in the world—outpacing HIV—there are still many who aren’t aware of the disease and its ongoing global impact. 

Here are 5 misconceptions we often hear regarding TB:  

1. TB is a disease of the past. 

In reality, the prevalence of TB has been rising. Globally, the incidence rate of TB is 134 per 100,000 people, which, after two decades of trending downward by about 2% per year, amounts to an increase of 3.6% from 2020 to 2021. This increase can be partially attributed to disruptions caused by the COVID-19 pandemic as people isolated together and spread the deadly bacteria while there was limited access to health services to detect, prevent, and treat the disease. Even the United States saw a growing number of cases in 2022 with 8,300 reported, compared to 7,874 cases reported in 2021.  

2. TB doesn't kill many people anymore. 

Along with the increase in prevalence, there has also been an increase in the number of deaths from TB, reversing many years of slow decline. In 2021, 10.6 million people fell ill with TB and 1.6 million people died. Despite being both treatable and preventable, TB is a leading infectious killer, above HIV/AIDS. 

3. MDR-TB is incurable. 

There are drugs available that can treat and cure MDR-TB, a more severe form of the disease. Over two decades, PIH has treated more than 10,500 people for drug-resistant TB in Peru and has a 77% cure rate for MDR-TB thanks to new medications. 

Unfortunately, as only 10% of people with drug-resistant TB receive treatment that cures them, MDR-TB is still a public health crisis. The primary form of transmission for MDR-TB is through contact with someone who has drug-resistant TB, regardless of any previous infection with the disease, making treatment even more critical to stop the cycle of infection.  

Since 2016, PIH has worked with partners on the endTB project to dramatically improve the treatment of MDR-TB through access to medications, clinical trials of new drugs, and shorter treatment regimens. 

4. TB care is prohibitively expensive. 

TB has a global impact that warrants large investments. One plan to address TB estimates funding needs around $15-32 billion per year to prevent, diagnose, treat, and conduct research for TB until 2030. However, the amount spent globally on TB is absurdly low. With only $5 billion going to combat TB annually, just half of what Americans alone spend annually on celebrating Halloween, we aren’t close to fulfilling the financing needs. The world needs much greater international cooperation and investment in resources to end this curable disease.  

According to a recent analysis, if governments meet the WHO 2030 End TB goals, as many as 23.8 million lives could be saved and $13.1 trillion in economic losses averted. Additionally, it’s estimated that every dollar invested in TB research and response will yield $40 in economic benefits alone through 2050–not to mention the lives saved. 

There are also ways pharmaceutical companies can make TB care less expensive and more accessible. For example, patents on lifesaving medication contribute to increased drug costs and restrict access to care for many of the populations where resources are already limited. At PIH, we are urging further steps to ensure critical TB drugs, including bedaquiline, are available to all.  

5. Treating TB and MDR-TB is too complex to be achieved in settings of poverty. 

Since the 1980s, PIH has been working in impoverished communities with significant TB burdens to advance treatment and improve the health of patients. PIH takes a community-based approach to TB care, including recruiting community health workers who provide in-home care and support, partnering on clinical trials to improve the treatment of MDR-TB, and deploying mobile clinics to bring screening, education, and treatment directly to vulnerable populations.  

This approach is changing local, national, and global systems of care and providing a model for fighting the disease. Three of our original MDR-TB pilot projects have successfully been handed over to ministries of health, where they can be scaled up nationally and leaders can provide training and technical assistance to neighboring countries. 

In late July, Partners in Health opened a new maternal health center in one of the deadliest places to give birth in Chiapas, Mexico. The center, called Casa Materna, will provide dignified care for mothers and newborns in the rural community of Siltepec, serving a population of up to 32,000 people.

The new center follows the model of PIH’s first Casa Materna in Jaltenango, bringing maternal health care, including support for pregnancy, childbirth, and postpartum, within reach. Just months ago, new and expectant mothers in Siltepec had to take long, risky, and costly trips to other cities to access such care or give birth at home with assistance from a traditional midwife.

"The [new] Casa Materna provides a safe space for quality care for mothers and their babies," says Estefanía Monterrosas, clinical supervisor at the Casa Materna in Jaltenango. "We come to strengthen the health system in Siltepec, to understand its work, and to complement it with our skills and knowledge."

The first Casa Materna was opened in 2016 in Jaltenango, a central city in the rural Sierra Madre region of Chiapas. Partners In Health, known locally as Compañeros En Salud, established the maternal health center in collaboration with the Mexican Ministry of Health and the community hospital, Hospital Básico Comunitario Ángel Albino Corzo. Last year, the center provided care for 1,490 women and supported the delivery of 292 babies.

Compañeros En Salud has worked in Chiapas since 2011, providing health care at 10 rural clinics and at the community hospital and Casa Materna in Jaltenango—work that has now expanded to Siltepec.

Respectful Childbirth

Siltepec is one of the deadliest cities for mothers to give birth in Chiapas, with one of the state’s highest maternal mortality rates. Also troubling are the rates of medical abuse and mistreatment that mothers routinely experience from clinical staff. Across Mexico, more than 33% of women who have given birth reported having suffered some type of mistreatment at the time of delivery. This mistreatment, including shouting, insults, humiliation, and non-consensual procedures, is known as obstetric violence and can have lasting effects on women’s physical, emotional, and mental health.

These issues make Casa Materna’s model of “respectful childbirth,” first practiced at the center in Jaltenango and now at the new center in Siltepec, critical.

"We want to rethink and rebuild the way births are attended in Chiapas, so that women recognize that their body is theirs and that they can have control over the care they receive," says Monterrosas.

The respectful childbirth model centers the needs of patients by recognizing their autonomy and empowering them to make decisions at the time of delivery. These decisions include birthing positions, whether or not to use medications, preferences about set up within the labor room, and the people who are present. 

It is also led by midwives and nurses—not doctors. The United Nations found that models of care that include midwives help prevent two-thirds of maternal and neonatal deaths. At the Casa Materna in Jaltenango, midwives regularly facilitate consultations, labor, and delivery.

 "The role of nursing is also something fundamental, since we have the first contact with the patients, and we build relationships of trust with them, making them feel safe," says Julieta Gonzalez, head nurse at the Siltepec Health Center.

The Casa Materna de Siltepec will have a labor room, a delivery room, and a multipurpose area, among other spaces. This design will allow patients to have privacy during consultations and childbirth, helping them feel protected and avoiding putting them in vulnerable situations.

”Our ultimate goal at Casa Materna is to provide a safe space and quality care for dignified births, through collaborative work and respect for pregnant women,” says Monterrosas.

For centuries, cholera killed millions of people. The diarrheal disease could cause dehydration, shock, and death within 24 hours. Since the 1970s, it has been treatable by a simple therapy: oral rehydration solution, a mixture of water, salt, and sugar.  

That medical advance has saved millions of lives. 

Cholera remains an urgent issue in low- and middle-income countries, especially in the wake of disasters such as flooding and earthquakes. But its simple, low-cost treatment offers proof of global health’s progress. 

Over the past 50 years, the world has seen advances in science and medicine, public health, and advocacy that have helped millions worldwide access care, reaching patients once neglected and diseases once untreated.  

Global health inequities persist, and the movement for free, universal health care remains as urgent now as ever. But in a world rife with injustice, it is important to also look to moments of progress—moments that invite us to reject despair and cynicism and show that, with concerted effort, resources, and support, historic change is possible. 

1. AIDS-related deaths have declined more than 60% since the peak in 2004. 

Massive strides have been made in the fight against HIV/AIDS. At the peak of the epidemic in 2004, some 2 million people died of AIDS. In the years since, as access to treatment and care improved, deaths have declined dramatically. Additionally, progress has been made in finding a cure, with the virus cured in mice using gene-editing technology. Still, millions worldwide live with HIV and access to treatment and care remains an urgent issue. 

2. Child mortality has fallen by nearly 60% over the past 30 years. 

Over the past half-century, millions of children’s lives have been saved due to improved access to vaccinations, nutrition, and other forms of medical care. In 1990, 1 in 11 children under 5 died. By 2021, that rate was 1 in 26, more than halved. Despite this progress, child mortality continues to take a devastating toll. In 2021, roughly 13,800 children under 5 died each day, showing how much progress has still to be made.   

3. Smallpox has been eradicated and polio, nearly eradicated 

Global health advocacy and scientific and medical advances have led to the end of once-deadly diseases. Smallpox, a disease that killed 300 million people in the 1900s alone, was declared eradicated in 1980, thanks to vaccination campaigns that enlisted the help of thousands of health workers worldwide. Global health initiatives have also led to a 99% drop in cases of polio, a disease that can lead to lifelong paralysis, since 1988. 

4. World’s first Ebola vaccine approved 

In 2019, European health regulators approved an Ebola vaccine, opening the door for the vaccine to be widely deployed as opposed to limited to experimental programs. The 2014 outbreak in West Africa, which Partners In Health responded to in partnership with ministries of health, killed more than 11,000 people. More recent outbreaks in the Democratic Republic of Congo have killed more than 2,000. 

5. COVID-19 vaccine developed in record-time 

Vaccines to fight the COVID-19 pandemic were the fastest vaccines ever created in history. Normally, vaccine research and development can take as long as 10-15 years. COVID-19 vaccines were developed in less than 12 months, without compromising safety—the vaccines were built on decades of existing research and the testing process did not skip any steps. Despite this breakthrough, vaccine inequity has persisted. Only 24% of people in low-income countries have received at least one dose. 

6. World’s first malaria vaccine approved 

After 100 years of research and clinical trials, the world’s first-ever malaria vaccine was approved by the World Health Organization in October 2021—a historic moment that marked a turning point in the fight against the deadly disease, which kills about 500,000 people each year. Questions remain about cost and access to the vaccine, but its approval has the potential to change the course of global health.

Herlinda Basilio, now a midwife, still remembers the first birth she witnessed.

"I'm the oldest of three sisters," says Basilio, who now works with Partners In Health, known in Mexico as Compañeros En Salud. "When I was about 7 years old, my youngest sister was born, and I wanted to see it. I wanted to watch the birth happen."

Because of her young age, Basilio was not able to see the entire birthing process. But she was able to see the care provided by her grandmother, before and after the birth. She remembers something else about that day, too: her grandmother waited for the placenta to come out and then buried it next to a fig tree.

It was a tradition linked to her Purépecha heritage. The Purépecha are one of 68 indigenous groups in Mexico. Most live in the northwestern Michoacán region, where Basilio grew up. Her parents were artisans, making bells and wicker mats that they sold at local markets. The family wore traditional clothes, and Basilio and her sisters grew up speaking Purépecha at home—not Spanish.

Over 7.3 million Mexicans speak indigenous languages, representing 6% of the country's population. More than half of this population lives in indigenous regions. However, most of these municipalities are impoverished, making access to education far from a guarantee, especially for girls.

Basilio knew from a young age that she wanted to go to school. Witnessing the birth of her sister and her grandmother’s caregiving inspired her to set her sights on a career in health care.

Breaking Barriers

She first started nursing school at Patzcuaro, an hour from her home.

It was a tough transition.

"My native language is Purépecha. So at first, I got tired of speaking Spanish all day," she recalls. "It was also difficult because my classmates would see my family, [including] my mom [and] how she was dressed in traditional skirts, and they would ask me why she was dressed like that."

The microaggressions went beyond the classroom.

"Once I did rotations in a private hospital. I felt like they treated me differently,” she says. “They asked me what I was doing there, if I was indigenous. They wouldn't let me see patients.”

Basilio was far from alone in her experience.

Mexico’s National Institute of Statistics and Geography found in 2020 that 24% of the indigenous population in Mexico had experienced at least some type of discrimination, because of their speech, clothes, or religious beliefs. Those patterns extend to the health care field as well, where health workers of indigenous descent routinely experience discrimination, offensive comments, and mistreatment.

As Basilio continued to study nursing, coming to terms with the discrimination, she had another revelation. Nursing wasn’t what she truly wanted to do. She wanted to deliver babies. Halfway through her studies, she learned about a school called Mujeres Aliadas and met with the director. The meeting inspired her to change her educational path and study professional midwifery.

She still vividly remembers the first time she was present at a birth as a midwifery student. It was a dream she had long had: to be able to accompany someone during such an important moment. She, along with her classmates, prepared the space to tend to the woman who would give birth that day. They massaged her belly and prepared a tub with water and herbs.

"My more experienced colleagues were the ones in charge of attending the birth, but I was accompanying them and I was surprised,” she says. “[I realized] this is what I like. I discovered that this was my place."

‘This is my dream’

Now, Basilio is a midwife with Compañeros En Salud, as Partners In Health is known in Mexico. Her work at Casa Materna, a maternal health center in Jaltenango, is far from her home in Michoacán. But her cultural and medical knowledge guide her work every day.

"For me, midwifery means something very beautiful, because it's accompanying women during this process," she says. "It's being able to give her the freedom to choose in which position she wants to give birth, who she wants to accompany her...and every woman's story is different."

She is completing her year of social service, mandatory for all students in Mexico, with Compañeros En Salud. She then plans to return to her hometown, San Andrés Tziróndaro, to support the women in her community.

Each year, Compañeros En Salud accepts 10 first-year clinicians—including doctors, nurses, and midwives—as part of its pasante program. The program aims to strengthen health systems by providing training and mentorship to young clinicians across Mexico who come to live and work in Chiapas for one year.

At Casa Materna, Basilio spends her days meeting with mothers to discuss pregnancy and birthing, preparing labor and delivery rooms to meet their needs, and learning from the professional and traditional midwives on staff. And she does what she loves most of all: she delivers babies.

"I feel proud to be a midwife,” she says. “This is my dream. And I want to accompany each of the women I have the opportunity to care for."

As an organization that believes passionately in bringing the benefits of modern medical science to those most in need of them, PIH is cautiously optimistic after hearing today that Johnson & Johnson plans to work with the Global Drug Facility, a United Nations-based procurer of medications for public health systems around the world, to open the doors to generic medication for tuberculosis. A few hours ago the Stop TB Partnership, an organization which runs the Global Drug Facility, posted a blog saying J&J had given the Facility approval to purchase and supply generic versions of bedaquiline, a key drug in treating tuberculosis, to “the majority of low-and middle-income countries.” If J&J lives up to the spirit of this agreement, bedaquiline will lower prices of TB treatment, make treatment more accessible to people, and save lives. 

Many partners and friends have recognized the need for increased access to bedaquiline—TB kills some 1.6 million people each year, making it the most deadly infectious disease in the world—and have pushed for urgent action, including author and PIH trustee John Green and the Nerdfighteria community. At PIH, we will build on the work we’ve done as TB activists and clinicians—publicly and privately calling on J&J to increase access to bedaquiline, running two global clinical trials to make sure bedaquiline is prescribed in the most optimal way, and more.

While optimistic, we will not be ready to celebrate until J&J takes steps to ensure access. First, J&J needs to formalize its commitment to equitable access to bedaquiline by making the details of the Stop TB deal public, including specifics about eligible countries, quantities, and indefinite duration. Second, we must maintain solidarity with people suffering from TB. Despite a positive step today, the same cruel pharmaceutical system remains. Companies can still get patents for fake “innovations,” can still privatize publicly funded research and development, and can still put profits over patients. Whatever comes of the promised deal, PIH will keep working to address these systemic inequities and advance long-term solutions in the fight against TB.

It is late June, and farmers in Kirehe, a rural district in eastern Rwanda, are harvesting, cleaning, and packaging yellow and red peppers for transportation to the market. This achievement didn’t come easily: it is the result of a greenhouse, where carefully-planned conditions have helped the vegetables develop their ideal color, shape, and size.

This greenhouse, established in 2020 by Inshuti Mu Buzima, as Partners In Health is locally known, is specifically aimed at addressing food insecurity and creating sustainable sources of income for impoverished families. Farmers enrolled in the program include those with chronic illnesses and those with young children suffering from malnutrition.

One of the farmers at the greenhouse is Anthonia Nyiransengiyaremye, 61, a single woman who found herself caring for her malnourished grandchildren after her daughter was diagnosed with HIV and moved out.

“When my daughter found out that she was sick, the news took a toll on her mental health,” said Nyiransangiyaramye. “She moved far from the neighborhood to start a new life, leaving me with two babies, aged 9 months and 3 years old.”

Nyiransengiyaremye struggled to provide for the babies for several months. Then, she visited the local health center for a workshop on nutrition and learned of a new resource: a farming collective called the Twitezimbere self-help group, supported by Inshuti Mu Buzima. (Twitezimbere translates to "self-empowerment" in English.)

The group provided her and other members, selected based on financial and health needs, with stable access to food and cash to support their households. Inshuti Mu Buzima supports 148 similar groups with 1,744 members and 5 cooperatives with over 733 members in Burera, Kayonza, and Kirehe districts in Rwanda. Members of these groups are involved in agriculture, livestock rearing, crafts such as basket-weaving, and financial savings, among other activities.  

Nyiransengiyaremye and other members were given livestock and received training sessions on various topics, including modern farming techniques. They expressed a desire to focus more on agriculture. In late 2020, Inshuti Mu Buzima constructed a greenhouse for the group, provided seeds, organic manure, and pest control, and even hired an agronomist to mentor the farmers. 

“This greenhouse is a great resource,” said Nyiransengiyaremye. “The crops we cultivate in this greenhouse grow well and the harvest is sold well on the market.”

Climate Resilience

Producing crops and growing families’ income aren’t the only outcomes of the greenhouse. It’s also a way to build resilience to climate change.

This modern farming initiative in a rural community exemplifies how Inshuti Mu Buzima, through its Program on Social and Economic Rights (POSER), strives to break the cycle of poverty and illness by building farmers' resilience to climate change. Located in the eastern province, the hottest part of Rwanda, Kirehe has experienced changing weather patterns over the past several years that have disrupted the traditional agricultural seasons. Small subsistence farmers like Nyiransengiyaremye, who depend solely on natural conditions for crop cultivation, have been particularly affected. 

Rwanda's agricultural seasons are typically divided into two main cultivation seasons: the first season runs from September to January and the second season from February to June. During the dry season between June and September, the scorching heat and dry soil mean that farming is only possible with irrigation—a labor-intensive task that involves fetching water from streams downhill and carrying it up the mountain to the fields. However, many members of the Twitezimbere group lack the strength and money required for this method.

Even during the cultivable seasons, a single climate shock such as heavy rains can devastate entire crops, jeopardizing the livelihoods of farmers and their families. In May, for example, heavy rainfall caused floods and mudslides that resulted in the loss of 130 lives, as well as destruction of houses and crops in different parts of Rwanda.

Jeanne D’Arc Murekatete, Inshuti Mu Buzima's livelihood manager, explains that as farmers achieve economic stability through agriculture, they can access essential needs.

“Our farmers pay health insurance on time,” said Murekatete. “Even when they are sick, they can afford the cost of treatment and medication because they have savings from the fruits of their labor.” 

She also highlights that bringing farmers together regularly plays a key role in building a sense of community and supporting their mental health, especially for those who struggle with depression. 

Projects like the greenhouse and farming groups also serve as a financial safety net for communities, enabling farmers to generate income from their harvests and use the funds for essential services such as education, quality housing, health care, and food.

“We used to provide direct support like food packages, “said Murekatete. “But now we don’t have to, because they pay for it using the money they make.”

As the members of Twitezimbere wind down a busy day of harvesting, they have successfully harvested 603 pounds of peppers which will be sold at nearby markets and in bigger cities like Kigali.  

“We are thinking of planting peppers again because it is a good cash crop,” said Nyiransengiyaremye.

In the past 50 years, global health has seen medical and scientific breakthroughs, from the eradication of smallpox to dramatic declines in AIDS-related deaths to the approval of the first-ever malaria vaccine.

But glaring inequities persist—realities that are as alarming as they are steeped in history, namely centuries of colonialism and war that left countries in the Global South impoverished and millions worldwide without access to health care.

In many communities where PIH works, the nearest clinic is several hours away, only accessible by dirt roads. Doctors must prescribe medications that aren’t available in their community or even countrywide. Mothers must give birth by candlelight when the power goes out.

For more than 30 years, PIH has been on the forefront of a global movement to fight these inequities—training thousands of local doctors and nurses, funneling resources to government-run hospitals and clinics, enlisting community members to provide basic health services, and advocating for policy change at the local, national, and global levels.

Despite the immense progress of the past decades, PIH’s fight for global health equity remains as crucial now as ever.

Below are six facts that highlight the startling extent of global health inequity:

1. Sierra Leone—a country of 8 million people—has only 3 psychiatrists.

Sierra Leone, a West African nation that has endured colonialism, the trans-Atlantic slave trade, and civil war, has only 3 psychiatrists for its population of over 8 million. The country also has only one hospital dedicated to mental health care: PIH-supported Sierra Leone Psychiatric Teaching Hospital.

2. 1 in 6 adults in Mexico live with diabetes.

Diabetes is one of the leading causes of death in Mexico. PIH, known locally as Compañeros En Salud, is enlisting the help of community health workers to respond to diabetes and other noncommunicable diseases in the rural, mountainous Sierra Madre of Chiapas. Community health workers are local residents hired and trained to provide medications, emotional support, accompaniment to appointments, and other health services.

3. Before 2011, cancer care was virtually nonexistent in Rwanda.

Just a little over a decade ago, cancer care was nearly nonexistent in Rwanda, leaving patients with nowhere to go for care and treatment, including chemotherapy. In 2011, PIH broke ground on Butaro District Hospital in partnership with the Ministry of Health and, the following year, opened Butaro Cancer Center of Excellence. These programs have since enrolled more than 14,000 patients and provided care for over 20 types of cancer.

4. 1 in 4 people in the world have tuberculosis.

Tuberculosis is the world’s deadliest infectious disease, despite treatment being available in wealthy countries. As part of the endTB project, PIH has continued its decades-long TB work by helping patients access shorter, less toxic treatment regimens through observation studies and clinical trials. The project works in 17 countries where the multidrug-resistant form of the disease is prevalent, including Peru, Lesotho, and Kazakhstan.

5. 50% of people around the world lack access to essential health care.

At least half of the world’s population lacks access to basic health services, such as immunization and family planning. PIH’s medical care and social support are crucial to helping patients access the care they need, from community health workers knocking on doors to mobile clinics visiting rural communities. Also critical is PIH’s partnership with governments to strengthen public health systems and advocacy at the local, national, and global levels.

6. 94% of maternal deaths occur in low- and lower middle-income countries.

The vast majority of maternal deaths happen in the Global South. In Sierra Leone, for example, a woman has a 1 in 20 lifetime risk of dying in pregnancy or childbirth. These inequities make maternal health vital to PIH’s work around the world, from lifesaving c-sections to facility-based deliveries to dignified childbirth with traditional midwives.

Partners In Health (PIH) announced that the organization’s University of Global Health Equity (UGHE) in Rwanda was ranked 8th in the Sub-Saharan Africa University Rankings by Times Higher Education.

This inaugural ranking included 117 universities from across sub-Saharan Africa, with a final ranking of 88 institutions. Times Higher Education developed these rankings to evaluate universities' impact in addressing the most pressing challenges faced in the region. The methodology assessed five key pillars: resources and finance, access and fairness, teaching skills, student engagement, and Africa impact. Universities and students collected the data directly through surveys, and bibliometric data was provided by Elsevier.

UGHE earned second place in the “Africa Impact” metric, which measured African research citations, African research co-authorship, policy, lawmaker outreach, and education. This ranking underscores UGHE's significant contributions to research on the African continent.

Times Higher Education’s recognition of UGHE as a Top 10 Sub-Saharan Africa University is a testament to the leadership, faculty, staff, and students at UGHE and their unwavering commitment to providing high-quality education and research, as well as improving health outcomes and social systems. 

"This is a testimony of the extraordinary vision of our founder, Dr. Paul Farmer, the unwavering commitment to excellence of our staff, and the unique environment Rwanda offers as a country,” said Dr. Joel M. Mubiligi, UGHE vice chancellor and executive director of Partners In Health Rwanda.

PIH launched UGHE in 2015 with the support of the Cummings Foundation, the Bill & Melinda Gates Foundation, and the Government of Rwanda. The campus operates alongside PIH-supported Butaro District Hospital, the first district-level teaching hospital in the country.

UGHE and the hospital are accelerating collective efforts to increase the number of health care workers in Rwanda and around the world. At the current pace of growth, it will take three decades for the global health workforce to expand enough to meet people’s basic health needs, according to the World Health Organization.

This month, Partners In Health United States (PIH-US) released a policy paper providing recommendations to state policy makers on how to establish more sustainable funding for community health workers.  

Community health workers form the backbone of PIH’s work across the globe, and are central to our vision for equity-centered public health systems in the U.S. While this crucial workforce has too often been underfunded and under supported, many states have begun to integrate community health workers into their Medicaid programs. As a public health insurance program administered by states, Medicaid covers many Americans, including low-income individuals and vulnerable populations. While community health worker services can be beneficial to everyone, community health workers are particularly effective in supporting populations more likely to be covered by Medicaid. State policymakers are increasingly recognizing the crucial role community health workers play in promoting health equity and have started integrating this workforce into Medicaid programs by utilizing existing policies to fund their services. 

Our new policy paper examines best practices from states and recommends five key principles that every state can follow to fund community health workers through Medicaid and promote health equity. This tool provides key reference information for PIH-US and our partners and can be used for advocacy. The recommendations in this paper were informed by our work with community health workers around the world and in the U.S., as well as by national partners and experts. We aim for this tool to actively contribute to supporting sustained investments in community health workers by recognizing their value, preserving what makes them unique and effective, and promoting community health worker leadership in policy-making processes. 

By following these recommendations, state policy makers can more effectively support community health workers and leverage their expertise to promote health equity and improve health outcomes in their communities. 

Download the policy paper

On April 19, over 80 community health workers from 24 counties across North Carolina descended on the state’s capital, Raleigh, for an Advocacy Day to educate representatives about their profession and make their voices heard throughout the halls of power. After arriving a bit nervous, Monique Onema, a certified peer support specialist and community health worker from Cabarrus County, felt encouraged after she was able to help her representative reframe his perception of community health workers.  

“[My elected official] was telling me how he was helping a gentlemen get housing and get into treatment, and I explained to him that’s exactly what we do too. I said, ‘See, you’re a community health worker too,’” explained Monique. 

For advocates like Monique, this trip to the capital came at a time of uncertainty. As the federal government discontinues funding supporting state-led public health programs launched in response to COVID-19, Monique and her colleagues fear that the key social supports they’ve been demanding for decades – services like housing support, healthy foods, and public transportation - are once again at risk.  

Over the last three years, North Carolina has invested roughly $75 million dollars of pandemic funding into training, certifying, and employing nearly 800 community health workers to support the COVID-19 response in the most rural and underserved areas of the state. This investment helped community-based organizations and local health systems develop outreach and social support programs for thousands of people affected by the pandemic. Without additional investments, there is no clear path to ensure this critical work continues. Community health workers are key trusted messengers, system navigators, and health equity champions. That’s why PIH-US and our partners are mobilizing community health workers as we encourage decision-makers to champion policies and initiatives that prioritize this essential workforce.  

Since PIH-US' initial engagement in North Carolina in May 2020, we have supported a growing network of public health implementers and community-based organizations like Monique’s to elevate community health worker voices at the state and federal levels. As a strategic thought partner and advisor to North Carolina’s Department of Health and Human Services (NCDHHS), the North Carolina Community Health Worker Association (NCCHWA), and additional partners within the NC Community Health Worker Initiative, PIH-US works to strengthen the statewide infrastructure for community health workers including training, certification, employment, and systems integration, while also developing sustainable financing mechanisms to assure the long-term success of this workforce.   

Organizations like NCCHWA, which co-hosted the Advocacy Day with PIH-US in April, are elevating the impact of this workforce on communities across the state and urging legislators to support plans to sustainably integrate community health workers into North Carolina’s public health infrastructure.  

“Community health workers were spotlighted during COVID-19, but we’ve been here for decades. We are the bridge between underserved communities and health systems, ensuring that families across North Carolina have the resources needed to not just survive, but to thrive,” says Honey Estrada, NCCHWA’s president and a proud community health worker. “The work we do is valuable and needs to be respected as such.” 

This drive to raise awareness is what led to such a strong turnout for the Advocacy Day in Raleigh, where community health workers were able to meet with over 50 elected officials. In addition to meeting with state legislators, community health workers had the opportunity to connect with peers from across the state and share their experiences.  As Josymar Garcia, a member of the U.S. Army reserve and a community health worker from Kinston, North Carolina, put it, "We're the frontline workers. We’re the ones going into people’s homes and going into the migrant camps. We’ve got to stick together.” 

To prepare community health workers like Josymar and Monique for the Advocacy Day, PIH-US and NCCHWA hosted a series of trainings on legislative advocacy to ensure that attendees felt comfortable and confident sharing their stories and advocating for their communities to policymakers. After meeting with his local representatives, Josymar told us, “Coming from a Hispanic background, it’s not very often we’re able to spread our voices. Being able to advocate for the people that we serve, both Hispanics and other ethnicities, made us feel really good. It was awesome to be able to speak to them in person.”  

NCCHWA is hoping that advocacy efforts like Josymar’s lead to concrete policy change at the state level. “We’re in conversations with decision-makers about the state budget and how community health workers fit into the fabric of North Carolina’s public health system. We’re hoping to continue working with our partners at NCDHHS and the General Assembly to craft a sustainable and integrated role for community health workers to continue supporting communities across North Carolina,” said Honey.  

Looking forward, PIH-US is supporting community partners to build out these advocacy efforts and implement health equity initiatives across North Carolina. As for Monique, she plans to continue to share her experience to inspire action.   

“Advocacy is a hugely important part of the work that we do,” she said. “We are the voice for others when they can’t have a voice themselves – and I am so proud to be a part of it.” 

Content warning: this story contains mention of child sexual abuse and violence against transgender women

When Alexia*, 26, first arrived in Lima she was disappointed. She didn't like the cooler weather, and the thought even crossed her mind to return to Pucallpa, a city in the Peruvian jungle where she had lived before.

"What I missed most was making money,” she says. “The cold didn't let me work."

During her first winter in Lima, she had to wear two jackets to endure the cold as she stood on the streets, waiting for clients.

More than 62% of transgender women in Peru are engaged in sex work, due to a lack of employment opportunities, according to Peru’s Ombudsman’s Office.

Alexia is one of them.

She was forced into sex work at the age of 11, when she was still living in her native Iquitos. There, her days were split between a family at home that did not accept her and a shelter for children and adolescents from which she had to escape for safety reasons.

"I practically grew up alone," she says.

She arrived in Pucallpa at 15 years old. That’s when Alexia, assigned male at birth, started taking hormonal contraceptives, as a gender-affirming method due to lack of access to hormone therapy, to begin her transition.

Unexpected Diagnoses

In Lima, 86% of transgender women have faced discrimination, and more than half experienced domestic violence. That violence and discrimination is not only reflected in the limited employment opportunities or family rejection that transgender women face, but also in their limited access to health care, often due to their lack of identity documents that match their gender. Many are unaware of health conditions that they are living with, including sexually transmitted infections (STIs).

That’s one of the urgent issues that Socios En Salud, as Partners In Health is known in Peru, is responding to through JunTrans, a community-based intervention that seeks to improve access to health care for transgender women in Lima.

Free screenings are critical to that mission. JunTrans screened more than 400 transgender women for STIs, tuberculosis and mental health disorders between July 2022 and March 2023 by running mobile clinics and visiting homes for transgender women in Lima.

Alexia was among the women who accessed free screening in December 2022, previously unable to access any health services due to her lack of identity documents. The results were not what she expected: she tested positive for HIV and tuberculosis.

She describes the whirlwind of feelings that swept over her as like a bucket of cold water.

"I didn't feel like working,” she recalls. “I was disgusted by men—angry."

Fear, anger, and other complex feelings are common with such diagnoses, according to Carla Rodríguez, coordinator of JunTrans. It’s why the program goes to great lengths to connect patients not only with care for their physical health conditions, but also mental health care and social support, such as food and safe housing.

"We can want many things [for them], but we cannot pressure the person," she says.

After her diagnoses, Alexia was immediately connected with psychotherapy delivered by mental health specialists from the JunTrans team. Over time, as she processed her feelings over several sessions, she came to terms with her conditions, realizing how many people lived full, beautiful lives while managing their conditions.

"I'm not the only person in this world who has it," she recalls thinking. "So why should I be crying or getting depressed?”

She then agreed to start treatment, which included antiretroviral treatment for HIV and oral medication for TB. She was also assigned a community health worker for support and accompaniment.

‘A beautiful stage in my life’

Alexia considers herself a romantic girl. She likes ballads that talk about love, and in her room in downtown Lima, heart-shaped stuffed animals are everywhere.

She says that the room she previously rented, located inside the same house where she now lives, was bigger and had the perfect amount of space for all the dolls and stuffed animals she wanted. When she changed rooms, she had to get rid of many of those things. 

"It hurt me to sell a lot of things," she confesses.

She’d had to leave the first room as fast as possible, fleeing to Huánuco as a wave of violence against transgender women swept through downtown Lima in February. Girls she knew, including others supported by JunTrans, were murdered by an organized crime group that charged quotas to trans women for working on the streets.

The violence not only put Alexia’s life in immediate danger, but also affected her health, as she was forced to leave her supply of medications behind.  

Alexia has since returned to the house and is now in stable health, following her antiretroviral treatment to the letter and resuming her treatment for tuberculosis.

In the meantime, the JunTrans team is helping her to obtain her ID card, which she has never had before. She already has big plans for the future, once her identity documents are in order.

"God willing, I'm going to another country.... Italy or Paris [France]," she says.

Having access to health care, and a path to get her ID card, has allowed her to dream again. Now, Alexia is at peace with herself, confident that her health will open new doors. 

"I'm in a beautiful stage of my life," she says.

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

*The patient's name has been changed for safety reasons

In the midst of political and economic insecurity and widespread violence, why is Zanmi Lasante (ZL), as PIH is known in Haiti, focusing on expanding and improving its solar power system? The answer is clear: The collaboration between ZL and Build Health International (BHI)— to replace and improve the solar panels atop Hôpital Universitaire de Mirebalais (HUM) —is key to energy self-sufficiency at the site, allowing for a stable, reliable source of electricity.  

The project will lead to increased functional independence, so the medical team can think less about non-negotiables (electricity, water, adequate facility space, etc) and more about providing patients with top-notch care. 

HUM already has a robust solar energy system, with 1800 rooftop panels delivering power. The new system more than doubles the solar production capacity and does not rely on the national grid. 

We spoke with members of the solar project team, including ZL Program Manager, Léonardo Virgo Charles; PIH Associate Director of Facilities, Forrest Shroyer; and HUM Facility Manager Dieudonne Fanfan to find out more about the plans. Here, edited and condensed, are their answers.   

What’s the main rationale for this project? 

Recognizing the vulnerabilities caused by HUM’s dependence on fuel-powered generators, the new solar system serves as a promising solution. Haiti’s current insecurity means that roads are often blocked, so accessing fuel is sometimes impossible. Other times, fuel might not be available at all or it is outrageously expensive on the black market. By harnessing solar energy, HUM will significantly reduce its reliance on fuel and the associated challenges of obtaining and maintaining a steady supply. 

How will the new system improve energy delivery? 

The project will more than double the current solar production capacity, from 509 kWp (kiloWatt-peak) to 1,316 kWp, and reduce a projected 2,298 tons of CO2 from hospital emissions annually. This will reduce reliance on HUM’s generator, leading to an estimated annual savings of $820,000 per year from solar alone, which can then be redirected to serve patients. Additionally, savings from the installation of high efficiency lighting and other improvements is estimated to add another $80,000 in annual savings. 

During the last year of instability, how often has HUM lost power to the point that it impacted hospital operations?  

During the past year, the escalating gang violence and instability in the region have posed challenges in obtaining an adequate fuel supply to power the hospital's generators, not to mention the fact that the power on the national grid is unstable, causing HUM to rely exclusively on diesel-powered generators.  

Consequently, the hospital encountered power loss due to these circumstances approximately four to five times in November and December of 2022. Most of these outages were relatively short, lasting between one to two hours. However, there was one particular instance where the hospital endured an extended outage lasting nearly seven hours. All hospitals and services were interrupted. At that point, everyone at the hospital was mobilizing to find fuel and smaller generators to support critical services. 

These power outages have had a significant impact on the hospital's ability to provide uninterrupted care to patients. Critical medical equipment, such as life-support machines and refrigeration units for medication storage, rely heavily on a stable power supply. 

How will the new solar project help doctors, medical providers, and patients at HUM?  

The new solar project reduces the number of hours necessary to run the generators from 24 hours per day to 4 or 5 hours per day. The main points here are accessing a more reliable power system and huge savings on fuel.

From a medical standpoint, the solar system will provide consistent and high-quality power supply to support biomedical equipment and critical HVAC systems. Biomedical equipment, including lifesaving devices and diagnostic tools, requires a stable power source to operate effectively. By eliminating power disruptions, the solar system enhances the ability of doctors and medical providers to diagnose, treat, and monitor patients, thereby improving the overall quality of care. 

Moreover, the solar system's reliable power supply directly benefits patients. It ensures uninterrupted access to lifesaving essentials such as oxygen supply and other critical medical needs. This is particularly important for patients with severe health conditions who depend on life-support equipment or require constant medical attention. 

How many workers were hired for this project, and what percentage of them were Haitian? 

For this project, BHI has a dedicated workforce consisting of approximately 50 individuals per day, spread across the electrical and masonry crews. It is worth noting that an overwhelming majority, around 98%, of the workforce are Haitian nationals. 

What else is important to know about this project and why it aligns with PIH’s mission? 

Building solar capacity at HUM and across our sites deeply aligns with PIH’s mission because: 

--It ensures that lifesaving services continue despite fuel shortages around the country; solar capacity will ensure that critical services requiring electricity can continue even when other surrounding facilities and in Port-au-Prince can’t function; 

- Mindful that the climate crisis greatly impacts global health, we are working to reduce our carbon footprint;  

- Investments now lead to cost-savings. For example, our site at Belladere has been fully solarized since February 2023 and the need to transport fuel has been significantly reduced (fuel consumption reduced by 70%); enabling us to save money for fuel and put it towards patient services such as women’s health, nutrition, or oncology, among others. 

With this additional solar power and upgrades to the system, how will you manage storage?  

The new system includes 12 large Tesla battery cabinets which will be used for energy storage.  

As mentioned above, HUM relies exclusively on diesel-powered generators and has been disconnected from the grid for at least 8 years. Therefore, no power will be collected from the grid. 

When will the new solar power system be complete? 

Currently, we are actively engaged with BHI in the installation of the new solar system. The new system will likely be ready for use in the coming months.  

About half of Partners In Health’s (PIH) clinical workforce are nurses and midwives, mirroring global trends.

Midwives, in particular, are vital to women’s health. The care they provide helps women with the spiritual, psychological, and physical experiences of childbirth and motherhood. 

In Sierra Leone, PIH is honored to work with 14 midwives that support mothers from preterm care to postpartum care at PIH-supported Wellbody Clinic and Koidu Government Hospital (KGH) in Kono District. These midwives, in partnership with PIH, work to reduce maternal mortality across the country. 

Meet midwives Aminata Kamara and Harolda Onike, who share more about their work below.

Aminata Kamara

Aminata loves being part of a mother’s journey. A special bond is created between mothers and midwives, she says, that spans from the early weeks of pregnancy to postpartum care.  

And for her, the most joyful moment is “when you hear the baby cry, affirming that you have delivered a healthy baby and a healthy mother.”

Aminata has come a long way. The 34-year-old former nurse was once afraid of delivering babies.

With mentorship from colleagues and hands-on experience at KGH, she has since faced that fear. She has delivered more than 200  babies since 2019, when she began working as a midwife.

In the future, Aminata hopes that midwife training becomes widely available across Sierra Leone and that there is at least one midwife for every pregnant woman. Right now, she cares for about five or six women in labor at the same time. Across the country, she’s one of fewer than 500 midwives. Another part of her job is to investigate maternal deaths to determine the cause. Simultaneously, she finds ways to support grieving families.

It’s a challenging job, but also rewarding—especially when babies are delivered safely. Building relationships is a key part of the work. In fact, Aminata often runs into former patients while shopping at the local market. 

“They approach you with so much gratitude, saying ‘oh sister, you are the one who delivered my baby and they are so big and healthy now,’” says Aminata, noting that sometimes the women give her food to show appreciation. “Moments like these are priceless and affirm how special the support of midwives truly are.”

Harolda Onike

Since she was a child, Harolda Onike has admired her grandmother’s work as a midwife. It inspired her to pursue midwifery, too, and ultimately find her “spiritual calling.” 

“The most beautiful thing is bringing a life into this world,” says Harolda, a midwife in KGH’s maternity ward. “It gives me so much passion to safely deliver a baby into the world without complications."

On a typical day, Harolda supports the delivery of ten babies during her 12-hour shift—from 8 a.m. to 8 p.m. The deliveries are usually a mix of natural births and scheduled and emergency C-sections.  

Recently, she supported a lifesaving delivery. A first-time mother was referred to KGH by a smaller clinic. Upon arrival, she was diagnosed with obstructive labor pains and was making minimal progress. At one point, the baby wasn’t breathing; the mother was given an IV, among other types of care. Within an hour of arriving at KGH, staff began an emergency C-section and the mother delivered the baby—but it still wasn’t breathing. With the support of the special care baby unit staff, Harolda and her colleagues resuscitated the baby. Both mother and baby are now happy and healthy.  

Stories like this—and seeing Sierra Leone’s progress in maternal health care—are what gives Harolda hope. In particular, she looks to the Maternal Center of Excellence, which broke ground in April 2021 and will provide advanced maternal and child health services in Kono District and beyond. 

“With that structure, people all over the country will be able to access free and quality health care,” she says.

Eight years into her career, she remains passionate about this work and supporting midwives. On a daily basis, she mentors junior colleagues, providing the same support she received early on. 

To current and future midwives, she says, “Keep the fire burning…although there are challenges, this is the most beautiful and fulfilling work.”

The United States has the highest maternal mortality rate of any high-income country, and this crisis is only worsening. Maternal deaths have increased by 40 percent over the last few years, Black women are three times more likely to die from a pregnancy-related cause than white women, and maternal mortality rates are nearly two times higher in rural areas than urban areas.  

More than 80 percent of these deaths are preventable. The structural racism and social and economic inequities that lead to poor maternal health outcomes in this country are preventable, too. 

Last month, the Black Maternal Health Momnibus Act, an ambitious legislative package that aims to solve the U.S. maternal health crisis, was re-introduced to Congress. More than 200 organizations, including Partners In Health, have endorsed this bill which calls for historic investments critical to addressing racial inequities in health outcomes, advancing maternal health equity, and building robust, community-led health systems. 

Below, we outline the provisions of the package and how you can take action. 

What is the Black Maternal Health Momnibus Act?  

The Black Maternal Health Momnibus Act is a comprehensive legislative package to solve the U.S. maternal health crisis and end racial and ethnic disparities in maternal health outcomes. Called the “Momnibus” for short, this package includes 13 evidence-based bills to address different drivers of the maternal health crisis, including bias in the health care system, investments in social determinants of health, and growing and diversifying the health workforce.  

The Momnibus package was introduced by the Black Maternal Health Caucus, a group of Congressional members working to establish Black maternal health as a national priority. Overall, the Momnibus includes more than $1 billion to help address systemic inequities that lead to worse health outcomes, particularly for communities that have high rates of maternal mortality and large maternal health disparities between racial and ethnic groups. 

What does the Black Maternal Health Momnibus Act include? 

“Omnibus” is a term for a legislative package consisting of multiple smaller bills. The historic Black Maternal Health Momnibus Act includes thirteen individual bills that will: 

• Make critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.  

• Extend the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligibility in the postpartum and breastfeeding periods.  

• Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity.  

• Increase funding for programs to improve maternal health care for veterans.  

• Grow and diversify the perinatal workforce to ensure that every mom in America receives maternal health care and support from people they trust.  

• Improve data collection processes and quality measures to better understand the causes of the maternal health crisis in the U.S. and inform solutions to address it.  

• Support moms with maternal mental health conditions and substance use disorders.  

• Improve maternal health care and support for incarcerated moms.  

• Invest in digital tools to improve maternal health outcomes in underserved areas.  

• Promote innovative payment models to incentivize high-quality maternity care and non-clinical support during and after pregnancy.  

• Invest in federal programs to address maternal and infant health risks during public health emergencies.  

• Invest in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies.  

• Promote maternal vaccinations to protect the health of moms and babies. 

How will the funding be disbursed? 

The funds are allocated across different programs to meet specific needs in maternal health. For instance, $100 million would go to community-based organizations, tribal organizations, Native Hawaiian organizations, or nonprofits that work with multiple community-based partners. The money can be used to hire and train staff, develop culturally and linguistically appropriate resource centers or materials specific to communities, create demonstration projects that address social determinants of health, and host community-led consultations. These funds will also give communities the ability to develop tailored plans  and build out culturally competent trainings. Funding will also be used to increase and diversify the nursing workforce in maternal and perinatal care, grow the doula workforce, and increase the maternal mental health and substance use disorder workforce. In addition, money will be allocated for grants that would allow educational institutions to train midwives, physician assistants, and others in maternal health.  

What progress has been made thus far? 

An earlier iteration of the Momnibus was first introduced in Congress in 2020. In 2021, Congress passed the Protecting Moms Who Served Act, making this bill the first piece of the Momnibus package to be signed into law. 

The reintroduction of the Momnibus is unlikely to garner enough support to pass in its entirety due to the current political climate, but Congressional champions are working to advance components of the package one bill at a time. This means that PIH can both advocate for the ambitious and visionary package as a whole, and pragmatically push for individual bills within the package at the same time. 

What can people do to support this? 

All moms deserve care and dignity in their health care, regardless of race or circumstances. Congress must work together to pass the entire Momnibus. 

Use this action tool to contact your members of Congress and tell them to support investments in maternal health. 

The phones keep ringing.

Some people call seeking assistance for their anxiety or depression. Others call for help with time-sensitive emergencies, such as domestic violence or suicidal thoughts. Regardless of the reason, they all call for the same purpose: to receive free, confidential support.

Until recently, that wasn’t an option. Mental health resources were scarce and not integrated with other services.

In November, Partners In Health (PIH) Sierra Leone, in collaboration with the Ministry of Health and Sanitation, launched the country’s first toll-free, mental health helpline. Since its inception, more than 430 people have called. 

The helpline is staffed 24/7 by psychosocial counselors and a community health officer manager in Kono District, a rural eastern region of the country. When a person calls the line for themselves or a loved one, they receive a range of advice and resources. This includes basic mental health tips, addressing mental health myths and stigma, and linkage to follow-up medical care. 

Such a helpline was much needed in Sierra Leone. With a population of more than 8 million people and only three psychiatrists in the country, mental health services have historically been nearly nonexistent and until recently, largely centralized in the capital, Freetown. For many Sierra Leoneans, transportation and lack of access are barriers to receiving life-saving mental health care. 

The mental health helpline and other initiatives—such as PIH-supported Sierra Leone Psychiatric Teaching Hospital—are working to change that.

A Historic Need

When asked what inspired the launch of the helpline, Chenjezo Grant Gonani, PIH Sierra Leone’s mental health program manager, shared that it’s important to consider how much suffering the country has gone through.

“Sierra Leone has been a country faced with a lot of devastation,” says Gonani, citing the country’s 11-year civil war from 1991-2002, the 2014 Ebola outbreak, the 2017 mudslides, and the COVID-19 pandemic. “Yet, despite all of these unfortunate events, access to mental health treatment and psychosocial services are still extremely limited, and 90% of people are still not able to get the support they need.” 

The helpline seeks to fill that gap. 

Originally launched during the COVID-19 pandemic in 2020, the line was designed for people quarantined at home or in isolation units. It was very successful  in offering immediate psychosocial support and linking people to care. So, the team brainstormed ways to expand the line beyond COVID-related scenarios. 

Before transitioning the line, the team did thorough research to set it up for success. Other organizations had developed similar lines, but they were short-lived. After a year of research, planning, and mobilizing resources, the line transitioned to a general mental health resource. 

During the first month, 250 people called. 

“Of course, we have had our challenges with the helpline,” states David Mafinda, a psychosocial counselor. “For example, during Christmas time we had a little boy call the helpline and ask us for a bike. Another asked us for money. While we are many things, I had to explain that we are, unfortunately, not Santa Claus,” he says with a smile.

Lessons Learned

Today, the phones continue to ring, and people are calling in hours away from Kono, the pilot area. They’re calling from Makeni, Kenema, Falaba, and Freetown, likely because family and friends shared the number. To respond to this growing need, the helpline team is actively documenting where calls are coming from to offer location-specific referrals and, eventually, to fully expand helpline services with dedicated staff for those regions. Their immediate priority is to expand to Kailahun District, where many referrals are coming from.  

It's a team effort. The mental health team is collaborating with PIH’s electronic medical records team to keep track of patient calls and the IT department to manage missed or dropped calls. The local mental health team also partners with PIH’s cross-site mental health team for technical advice and support.

As demand for services grows, more staff is needed. When the helpline started, there were originally four counselors. Now, there are seven. Judith Conteh, who has been on PIH’s mental health team since 2019, is one those counselors. 

“The weapon that I used to serve my country during the 2014-2016 Ebola crisis was my psychosocial skills,” Conteh reflects. “Over the years, I have maintained my strong passion for this line of work. Watching people cope with their challenges is so rewarding and is what keeps me going.”

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