As COVID-19 remains a threat worldwide, lifesaving vaccines continue to be inaccessible for the majority of the world’s population—including Indigenous communities in Latin America and the Caribbean. 

A new letter published in The Lancet Regional Health – Americas by researchers including Zeus Aranda of Compañeros En Salud, as Partners In Health is known in Mexico, calls for vaccine campaigns to address the needs of Indigenous peoples in these regions—historically marginalized communities that continue to be disproportionately impacted by global crises, from COVID-19 to climate change. 

The letter, titled ‘A call for COVID-19 immunization campaigns that address the circumstances of indigenous peoples of Latin America and the Caribbean,’ contends that Indigenous people have been neglected in national COVID-19 vaccine strategies in Latin America and the Caribbean, putting them at risk of a lack of vaccine coverage, even as COVID-19 continues to threaten the regions. 

“Most national immunization plans,” the authors write, “did not involve indigenous communities’ representatives in their development, and lack sociocultural appropriateness, use of indigenous languages, and consideration of the living conditions and socioeconomic adversities affecting these populations.”  

The letter also highlights the repeated violation of Indigenous peoples’ rights by public health workers, resulting in mistrust among some Indigenous communities and reluctance to use government health services. 

For more than a decade, Compañeros En Salud has worked to strengthen Chiapas’ health system in partnership with the Mexican Ministry of Health, focusing its efforts on making health services accessible for historically marginalized communities, including Indigenous peoples. Chiapas is home to about 14% of Mexico’s Indigenous population, as well as a destination for Indigenous people traveling north from Guatemala for seasonal work harvesting coffee in the Sierra Madre region.  

Compañeros En Salud’s pandemic-related work has included fighting misinformation around COVID-19 and strengthening access to vaccines and health information—measures that the letter outlines are critical for governments to consider when developing their vaccine strategies. 

The letter also calls for a breakdown of data that would show vaccination rates in Indigenous communities—evidence that would help health officials better understand the scope of the problem and find solutions. 

When developing vaccine strategies, the letter says, it is crucial for government authorities to respect Indigenous peoples’ rights to autonomy and self-determination—giving historically marginalized communities a seat at the table, listening to their needs, and trusting them to find culturally relevant and effective solutions that will save lives, one vaccine at a time. 

Tuberculosis, one of the world’s most deadly diseases, kills nearly 4,000 people per day and has a daunting list of physical symptoms—coughing, chills, weight loss, night sweats. But lesser known are its effects on mental health.

Studies have shown that tuberculosis often comes with mental health conditions such as depression—a reality that clinicians, psychologists, and social workers see first-hand in the parts of Kazakhstan where PIH works.

To tackle these challenges, PIH launched a mental health program in Kazakhstan in January 2020 to provide free, comprehensive mental health care to patients living with tuberculosis—furthering PIH’s mission to advance health care as a human right and ensure that patients can access care for their mental health and well-being. The program was established through the support of the Many Voices Collaborative in Community-Based Mental Health Care, a cross-site initiative begun in 2018 to support the development of mental health services across the countries where PIH works.

Psychological First Aid

Kazakhstan, a landlocked nation of 18 million in Central Asia, has one of the world’s highest burdens of multidrug-resistant tuberculosis (MDR-TB)—a variant of tuberculosis that is resistant to most medications. Despite the country’s economic growth since its independence from the Soviet Union in 1991, half of the population lives in rural, impoverished areas with little access to health services and MDR-TB has increased, putting patients’ physical and mental health at risk.

PIH has worked in Kazakhstan since 2010, focused on caring for patients with MDR-TB and XDR-TB, an even more severe drug-resistant variant of tuberculosis. That work spans 7 regions of the country and includes people who are disproportionately at risk of contracting tuberculosis, such as health workers and caregivers of TB patients. And it has continued amid COVID-19, with PIH working with the Ministry of Health to deliver food support, medications, and care for patients living with TB and HIV.

Many Voices is the latest chapter in PIH’s ongoing work in Kazakhstan.

Launched in January 2020, the project integrates mental health care into the tuberculosis response, providing counseling, monitoring, and food and transportation support to MDR-TB patients in their homes and at clinics, reaching those who would otherwise be untreated.

“The project provides psychological support and social services for TB patients,” says Serik Kozhabekov, coordinator of PIH's mental health program in Kazakhstan. “It takes into account the duration of patients’ MDR-TB treatment, as well as those who are most vulnerable, which improves adherence to TB treatment and treatment outcomes.”

One of the key tools of the project is psychological first aid: an intervention from the World Health Organization designed to help provide support to people in distress caused by emergencies and traumatic events—support that has been all the more critical during a pandemic that has killed more than 15,900 and infected 969,000 in Kazakhstan.

Reaching Patients, Saving Lives

Since its launch, the Many Voices Collaborative has strengthened mental health care for thousands of patients globally. In the first six months in Kazakhstan alone, the project served 29 patients, helping them care for their mental health and follow their TB treatment plans. By mid-2021, the project had served 114 clients from among the most vulnerable TB patients. As part of the COVID-19 response, the PIH team conducted 455 virtual mental health consultations with patients and their families and friends, visited 105 patients in person, and trained 238 health workers in psychological first aid—trainings that were held in Russian and adapted to local contexts. Because of partnerships with local nonprofits, 35 TB clients were able to receive social services from the government.

In addition to medical care, the team helped patients access food and transportation, through food vouchers and reimbursement for travel expenses—essential resources, also known as social support, that can make or break patients’ ability to access care, especially in impoverished areas where taxi fares and time away from work can wreak financial havoc on families already struggling to make ends meet.

This year, the team hopes to reach hundreds more patients with mental health care and social support. In early 2021, the project conducted psychological first aid trainings for 238 health workers in the cities of Almaty and Karaganda, equipping them to provide screening and care for depression and other mental health conditions among the patients they serve.

And leaders of the project hope these achievements are just the beginning.

The team plans to launch more programming in Karaganda, including trainings for health workers and psychologists in primary health centers. It also aspires to pilot a mental health intervention for adolescents, focused on suicide prevention and suicide outreach.

“Health professionals should have a common understanding that without mental health, there is no health at all,” says Kozhabekov. “We should strive to ensure that all people with mental health problems have an equal access to mental health diagnosis and mental therapy services.”

NJ Spotlight News: Newark nearly doubled its youth vaccination rate in two months. Here’s how. 

While much of the nation is struggling to increase vaccination rates, Newark, NJ scored a big win recently, nearly doubling its youth vaccination rate in two months, according to an article in NJspotlight.com.   

How did the city drive its share of vaccinated young people from 30% in July up to 55% in September? Here's how, according to Dr. Mark Wade, director of the city’s health department, and a PIH-US partner: 

The key, said Wade, has been meeting residents where they are. That has meant not only setting up vaccination clinics in schools and neighborhoods across the city, but also patiently listening and responding to residents’ concerns. “The availability of vaccines was not an issue,” he said. “It was literally convincing and assuring community residents that it’s safe, it’s effective, and worth doing — not only for one’s individual health, but to protect the community as a whole.” 

Read the full story here. 

Inside Philanthropy: With All Eyes on COVID Vaccination Rates, Funders Nationwide Battle Hesitancy and Inequity 

The Chicagoland Vaccine Partnership, a coalition of representatives from health care, government, academia, philanthropies and community and faith-based organizations addressing inequities in the region’s COVID-19 response, was featured in the recent issue of Inside Philanthropy. 

Max Clermont, the Senior Project Lead in Chicago for PIH-US, talked about the importance of the CVP’s new “rapid-response” grants that have allowed smaller, neighborhood-focused community organizations to pivot to equitable vaccine outreach. For example, Clermont describes a Chicago grantee that runs a food pantry and youth boxing program. The organization is now using its deep knowledge of and presence in the community to help get people vaccinated and provide accessible information on the virus.  

“This model can be expanded beyond COVID-19 to connect people with a wider set of public health resources,” Clermont said. 

Read the full article here. 

Naples News: ‘Who Is Going to Help Me?’ How a Florida Team Brings Healthcare to this Community 

If you want to learn more about community health workers, and the critical role they play in communities, check out this piece in the Naples News. The story follows an Immokalee, Florida, health worker (also called a health promotor) employed by a PIH-US partner in the region, through a typical day: 

Delivering food is one way health workers connect with sick residents in the immigrant-rich agricultural community of Immokalee, Florida, which was ravaged by COVID-19 last year. It creates an opening to see them in-person. Lopez Hernandez has found residents will say they’re OK even if they’re not. Another route to building trust is by guiding residents through systems they may be wary of to get the support they need. Lopez Hernandez dialed the Healthcare Network — the federally qualified health center that employs him and the rest of the COVID-19 response team — on speaker. A nurse consulted a doctor, who advised [patient] Gaspar go immediately to the hospital, a 30-minute drive away. "Do you have someone who can take you?" Lopez Hernandez asked. Yes, she said, her son. The woman blinked away tears. “Thank you so much for coming to see me, because I’ve been feeling like, who is going to help me?" 

Read the full story here. 

Montgomery: An Intentional Approach to Vaccination 

In a powerful op-ed co-written by Montgomery Mayor Steven L. Reed, and Cicily Gray and Grace Lesser of PIH-US, the authors discuss the nuances of meaningful engagement with community members when it comes to COVID-19 vaccines. They write: 

We’re making progress because we recognize that in large part, the vaccination challenge is not a one-size-fits-all approach: we have identified the different barriers to access and reasons why people have not gotten vaccinated. Improving vaccine access and equity means meeting people where they are. It means working with churches and community-based organizations to stand up vaccine clinics, integrating food distribution by trusted providers, offering gift cards on site, and responding to the plethora of economic and social needs through Patient Navigators and Community Health Workers. It means digging deep into the community.

Read the full piece in AL.com here. 

On October 5 and 6, Compañeros En Salud, as Partners In Health is known in Mexico, will bring together an array of health experts—from midwives to epidemiologists—for a conference on global health and social medicine in Latin America.

The conference, which will be held virtually and in Spanish, will convene experts from across Latin America to discuss a range of topics, including: the impact of COVID-19 on HIV care; the role of primary care services in guaranteeing reproductive autonomy; integrating mental health into primary care; and the history, trends, and future of community health in Latin America.

Additionally, the conference will explore Compañeros En Salud’s decade of work in the Sierra Madre region of Chiapas, examining how Compañeros has delivered care and resources for rural, impoverished communities and how that work can serve as a model for health services in rural communities across Latin America.

Conference organizers hope the event will connect health professionals throughout Latin America and spark engaging conversations, bringing the region one step closer to achieving the United Nations' goal of achieving universal health coverage by 2030.

Speakers will include Dr. Eliette Valladares Cardoza of the World Health Organization, Dr. María del Rocío Sáenz of the University of Costa Rica and Costa Rica’s former Minister of Health, Elsa Santos of the United Nations Population Fund, Laura Sánchez of the National Institute of Epidemiology in Argentina, and Dr. Jimena Maza of Compañeros En Salud.

This page will be updated regularly.

September 24

Now more than a month past the August 14 earthquake, Partners In Health (PIH) is transitioning from emergency response to recovery across Haiti’s southern peninsula while supporting mobile clinics, helping local partners obtain needed supplies and medications, and preparing for the reintegration of patients directly served at Hôpital Universitaire de Mirebalais. 

Meanwhile, PIH teams are advocating for justice for repatriated Haitians forcibly removed in recent days from the United States-Mexico border. In collaboration with human rights and advocacy organizations, PIH has called on President Biden’s administration to stop the unjust and inhumane detainment and removal of Haitian migrants from the border near Del Rio, Texas, where more than 14,000 Haitian migrants have arrived in recent weeks after traveling—sometimes for years—through Central America and Mexico in search of asylum.

Seven daily flights have left in recent days, carrying hundreds of Haitians back to the capital of Port-au-Prince and Cap-Haïtien, the largest city along Haiti’s northern coast. This influx of repatriated Haitians has led to heightened nationwide security concerns.

Simultaneously, the team at Zanmi Lasante, PIH’s sister organization in Haiti, has experienced challenges with safe transfer of staff and supplies to the earthquake zone, depending solely on air transport for movement. Partner hospitals also express concern they may run out of supplies and medications should the situation remain unstable.

Nonetheless, PIH’s global supply chain and logistics team is preparing the next flight to Haiti, which will arrive on October 3 and carry ultrasound equipment, orthopedic products, and other supplies essential for the earthquake response.

Zanmi Lasante leadership will soon complete a plan with Haitian government leaders in each of the three departments impacted on how best to continue to support the running of short-term mobile clinics, which Zanmi Lasante and partners are using to bring medical care and attention to remote communities throughout the Grand’Anse, South, and Nippes departments. Meanwhile, the team has noted that international crisis response is slowing down. Several first-response organizations have packed up operations—from those providing medical care to the delivery of hot meals—and left communities and government officials scrambling to fill the void.

Zanmi Lasante, however, remains a firm and reliable partner. Close to 99% of staff is Haitian; they continue responding to the needs of their neighbors, friends, colleagues, and families.

Across the lower Artibonite and Central Plateau regions—where Zanmi Lasante provides the majority of its care, COVID-19 vaccinations are rolling out across hospitals and clinics for the general population. In the United States, PIH continues to urge the Biden administration to provide a steady supply of donated vaccines to the Haitian government.

Care continues for earthquake survivors airlifted to Zanmi Lasante’s Hôpital Universitaire in Mirebalais. So far, 31 patients have received specialized care for injuries resulting from the August 14 quake; seven of whom are now awaiting discharge.

August 31

While Partners In Health collaborates with multiple organizations to assess earthquake damage and meet hospitals’ needs across the South of Haiti, the team is deepening its support of mobile clinics in hard-to-reach areas, where many survivors have yet to receive care and support.  

Zanmi Lasante, PIH’s sister organization in Haiti, and its partners completed thorough assessments health clinics and centers across the South to help Haiti’s Ministry of Health determine the extent of earthquake damage and prioritize which facilities are in need of repair or reconstruction. Many buildings suffered such catastrophic damage that clinicians can no longer care for patients within their walls. Zanmi Lasante staff are trying to discover where patients are seeking care instead, so that they can send resources and assistance. 

Among the needs that emerged during that assessment was a dire shortage of oxygen at Hôpital Immaculée Conception in Les Cayes, where the production plant was destroyed during the 7.2-magnitude earthquake on Aug. 14. Canisters could not be refilled, which tragically lead to the death of one infant.  

In response, Zanmi Lasante staff worked with partners to send 40 oxygen cylinders to the region and four oxygen concentrators to the hospital to help meet demand. Meanwhile, at least one patient requiring a regular supply of oxygen was airlifted on Friday to PIH-supported Hôpital Universitaire de Mirebalais, where one to two earthquake survivors have been arriving by helicopter daily for specialized care. As of Tuesday evening, a total of 25 patients have been airlifted to the hospital so far. 

Additionally, Zanmi Lasante has provided supplies and transportation for mobile clinics set up in remote communities across the South, staffed by clinicians from partner Health Equity International’s St. Boniface General Hospital and Hôpital Immaculée Conception. The team will send supporting staff to these clinics in coming days to help relieve local clinicians. 

Mobile clinics are essential in disaster response, as they provide basic emergency and primary care and can serve up to 300 people a day. The clinical team sets up several stations for patients to flow from triage, to evaluation, pharmacy, and treatment tables. Team members care for everything from earthquake-related injuries to prenatal concerns, as patients lack ready access to care or can no longer visit their local clinic, which collapsed in the earthquake.  

This is all happening while COVID-19 remains a concern across Haiti, where the vast majority of people are unvaccinated. The Zanmi Lasante team hopes to soon incorporate COVID-19 vaccination into its earthquake response in the South. Until then, vaccination continues in the Central Plateau, where 50 people received their first or second dose in Hinche on Monday. The team will continue vaccination in Mirebalais this week. 

In just eight minutes, everything came crashing down.

As Carlos* stared at the HIV test, he wondered what he would do. How he would work. How he would eat. How he would stay alive.

The 39-year-old was already struggling to get by in San Martín de Porres, an impoverished district in northern Lima. A migrant from Venezuela, he had come to Peru three years ago, fleeing political unrest in his home country. But he came without papers—a status that forced him to work multiple jobs, including starting a business selling fruit and beauty products, with little guarantee of a steady, livable income.

And surviving was only getting harder.

For months, he had felt healthy and didn’t have any symptoms of HIV. But when he decided to take a free HIV test at a mobile clinic, knowing that one of his past partners had died of the disease, his life changed—within minutes.

“I didn’t expect it,” he says, of the positive test. “It was a very strong blow.”

Breaking Down Barriers

The test was offered as part of a months-long HIV intervention run by Socios En Salud, as Partners In Health is known in Peru, and the Ministry of Health. The intervention, which began in May, brings health workers into impoverished communities in Lima, offering free testing, consultations, and referrals for treatment.

Sexually transmitted infections such as HIV affect millions of people worldwide. In Peru, an estimated 91,000 adults and children live with HIV, with 44% of the new cases reported last year occurring in Lima. Yet, widespread stigma, systemic barriers, and lack of social support prevent many from getting the care they need.

For more than 25 years, Socios En Salud has worked to break down barriers to health access in Carabayllo and other communities surrounding Lima, partnering with the Ministry of Health to provide a range of health services and mobilizing 90 community health workers to bring care directly to patients.

Since May, Socios En Salud has partnered with the Ministry of Health to respond to HIV in three communities in Lima—San Martín de Porres, Rímac, and Los Olivos—where prevalence of the disease is high and where at-risk populations, including migrants, lack access to quality care. The intervention comes as part of Socios En Salud’s ongoing work in sexual health and reproductive care.

Comprehensive Care

Timely diagnosis of HIV is critical in ensuring that patients receive the care they need. But in the communities where Socios En Salud works, patients often don’t have the time, money, or resources to get to a clinic for screenings. In a way, Socios En Salud’s answer to that problem is deceivingly simple: instead of making patients travel to the clinic, bring the clinic to the patients.

“Through urban mobile clinics, we strengthen case-finding for people who test positive for HIV,” says Erika Gonzales Monzón, coordinator of the project. “We not only focus on clinical care, but we also ensure access to mental health care and the necessary socioeconomic support to address the disease in a comprehensive manner.”

These “mobile clinics” are teams of health workers dispatched into communities with free rapid tests and educational resources. Since May, these teams have screened 344 people for HIV and have distributed HIV information to 360—making it possible for patients like Carlos to get tested and diagnosed quickly.

“I was impressed with how fast the process has been,” he says. “A few days went by and I had already started treatment.”

He takes antiretrovirals once a day, after dinner. And his treatment plan includes more than just medical care. He is also enrolled in Socios En Salud’s mental health program, meeting with a licensed psychologist for therapy sessions to unpack his feelings of anxiety surrounding his diagnosis.

Such care reflects Socios En Salud’s comprehensive approach to sexual health care, treating more than just patients’ physical health. A holistic approach is especially critical in clinical areas like sexual health, where stigma makes conversations difficult, even with loved ones.

Carlos’ diagnosis came weeks ago. But he hasn’t shared the news with his family—yet.

“This is not a secret that I can keep forever,” he says. “But I want to feel ready and say it at the right time.”

Even as he contemplates the right time and place to share the news, Carlos isn’t dwelling on the past. He’s looking ahead—dreaming, even. He hopes to return to Venezuela to be with his family, one day—a future he couldn’t have imagined, just months earlier.

“Life goes on,” he says. “I never thought I would go through something like this. But without a doubt, if I can help and contribute to the prevention of any disease through my story, here I am.”

*Name has been changed for anonymity

When Dr. Aaron Berkowitz read Mountains Beyond Mountains during medical school, he quickly became interested in Partners In Health (PIH). But he wasn’t quite sure how a neurologist could get involved in global public health. So he reached out to PIH leaders, including Drs. Kerling Israel and Michelle Morse.

“And they said, without missing a beat: you can teach,” says Berkowitz, PIH’s neurology advisor. “You can build systems of care around neurology in Haiti. There’s tons of stroke, Parkinson’s disease, epilepsy, migraine, and other neurological disorders and people need to learn how to treat these conditions.”

Since that eye-opening conversation, Berkowitz has helped develop the first neurology training program in Haiti, in collaboration with Zanmi Lasante, as PIH is known in the country, and the Department of Neurology at Brigham and Women’s Hospital. The program is one of many offered through Hôpital Universitaire de Mirebalais’s medical education program, which has trained 152 clinicians since 2012 in residences across family medicine, pediatrics, internal medicine, nurse anesthesia, surgery, emergency medicine, and OBGYN. There are also fellowships in plastic surgery and emergency sonography.

In Berkowitz’s new book, One by One by One: Making a Small Difference Amid a Billion Problems, he discusses his work with PIH through the story of Janel, a young man in Haiti who had a brain tumor removed through surgery in 2015 and continues to receive support from Zanmi Lasante’s mental health and social work teams, among others. The conversation below, edited for brevity and clarity, gives an inside look at the book and highlights the importance of neurology training.

What inspired you to begin the book with PIH’s mission statement?

When meeting patients like Janel with advanced, debilitating neurologic disease in rural Haiti, I asked myself, “how am I going to live up to the mission statement in the context of these patients and as a neurologist?” This book traces how I wrestle with that question in collaboration with our colleagues in Haiti. I had read the mission statement and quoted it in talks about my work with PIH, but I think there’s so much depth to the statement and every time you read it, having done this work, you go a little deeper into it. You can read about PIH, donate to PIH, work for PIH, but what PIH is really asking us to realize is the accompaniment model—and what does that really look like? And that’s what I wanted to bring out in the book. I think Mountains Beyond Mountains is in some ways a hero’s tale of larger than life figures like Paul Farmer, Jim Kim, and Ophelia Dahl. In my book, I wanted to zoom in on someone who is just a regular person like me–a neurologist who got interested in PIH and asked “how can I help?” I kept returning to that mission statement, and so after I finished writing the book, I decided to put it at the beginning because it is the guiding principle for our work.

A conversation with Dr. Kerling Israel (detailed on page 149), PIH’s senior advisor for medical education in Haiti, made you realize neurology was equally important as other needs in Haiti, such as tuberculosis and malnutrition. Shortly after, you helped start a neurology training program. How has the fellowship grown since it began nearly a decade ago?

I began working with PIH in 2012 and at the time, there was one neurologist for all of Haiti’s 11 million people. That would be similar to having one neurologist for all of Manhattan or Los Angeles County. And most medical school students in Haiti were not having any contact with a neurologist. Primary care doctors who were seeing patients with neurologic diseases didn’t have significant training in neurology because there was no neurologist to teach them. Before HUM was built, I started working at Hôpital Saint-Nicolas de Saint-Marc with PIH’s family medicine program, which was in its first year. Our goal was to try to help these front line doctors care for their patients with neurologic diseases. Then when HUM opened and started their residencies, we did the same for their internal medicine residents. Around that time, the one neurologist in Haiti died, so there was a huge gap. We realized the best way to improve neurology care in Haiti was not only to increase the neurology knowledge of primary doctors but to train a few neurologists. So at HUM we started Haiti’s first neurology training program, a two-year neurology fellowship for graduates of internal medicine or family medicine residencies in Haiti. 

Dr. Francois Roosevelt was our first graduate. He was our pioneer and he did phenomenally. During his first year, Zika came to Haiti and we started seeing a lot of cases of neurologic disease related to Zika. He presented the results of what we saw at a national conference in Boston and won an international scholarship. There’s since been two more graduates (one works in Hinche and the other in St. Marc) and the fourth trainee graduates in 2022. And for the first time, this year we have two first-year fellows. I like to say that we increased the number of neurologists in Haiti by infinitely because we went from zero to a few. 

Ultimately, our goal is to have a neurologist in all 10 regions of Haiti over the next 10 years.

You write in the book (on page 46), “HUM is a testament to the depth and breadth of PIH/ZL’s thirty-year commitment to and collaboration with the communities they serve.” With that in mind, how did it feel when HUM received international accreditation last year, affirming it meets the highest global standards as a teaching institution? 

It was an amazing moment. I remember my first visit to Mirebalais, after HUM just opened, and people had already begun working to make sure the program met international standards. While I wasn’t part of that team, many people I work with and admire, including Dr. Kerling Israel and Dr. Michelle Morse, who are both profiled in the book, contributed to the amazing accomplishment.

What impact has the COVID-19 pandemic had on neurology training in Haiti?

Despite very challenging circumstances, the program is still running under the leadership of Dr. Francois, and the neurology clinic is still seeing patients. The goal of the program was always to make it a Haitian-run, independent program. And even before the “Zoom era” with COVID-19, we started having some faculty teach and discuss patient cases remotely. There’s a lot you can do remotely, but there’s nothing like examining a patient in person and being able to discuss the patient’s case with another doctor. But the silver lining is we were actually able to grow the team and now have more people supporting neurology remotely, including sub-specialists in Parkinson’s disease, epilepsy, and stroke whereas before we just had a small group of neurologists who could spend time on the ground in Haiti. 

What do you want readers—both new to PIH and longtime supporters—to take away from your book?

The goal in writing this book was to highlight the challenges in Haiti—they may seem insurmountable, but they’re not. I also wanted to profile the extraordinary courage and faith of the patients whose stories I tell. They wanted their stories told so other patients did not lose hope that there is always a possibility if you are courageous and faithful. These are some of the patients who have the least access to health care and the least access to any resources and are some of the poorest patients in the world. What does it mean to be in “solidarity and not charity alone” and to “provide healthcare as if we were providing it to members of our own family” as the PIH mission statement inspires us to do? I tried to answer that question through this book.

On September 15, five nations in Latin America—Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua—celebrate the anniversary of their independence from Spain. Mexico and Chile commemorate their independence just days later.

In the United States, this historic day marks the start of Hispanic Heritage Month—a national occasion to celebrate the histories, cultures, and contributions of Hispanic, Latino, and Afrolatino communities. The month runs from September 15 to October 15.

At PIH, we recognize the contributions of our colleagues at Compañeros En Salud in Mexico and Socios En Salud in Peru and our U.S.-based colleagues of Hispanic, Latino, and Afrolatino descent, especially as we continue our COVID-19 response in predominantly Hispanic communities, such as Immokalee, Fla.

And we reiterate our commitment to advocating for health equity in tandem with racial justice and immigrant justice, as we continue to see Latino communities in the U.S. and abroad disproportionately impacted by COVID-19 and other barriers to health access due to longstanding systemic injustices, from mass incarceration to the legacy of colonialism.

This year’s theme, “Esperanza: A Celebration of Hispanic Heritage and Hope,” allows us to contemplate the power of hope in the context of our present moment, as we fight to expand vaccine equity in communities of color and honor the history of independence and revolution that continues to resonate across Hispanic, Latino, and Afrolatino communities today.

It’s almost 5 p.m. in rural Kono District, Sierra Leone, and the wind is picking up while dark clouds threaten rain. Still, though they have families to get home to, preferably before the downpour begins, 25 students—most in their thirties and forties—remain in the classroom, focused on the math problem on the chalkboard.

The class agrees on a sum, then moves on to copy additional problems for their homework. They’ll complete that assignment before class tomorrow—in between work, taking care of their children, and tending to their homes.

Though most of these students make a living using basic math—selling fruits on the streets of Koidu, managing farmland and harvests—Partners In Health’s adult education program is their first time formally learning addition and subtraction. Last year, it was also their first time learning the alphabet and how to read and write. The 50 students currently enrolled in the program in Kono, as well as the 200 enrolled in the program in Port Loko District, had never before stepped into a classroom.

In Sierra Leone, illiteracy is the norm—the product of extreme poverty and especially prevalent in rural areas and among women. Across the country, only 43% of people are literate—defined as being able to read and write in either English or Arabic, or Mende or Temne, two local languages. Among women, that number drops to 35%.

PIH began offering adult education in Sierra Leone after West Africa’s historic 2014 Ebola outbreak, as survivors in Port Loko, a hotspot of the epidemic, expressed one common goal: to learn how to read. They knew first-hand that illiteracy had not only fueled Ebola’s spread—as people unable to read health messaging were more susceptible to the virus—but had also exacerbated the poverty that had weakened Sierra Leone’s health system and paved the way for the epidemic to take hold.

PIH’s adult education program was established in Port Loko for these survivors, as part of the shift from responding to Ebola to rebuilding Sierra Leone’s health system. To date, the program has served upwards of 900 students and expanded its reach to all interested community members—more than 80% of whom are women. And its programming has grown beyond basic literacy and numeracy to also include business planning and a financial savings association.

Below, step inside Kono and Port Loko’s adult education classrooms and meet some of their students:

Jeneba Barrie is in her third year of the adult education program in Kono. Growing up with four sisters and one brother in Moyamba District, in southern Sierra Leone, only her brother was sent to school, because it was considered taboo for girls to pursue education. “This did not make us happy,” Barrie said.

Barrie makes her living by dyeing and selling fabric; she says learning math has helped her better calculate her profits. “I’m so happy for this program,” she added, “because I had never been to school before. If this program wasn’t here, I wouldn’t be able to spell my name or identify the alphabet.”

Barrie has one daughter and has sent her to school, as a firm believer in education for girls. “One day, [a girl] could be Minister, or a chancellor,” she said. “They can be important.”

When Port Loko’s adult education program began serving community members beyond Ebola survivors, in 2019, the first student enrolled was Abu S. Koroma, 42. Koroma actively recruited other adult learners to join him, encouraging friends and neighbors to enroll in the program.

“I didn’t want to die without any education,” Koroma said.

Coming from a long line of Port Loko farmers who’d also never gone to school, Koroma remembers the sense of longing that accompanied seeing other kids his age in their school uniforms.

“I felt bad seeing my peers going to school,” he said, adding that he dreamed of becoming a teacher when he grew up, to bring more education to his community.

Koroma says learning how to read, write, and do arithmetic have helped him live a better and more fulfilled life; communication, for instance, is now easier because he knows numbers and is able to dial them on a phone.

His favorite thing about the program, however, has been building community with his fellow students. He says he now feels less isolated, "because I can share my problems with others in my school community and work together to solve them.” For example, when Koroma recently fell ill, his fellow students all chipped in to help him buy the medication he needed.

“I never had a family of this nature,” Koroma continued. “I feel belonging and I feel happy, as part of a family that cares for each other.”

Sherry Bangura, social protection manager for PIH and the founder of the adult education program, sees its units not only as avenues to empower people personally and financially, but also as a source of societal development. Based on student feedback over the years, Bangura has introduced additional adult education programs in Port Loko, including a unit dedicated to helping students create formal business plans.

“People see adult education as a lifetime education, a place to build yourself up, take off to the next stage, and achieve economic stability,” Bangura said. “It’s also a platform for people to understand and help develop their communities, especially women, who have long been deprived economically and politically. If we give women the opportunity to understand the role they can have in society and be economically independent, they can contribute meaningfully to ending poverty.”

Bangura notes that for many students, class attendance can be a struggle amid many other competing priorities—and that this tension only grew during the COVID-19 pandemic and its economic impacts. As periodic lockdowns halted business, many learners and their families lost wages that could only be made up—maybe—through extra hours working.

In response, Bangura created the Village Savings Loan Association (VSLA), a sort of community bank within the adult education program that aims to support student businesses, encourage saving, and provide women access to non-predatory financing.

In so doing, the VSLA also aims to ease some of the financial pressures on women who would otherwise have to choose between class and work.

Earlier this year, each student was provided a loan of 400,000 Leones—the equivalent of $40 USD—that they could use to support their livelihoods, from trading to farming. Within a year, they will have to pay back the loan with a minimum contribution of 10,000 Leones—one dollar—per week. They have the option to contribute more as a form of savings; and no matter what, putting a dollar a week into the bank means that every student will come out with 12 more dollars than their initial loan.

26 weeks into the VSLA, after class, the students gathered to count what was in the bank. Between 20 students, there were 5.6 million Leones—or, $560 USD.

“It’s about moving people from absolute poverty to relative poverty,” Bangura said.

Mabinty Sesay, 45, is enrolled in adult education in Port Loko, having never been sent to school as a child, following the death of her mother. She says that as a young girl she "did not feel fine" not going to school, and over the years grew increasingly frustrated as people younger than her achieved success she couldn’t,  without an education. For example, as a volunteer at her local community health center, she dreamed of being promoted to a community health worker—for which literacy is a requirement.

These hardships inspired Sesay to enroll in the program, which has given her a basic education and enabled her to be promoted to community health worker. It also has helped her jumpstart a small business. With academic support in developing a business plan, as well as a loan from the VSLA, Sesay started a business selling fish and has already made enough profit to support her 25-year-old son’s college education.

And her ambitions don’t stop there. Sesay has three more children, ages 15, 10, and 7—all of whom are in school. She says she made sure to send them, “so they wouldn’t be like me.”

“Being uneducated, you suffer,” she explained. "I want to tell PIH tenki, because I wasn't able to do anything. Now, I can do something with my life."

Amara Kamara, 61, is in his fourth year of the adult education program in Kono. When asked why he’d never before attended school, he answers in one word: “Poverty.”

Kamara is a farmer and says learning math has helped him better manage his resources, from what to harvest and what to sell to what to save for his next crop.

"I'm so happy because I had no education, and now I know numbers and the alphabet. I can write my name and do calculations, which makes me feel proud,” Kamara said. “I need more—I want to reach a higher level and learn large-scale agriculture.”

He also notes that before he entered the classroom, PIH provided him seeds and farming tools, which helped his farming business enough that he began to make profits. He has used this money to send his four children to school; one of them is even in college now, which Kamara says is an immense source of pride. “My children can teach other people and give back to our community,” he said.

Hannah Charles, 51, has been a traditional birth attendant (TBA) for 31 years. Since 2015, she has worked at PIH-supported Wellbody Clinic, providing maternal health care hand-in-hand with clinicians to make sure women can give birth safely and comfortably. She’s been enrolled in the adult education program in Kono for three years—her first time attending school.

Charles, who grew up in Kono, says her family kept her at home for fear that she would get pregnant if she went to school, based on how many pregnant students they had seen in their community. But her brother did attend school. “I wanted to go,” Charles said, “but I had no support. When my brother talked, everyone listened, because he was educated. That wasn’t the case for me.”

In the wake of Sierra Leone’s civil war, Charles caught a glimpse of the opportunity that could come with an education, when an NGO arrived in Kono with a program to help traditional birth attendants enroll in nursing school. Charles was interested—but because she had never been to school, she was ineligible to participate. “I had the ambition, but not the formal education,” she said.

Learning to read and write through PIH’s adult education program has been immensely helpful for her work—and her confidence.

“I couldn’t even recognize my own name,” Charles said. “When I would attend workshops, or arriving at the front gate every morning at Wellbody, I would need to wait for a colleague to sign me in. Now, I can sign for myself. And I can identify patient names when I am looking at charts. I feel good!”

Content warning: This story contains brief, general mention of suicidal ideation.

The taxis are gone, again.

But it isn’t the first time that Gábriel* has shown up to an empty lot. As one of dozens of motorcycle taxi drivers in San Juan de Lurigancho, an impoverished community just 8 miles northeast of Lima, he knows that motorcycle rentals are in high demand.

It’s why, each morning, he wakes up at 4 a.m. and rushes to the lot, where he must compete with several other drivers for a limited number of motorcycles. It’s always a first-come, first-serve basis. Some days, he’s just minutes too late. And it takes a toll.

“If I don’t work today, tomorrow we have no income,” he says. “That worries me every day because there are days when I don’t manage to rent the motorcycle taxi and I get frustrated…then, at that moment, is when negative thoughts invade my mind and I feel that I can’t take it anymore.”

He has dealt with negative thoughts, connected to his depression, for years. But as COVID-19 swept across San Juan de Lurigancho, leaving him unemployed and struggling to put food on the table, Gábriel could feel his depression deepening. There were days when he didn’t want to live.

But even in his darkest moments, he wasn’t alone. His wife, María*, saw the warning signs. And she knew where to get help.

Mental Health Amid COVID-19

Depression and other mental health conditions have intensified during COVID-19, as the virus has claimed millions of lives worldwide and forced millions more into weeks of isolation.

In impoverished, historically marginalized areas such as Carabayllo, a hillside community on the outskirts of Lima, mental health conditions have been compounded by a lack of access to quality medical care, skyrocketing unemployment, and food and housing insecurity—systemic barriers that, amid a pandemic, make mental health care feel like a last priority, if patients even know where to go for help or have the means to access care at all.

For more than 25 years, Socios En Salud, as Partners In Health is known in Peru, has fought to break down barriers to health access, in partnership with the Ministry of Health, and mental health has been one of its key programs. As Socios En Salud’s broader team focused on the overarching COVID-19 response—such as testing capacity, safety protocols, and supply chains—the mental health team turned its attention to finding patients in need of mental health care and connecting them with that care, whether through in-person outreach by community health workers or through Bienestár, a chatbot app the team launched last year to connect patients with psychologists, virtually.

The timing could not have been more urgent.

From patients coping with the death of loved ones, to those struggling to make ends meet or dealing with their own diagnosis with the virus, there was never a shortage of need in the communities where Socios En Salud works.

But the team pressed on. No issue was too small and no condition, too complicated.

From July 2020 to March 2021, Bienestár reached more than 111,500 people in Carabayllo, San Juan de Lurigancho, Callao and Trujillo, connecting thousands with mental health care ranging from psychological first aid to bereavement therapy and helping patients cope with depression, alcohol and drug use, suicidal ideation, and a range of other mental health conditions.

The effort has saved lives.

Step By Step

When María saw her husband’s mental health taking a turn, she decided to share her concerns with a trusted resource in the community: Socios En Salud. As she filled out the screening questions for the CASITA program—Socios En Salud’s program for caregivers and children with developmental delays, where her son is enrolled—she mentioned Gábriel’s depression and what she had been seeing at home.

Within days, Lucia Caparachin, a psychologist with Socios En Salud, was assigned to the case. Over the next several weeks, Caparachin provided care and support for Gábriel through a strategy called Problem Management Plus (PM+), an intervention from the World Health Organization that uses group and individual counseling to help patients manage anxiety, depression, and stress.

The change was slow, but significant—and Caparachin saw it first-hand.

Gábriel’s mood was improving. He was opening up about his problems and accepting emotional support from those around him. He was identifying the things causing him stress and figuring out ways to reduce that stress or reframe his mindset.

“Having the support of his family and Socios En Salud has been key to improving his physical and mental health,” says Caparachin.

And mental health wasn’t the only aspect of his life improving. Through Socios En Salud’s support, he received food vouchers to help feed his family—meeting an essential need that no amount of mental health care could fix. And his children continued to receive care through the CASITA program, which was helping his son learn to walk.

Step by step, Gábriel was moving forward, too.

‘They Give Me Strength’

Mental health professionals like Caparachin are careful to emphasize that mental health isn’t a linear process—it’s an ongoing journey. When it comes to treating chronic depression, she says, it’s crucial to check in with patients regularly and be aware of any changes that could impact their mental health and exacerbate their depression.

To help Gábriel manage his depression, Caparachin got him a referral to a local health center for ongoing mental health treatment, including weekly support sessions.

It has only been a few weeks, but the sessions have already helped substantially. They’ve reminded him of who he is—and who he can turn to for support.

“My family is the most important thing I have,” he says. “They give me the strength and courage to go on.”

*Name has been changed to protect privacy

At the end of 2020, after almost a year of uncertainty, social isolation, and anxiety, a glimmer of hope appeared: the arrival of COVID-19 vaccines in Mexico.

By August, 17% of Mexicans had been fully vaccinated, and 26 million had been given at least one dose. But that progress, while significant, has been overshadowed by a worrying reality. Across the country, 91 million people are still waiting for vaccines, even as the the third wave of the pandemic triggers a surge of new cases in several areas.

Those concerns have intensified for clinicians in the rural communities in Chiapas where Compañeros En Salud, as Partners In Health is known locally, has worked for more than a decade.

Although vaccinations began there in early July for people over 30, health workers were surprised to find that many of the vaccination centers were completely empty. People were simply not showing up. It was not for lack of outreach, or lack of vaccines in the area, or limited hours of operation. The main obstacle was much harder to pin down: misinformation.

"We have found that there are many rumors and myths about the vaccine," says Sandra Vázquez, a community manager with Compañeros En Salud. "This misinformation happens all over the country.”

The rumors around COVID-19 and vaccinations range from plausible—such as the idea that vaccines are ineffective—to sensational—that temperature check devices used to screen for COVID-19, when aimed at someone’s head, will wipe their memory, or that the vaccine implants a microchip into the patient, used by the government for tracking.

Such misinformation makes the push to vaccinate everyone that much harder. But health workers like Vázquez are determined to face these issues head-on.

To fight misinformation, Vázquez partners with Compañeros En Salud’s dozens of community health workers—driving out to the rural communities, knocking on doors, and distributing pamphlets with information about the virus and the vaccines.

The efforts, so far, have paid off—while data on vaccine acceptance is difficult to come by, Vázquez and her colleagues at Compañeros En Salud have seen an uptick in people lining up for vaccines, following her team’s outreach.

Community clinics, once empty, are now filled with people asking about vaccines. At the clinic in Reforma, for example, a one-day vaccine campaign successfully vaccinated 300 people—so many that health workers ran out of vaccines. In Honduras de la Sierra, a two-day campaign vaccinated 500 people against the virus.

The key to countering misinformation, says Vázquez, isn’t talking—it’s listening.

Listening opens the door for conversation—and change.

“Exchanging knowledge and dialoguing is how we can better understand where these myths come from and share official information," she says.

Listening has been core to Compañeros En Salud’s work for years, as it has closely partnered with nine rural communities in the coffee-growing Sierra Madre region of Chiapas.

From incorporating traditional forms of midwifery and care into its clinical practices, to regularly meeting with community leadership and government partners, Compañeros En Salud has for years sought to be not only an implementer, but a partner in providing culturally appropriate and quality care locally.

In few moments has that spirit of partnership been as clear as during COVID-19, as Compañeros En Salud rapidly mobilized to respond to a pandemic that has devastated millions worldwide—providing the PIH-supported community hospital in Jaltenango with training, resources, and staff; implementing strict infection and prevention control measures; and opening a brand new, seven-bed Respiratory Disease Center for patients with severe COVID-19, in an area where such facilities are extremely rare.

"What I enjoy most about my work is talking with people, sharing their dynamics, and learning from their experiences," says Vázquez. "I have seen in them a lot of strength, resilience, and resistance.” 

Just months ago, COVID-19 cases were down in Chiapas, and the majority of patients were those considered highest-risk, such as the elderly. But now, as the third wave of the pandemic sweeps across Mexico and its mountainous southern state, cases are on the rise—and the patients filling beds in Jaltenango’s COVID-19 unit are younger.

The hospital’s youngest patient on oxygen was 6 years old.

“The incidence of contagion at this moment is very high,” says Miguel Ramírez, a paramedic with Compañeros En Salud, as Partners In Health is known in Mexico.

It’s a trend that Ramírez sees firsthand in the ambulance, as he cares for COVID-19 patients on oxygen. Even as his patients struggle to breathe, he knows ICU beds and ventilators are limited at their destination—the nearest advanced hospital in the region, which is at least two hours away and one of only a few hospitals in the state with an intensive care unit.

But Ramírez and his colleagues keep on driving.

It’s a desperation that many clinicians at Compañeros En Salud have felt in recent weeks, as they race to respond to a troubling new wave of the pandemic. Unlike the COVID-19 surge last winter, which most affected the elderly and chronically ill, the third wave has infected hundreds of young adults and children—those least likely to be vaccinated in Mexico, due to the national vaccine rollout that prioritized patients based on age.

“The [pandemic] response has been much faster and more effective [recently] in the sense that we have more trained personnel and we have more information about the virus in general,” says Dr. Ana Laura Rodríguez, coordinator of Compañeros En Salud’s COVID-19 response. “But the numbers have been quite alarming.”

'It's Hard Times'

The pandemic isn’t the first challenge Compañeros En Salud has faced in Chiapas.

Compañeros En Salud has worked in Mexico’s southernmost state since 2011, partnering with the Ministry of Health to provide health services, strengthen hospitals and clinics, and train clinicians and community health workers. This decade of collaboration made Compañeros En Salud a trusted partner in the Ministry of Health’s COVID-19 response from the early days of the pandemic.

As the pandemic struck Jaltenango and the nine rural communities where Compañeros En Salud works, clinicians and support staff sprang into action, implementing new safety protocols at hospitals and clinics, adapting routine health services, securing essential resources such as masks and sanitizer, and training staff to respond to a fast-moving virus. After a surge in the winter, as people traveled for the holidays and testing capacity improved, case counts more or less stabilized, staying in the double digits for several months.

Then, beds began filling up.

“In July, we started to see an increase in outpatient visits,” says Rodríguez. “We went from seeing an average of 50 patients per month during the low months to 250 consultations in that same month.”

Since late July, Chiapas has recorded hundreds of new cases each day. The COVID-19 unit of the PIH-supported hospital in Jaltenango, a seven-bed facility for patients needing oxygen, has been at 80-100% capacity for weeks.

“I think the hardest thing is that we had a little hope that this was [over] already,” says Dr. Valeria Macías, executive director of Compañeros En Salud. “Then we realized that it seems like it’s just the beginning of many more things. We know that probably right now it’s because of the Delta variant and that there are other variants out there.”

Even as new variants spread, lifesaving resources—from oxygen to ambulances—remain few and far between.

Although oxygen concentrators are available in Jaltenango, these devices require electricity in order to run—a resource that is unreliable in Chiapas, especially during the rainy season from May to November. Oxygen tanks—used only in the most desperate of emergencies—are even more scarce; a standard tank lasts about 10 hours and to refill it, Compañeros En Salud staff must drive to Tuxtla, three hours away.

And patients who need intubation, a level of life support not available in Jaltenango, must be transported to advanced hospitals hours away—in the city’s one and only ambulance.

It’s a desperate drive that Ramírez—the only paramedic in Jaltenango—has made many times. Recently, in a single day, he transferred three patients to the nearest advanced hospital, amounting to a shift of 15-16 hours.

At least twice, he’s had to pull over and, with the help of nursing staff, care for the patient in the back of the ambulance. And once, when no driver was available, he had to drive the ambulance himself.

COVID-19 patients aren’t the only ones in need of emergency care, forcing clinical staff to make impossible decisions about who to put in the ambulance or who the advanced hospital is most likely to admit. More than once, women in labor have been denied admission to advanced hospitals.

“It’s hard times,” says Macías. “We have nowhere to send these patients. Every advanced hospital is at their fullest capacity.”

A Call For Solidarity

In Jaltenango, too, some patients have had nowhere to go.

When the hospital’s COVID-19 unit was at capacity, patients requiring very low flows of oxygen were discharged with portable concentrators. There were simply not enough beds.

Lately, Rodríguez has seen more young adults and children in the hospital with COVID-19, including a 6-year-old who was hospitalized for three days.

Most of the time, patients recover and return home to their families. But some don’t make it.

“It is painful to accompany the death of a large number of people,” says Rodríguez. “It happens constantly as a doctor. You are used to accompanying death.”

It’s more than just resources complicating the pandemic response. It’s also the misinformation that has circulated in rural communities. The vaccine hesitancy. The public’s fatigue with mask wearing and social distancing. The burnout and attrition of staff.

Everywhere Rodríguez looks, there is another fire to put out. But she isn’t giving up.

“The most important message that I would like to share is that of solidarity,” she says. “It is difficult to give up some of the things that we are used to before [the pandemic]. But the behavior of this disease is not going to change, until we are all vaccinated.”

Immediately after the 7.2-magnitude earthquake struck Haiti, Dr. Dyemy Dumerjuste and his colleagues quickly assessed the situation from Port-au-Prince. And shortly after, he was on a helicopter, as part of the first team to evacuate survivors from the Nippes department, a devastated region in the South near the epicenter of the Aug. 14 earthquake. 

Upon arriving on site and bringing children into an ambulance, he soon faced the heart-wrenching task of declaring multiple deaths due to blunt trauma and head trauma--injuries typically seen after a massive earthquake. Other children with the most critical injuries were triaged and then evacuated on a helicopter to receive care at Hôpital Universitaire de Mirebalais, the 350-bed teaching hospital built by the Haitian government and Zanmi Lasante, Partners In Health’s sister organization in Haiti. Since then, 23 patients have been transported, including five children under 12-years-old. More than two weeks after the earthquake, clinicians continue to work around the clock to respond to health emergencies.

“I already lost a patient from tetanus directly related to his wound from the earthquake,” says Dumerjuste, an emergency medicine physician at Health Equity International (formerly St. Boniface Haiti Foundation) and a flight physician at Haiti Air Ambulance. 

As an emergency medicine physician, Dumerjuste is accustomed to devastating scenes and injuries. And he’s well-trained to properly react and provide high-quality care. During his four-year emergency residency program at Hôpital Universitaire de Mirebalais, the first and only program of its kind in Haiti, Dumerjuste received training to deal with natural disasters, epidemics, gun violence, motor vehicle accidents, and more. The training equips clinicians to respond across different settings, both in and out of the hospital. Since the program began in 2014, twenty emergency medicine physicians have graduated--Dumerjuste among them.

He is also among a handful of Hôpital Universitaire de Mirebalais graduates currently working in the hardest hit areas of southern Haiti, where at least 2,200 were killed and 12,200 injured, with both numbers still rising. In the coming days, additional alumni are expected to offer care across settings. 

Since 2012, Hôpital Universitaire de Mirebalais’s medical education program has trained 152 Haitian clinicians across specialities including family medicine, pediatrics, internal medicine, nurse anesthesia, surgery, emergency medicine, and OBGYN. There are also fellowships in neurology, plastic surgery, and emergency sonography. Of those graduates, 98% currently work in Haiti, with 88% working in PIH-supported or other rural health facilities. Hôpital Universitaire de Mirebalais, an internationally accredited teaching hospital, is a world-class facility built following the country’s 2010 earthquake, with 127 residents currently in training.

On a cloudy July morning on the lush green outskirts of Freetown, Sierra Leone, Dr. Elizabeth Allieu stands in front of a classroom of preteen and teen girls, encouragingly telling them that there are no wrong answers to the question she just posed:  

“What is mental health?” 

A few of the teens shyly offer some word associations: Frustration. Anger. Stress.  Allieu leads the room in clapping for each girl who speaks up, then launches into her own explanation. 

“When we say mental health, we mean the well-being of your mind,” Allieu, a pediatric specialist, says. “When you’re not well, what do you say? That you’re sick? Mental health can mean when your mind is sick.” 

She then asks if any of the girls are familiar with Sierra Leone Psychiatric Teaching Hospital. Most say no. But when their teacher cuts in to revise the question—“Who has heard of Kissy Mental Hospital? The crazy yard?”—heads start nodding. The whole room knows about Sierra Leone’s only hospital dedicated to mental health care. 

Based on how they still use the hospital’s decades-old nickname, however, they don’t know the extent to which the hospital has transformed. Since support from Partners In Health began in 2018, Kissy Mental Hospital has become Sierra Leone Psychiatric Teaching Hospital—a revolutionary change. For decades, the deeply stigmatized facility had no electricity, running water, or psychiatric medications. Members of the surrounding community feared Kissy’s patients, who often were chained to their beds by desperately under-resourced clinicians.  

Now, Sierra Leone Psychiatric Teaching Hospital is a chain-free facility with modern amenities and stocked pharmacy shelves, where improved services are enabling clinicians to care for more outpatients than inpatients. Amid the fear, misunderstanding, and sometimes cruelty that surrounds people living with mental health conditions, the hospital is slowly but surely changing the face of mental health care. 

Nonetheless, one group had been left out of this process: children. That is, until May, when clinicians at Sierra Leone Psychiatric Teaching Hospital opened the facility’s, and the country’s, first child and adolescent mental health unit. 

The new unit was spearheaded by Allieu and is the reason for her visit to the girls, all of whom have suffered severe abuse and now live in a group home run by a local nonprofit. 

“The child and adolescent mental health unit is for you, and it’s free of charge,” Allieu tells them. “Whenever you feel stressed, when you’re not feeling okay, when you have an illness in your mind, you go there. You talk to a teacher or someone very close who you trust, and come with that person to us. And we can help.” 

After asking each girl her name and what she wants to be when she grows up, Allieu goes on to deliver the same message to two more classrooms of children and teens from the home, ensuring they and their caregivers know about this new resource for counseling and psychiatric support.  

It’s part of Allieu and unit staff’s ongoing effort to reach as many schools, group homes, and orphanages throughout Freetown as possible. Their goal is to spread welcome news: In a country with the oldest psychiatric hospital in sub-Saharan Africa, yet with only two psychiatrists and extremely limited mental health services—none of which have ever been specialized for pediatrics—young people now have a dedicated place to go for their mental health needs. 

“They aren’t meant to suffer” 

Since she started medical school in her home city of Freetown, Allieu has been determined to care for children. 

“I think one of the main things I like about children is they don't tell lies. They tell you exactly how they feel, and they don't pretend,” Allieu said. “I just see the need for them to have a healthy life. That's why I’ve always been working with them: I need to protect them. They aren’t meant to suffer.” 

After training and working in pediatric departments in hospitals and health centers throughout Freetown, Allieu moved to London to pursue a master’s degree in advanced pediatrics. That experience, she said, is how she fell in love with pediatric mental health. 

“My driving force was a paper I came across talking about Sierra Leone’s treatment gap for children living with mental health conditions. They noticed we had a 99.3% treatment gap,” Allieu said. “We’ve gone through a lot, from the civil war, to Ebola, to mudslides. Imagine what children have gone through. 

“I kept the paper,” Allieu continued, “and said to myself, ‘When I come back home, I’ll try to do something.’” 

In the fall of 2020, Allieu moved back to Freetown and began talking with Dr. Abdul Jalloh, the medical superintendent of Sierra Leone Psychiatric Teaching Hospital and one of the only psychiatrists in Sierra Leone, about the idea of the unit. He offered a space and the resources of the PIH-supported hospital. With additional private funding, the unit was quickly planned, staffed, and filled with books, toys, and inspirational murals. By May, it was ready to welcome its new young patients. 

“I vividly remember the first meeting we had with Dr. Allieu and Dr. Jalloh,” said Chenjezo Gonani, PIH’s mental health program manager. “It was very, very clear that this is a matter of urgency, and we had no choice but to find the resources for this facility. With their enthusiasm and leadership, we were able to pull this facility through within a very short time.” 

Low Information, High Stigma 

As Allieu notes, trauma—experienced and inherited—plays a large role in shaping mental health for Sierra Leone’s population, children included. As she conducts more outreach visits to promote the unit, especially to high schools, she anticipates an uptick in patients arriving for care for depression, anxiety, and trauma. 

Thus far at the unit, however, she’s mostly been observing the biology and genetics behind mental health conditions, as well as how extreme poverty, and its resulting lack of access to nutrition and education, can disrupt children’s cognitive development and emotional well-being. The majority of kids have been arriving with speech delays, ADHD, autism, and epilepsy (a condition that falls under the umbrella of mental health in Sierra Leone, and in much of sub-Saharan Africa). 

While these roots are well-known, the exact burden of pediatric mental health conditions in Sierra Leone remains mostly a black box. With services long non-existent for the country’s youth, there has been no public platform that could provide data on the prevalence of mental health conditions among kids and adolescents. This lack of information obscures the exact need for pediatric mental health services and becomes part of a familiar cycle between lack of resources, lack of care, and stigma—which Allieu says is doubled for children. 

“Mental health conditions don’t just affect the child; they affect the family, also,” Allieu said. “That’s what makes it worse: The family stigmatizes the child. They keep them out of school, at home, and don’t associate them with other children.” 

Such stigmatization is often a form of protection. Given the lack of treatment available, and given deeply rooted cultural beliefs, most families opt to take their children to traditional healers in their communities when they exhibit signs of a mental health condition, which are commonly thought to result from witchcraft or demonic possession. When the child inevitably does not get better without clinical intervention, families often feel they have no choice but to bow to stigma and keep their children away from those who might misunderstand or hurt them, or their entire family. 

Not only does Allieu want to provide direct care to families for whom treatment has never been available—in so doing, she also wants to begin developing a comprehensive understanding of what illnesses are affecting what children. 

“That’s the question I want to answer: ‘What’s the real picture?’” Allieu said. “What’s the percentage of diseases? What’s the economic burden? Because we started this clinic, we’ll be able to collect some numbers—how many patients we have, their conditions—and tell the public that this is what we’re dealing with. Everything comes back to awareness.” 

Gonani also noted the generational shifts the unit could potentially enact. 

“We’re looking at the continuum—mental health from a young age, the developmental stages, up to the adult world,” Gonani explained. “If we create this base of services to respond to the mental health needs of young people, we will reduce the burden of mental health in the adult population. And we know the burden of mental health on adults trickles down to young people. So if we are able to strengthen this aspect of care, we can have a significant mark on the history of this country.” 

Reinvention 

Allieu knows this could be a slow process. In its first three months, the pediatric mental health unit has seen 21 patients, ages 3 to 16, with an average of four coming in each Wednesday, when Allieu provides checkups and new intakes. Much of Allieu’s week is dedicated to outreach visits to promote the unit and its unprecedented services. But she says the low patient volume does have an advantage: enabling her to spend adequate time on each case, especially as the only doctor in the unit. 

Her approach to care is gentle and family-oriented. She avoids prescribing medications wherever possible, and emphasizes the power of knowledge, socialization, and parental involvement. 

“If you notice, we don’t have inpatients,” Allieu said. “We’re trying to de-institute. I’m involving the parent more than I’m even involving myself. When a patient comes in, the first thing we do is psychoeducation. We explain to the family what the condition is, what they’re dealing with. I try to push a policy for families to not keep children at home—to send them back to school or to a special needs school. We do counselling. We teach parents techniques for some at-home speech therapy.” 

With extreme poverty as the backdrop of many patients’ lives, Allieu makes referrals to PIH social support programs and works to provide opportunities for play, enrichment, and learning. She sends every patient home with a toy or book after their appointment, and is working to develop partnerships to introduce art and music therapy. She’s building a small playground inside the unit, complete with a swing set and AstroTurf. And soon she’ll establish an evening support group specifically for parents. 

The goal, ultimately, is to set young people on a path to outgrowing their condition or easily managing it—a path many of Sierra Leone Psychiatric Teaching Hospital’s adult patients were never put on, especially with a lack of family support. 

“Some mental health issues are not lifelong if they are treated early,” Allieu said. “In adults, it's rehabilitation; in children, it's reinventing, giving them new skills.” 

It’s also to establish a model for child mental health in Sierra Leone. 

“Not only is this a center of specialized mental health care for young people,” Gonani said. “It’s also a hub to build and strengthen child mental health services elsewhere across the country.” 

“Today, she’s smiling” 

Though there are no quick fixes when it comes to mental health, many patients of the unit have already seen their lives change with the ability to finally access proper care. 

Shortly after the unit opened, 15-year-old Mabinty Mansaray arrived with a two-year-old struggle: Every time she got her period, she also experienced seizures. She hadn’t stepped inside her classroom ever since; amid the dangers of seizing at school, her parents kept her home. And amid suspicions of witchcraft from neighbors, her mother stopped her from leaving the house altogether. 

Staying home all day, every day, Mansaray found herself in a hole of depression. 

“She said she felt left out,” Allieu said. “I think that day she was even crying, that she can’t see her friends and she needed to go to school again.” 

Allieu took her usual approach: psychoeducation, family involvement, and then medication, as well as counselling. 

“The first thing was, she needed to understand what epilepsy was,” Allieu continued. “I told her that once she is on medication, she can go to school. She can do whatever she wants to do. There are people out there with epilepsy that are carrying on with their life.” 

Mansaray’s sister had brought her to the unit, but Allieu quickly called her parents to come in to relay that same message, before beginning Mansaray on medication. 

Finding the right dosages in accordance with Mansaray’s hormones required close monitoring. And convincing Mansaray’s parents of their daughter’s hopeful future required persistence. 

“It was really a battle for her to take her medication,” Allieu said. “When we started the medication, her parents said they didn’t want her to go to school because they said she would always have seizures.” 

But, Allieu continued, “They are all really happy now, because they notice that if she takes her medication, she doesn’t have a seizure.” 

In mid-July, coming in for a check-up, Mansaray reported good news: She hadn’t had a seizure for a full month, and expected to re-enroll in school in September. 

“She was really not smiling,” Allieu recalled of her first meetings with Mansaray. “Today, she’s smiling.” 

The nation may be struggling with yet another COVID-19 surge, but the outreach workers of the Antioch Community Social Service Agency in Chicago are racking up successes.

Ten newly hired Youth Community Outreach workers -- all young adults – are going door-to-door in neighborhoods around the city to share information about COVID-19 vaccinations with other youths and help them sign up for appointments. At the same time, the agency, which provides social services to residents of low-income housing, is using its long-established network of trusted workers to secure transportation, food support, and co-pay assistance for seniors at vaccination events. The organization’s first six weeks of outreach led to over 350 vaccinations.

"People in Englewood trust us because they know us. I live in the community, went to high school here, and people know me from the food drives and back to school events we've done for years. That trust is important," said Eddie Johnson III, executive director of Antioch Community Social Service Agency.

This is just one of the local community groups that has received support from the  Chicagoland Vaccine Partnership (CVP), a coalition created in response to the COVID-19 crisis. Partners In Health’s U.S. Public Health Accompaniment Unit expanded the CVP, which it now staffs and manages, bringing together community-based organizations, public health experts, government officials, and philanthropists to focus on closing stark health equity gaps that have become more apparent during the pandemic. 

“Our role is to facilitate critical connections and collaborations,” said Max Clermont, USPHAU’s senior project lead in Chicago.

“Equity is not a one-off thing or a box to check. This is about listening to what people in the community, doing the work, need. It’s about building trust at all steps.”

Clermont, a former community organizer, worked behind the scenes to help establish the first “rapid response grants” given to several local community-based organizations, like the Antioch group, to support vaccine outreach to individuals and families who remain unvaccinated and vulnerable to the virus. The grants were awarded by the Health First Collaborative (HFC), an incubation effort of Michael Reese Health Trust, which initially launched the CVP. Some of the organizations receiving grants had not been working in the traditional public health sphere, but when the pandemic hit, they pivoted: food pantries and youth boxing groups and violence prevention organizations, for instance, shifted to vaccine outreach in the neighborhoods they already served.

Clermont said this flexibility has been critical. 

“The groups basically said, ‘We're not a health-oriented organization, but this is a health crisis affecting our communities and there's a role for me to play,’” Clermont added.

A Shift in Vaccine Strategy

In August, a new round of rapid-response grants will be awarded. For the philanthropies driving this effort, the strategy of funding small, under-the-radar community groups marked a shift in approach.

“The Chicagoland Vaccine Partnership and Health First Collaborative have been working to change the way local philanthropies fund public health outreach,” said Rachel Reichlin, RN, senior program officer at Michael Reese Health Trust. “Our vaccine community mobilization grants are flexible, so if a group says, ‘We want to hire an outreach worker to go to BBQs,’ or ‘We need funds to fix our outreach van,’ they can get the support to meet their community where they are -- where they live, work, learn, play and pray.”

The CVP’s journey has been swift. It began as an inclusive, open-invitation Zoom call among the region’s stakeholders to problem-solve in real time. This was at the height of the pandemic, when it became clear that the disproportionate burden of illness and death was falling on neighborhoods and residents already suffering the impact of long-standing segregation, and historic racial and economic injustice. Before the pandemic, there was a life expectancy gap of 16 years between the city’s wealthiest and poorest neighborhoods; in the first months of the pandemic, 70% of COVID-19 deaths were among Black people.

At that time, Clermont said, the city, county and state public health departments needed support to align on the most effective COVID-19 response strategies. The CVP meetings, held every Tuesday, serve as a safe space for community leaders to connect with health officials, and allow people from all sectors to discuss barriers to vaccination they are seeing in their neighborhoods and brainstorm potential solutions.

The CVP now includes about 135 participating organizations. While its reach has broadened, its mission has come into clearer focus: to mobilize trusted community leaders to share accessible information about vaccines; educate community members about the latest COVID-19 science and offer public health skill-building; and elevate coordination among community-based organizations, government, health care, and philanthropy to boost vaccination efforts and support a public health workforce.  All of this, Clermont adds, should be built on a foundation of equity.

“Any serious efforts to improve health outcomes must confront racism and understand how our history shaped the problems we are working to address,” Clermont said.

Town Halls and Cupcakes to Stop COVID-19

To leverage deep knowledge among local health professionals, the CVP created a Speakers Bureau that connects area doctors, nurses, and other providers with interested community groups to share accurate, accessible, up-to-date information about COVID-19 and vaccines. All of the speakers are experts in their field and able to clearly and compassionately address community concerns while engaging in non-judgmental conversations with a variety of audiences. 

The CVP so far has facilitated more than 37 events, where more than 700 people have learned about COVID-19 vaccines, with information in English, Spanish, Arabic, and Urdu. Events have included online town halls, staff trainings, and even a Zoom cupcake-baking class.

Additionally, the CVP has partnered with Malcom X City College and the Chicago Department of Public Health to offer a free online training that helps community members speak to their neighbors about vaccination. After taking the course, vaccine ambassadors can continue to get support and grow their public health skills through an online learning community managed by PIH’s U.S. Public Health Accompaniment Unit. To date, 3,000 people have signed up to become Vaccine Ambassadors and over 350 have joined the learning community. The CVP is now hiring six to eight fellows who have interest in public health careers. The learning community fellows will co-design community learning opportunities, help create an extended public health workforce and advocacy curriculum, and support engagement and growth of the learning community.  

A More Just Future, A More Robust Public Health Workforce

The pandemic has exposed many glaring inequities in Chicagoland’s public health infrastructure, Clermont said, and so the CVP is building a Health Justice School to help community members grow their public health knowledge and opportunities. The school will be based in community knowledge and what has been learned through community-driven health responses during the pandemic, in order to expand health equity beyond COVID-19.

The CVP will no doubt persist even after the pandemic has faded, continuing to support community-based organizations and the city with ongoing health efforts, informed by local leaders, to make the region a more equitable place for all residents, no matter which neighborhood they may live in.

“While our work is focused on equitable vaccine access now, we hope that our approach can continue to expand access to health care beyond the pandemic,” Clermont said. “Ultimately, investing in community-led health outreach can transform how our public health systems connect with people in Chicagoland.”

Dr. John Welch faced a hiring challenge. 

It was April 2020, and the director of Partners In Health’s COVID-19 response in Massachusetts was on a tight deadline to determine how many people would be needed to launch an ambitious, statewide contact tracing workforce to help bring the newly raging pandemic under control. 

So Welch, along with Emily Dally, PIH’s impact director, pored over a few early papers out of Wuhan, China for reference, and then got to work. They required a detailed hiring plan and budget for the Massachusetts Contact Tracing Collaborative, in which PIH was partnering with the state. How could they predict and plan for shifting workforce needs during an ever-changing pandemic?  To start, they had to figure out how many COVID-19 cases there would likely be in the state, and how much time it would take to investigate those cases, reach out to contacts, support individuals and families with additional needs during the crisis, as well as other critical data. 

“We were on Teams late into the night modeling together,” Welch said. In the end, they’d built a basic, “little” workforce calculator that partners from the professional services company Accenture later helped to adjust and improve over the year, through case surges and plateaus.  

“One of the things that’s been so fascinating is how all of this [U.S.] work unfolded,” Welch added. “It started with contact tracing and then just kept going.”  

Indeed, the journey of the workforce modeling tool reflects the scope of work PIH has taken on in the U.S. That work includes accompanying and advising public health workers and communities during the acute phases of the pandemic -- from contact tracing to vaccine rollout; supporting learning with up-to-date public health guidance, protocols and research made available to peer organizations and community leaders throughout the country; and urging lawmakers in the top ranks of government to adopt policies that lead to stronger public health systems that meet the needs of underserved, neglected communities. “The tool, in its flexibility and effectiveness in a variety of contexts,  mirrors the three pillars of our overall model,” said Katie Bollbach, director of the USPHAU. “Advising, Learning, and Advocacy.” 

A Tool Reimagined 

In July, a few months after PIH’s U.S. Public Health Accompaniment Unit was launched to assist states, cities, and communities build a more equitable, comprehensive public health response to COVID-19, the tool appeared again. The USPHAU Learning Team which develops and distributes the latest public health guidelines, protocols, and research to peer groups around the country, realized that the workforce calculator used in Massachusetts could be useful to other health departments nationwide. So, the team adapted it for general use, making the PIH Contact Tracing Workforce Modeling Tool accessible to peer organizations and partners via the USPHAU’s online resource library. Representatives of 117 organizations in 30 states have access to the library and the tools, protocols, and frameworks it contains.  

The following month, a request came in from the Illinois Department of Public Health. State administrators asked for assistance estimating the size and scope of its COVID-19 workforce. Dr. Pranali Koradia, a USPHAU adviser, turned to the calculator for guidance, and the team supporting Illinois tailored the tool’s methodology to help predict Illinois’ hiring needs based on epidemiological trends and case rates. Ameet Salvi, the former project lead in Illinois, said the team generated hiring estimates for all 97 of the state's local health departments and outlined the assumptions and mechanics of the model to encourage hiring.  "I can't draw a direct correlation between our contributions and specific impact, but I would say the exercise provided a directional target that jumpstarted hiring and contributed to the state eventually achieving contact tracing targets."  Eventually, the state hired 2,520 workers, including contact tracers and case investigators, to support the COVID-19 case load.  

A Nationwide Public Health Workforce 

At the same time, then-presidential candidate Joseph Biden had been promoting a new, nationwide public health workforce, including 150,000 community health workers and 100,000 contact tracers.   

Justin Mendoza, PIH’s advocacy lead, was closely tracking Biden’s health agenda. He knew those numbers wouldn’t be high enough to meaningfully improve the nation’s chronically underfunded public health infrastructure and make the system far more equitable to communities long hurt by structural racism and also hit hardest during the pandemic. He just wasn’t sure what the right numbers should be. 

Mendoza said he needed evidence to make the case for a bigger, more ambitious public health workforce: one that he thought should be closer to one million strong. Enter: the workforce modeling tool, yet again. Impact Manager Lindsey Wang and Senior Project Leader Grace Lesser used the modeling methodology to identify staffing needs of a new nationwide workforce -- including about 550,000 community health workers -- that could address the immediate health crisis and then transition into longer-term public health work to strengthen the system well into the future. 

Community Health Workers, Now 

With a detailed workforce plan in hand, PIH’s advocacy team launched a new Public Health Jobs Now! Campaign in November 2020, joining forces with organized labor, faith-based, and community organizations. The new coalition’s agenda focused on urging Congress to create more than one million public and community health jobs. In addition to the community health worker jobs, the coalition recommended funding for 100,000 contact tracers, 400,000 school-based workers, 250,000 traditional public health positions, and 50,000 legal jobs to address the nation’s housing crisis. These calculations, Mendoza said, would form the basis of the federally funded and locally managed public health jobs corps.  

 To help popularize the concept, PIH’s CEO Sheila Davis co-wrote an op-ed with Sen. Kirsten Gillibrand of New York in February 2021, published on CNN, calling for an expanded public health workforce to take on COVID-19.  

In March, President Joseph Biden signed the American Rescue Plan Act, which included $7.6 billion to invest in the types of community-centered jobs that PIH and the Public Health Jobs Now! Coalition had advanced. This historic law called for far more public health jobs than initially envisioned; and it constituted the largest one-time investment in public health and community health in the past three decades. After many months spent developing partnerships and building relationships with influential decision makers and laying out a compelling agenda, PIH viewed the new law as a major breakthrough.  

Influencing the Deciders 

The work did not stop there. Based on recommendations from the Public Health Jobs Now! Campaign and community-based partners, PIH hosted a roundtable with officials from the White House and U.S. Department of Health and Human Services on workforce investments in March, and encouraged decision makers to invest in community and public health roles. Many of these recommendations informed the structure of programs led by the Centers for Disease Control and Prevention and other key agencies.  

One of these programs, under the Health Research and Services Administration at the Department of Health and Human Services, is a historic $250 million investment in vaccine equity and access, including $120 million earmarked for local community-based organizations as essential stakeholders in the fight against COVID-19. 

PIH is continuing its efforts, seeking to build off these initial investments to create long-term funding so community-based organizations can continue the kind of locally inspired, on-the-ground work that saves lives. 

“What makes this story unique,” Mendoza said. “is that we were able to take something -- a highly technical answer to one problem in one state -- and use it to change the entire space in public health funding. That’s the beauty of this team: We are on the ground in communities, but also able to influence national policy in critical ways.” 

Gloria Rukomeza, a health professional from the Democratic Republic of the Congo, is one of 23 students who graduated in a virtual commencement on Sunday, August 22, 2021 from the University of Global Health Equity (UGHE) in Rwanda. Additionally, Rukomeza, who earned a Master of Science in Global Health Delivery, was selected as this year’s recipient of the Moskovitz Scholarship for Women in Global Health Leadership, which is given to women in the Global Health Delivery program who have shown a commitment to equity and a strong ambition to improve global health delivery.

As a health professional with a passion for leadership and management, health advocacy, and community development, Gloria spoke to us about her year with UGHE and her commitment to advocating for women’s representation in global health leadership.

Could you tell me about yourself and your career aspirations?

I was born in the Eastern part of the Democratic Republic of the Congo, along with nine siblings. Being born into such a big family taught me from an early age about love and care. 

When I was a child, I remember seeing individuals die due to a lack of health professionals. It inspired me to learn more about health care delivery and how I could play a part in changing it for the future. I left my country shortly after and arrived in Rwanda in 2017.

To me, this country and its health system showed me what excellent health care should look like. Studying at UGHE helped me realize a long-held goal of not just studying healthcare delivery but also getting practical experience in the community. Throughout my UGHE experience, I was inspired by a number of powerful women challenging the status quo in global health, which sparked my interest in a career in health advocacy and communications. I want to use my knowledge to enhance both community and women’s health.

What first drew you to the University of Global Health Equity and the Master's In Global Health Delivery program?

I was enthusiastic about the practical experience outside the classroom that students receive while attending classes. Its mission was really connected to my passion—that of transforming community health and bringing this to my country. 

As we study in the community, we get opportunities to learn about health inequities and structural barriers impacting access to quality healthcare and it teaches us different ways of addressing the barriers to improve people’s living conditions.

What Global Health Delivery module stood out to you most, and why?

Before joining the Global Health Delivery program, I knew very little about global health, but had a strong desire to improve people’s health situations. The principles of the global health equity module provided an opportunity for me to learn about the real-life application of global health equity. To effect change, we must first identify the root causes of the issues. I learnt about the underlying causes of health inequities, as well as creative problem-solving methods—for example, tackling socioeconomic determinants of health, structural violence, and a plethora of other health disparities.

As students, we’d have conversations with students about subjects such as equity, equality, and health as a universal human right, to mention a few. During these class talks, I was able to learn a lot from the experiences of my classmates. As a global health leader, I am certain that I will be able to make informed choices to enhance health care delivery with a focus on the underserved.

You are this year’s Moskovitz Scholar. How do you plan to advocate for women in global health leadership in your next chapter? 

For a long time, the global health sector has been controlled by men, and I believe it is difficult for nations to achieve equitable health care delivery with uneven gender ratios in health care delivery. Women’s contributions are critical in providing excellent health care and combating persisting inequities in communities. I will advocate for women in positions of global health leadership. Women need to be represented in decision-making positions. We must break down the gender barriers that prevent women from taking an active part in addressing community health issues and instead empower them via education and training. 

Read the original article on UGHE's website.

The ticking clock of emergency care, and what it can mean for patients’ lives, is on the minds of every Partners In Health clinician caring for survivors of the devastating 7.2-magnitude earthquake that struck Haiti on Aug. 14.

One week after the disaster, followed by Tropical Storm Grace two days later, clinicians are focused on treating broken bones and complicated injuries—essential to saving lives and preventing permanent disability. So far, Haitian officials surveying the affected region have reported more than 12,000 injured from the quake, which centered on Petit Trou de Nippes along the southern peninsula, leveled houses, and collapsed or severely damaged multiple health facilities.

Dr. Shada Rouhani, director of emergency and critical care at PIH and an emergency medicine physician, has worked for years alongside colleagues at Zanmi Lasante, as PIH is known in Haiti. That work includes helping establish the emergency department and emergency medicine residency—the only one in the country—at Hôpital Universitaire de Mirebalais in the years following Haiti’s 2010 earthquake and supporting training programs for emergency care. Now, she is helping support the rapid response led by her Haitian colleagues, some of whom she trained nearly a decade ago. Their efforts have made a critical difference in emergency response between 2010 and today.

Below, Rouhani discusses clinicians’ primary concerns following an earthquake, how they rapidly respond with lifesaving care, and why such tragedies also can have a lasting impact on the lives of those not immediately injured during the disaster.

What types of injuries typically result from a massive earthquake, such as the recent one in Haiti?

In the first few days, we usually see multiple forms of trauma: people with head injuries, bleeding into their abdomen or chest, and severe crush injuries and broken bones. High-quality, immediate emergency and surgical care can save lives.

For example, bleeding in the abdomen often needs surgery. Where there is a trained surgeon and an equipped operating room, the bleeding can be stopped. Where this does not exist, bleeding cannot be stopped and patients will die unnecessarily. Some broken bones are also associated with significant bleeding. A broken femur or pelvis can cause fatal bleeding; emergency care can help stop the bleeding until surgery can cure it. 

That concept—broken bones can lead to death—is hard to fathom. Can you explain how that’s possible, and how clinicians respond to these emergencies?

Broken bones can be “closed’ or “open.” Closed means the bone does not break the skin. Sometimes these are treated with casts, sometimes with surgery. But, if they are not treated correctly, bones will not heal correctly. This can lead to permanent deformity and disability. Since many people in Haiti need physical labor to survive, this can be especially devastating. PIH clinicians are able to correctly identify and treat broken bones to prevent this.

Open means there is a cut that exposes the broken bone and can leave the bone poking through skin. In these cases, there is also a risk that the bone and wound can become infected if the patient does not get antibiotics and surgery. Delays in antibiotics and/or surgery create infections, which can require amputations to treat. In severe cases, infections can spread to the rest of the body and kill the patient. 

Our emergency care teams can correctly diagnose open fractures and treat them with antibiotics and splints until our surgical teams take them to the operating room to clean the wound and fix the bone. 

How are other types of injuries treated?

Sometimes people will have significant wounds that they do not get treated initially, or that are incorrectly treated. These cuts can then get infected. Without quick antibiotics and the surgical removal of the infected tissue, these infections can spread and lead to amputations and/or death. 

In severe infections that have spread to the blood, emergency and critical care are needed to help stop the infection and reverse damage it may have already caused to organs.

Why do so-called “crush injuries” sometimes require kidney dialysis?

Crush injuries can cause muscle proteins to break down rapidly in the blood. When too much of this protein breaks down at once, it can cause kidneys to fail and dangerous imbalances of electrolytes in the blood that can stop the heart. Dialysis balances out these electrolytes while medical treatment, often IV fluids, are used to revive the kidneys until they can begin to work again.

How do earthquakes have an impact on other patients who may not have been injured?

In the first few weeks after a disaster, we will start to see exacerbations of chronic diseases. People are cut off from their medications and care for chronic diseases—such as diabetes, heart failure, high blood pressure—and can become very sick, very fast.

Think of those chronic medications as keeping things balanced and working in the body. When they are removed, the disease takes over and people can present with acute crises, such as diabetic ketoacidosis, strokes, and severe difficulty breathing. In heart failure exacerbations, fluid can back up into the lungs when the heart isn’t working well. When the lungs are filled with fluid, you can’t breathe and can even get respiratory failure.

In addition, earthquakes can cause post-traumatic stress disorder. The recent earthquake risks retraumatizing individuals who were also affected by the 2010 earthquake. PIH’s mental health teams are working to support individuals through these crises.

Fully equipped health systems, like those at PIH-supported Hôpital Universitaire de Mirebalais, ensure that there are key elements of quality care: physicians to diagnose these problems correctly and to start the correct treatments; medications and supplies to treat these issues; hospital beds to care for these patients; and outpatient supports to help them get back on their feet and restart treatments. 

Dr. Michelson Padovany, a surgeon for Partners In Health in Haiti, said he saw suffering families, collapsed buildings, and debris-filled roads everywhere he went on the country’s southern peninsula this week, visiting affected areas as part of response efforts after the country’s disastrous Aug. 14 earthquake.

“We traveled from Port-au-Prince to the south yesterday. It was difficult for us because roads were blocked by debris. And not only from Port-au-Prince to here, but also from St. Boniface (General Hospital) to Les Cayes, from Les Cayes to Jérémie, in the Grand Anse where we are right now,” he said. 

Padovany is a cross-site surgical coordinator with Zanmi Lasante, as PIH is known in Haiti, and has worked at St. Boniface General Hospital in the country’s south for the past two years. He knows the earthquake’s hardest-hit region very well, making the assessments of damage and health conditions all the more heartbreaking.  

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“You can tell that people are suffering from Les Cayes to Jeremie,” he said. “You can see that every single building collapsed. I think what we need now is help for our people. We need help for children, help for adults, help for families. They need water. They need food. They need somewhere to stay at night.”

Padovany was among several Zanmi Lasante clinicians who traveled from Port-au-Prince and Mirebalais to the country’s south late this week to assess damage, assist in coordination efforts, and provide medical expertise in the immediate days following Saturday’s 7.2-magnitude earthquake. 

International news reports Friday reported more than 2,100 killed and 12,000 injured, with both numbers still rising. The earthquake destroyed more than 50,000 homes and damaged nearly 80,000 more, leaving tens of thousands of people displaced or without homes.

Another doctor involved in the response cited widespread structural damage, including to health centers.  

“We are now in Jérémie, which is the main city of Grand’Anse, one of the departments that has been affected greatly,” he said. “We went to the south and to (Petit Trou) de Nippes, (a small town near the epicenter) and we found multiple health centers were completely collapsed.”

Clinicians said there is enormous need for staff, stuff, and space -- three of the five pillars of PIH’s model health system -- as overflowing facilities continue to receive patients with serious injuries and trauma. 

The recently arrived Zanmi Lasante staff stand with all those affected this week. Padovany echoed that solidarity, and cited additional damage and impacts from Tropical Storm Grace just two days after the earthquake. 

“It’s even more difficult in this time because of other weather-related issues,” he said. “So, if I have one message to the world, it is: We need your help.” 

Trauma patients from Saturday’s earthquake in southern Haiti are now receiving care at Partners In Health’s University Hospital in Mirebalais (HUM), a world-class facility that PIH and Haiti’s government built after the country’s 2010 earthquake. The first air ambulance arrived Thursday afternoon.

At least 30 patients, nearly all with orthopedic injuries have been referred to University Hospital so far.

PIH runs the 300-bed teaching hospital in partnership with Haiti’s Ministry of Health, and it is the flagship facility for Zanmi Lasante, as PIH is known in Haiti.

Dear PIH friends and supporters:

I am never more proud of Partners In Health than I am in the hardest of times, when our teams respond to crises with expertise and compassion, mobilizing on the spot to provide vital medical care and spread hope amid despair.

That has been the case over the three days following Saturday’s massive earthquake in southern Haiti. We’re still learning about the scope of the disaster and assessing the needs in the most affected areas of Haiti’s southern peninsula. But we know that there are thousands of casualties in the larger population centers and in outlying areas, many of which remain cut-off from outside support.

Our immediate efforts are focused on mobilizing support to these hard-hit areas, including the cities of Jeremie, Les Cayes, and Petit-Trou-de-Nippes, the epicenter. Our first team of doctors arrived in Les Cayes on Monday morning and are triaging patients and assessing surgical needs. Those doctors and nurses are part of a Zanmi Lasante staff that is 99% Haitian and more than 6,500 strong, partnering with the national health authorities to constitute the country’s largest and strongest health system.

We are deploying additional teams—including trauma and orthopedic specialists—to the peninsula when roads are cleared. Our construction partner, Build Health International, is on the ground conducting safety assessments in places with significant structural damage.

Staff at Zanmi Lasante, as PIH is known in Haiti, are hard at work across the country, mustering hospital beds and supplies, and creating teams to care for people from beyond our catchment areas. Our teams in Mirebalais, Saint-Marc, and Hinche have enacted emergency protocols developed after Haiti’s devastating earthquake in 2010, and PIHers in Fonds des Blancs—supporting the excellent St. Boniface Hospital, two hours from the epicenter—are also helping prepare for an influx of patients. We have 10 operating rooms across facilities in the Central and Artibonite Departments, and are ready to receive and treat critically injured patients.

The health authorities have worked up a list of pressing needs, and we’re working to source and ship supplies, medicine, and equipment for the Ministry of Health, our partner organizations, and Zanmi Lasante.

Meanwhile, storms literal and figurative continue to mount in Haiti. Hurricane season is upon us, and Tropical Storm Grace struck Monday night, bringing floods and fuel shortages to a country beset by political turmoil, including the assassination of its president only a few weeks ago. Heavy rainfall is likely to cause mudslides and further hamper transportation on or across already damaged roads and bridges.

An additional concern from Grace is cholera, which PIH helped to curb in Haiti through comprehensive vaccination and clean-water campaigns in recent years. As acute crises pile on top of each other, COVID-19 cases are rising in the country, as well, with Zanmi Lasante reporting many new cases this week.

We also are taking steps to address the mental health needs of the population, as Saturday’s disaster has surely brought back traumatic memories from 2010. We all feel it, too.

As Zanmi Lasante responds to these urgent needs, our teams will continue to provide access to the lifesaving care that is their vocation, serving millions across the country.

And, as always, we are deeply grateful to you, our dedicated and steadfast community of supporters.

We will continue to update you in the days ahead.

With gratitude, and in solidarity,
Paul

Dear PIH:

By now you’ll have heard that a 7.2 magnitude earthquake has just struck Haiti. The US Geological Service estimated that its epicenter was about 80 miles west of the capital. Although the temblor appears, right now, to be almost as large as the big one in 2010, it did little more than shake Port-au-Prince and points north. The more affected areas in the south and its peninsula were, however, affected, with significant structural damage in the cities of Cayes and Jeremie, on the tip of the peninsula. Preliminary reports from Cayes (also known as Aux Cayes) and the smaller towns of Aquin and Petit Trou de Nippes suggest many downed buildings and people trapped under rubble, and we will no doubt know more soon. Members of the Zanmi Lasante (ZL) staff report that the cell phone service in those parts are affected and so everyone in Haiti is awaiting news, too. Our friends (and family) in Fonds des Blancs are safe, and the hospital there undamaged, but they will prepare for casualties from not far west of their catchment areas.

We know everyone on this list, and of course millions more, want to see Haiti catch a break and continue with a vaccination campaign too often deferred and only now beginning. And that’s before mentioning our regular clinical activities. I’m confident Zanmi Lasante will be able to muster both hospital beds and outreach teams, and already has a cracker-jack trauma team. We didn’t have that latter capacity in 2010, but do now, and ZL will let us know more this afternoon, as we and others gather information or as it comes in from the south. The teams in Mirebalais, Saint-Marc, and Hinche are enacting their emergency protocols, which we also didn’t much have back then. In spite of that, and much smaller capacity, all of you will remember that ZL had teams within the quake zone within 24-48 hours. They can do more, and faster, than back then, and will be counting on all of us for the pragmatic solidarity they deserve. That will be, as usual, in the form of staff, stuff, space, and support, since we now have Haiti’s biggest and strongest health system, much of it mobile when needed. Of course, they are already dealing with COVID and political disruption, but we have the US Coordination team on standby too.

I will only add that we have also heard from our teams as far away as Rwanda and Sierra Leone, who also expressed concern for the team in and people of Haiti. I’m sure you’ll join me in praying for the break Haiti so richly deserves, as well as expressing our material and pragmatic support for the work at hand. We are checking in with the teams in central and Artibonite districts this afternoon, when we should have a clearer sense of what is needed.

We will update you throughout the days to come.

Paul
 

Demanding an end to “Band-Aid” measures that neglect lower-income communities, local health officials and advocates rallied outside the Massachusetts State House earlier this month calling for the state to direct $250 million toward strengthening local public health departments. These funds stem from the American Rescue Plan Act, which passed the United States Congress in March. Barbara L’Italien, Partners In Health’s senior government affairs advisor and a former state legislator, was at the rally. We asked her for what purposes advocates want that money in Massachusetts, and how their plan fits into PIH’s broader vision of reimagining public health systems across the U.S. after the pandemic.  

Public health advocates want federal money spent on local health departments in Massachusetts. Where would that money come from? 

The money comes from Massachusetts’ over $5 billion portion of the $1.9 trillion American Rescue Plan Act of 2021, signed into law by President Joseph Biden in March. Advocates from the Coalition for Local Public Health and the Massachusetts Public Health Association have asked the state legislature to allocate $250 million to shore up the inefficient and inequitable state public health infrastructure.  

How would the money be used? 

The proposal  would allocate federal American Rescue Plan Act (ARPA) funds over the next five years to upgrade local health departments in Massachusetts. The state has 351 cities and towns, each with its own public health administration, and it’s one of the only states in the nation with no dedicated funding directed to local public health. This has led to major gaps in health spending in local communities, which has taken a toll on lower income individuals and families. The plan calls for spending in three major areas, including $95 million to boost staffing and address health disparities; $37.5 million for workforce development and training; and $118.4 million to enhance public health data systems. 

Why is the money needed now? 

The COVID-19 pandemic has further exposed long-standing inequities in the health system, with Black, Hispanic, and other communities of color disproportionately impacted by illness and death. Even though lifesaving vaccines are now widely available in the U.S., Black and Hispanic Americans’ vaccination rates are still lagging in almost every state. 

How is PIH involved in this effort? 

I worked as a supervisor for the Massachusetts Community Tracing Collaborative – a contact tracing workforce launched by PIH at the request of the Commonwealth of Massachusetts in April 2020 -- for six months and then transitioned over to work as an advocate/lobbyist for PIH last October. I have worked with the Coalition for Local Public Health and the MA Public Health Association to ensure that the state would implement the findings of a Public Health Commission to reimagine and strengthen the state’s local public health system so that it is fully capable of addressing future needs. The work is really to bring the Massachusetts system into the 21st century. 

My work has included weekly meetings to assist with strategy, training local health members on oral and written testimony with the aim of building support for the legislation within both the state fiscal year budget and the special ARPA funding budget bill. I assisted in planning the rally—from messaging, timing, promotion, outreach to legislators, to management of the event itself. It was really fun to be on the organizational side of an event like this after many years of attending rallies as a state representative and state senator! Post rally, the work is focused on both growing grassroots support to advocate to the broad legislative membership for the ARPA request, while simultaneously meeting with the chairs of the House and Senate Ways and Means committees and preparation for a September ARPA hearing that will focus on health care.  

PIH has worked with more than 15 local, county, and state health departments to build up COVID-19 response and partnership, through our U.S. Public Health Accompaniment Unit.  

As a part of our efforts, PIH has elevated the voices of partners across the country to help advocate for a stronger investment in the public health infrastructure. These efforts have included joining the National Community-Based Workforce Alliance, co-founding the Public Health Jobs Now! Campaign, and joining the MA Vaccine Equity Now coalition. These efforts have been designed to inform and partner with the Biden administration and allies to ensure that equity is a central part of the COVID-19 response, and that states are leveraging opportunities to expand public health in the hardest hit communities. Now that we are starting to think about post- COVID-19 recovery, we believe it’s critical to strengthen local public health systems so that all communities have access to high-quality health care and support for social needs. 

How have communities in Massachusetts been hurt by this lack of funding? 

Funding varies for each of the 351 cities and towns in the Commonwealth depending on the relative willingness and ability to financially support public health – from contact tracing to water quality, housing, restaurant, and business inspections. During the COVID-19 pandemic, many communities lacked enough staff, with some relying on elected or appointed health boards with no full-time health professional. The Massachusetts system lacks a cohesive set of uniform standards by which all local boards of health operate and many desired additional pandemic-specific training and local epidemiological expertise. Outreach to communities of color particularly hurt by the pandemic was limited due to staffing and other resource issues. There has been high burn-out due to limited personnel working long hours. Some people have resigned but the vast majority have stayed. And now, public health departments need to be able to hire permanent employees and access technical assistance. 

Are any other states mounting similar efforts on behalf of local health departments? 

I would assume so, but most states operate county-wide systems. Massachusetts is an outlier in operating 351 separate entities. 

What’s the vision beyond the state of Massachusetts? 

Our post-COVID-19 work in the U.S. focuses on four major areas: building up the capacity of public health departments to deliver health equity and sustain resilient responses to novel challenges; institutionalize community health workers as core components of a community-based health workforce; strengthen the integration of services addressing social drivers of health -- food, referrals to care and insurance, housing programs, etc. -- within health care across public and private sectors; and elevate community leadership in defining priorities of local health providers in order to improve primary care coverage and available resources. This is a national effort but we need to help make it happen, state by state, community by community. 

How can people learn more about this proposal? 

More details can be found here.  

How can people get involved? 

The Massachusetts State Legislature is interested in hearing from individuals, organizations, and experts on how best to allocate the ARPA funds. Public hearings will begin this month and extend into the early fall. Those interested in promoting public health strengthening can submit written testimony to both the Ways and Means Committees of the House and Senate, and the COVID-19 Federal Assistance Committee. Additionally, there are opportunities to sign on to a public letter organized by the MA Public Health Association and Coalition for Local Public Health to connect with your representative and senator via phone or email to urge them to prioritize this funding to bring our public health system in line with 21st century needs. 

On the piers of New Bedford, timeworn boats idle at the dock, as they have done for decades, loaded with crate after crate of the catch of the day. The boats are fixtures in the Whaling City, the economic center of southeastern Massachusetts and home to the most lucrative fishing port in the United States. But during COVID-19, that rich history came with its own set of challenges. And it was the job of local health liaisons like Amrith Fernandes Prabhu to help the city find solutions, as officials took action to protect workers in the seafood industry.

As part of the Massachusetts Community Tracing Collaborative (CTC), Fernandes Prabhu was tasked with accompanying city officials in New Bedford as they navigated the COVID-19 response—from contact tracing to care resource coordination.

“A lot of the clusters we were seeing earlier on, like last summer and into the fall, were around fishing boats,” she recalls. “The clusters would just sort of expand because people couldn’t quarantine on the boats.”

The CTC was launched by Partners In Health in April 2020, in collaboration with the Commonwealth of Massachusetts and local boards of health, combining PIH’s decades of experience in public health and contact tracing with local health departments’ deep community trust to strengthen the state’s response.

According to state databases, New Bedford was one of the hardest hit cities in Massachusetts, with its numbers peaking at 264 cases per day in January, making it a crucial partner for the CTC—and local health liaisons like Fernandes Prabhu made that partnership most effective.

Just A Phone Call Away

The local health liaison program was established in the summer of 2020, just months after the launch of the CTC, with 16 liaisons serving as the sole points of contact for health officials in 351 jurisdictions and two local tribes across Massachusetts.

These liaisons served as vital connectors between local health departments and the CTC’s dozens of contact tracers, care resource coordinators, and epidemic intelligence unit analysts, preventing gaps in communication, especially during the pandemic’s deadliest months. As city officials shifted to respond to the pandemic, often with limited resources and staff, local health liaisons were critical partners at every turn.

During New Bedford’s most difficult months of the pandemic, as well as the quieter stretches, Fernandes Prabhu was just a phone call away, always ready to help public health officials get the resources, information, and support they needed to serve the city’s population of over 95,000.

“If there was a car accident or a parade or anything, I was in it with them,” she recalls. “I knew what to expect, what kind of cases were going to drop.”

Each day, Fernandes Prabhu shared valuable insights on contact tracing, cluster outbreaks, and essential resources from across the entire CTC team, helping the city identify the places where support was most needed and where their resources would make the most difference. She provided important contact tracing related data to the city as it worked with the state to organize mass vaccination sites in February 2021 for the 15,000 seafood processing workers, fishermen, and other residents who were among the most vulnerable.

New Bedford wasn’t the only community where local health liaisons made an impact. More than 100 miles away, in the heart of western Massachusetts, liaisons provided crucial support in another hard-hit community: Holyoke.

From Contact Tracing To Food Support

An industrial town historically known for its paper mills, Holyoke sits just eight miles north of Springfield, the commercial hub of western Massachusetts, and is home to 40,241 people, with more than half of its population identifying as Hispanic. Like New Bedford, Holyoke saw its COVID-19 numbers peak in January, following the holidays.

In Holyoke, as in many cities in Massachusetts and beyond, the pandemic compounded longstanding challenges, including food and housing insecurity and a staggering unemployment rate—currently as high as 10.1%, nearly twice the national rate of 5.8%.

These challenges led to Holyoke joining New Bedford and 18 other cities and towns as part of Massachusetts’ COVID-19 Vaccine Equity Initiative, released in February 2021—a statewide effort to prioritize vaccine distribution and support for the 20 hardest-hit communities, as designated by Governor Charlie Baker’s administration.

But equity had long been essential to Holyoke’s pandemic response, says Sandra Aronson, the local health liaison assigned there. When she began working with the city, there wasn’t a liaison program. In fact, early in the pandemic, the city had opted to handle contact tracing and follow-up on its own, without assistance from the CTC.

But as case counts ticked upwards and the city’s needs shifted, the seeds for partnership, planted months earlier, took root. The city formally partnered with the CTC and its local health liaison program in August 2020.

“With the creation of the local health liaison program and having one person that they could respond to, I think that really made things a lot easier in terms of learning what the needs were for the community, learning what they were doing on the ground, and figuring out what was the best way we could support them,” says Aronson.

That support included monitoring COVID-19 cases, investigating outbreaks, and supporting the city’s efforts to distribute essential resources, such as food boxes and, later, gift cards to local grocery stores—a vital form of social support as families struggled to afford food amid a pandemic that left millions across the country unemployed.

“A common refrain at the CTC is that we are building the plane as we are flying it,” says Aronson. “It’s really been a progression, from them saying, ‘Please don’t follow cases or contacts, we are already doing the work’ to ‘Can you please help us with monitoring and support and care resource coordination?’ I feel like everything’s come full circle and it’s improved greatly.”

Strengthening Health Systems

Now, as vaccines are rolling out across the U.S. and as Massachusetts shifts federal dollars to local health departments to boost their own capacity, the CTC will continue to scale down—but lessons learned from the local health liaison program are still influential.

In New Bedford, the local health liaison program laid the groundwork for lasting partnerships, as shown by the ongoing work of PIH’s U.S. Public Health Accompaniment Unit there, which has helped the city orchestrate the vaccine rollout and develop public health campaigns—efforts that aim to strengthen New Bedford’s health system not only in response to COVID-19, but for years to come.

“What COVID has shown for a place like New Bedford is that health equity has to remain at the top of the agenda, even when there’s not a pandemic,” says Fernandes Prabhu. “Investing in long-term health, in livelihoods for all communities, building inclusivity and trust with folks who have historically not had the luxury of that trust…is really important.”

And in Holyoke, Aronson continues to accompany the city as it vaccinates its population and navigates evolving public health guidance—work that she continues to find both empowering and humbling.

“The local health departments—they know their community, they’re the experts on their communities. They are doing so much hard work on top of COVID and everything else,” she says. “I think that there’s a lot of good work that we can all do together and I’m looking forward to continuing to help them in any way that we can.”

A decade ago, a team of clinicians and health advocates in rural Chiapas united under a simple yet radical vision: every person has a right to health.

The team—Dr. Daniel Palazuelos, Lindsay Palazuelos, and Dr. Hugo Flores—had been providing health care in rural communities of the Sierra Madre region for years and had seen just how far that vision was from reality: dirt roads flooded and impassable, medications often out of stock, and clinical staff left unsupported.

They were determined to change that reality and push for justice in health care. In 2011, Compañeros En Salud was born.

In the years since, Compañeros En Salud has grown from a small, grassroots organization to a team of 200 people—from doctors to drivers to first-year clinicians—dedicated to making a difference. That growth has paved the way for broader change. Over the past decade, the team has served more than 25,000 patients and completed more than 133,000 consultations in areas ranging from maternal health to chronic diseases, providing free, high-quality medical care to patients in some of Chiapas’ most remote communities.

And the mission has always been more than medical. Through the Right To Health Care program, Compañeros En Salud has for years tackled health inequity at the root, connecting patients with specialized care in hospitals—often hours away from patients’ homes—and ensuring they have food, transportation, and housing assistance, known as “social support,” to help them access care, recover, and stay healthy.

Through it all, patients have always been at the center of Compañeros En Salud’s work.

Patients first inspired the work, decades ago; and patients continue to drive Compañeros En Salud to improve the quality of care provided. This is true, now more than ever, as the team responds to COVID-19 and continues to make the vision of health as a human right a reality for all people in Chiapas.

For years, Compañeros En Salud has hired and trained local residents to serve as community health workers, providing medications, basic health services, and accompaniment to their neighbors in the nine rural communities where it works. In this picture, Compañeros En Salud Co-founder Dr. Hugo Flores accompanies a community health worker on a house call in the community of Matasano in 2014. Compañeros En Salud’s team of community health workers has since grown to more than 85 people supporting their friends, neighbors, and family members. Photo courtesy of Compañeros En Salud.

Since its founding in 2011, Compañeros En Salud has made training the next generation of clinicians central to its work. The pasante program is one way that Compañeros En Salud accomplishes this goal. Each year, a cohort of first-year clinicians can apply and choose to complete their year of social service—required of all health care services graduates by the Mexican government—in one of the rural communities where Compañeros En Salud works. This program gives the new clinicians valuable work experience, mentorship, and the opportunity to serve the community. This picture features the second cohort of pasantes, including (front row, from left to right) Lindsay Palazuelos (co-founder), Dr. Daniel Palazuelos (co-founder), Dr. Valeria Macías (pasante at the time of the picture, now executive director), and Dr. Hugo Flores (co-founder). Photo courtesy of Compañeros En Salud.

In Jaltenango, a town of around 10,400, Compañeros En Salud has its main office and supports a hospital, which includes a respiratory disease center and the maternal health center, Casa Materna. But for the thousands of people living in rural communities outside of Jaltenango, these facilities, while crucial, can be difficult to access, especially during the rainy season, when dirt roads  become flooded and impassable. To counter these challenges, Compañeros En Salud has partnered with the Mexican Ministry of Health to staff and support clinics in nine rural communities, providing places for patients to receive vaccinations, medications, and check-ups without having to travel miles on unsafe roads or spend precious earnings on costly taxi fares. In this picture, Krysthal Dardon, a nurse, steadies a man’s arm before administering a vaccine at a rural clinic in Matasano in March 2014. Photo by Rebecca Rollins / Partners In Health.

Key to Compañeros En Salud’s work is accompaniment—walking alongside patients as they recover and stay healthy. In order to accomplish this, Compañeros En Salud enlists the help of dozens of community health workers, who make house calls, accompany patients to their medical appointments, and offer emotional support. These workers, who come from the communities they serve and bring years of cultural and linguistic knowledge, are essential to helping patients navigate a complex health system, get their medications, and follow their treatment plans. In this picture, Community Health Workers Yadira Roblero and Magdalena Gutiérrez approach a home in Laguna Del Cofre for a house call in March 2016. Photo by Aaron Levenson / Compañeros En Salud.

Over the years, Compañeros En Salud has also made maternal and child health a key focus, notably through Casa Materna—a maternal health center where expectant mothers receive prenatal care, lactation advice, and a place to stay before, during, and after their deliveries. The home is staffed by first-year obstetric nurses, who are supervised by obstetric nurse supervisors. A doctor and a gynecologist are available at the nearby PIH-supported hospital, in case complications arise. In this picture, Alma Rosa "Rosi" Valentin Martinez (left), an obstetrics nurse pasante fulfilling her social service year, examines 35-year-old Gloriena Elizabeth Roblero Mendoza, who came to Casa Materna pregnant with her fifth child in November 2017. She had been experiencing pain in her side and was afraid she was going into early labor, but Compañeros En Salud staff helped her get a blood test and ultrasound images and confirmed she was in good health. Photo by Cecille Joan Avila / Partners In Health.

For years, Compañeros En Salud has integrated traditional and modern forms of care into its clinical practice. At Casa Materna, the clinical team includes not just doctors and nurses, but also traditional midwives, who bring decades of experience in culturally relevant forms of healing and caregiving to help mothers deliver their babies in the way that feels most comfortable for them. Margarita Perez Jimenez, pictured in this photo on the left, was the first traditional midwife to assist her patient, Martha Domínguez López (right), during childbirth at Casa Materna in October 2017. Photo by Cecille Joan Avila / Partners In Health.

As COVID-19 swept through Mexico and around the world in 2020, Compañeros En Salud was ready to respond—training clinicians, implementing comprehensive infection prevention and control protocols, and adapting its programs to continue lifesaving services while prioritizing patients’ safety. Compañeros En Salud’s years of experience building trust and relationships in the communities where it works paved the way for its role as a key partner to the Mexican Ministry of Health during the pandemic response. In this picture, a nurse wearing personal protective equipment sits in the triage area of the PIH-supported community hospital in Jaltenango. Photo by Paola Rodriguez / Partners In Health.

Even as rising COVID-19 cases put Chiapas’ health system to the test, Compañeros En Salud continued to provide lifesaving medications and clinical services to thousands of patients, going above and beyond to ensure that patients had access to quality medical care and social support during a difficult and chaotic time. In this picture, Leini Escalante (right), a community health worker, supports  Erika Osorio (middle), a nurse, during an influenza vaccination campaign. Photo by Paola Rodriguez / Partners In Health.

If there’s a COVID-19 outbreak at a food processing plant, can we rapidly vaccinate the rest of the factory workers? Or if there’s an outbreak at a youth sports tournament, can we vaccinate all of the coaches and athletes from all of the teams?

When we include vaccination when responding to a new COVID-19 cluster, it’s called “tactical vaccination.” This is an innovative approach that can complement other efforts to increase vaccination rates, especially in vulnerable communities.

The first step to implement this strategy is to identify the cluster. This is typically done through retrospective contact tracing, which is when a tracer works with a person who has tested positive for COVID-19 to reflect on when and where they might have been infected and identify others present—in other words, a cluster of cases. More often, contact tracers do prospective contact tracing, which involves asking patients to identify their close contacts during the period of time they were most infectious. Both methods are effective, but retrospective contact tracing is a key component of tactical vaccination by identifying potential hot spots.

Next, people involved in the cluster are notified of their exposure and encouraged to get tested and vaccinated. One method is to send a mobile testing and vaccine team to the hot spot—which often has a low vaccination rate—with the goal of reducing barriers to accessing testing and vaccination. 

For nearly four decades, Partners In Health (PIH) has used this strategy to bring vaccines for many types of infectious disease, including cholera and Ebola, to communities where it works in many countries around the world.   

“We want to have true equity in access to vaccination, so we have to make tactical choices and decisions to support communities most at risk and those who have suffered from the highest burden of COVID-19,” says Dr. Regan Marsh, strategic advisor of PIH’s United States Public Health Accompaniment Unit.

As variants spread, including the highly contagious Delta variant, public health officials are considering ways, such as tactical vaccination, to reach communities most at risk of COVID-19 and most in need of vaccination support, including those who test positive for the virus. 

“By asking everyone coming for a COVID test if they need to be vaccinated, and vaccinating them on the spot if they do, we can vaccinate people on the leading edge of the pandemic and stop transmission. And in this phase, that is exactly what we need to do,” Dr. K.J. Seung, PIH's senior health and policy advisor on infectious disease prevention, preparedness and response, wrote in a co-authored article in The Atlanta Journal Constitution.

Tactical vaccination is important not only for the United States, but also for many other countries. Only 1% of people in low-income countries have received a single dose of a COVID-19 vaccine, compared to 51% in high-income countries. PIH will continue to push for equitable global vaccination distribution and envisions tactical vaccination will be an increasingly common strategy in both high- and low-income countries. 

A newly released report detailing a major outbreak of COVID-19 on Cape Cod, in Massachusetts, underscores the powerful transmissibility of the Delta variant and the way even fully vaccinated people who develop “breakthrough infections” can spread the virus. Indeed, 74% of infections in the Cape Cod cluster were in vaccinated individuals. 

“In July 2021,” the CDC report begins, “following multiple large public events in a Barnstable County, Massachusetts, town, 469 COVID-19 cases were identified among Massachusetts residents who had traveled to the town during July 3–17; 346 (74%) occurred in fully vaccinated persons. Testing identified the Delta variant in 90% of specimens from 133 patients.” 

It has now become clear that more than 800 cases have been linked to the outbreak. “The COVID-19 cluster in Provincetown that first emerged earlier this month has spiked,” according to The Boston Globe, and has impacted people across the United States. Still, it is important to note that even in this outbreak, “among persons with breakthrough infection, four (1.2%) were hospitalized, and no deaths were reported,” according to the report.  

In other words, COVID-19 vaccines, which are primarily intended to lower the risk of severe illness and death from the virus, are working. 

Still, the breadth and speed of the Cape Cod outbreak was a major driver in the CDC’s decision earlier this week to recommend that even fully vaccinated individuals should go back to wearing masks indoors in some regions where COVID-19 cases are surging. 

In the latest report, public health officials went further:  

“Findings from this investigation suggest that even jurisdictions without substantial or high COVID-19 transmission might consider expanding prevention strategies, including masking in indoor public settings regardless of vaccination status, given the potential risk of infection during attendance at large public gatherings that include travelers from many areas with differing levels of transmission,” the report concluded. 

The story behind the CDC report starts with public health sleuthing.

Soon after the Massachusetts Community Tracing Collaborative (CTC), a partnership between the Commonwealth and Partners In Health, launched in April 2020, a team of public health investigators known as the Epidemic Intelligence Unit was created to focus solely on “cluster-busting,” or pinpointing the sources of multiple infections, and then using a variety of tools to stop the spread. 

Throughout the pandemic, the unit has continually been on the lookout for clusters of infections, said Dr. John Welch, who leads the Massachusetts CTC, and earlier this month the team began hearing about cases linked to Cape Cod. At the same time, state health officials were also alerted about a spike in cases on the Cape. At that point, Welch said, the EIU was asked for support, and to focus, in particular, on business exposures.   

As part of its investigation, Welch said, the EIU made thousands of phone calls to every business impacted and to employees and customers – both known and potential contacts -- to get information to support local health departments in the investigation. The team also helped connect cases and contacts to resources, like food or other social support, they might need to safely isolate and quarantine, Welch added.  

He said that a major takeaway here is "the importance of a coordinated cluster response. We’re in this place now that if we can zero in on clusters, it can serve as the nexus of a more targeted COVID-19 response.” More generally, he said: “This should be a wake-up call for people who are eligible but remain unvaccinated. Vaccination is still the best tool to prevent serious illness, hospitalization, and death. We hope people use this moment to seek protection for their families and for communities around the country.” 

PIH’s Dr. Bram Wispelwey, senior technical lead for the U.S. Public Health Accompaniment Unit, which supports the COVID-19 response in hard-hit communities, said in a recent article that  “no vaccine is perfect, and breakthrough cases are expected; the Delta variant is causing more breakthrough cases than other versions of the virus. However, it is encouraging to see that the vast majority of these cases are either asymptomatic or mild. If you’re not vaccinated, you continue to be at significant risk of serious illness or death. While about half of Americans are unvaccinated, they currently make up at least 97% of hospitalizations and deaths.”

The New York Times, in its coverage of the new CDC report, reiterated the critical importance of vaccination and masking, now more than ever, and quoted Angela Rasmussen, a research scientist at the Vaccine and Infectious Disease Organization at the University of Saskatchewan in Canada, saying that: “Full vaccination is very protective, including against Delta. … Masks are a wise precaution, but the bulk of transmission is among the unvaccinated and that’s still who is most at risk.”

In a sign that the current COVID-19 surge is escalating further, the U.S. Centers for Disease Control and Prevention (CDC) on Tuesday recommended that even people who are vaccinated against the virus wear masks indoors in some regions of the country. The guidance comes as case rates steadily rise across the nation, driven by the more contagious Delta variant.   

The CDC’s change of course on masking comes just days after Dr. Anthony Fauci, the nation's top infectious disease expert, described the current state of the COVID-19 pandemic in dire terms, telling CNN that the country is "going in the wrong direction."  

With more than half the U.S. not fully vaccinated, we asked Partners In Health's Dr. Bram Wispelwey, Senior Technical Lead for the U.S. Public Health Accompaniment Unit, to answer a few key questions about what's driving the current COVID surge, "breakthrough" infections, and what actions the public might take to protect themselves and their communities. 

Why did the CDC change its masking recommendations for people who are fully vaccinated? 

The virus is changing, and the CDC recognized that its guidance also needed to change to reflect that reality. COVID-19 transmission has increased throughout the United States in response to multiple factors: the dramatic increase of the Delta variant over the last few weeks, the lifting of masking requirements and other measures, more time spent indoors to avoid the heat, and vaccination rates that are too low to curb transmission in much of the country.  

Should I start wearing a mask all the time, again, even if I'm vaccinated?  

For most Americans, if you’re indoors, the answer is yes. The CDC just recommended masking indoors for anyone – regardless of vaccination status – living in areas of substantial or high spread, which currently describes almost 2/3 of the country. If you are older than 65, have a compromised immune system or a chronic disease, or are living with people who fit into one of these categories, you may also want to consider masking indoors, even if you’re not in a substantial or high transmission area. Getting COVID-19 while outdoors is very unlikely in most scenarios, but if you’re in a crowded space, it’s also a good idea to wear a mask. You can find your county transmission level here.   

Why are we suddenly hearing so much about “breakthrough” cases? I thought getting vaccinated was supposed to protect us from COVID-19.  

COVID-19 vaccines are primarily intended to lower your risk of severe illness and death from the virus, which they continue to do very well. No vaccine is perfect, and breakthrough cases are expected; the Delta variant is causing more breakthrough cases than other versions of the virus. However, it is encouraging to see that the vast majority of these cases are either asymptomatic or mild. If you’re not vaccinated, you continue to be at significant risk of serious illness or death. While about half of Americans are unvaccinated, they currently make up at least 97% of hospitalizations and deaths.  

What role, exactly, does the Delta variant play in the current COVID-19 surge? 

The Delta variant is more infectious, meaning that it spreads more easily than other variants. It is now causing the vast majority of COVID-19 cases in the U.S. This means that more people will be infected, especially those who are not yet vaccinated.  

COVID-19 cases and hospitalizations are rising in the U.S., but how many of these are among unvaccinated people and how many are breakthrough infections among vaccinated individuals? 

While approximately half the country is fully vaccinated, the majority of cases and the overwhelming majority of hospitalizations and deaths (more than 97%) are among those who are not vaccinated. The available COVID-19 vaccines are working exceptionally well at preventing severe outcomes.  

How is all of this impacting PIH's work in the U.S.? 

PIH’s U.S. Public Health Accompaniment Unit continues to work with our public health and community partners to end the COVID-19 pandemic through contact tracing, case investigation, equitable vaccination, and care resource coordination, prioritizing the well-being and safety of the most vulnerable and marginalized communities. We know that vaccine access has been lower for communities impacted by structural racism and inequitable policies, and with the continuing impact of the Delta variant, PIH remains committed to improving access to COVID-19 vaccines for those with the most significant barriers.  

What's the most important takeaway people should consider during this summer's COVID-19 surge? 

This pandemic is not over. Vaccination rates in the U.S. are currently insufficient to stop viral transmission, disability, and death, and new and more infectious variants will continue to develop. Prevention efforts in the form of masking, distancing, and contact tracing will save lives while we continue to support everyone age 12 and older to get vaccinated. 

If you haven’t yet received your vaccination, now is the time. If someone you know hasn’t yet been vaccinated, talk to them about the benefits for themselves, for their loved ones, and for those who remain at high risk or are not yet eligible to receive a vaccine. This is lifesaving work.  

Weeks after the birth of her daughter, Jazmín Velázquez spent her days crying. The young mother was immersed in stress, worry, and sadness, despite the words of encouragement that a nurse had offered.

"Don't cry,” the nurse at Villaflores Pediatric Hospital had told her. “Having a daughter like this is a gift... Special children are born into special families." 

But believing the nurse's words was hard. How could a newborn girl face so many problems and so much suffering? It wasn't fair to her.

Velázquez’s daughter, Derly, is one of 8 million people in Mexico who live with a disability. Derly was born with Down syndrome, along with other complications that compromised her health. Doctors didn’t give her long to live.

All this came as a surprise to Velázquez. When the 19-year-old was pregnant with Derly, she had followed the rules of prenatal care to the letter: she went to all of her medical appointments at the clinic in Reforma, closely monitored her diet, and received care from her husband and family members. No one could have predicted the complications that would arise.

Velázquez gave birth at the Hospital Básico Comunitario Ángel Albino Corzo in Jaltenango, and it was there she learned that her daughter, in addition to having Down syndrome, had been born with hip dysplasia, a heart murmur, and nostril agenesis—the latter meaning that her nostrils did not form properly during pregnancy, so they were completely closed, and that a tracheotomy would be necessary for her to breathe. After she was born, Derly was hospitalized for three months at the pediatric hospital in Villaflores.

Those days were long and difficult.

"I would cry because I would see my baby, so tiny, connected to many machines, struggling to breathe," Velázquez recalls.

In order to support the family, Velázquez’s husband went to work in the United States. Despite the added financial support, the burden of care became heavier for Velázquez, who had to raise her daughter alone.

For the next five years, Velázquez and Derly's lives revolved around monthly medical appointments with pediatricians, otolaryngologists, and gastroenterologists—care made possible by Compañeros En Salud.

"We went to many different hospitals," says Velázquez. "But we wouldn't have been able to do it without the support of Compañeros En Salud."

Since 2011, Compañeros En Salud, as Partners In Health is known in Mexico, has cared for more than 7,000 children with different illnesses, while striving to break down barriers to health access and helping them recover and sustain their health. Often, that has been achieved not just through medical care, but through resources such as lodging, transportation to clinics, and food vouchers, known as “social support,” which are essential for patients to access health care.

These resources are delivered through Compañeros En Salud’s Right To Health program—a program that has served hundreds of patients, including Derly, providing them with the resources to access health services and accompanying them as they navigate a complex health system.

That support has made a world of difference.

Today, Derly is 8 years old and healthy—nowadays, she only comes to the clinic when she has colds or an upset stomach.

When Velázquez’s husband returned to Chiapas about two years ago, he was surprised to find their daughter much stronger and healthier than he remembered—a testament to Velázquez’s caregiving and the support provided by Compañeros En Salud.

"She is our example of courage and strength, after all that has happened," Velázquez says. "Now that my husband is back, we are a whole family again.

In a hospital ward, a hepatitis B infection can come from many places: A prick of a needle. An open wound. A cut from a surgical knife.

Hepatitis B kills around 887,000 people per year and infects as many as 257 million worldwide. Yet, most health workers in Sierra Leone aren’t vaccinated against this deadly disease.

A new study conducted by researchers from Partners In Health—in collaboration with hospital and university researchers—calls attention to the urgent need to screen and vaccinate all health workers in Sierra Leone against hepatitis B.

The study, published this year in a special edition of the journal Tropical Medicine and Infectious Disease, follows a health campaign in rural Kono District that screened hundreds of health workers and found that the majority were unvaccinated, despite their heightened risk of exposure—pointing to the need for systemic change.

“When we did the screening, we saw a very high prevalence of hepatitis B, even among the health care workers,” says Vicky Reed, director of nursing for PIH Sierra Leone and a co-author of the study. “In the U.S., the highest risk of exposure is because you have contact in a health care setting. In this environment, that’s just not the case. You can be exposed to hepatitis in just your daily life.”

A Lesser-Known Disease

In Sierra Leone, an estimated 18.6% of the population—1.2 million people—live with chronic hepatitis B. Although newborns have been vaccinated against hepatitis B since 2007, the majority of people in the country remain unvaccinated, and access to screening and treatment is severely limited.

For years, PIH has worked to strengthen screening and care for hepatitis B in Sierra Leone. In 2019, PIH opened a hepatitis B clinic at Koidu Government Hospital—the only clinic offering hepatitis B care in rural Sierra Leone.

But despite these strides forward, there are no national policies in place to mandate the vaccination of health workers or ensure that vaccines are free and accessible for them. Most health workers in Sierra Leone are unvaccinated against hepatitis B. That puts these workers—who regularly come into contact with open wounds, needles, and other sources of infection—at increased risk.

“We try to maintain infection prevention and control at the hospital,” says Dr. Marta Patiño, clinical services lead for PIH Sierra Leone and a co-author of the study. “But being punched with a needle is super easy…maybe you’re setting up an IV line, caring for a patient who is very agitated, or trying to discard needles.”

Hepatitis B is transmitted through blood and bodily fluids as well as from mother-to-child. The virus infects the liver and, if untreated, can cause lasting damage, completely changing the liver’s function and, in some cases, causing liver cancer and leading to premature death.

The study, which took place in December 2019, examines a health campaign that screened 632 health workers and hospital staff for hepatitis B. Among the screened, 97% had never received a hepatitis B vaccine and 10.3% had chronic hepatitis B.

These results, while unsettling, didn’t come as a surprise.

Researchers had long suspected that prevalence was high and vaccinations low among health workers. And the main barrier, as they had believed for years, was cost.

The campaign alone, which involved staff at just one hospital and a group of medical students, cost PIH and its partners nearly $70,000. And for health workers who came on-staff after the campaign had ended and got the vaccines privately, each shot of the three-dose regimen cost $100—putting vaccination financially out of reach for most Sierra Leoneans, including health workers.

Another issue the researchers found was a lack of education and awareness around hepatitis B, including among health workers.

“Everybody talks about HIV,” says Reed. “Nobody really talks about exposure to hepatitis if you get a needlestick injury, for instance, or if you interact with a patient.”

Protecting Patients and Staff

Reed, Patiño, and their colleagues hope the study can be a catalyst for change—from medical schools to the halls of parliament.

“The government needs to invest in making sure that health care workers are protected while they’re on the job,” says Reed.

The study calls attention to the urgent need to introduce mandatory screening and vaccination policies for all health workers in Sierra Leone. These policies would protect patients and health staff and help control transmissions throughout the country.

The study also highlights the importance of building trust with communities—before, during, and after vaccination campaigns.

“To be successful in this type of intervention,” says Patiño, “it’s very important that people know and trust those who are doing the vaccine implementation. There are a lot of myths about vaccines, even health workers’ doubt [that needs to be addressed].”

Follow-up is also key. After the screenings were carried out, the campaign offered free vaccinations to those who tested negative and free medical care for those who tested positive—paving the way for what researchers hope will become standard practice in hospitals and clinics across Sierra Leone.

“These kinds of interventions are very, very important. They help us to see the reality,” says Patiño. “New research like this is one of the best ways to keep growing and improving the level of prevention and care deserved by everyone in this unequal world.”

As some parts of the world prepare for their new normal, Haiti is still facing the harsh reality of COVID-19. The country was long thought to have been spared by the disease, but cases are rising at an alarming rate as the nation is in the midst of another wave of infections and heightened political turmoil, following the July 7^th assassination of President Jovenel Moïse.

Through it all, Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti, has kept its doors open, ensuring the safety of staff and delivering care to patients. In the early months of 2020, the team developed a COVID-19 task force and a preparedness plan to support the Ministry of Health. They also conducted an assessment of their 15 hospitals and clinics to quickly set up treatment centers for COVID- 19 patients.

Over the course of a few weeks, three sites were selected— Hôpital Universitaire de Mirebalais (HUM), Saint-Nicolas Hospital in Saint-Marc and Hôpital Sainte-Thérèse in Hinche—73 beds prepped, and the facilities equipped with an adequate number of trained staff, sufficient materials and supplies, and water, sanitation and hygiene infrastructure. Each site established a testing center, quarantine spaces for patients and staff awaiting test confirmation, and an infectious disease unit to treat patients testing positive for COVID-19.

Because of this preparation, Zanmi Lasante marked several major milestones in pandemic response. HUM became the first institution in Haiti to treat COVID-19 patients in March 2020. It was also the first and only institution to save the life of a COVID-19 patient who had slipped into a coma; clinicians continue to care for some of the most severe cases of COVID-19 in the country. And staff were the first to work on the border with the Dominican Republic to test tens of thousands of migrants over the past year.

Among the patients treated at HUM is Jean-Lucien Borges, director of Radio Ginen, one of the top radio stations in the country.

“I want to express my gratitude to the entire HUM staff, the nurses, doctors, the entire medical team for the care I received during my stay at the hospital. I can attest on behalf of all the people who have been treated by this team that we wouldn’t be here today if it wasn’t for them putting their life at risk to give us the care we desperately needed,” Borges said during a recent interview.

Overcoming challenges

These lifesaving moments are particularly impressive, considering the significant challenges the staff and country itself are facing—not least of which include the recent assassination, gang violence, fuel shortages, and rampant inflation.

While Haiti had managed to avoid a significant increase in cases since last summer, the arrival of the British and Brazilian variants through the reopening of airports and borders triggered an explosion of new cases. In December 2020, Haiti saw an increase in travelers as people returned for the holidays and, in February, Carnival was celebrated outside of the capital with large crowds of locals and foreigners. For several months, social distancing had been forgotten, sold out events were being held weekly, and public transport was full.

Dr. Kenia Vissières, ZL’s care and community support program director and a member of the COVID-19 task force, believes the severity of the second wave may be due in part to Haitians’ distrust of authorities and skepticism of the dangerousness or even the existence of COVID-19.

“Very few people wear masks across the country where schools, shops, churches, and markets generally operate without respecting social distancing,” she said. “Realistically, these measures cannot be applied by the poorest inhabitants of Haiti, who survive only thanks to the informal economy.”

Indeed, following the eight-day state of emergency declared in April, street merchants held demonstrations in markets throughout the country against what they called “oppressive measures” to restrict their activities. In Haiti, many people live on less than $2 a day and earn a living through the informal economy. Sheltering in place and working from home are luxuries most Haitians can't afford; they are forced to choose between dying from COVID-19, or dying of hunger.

Haiti lacks a nationwide sanitation system, many people do not have running water, and there is insufficient public infrastructure to promote handwashing and other prevention measures against COVID-19, which means disease can spread fast, especially where impoverished neighborhoods are densely packed.

“It’s also worth noting that common COVID-19 symptoms like fever, dry cough, headache, body aches, nasal congestion, loss of taste and smell, fatigue, etc. are trivialized by the population,” Vissières said. “These symptoms are typically associated with what they call a ‘small fever’ that can be treated using herbal medicine and teas.”

Responding to a second wave

Vissières was part of a team of health care professionals that conducted an assessment of 21 hospitals and health care centers throughout Haiti in May 2021. They determined that the vast majority could only offer basic diagnosis and were not equipped with the personnel, medical supplies, and infrastructure necessary to manage COVID-19 patients. Therefore, almost all positive cases have been referred to the Zanmi Lasante network.

There hadn’t been any new cases at HUM for some time, and the 50-beds dedicated to COVID-19 cases had been reassigned to other services, such as women's health and maternity.

“We had been settling back into our regular workflow, but we were suddenly getting new and more complicated cases at an alarming rate, and these cases required more specialized care,” said Thamar Julmiste, HUM’s chief nursing officer. “We had to set up a new infectious disease unit in the orthopedics unit since it was the closest building to the hospital entrance.”

Faced with these challenges, the hospital's leadership put in place updated protocols to ensure the effective management of new cases through pre-triage, triage, isolation, and care. And various infection prevention measures were reinforced to minimize contamination of staff.

Dr. Christophe Millien, HUM’s chief medical officer, was confident in his staff’s capacity to meet the surge: “We have doctors and senior residents in emergency medicine, anesthetists, and internists alongside the nurses who form a multidisciplinary clinical team for the care of patients. The availability of national and international intensive care physicians and pulmonologists represents a major asset in improving the quality of care.”

Yet, considering the number of critical cases coming their way, Loune Viaud, Zanmi Lasante’s executive director, knew the team would need more anesthesiologists, emergency doctors, specialized nurses, and personal protective equipment over long-term response.

Oxygen was already in short supply, Julmiste noted: “These new cases present acute respiratory failure that require intubation. The hospital’s oxygen generator has the capacity to fill a maximum of 50 cylinders per day, and now we were using up to 250 canisters in a single day.”

Zanmi Lasante can produce 90 cylinders of oxygen per day, 50 at HUM and 40 at its Cange facility. However, they have had to outsource more canisters from other health care facilities or buy more to meet the needs of patients—such as premature infants in the NICU. It is estimated that the hospital needs to have 500 tanks filled to best be prepared.

“HUM is the reference institution for all critical cases, and our medical staff has been working non-stop for the past 14 months,” Julmiste said. “They are exhausted and weary of these new variants of the virus. They are still pushing forward through it all, but, these preventable deaths are taking a toll on staff morale.”

From the time he was admitted to Lakka Government Hospital, Sierra Leone’s only dedicated tuberculosis facility, staff knew that 18-year-old Hassan* was special.

“He’s a very brilliant boy,” said Armah Quist, program officer at the Partners In Health-supported hospital, located on the outskirts of capital city Freetown. “He’s the type of person who will not wait for someone to walk up to him; he’ll walk up to you.”

“People know Hassan as the boy who helps others,” Dr. Girum Tefera, PIH clinical consultant at Lakka, added. “He would go out and run errands for patients, and would entertain them. He has respect for everyone.”

Both Quist and Tefera said they instantly recognized above-average intelligence, honesty, and determination in Hassan. But as they continued to get to know him—growing accustomed to hearing him sing and rap around the wards, and watching him befriend more and more patients around the hospital—they also soon recognized how difficult it would be to save his life.

Hassan had arrived with a case of multidrug-resistant tuberculosis (MDR-TB)—the harder-to-cure, and therefore deadlier, form of the infectious disease whose yearly death toll has only recently been surpassed by COVID-19. As is common with many TB and MDR-TB patients, Hassan was also living with HIV, which he was born with. The co-infection proved difficult to treat, and Hassan’s case of MDR-TB proved particularly persistent—demanding that Lakka’s staff outmatch it.

Inspired by Hassan, they committed to doing so—setting in motion a global effort to procure the right treatment and provide the right care.

“We were all so excited [to care for him] because we knew his potential,” Quist said. “To lose potential like him would be a loss to all of us.”

A Difficult Case

In the fall of 2018, Hassan woke up at his parents’ home in Freetown, feeling ill but determined to make it to school for another day of exams. He managed to arrive to his classroom and begin his first test; by midday, he was in an ambulance.

“I was very weak, with a high fever, and unable to walk,” he recalled.

A week after he was admitted to Freetown’s public general hospital, he was discharged and placed on medication for tuberculosis—a disease he’d had before, and had been cured of, 13 years earlier, at age five.

But several months later, Hassan’s condition was unchanged. He remained weak, and the cough he’d battled as a young child returned. Further testing revealed that his TB was drug-resistant—prompting referral to Lakka, and a wave of grief.

“When I heard the name Lakka, I started crying,” Hassan said. “I was thinking how poor it is, and thinking, ‘How will I see my mother again? How will I see my father again?’ Crying for days.”

For decades, Lakka’s reputation merited such a reaction. As a chronically under-resourced hospital without lights or running water, let alone the specialized staff and supplies to provide effective care, Lakka was  considered to be a death sentence. And MDR-TB long was a death sentence in Sierra Leone: It wasn’t until 2017 that drugs to treat and cure it were available in the country, when PIH and Sierra Leone’s National Tuberculosis Control Program partnered to invest in Lakka and introduce MDR-TB care.

The hospital Hassan arrived at in January 2019 was very different from the one he grew up hearing about—and resignation gave way to hope. Today, Lakka cures 75% of patients with MDR-TB, compared to a global average of 57%, thanks to the Ministry of Health’s rehabilitation of Lakka, supported by PIH. Together, the government and PIH have invested in 24-hour electricity and plumbing; fully-stocked pharmacy shelves, with MDR-TB drugs supplied by the national program and ancillary drugs supplied by PIH; renovated wards; social support programming, led by Quist; and doctors such as Tefera, who specialize in TB and MDR-TB care.

Immediately, clinicians started Hassan on treatment—a painful regimen, consisting of injectable drugs and 20 daily pills, but one that was meant to work quickly, within a year.

But even after six months, despite some initial improvement, Hassan remained ill—and his condition began further deteriorating.

“He continued testing positive for MDR-TB,” Tefera said, “and continued having symptoms: difficulty breathing, weight loss, swelling on his neck. We decided we needed to change his regimen as a final resort.”

“The Only Chance We Had”

Hassan was struggling.

“I was thinking I would get out—and then they told me the treatment was not working for me,” Hassan said. “I started feeling pain all over.”

Lakka staff did everything they could to support their young patient as he grew increasingly unwell—not just physically.

“It was a mental health issue as well,” Quist said. “He was very moody, he would not talk to anyone, he would burst into tears.”

Tefera said he observed “two Hassans.”

“By the time we told him his regimen wasn’t working, the boy who would help anyone had lost all hope,” Tefera said. “He would fight with anyone.”

Quist enrolled Hassan in PIH’s social support program to ensure he had money to buy food—relieving financial stress from him and his family and giving him an opportunity to leave the hospital. And nurses banded together to provide moral support.

“They would encourage me, help me wash, sing to me and pray with me,” Hassan said.

What ultimately was needed, however, was a new treatment plan. Tefera knew what drugs to try next to treat the MDR-TB—but using them would be risky.

“If we gave the new TB drugs with his HIV drugs, it would increase the risk of cardiotoxicity,” Tefera explained. “We couldn’t ignore the TB drugs, because that was the only chance we had. So we had to think, ‘Could we change the HIV medication?’”

The answer was, at first, no. Dolutegravir, the HIV drug that would work safely in combination with the new TB regimen, wasn’t available in Sierra Leone.

But then came a series of phone calls between PIHers around the globe. Tefera called Dr. Marta Lado, then chief medical officer for PIH Sierra Leone, who was lending her Ebola expertise to fight the epidemic in the Democratic Republic of the Congo.

“Around six hours later, she called me and said, ‘We found the medicine in Haiti,’” Tefera recalled. “The National TB Program gave us the go ahead to bring the drug to Sierra Leone, and a few days later, Dr. Joia [Mukherjee, PIH’s chief medical officer] brought it.”

Within a month of the new course of treatment, Hassan’s health dramatically improved: He breathed more easily, he gained weight. After two months, in October 2019, he was well enough to be discharged to outpatient care, taking daily medication at home and coming to the hospital only once per month for a check-up and drug refill.

“I was active again,” Hassan said. “I started dancing.”

National Impact

Quist was there to support Hassan as he reset his sights on the future. Hassan was determined to resume his education—though noted he did not want to return to his same school, because of stigma against his illnesses.

While he continued outpatient treatment, PIH helped him enroll in a computer course—where again, his intellect shone.

“He finished the course first in his class,” Quist said. “The instructor called me, saying, ‘This boy is very intelligent.’ I said, ‘We know. We saw it.’”

Outpatient treatment lasted 16 months, until late February 2021, when Hassan took his last MDR-TB pills and was declared cured of the disease.

By that time, he had also returned to high school full-time, with all fees covered by PIH.

“I’m so happy,” he said on the day of his last appointment at Lakka.

Today, Hassan dreams of becoming a journalist. And he’s an outspoken advocate for TB care in Sierra Leone.

“Some patients fear the disease; when they’re told they have it, they run away,” Hassan said. “What I say to them is, ‘Have courage and know that when you have the right drugs, you will be okay and stable, like me.’”

With thanks to Hassan’s case, “the right drugs” are increasingly available: After PIH procured dolutegravir, the National TB Program worked with Sierra Leone’s National HIV Program to stock the medicine in public health facilities nationwide, for patients whose co-infections, like Hassan’s, would otherwise be untreatable. Today, nearly all of Lakka’s patients living with HIV are taking dolutegravir; and across Sierra Leone, the drug is increasingly becoming the first line of treatment for co-infections.

“It’s changed the course of TB treatment nationally,” Tefera said. “Hassan was lucky; he would have died if not for everyone from PIH involved, across Sierra Leone, Haiti, and Boston. Our efforts were for one patient; but now they’re reaching everyone.”

*Name has been changed

More than a week after the assassination of President Jovenel Moïse and the wounding of First Lady Martine Moïse, Zanmi Lasante facilities remain open, as they have through years of political and civil unrest, devastating hurricanes, and the current COVID-19 pandemic.

In the coming weeks and months, Zanmi Lasante, Partners In Health’s (PIH) sister organization in Haiti, will continue operating with added measures to ensure the safety of patients, staff, and the children at Zanmi Beni—all of whom are safe and have been accounted for following the most recent tragedy in Port-au-Prince. 

Although the current political situation is fluid, as events continue to unfold following the assassination on July 7, Zanmi Lasante is committed to providing care to those who need it most, as clinicians and staff have done for nearly four decades. This is true, despite myriad obstacles—from fuel shortages and rampant inflation in the price of goods and services to gang violence and road blockages disrupting transportation of staff and patients.

Ongoing Care, for COVID-19 and Beyond 

While some small clinics and local hospitals have temporarily shut their doors, Zanmi Lasante facilities continue to accept patients. This is especially important considering a second wave of COVID-19 infections is impacting the Caribbean nation and vaccines have yet to become publicly available. The first 500,000 doses arrived in the country on July 14, all of which were donated by the United States through COVAX. Health care and frontline workers are anticipated to receive these first doses. However, Haiti needs many more vaccines for their population of 11.5 million, or approximately 7.7 million adults eligible to receive the COVID-19 vaccine, as do other low-income countries. Globally, less than 1% of people living in low and middle-income countries have received at least one dose of a COVID-19 vaccine compared to 50% of people in high-income countries amid a rapidly spreading Delta variant.

As they await vaccines, Zanmi Lasante staff across three sites—Hôpital Universitaire de Mirebalais, Hôpital Sainte-Thérèse in Hinche, and Hôpital Saint-Nicolas de Saint-Marc—are actively testing, isolating, and treating patients with some of the most severe cases of COVID-19 in the country. In addition, the team has tested more than 23,000 migrants at Belladere, a city along the border between Haiti and the Dominican Republic.

To meet the needs of patients, clinicians have worked around the clock for 18 months. Like patients, they need to rest too, which is why Zanmi Lasante is currently working to secure volunteer nurses, intensive care unit physicians, and pathologists from the U.S., who are expected for additional support. 

The global supply chain team continues to ensure necessary resources are available, such as oxygen, personal protective equipment, diagnostic tools, and pharmaceuticals. They do all this, despite constant challenges related to border closures and interruptions in the overall supply chain due to ongoing unrest and the pandemic.

While COVID-19 has the spotlight, patients seeking care for many health care needs continue to arrive at Zanmi Lasante-supported facilities. The team has consistently provided care and support to meet their needs—including malnutrition, cancer treatment, maternal and neonatal care, mental health, and social support—throughout the entirety of the pandemic. 

In 2020 alone, 6,300 children were treated for malnutrition, more than 700 patients received cancer treatment, and 1,500 people benefited from mental health services—to name several of many key areas of care. And at Hôpital Universitaire de Mirebalais, the innovative Journey to 9 maternal health program has enrolled 800 expectant mothers since it began in 2019, with 95% of women choosing to give birth at the facility, compared to a nationwide rate of 36%.

As new details continue to emerge every day, it is unclear what will happen next in Haiti, but one thing is certain: Zanmi Lasante’s gates will remain open, and the team will do whatever it takes to ensure the people of Haiti receive the support they need for COVID-19 and their health care needs.

Our hearts go out to the Haitian people, our colleagues, friends, and family at the news this morning of the assassination of President Jovenel Moïse and of the attempt on the life of his wife, Martine Moïse, whose condition remains unclear. We watch as this crisis unfolds and hope for stability, peace, and the continuation of hard-gained Haitian democracy.

We are in contact with our colleagues on the ground.

A quarter of a century ago, in the hillside communities of Carabayllo, Partners In Health dared to pursue a simple yet radical idea: no patient should die because a disease was considered “too expensive” or “too complicated” to treat.

That was exactly what the global health community had decided about multidrug-resistant tuberculosis (MDR-TB) in Peru in the 1990s, even as a deadly outbreak tore through Carabayllo, an impoverished community on the outskirts of Lima. And it was a status quo that PIH refused to accept.

As case after case of MDR-TB was uncovered there, PIH Co-founder Dr. Jim Yong Kim, Father Jack Roussin, a PIH friend and partner, and Peruvian colleagues came to realize that a solution was urgently needed—one that put Peruvian clinicians and communities at the center of the work and that upheld not convention, but justice.

On July 8, 1996, Socios En Salud was born.

In the 25 years since, Socios En Salud, as PIH in known in Peru, has not only triumphed in the face of MDR-TB—treating more than 10,500 people for the disease and achieving a cure rate of 83%, among the highest in the world—but also provided a time-tested model for what it means to work alongside local communities by delivering lifesaving medical care and essential resources, training the next generation of clinicians, and strengthening health systems before the next crisis hits.

As Socios En Salud’s decades of care and service demonstrate, injustice has a cure. A better world is possible—a world where health care is not a privilege, but a human right.

Below, a curated collection of photos tells the story of Socios En Salud, then and now—from its beginnings during the deadly MDR-TB outbreak to its leadership amid the COVID-19 pandemic.

PIH Co-founders Dr. Paul Farmer, Dr. Jim Yong Kim, and Ophelia Dahl worked closely with Peruvian leaders, including Dr. Jaime Bayona, former executive director of Socios En Salud, as the newly-formed organization responded to multidrug-resistant tuberculosis in Carabayllo in 1996. Farmer, Kim, and Dahl had begun their work in Haiti just years earlier, establishing a clinic in Cange to provide free health care to rural communities there and laying the groundwork for PIH, which was founded in 1983. In addition to calling for global health equity amid the MDR-TB outbreak in Peru and helping change WHO protocols for care, the team would go on to help lead the global health response during the early years of the HIV/AIDS epidemic—stories captured in the critically acclaimed documentary Bending The Arc.

Dr. Jim Yong Kim, PIH co-founder, stands with Peruvian children in Carabayllo, an impoverished community about 20 miles north of Lima, where Socios En Salud has worked for a quarter of a century. Carabayllo has a population of 321,752 with more than 23% of residents living in poverty. Socios En Salud’s decades of work there has strengthened the community’s health system and improved quality of care and access for thousands of patients and their families.

In the years since the MDR-TB outbreak, Socios En Salud has expanded its programs to clinical areas ranging from mental health to child health. It has also continued to provide social support, such as food and housing assistance, to Carabayllo’s communities, where poverty is so severe that just one missed paycheck can threaten a patient’s day-to-day survival and access to medical care. Social support is based on the idea that social and economic factors—not just medical—impact a patient’s health and that treating the whole patient—not just their illness—is essential to care delivery. In this photo, Hildo Miranda, a health promoter with Socios En Salud recruited by the late Father Jack Roussin, carries food supplements through the streets of Carabayllo in 2001.

Through the years, Socios En Salud has continued to set new standards for tuberculosis care, providing medications, screening, and support for thousands of patients in communities where treatment of the disease was once thought impossible. Socios En Salud’s tuberculosis program includes innovative interventions such as Backpack TB and TB Móvil, which sends vans equipped with rapid tuberculosis testing into Carabayllo’s remote hillside communities. Peru is also part of the endTB project, which PIH is co-leading to discover shorter, less toxic, and more effective treatments for drug-resistant TB. Since 2015, the endTB team has brought two new drugs to 17 countries burdened by MDR-TB and is completing two large clinical trials, with the goal of finding treatment regimens with better than 80% cure rate. In this photo, Dr. Epifanio Sánchez, a physician with the Ministry of Health at Sergio E. Bernales National Hospital, tends to a tuberculosis patient in Carabayllo in 2017.

To accompany patients through Peru’s health system, Socios En Salud enlists the help of dozens of community health workers, known locally as agentes comunitarios de salud. These community health workers are hired from the communities they serve and trained to deliver medications, social and emotional support, and basic health services through house calls and accompaniment to and from medical appointments. In this photo, Community Health Workers Inela Espinoza (right) and Dina Gomez (left) walk through San Gabriel, Carabayllo, after conducting a training session for caretakers and mothers in May 2016.

For years, Socios En Salud has worked with Peru’s Ministry of Health to improve infection prevention and control measures in Lima’s prisons, where incarcerated people are especially vulnerable to MDR-TB and—now—COVID-19. In this photo, Dr. KJ Seung, an infectious disease expert with PIH, and Dr. Joia Mukherjee, PIH’s chief medical officer, join tuberculosis experts from PIH, Socios En Salud and the Ministry of Health on a tour of a prison in Lima in September 2016, where a high incidence of MDR-TB pointed to the urgent need for care and support. Over the years, Socios En Salud has screened dozens of incarcerated people for TB, uncovering previously undetected cases, and has provided specialized care in 30-bed isolation and treatment rooms.

As the COVID-19 pandemic strained Peru’s health system and put marginalized communities at risk, Socios En Salud was ready to respond, bolstered by its decades of experience responding to tuberculosis and other diseases in Carabayllo. Over the past year, Socios En Salud has conducted COVID-19 tests for more than 41,330 people, with 18,066 testing positive. To counter the financial burdens of the pandemic, Socios En Salud has provided 1,605 families with food vouchers and 1,679 with socioeconomic support. Throughout its pandemic response, Socios En Salud has not only cared for COVID-19 patients but has also continued its lifesaving clinical programs for chronic disease patients—ensuring access to high-quality health care even in the most dire times. In this photo, Genaro Anco, coordinator of the social protection program at Socios En Salud, delivers cleaning kits to prevent the transmission of COVID-19.

The COVID-19 pandemic isn’t over yet. 

Although some businesses have re-opened and restrictions have loosened in the United States and Europe, a third wave of infections is affecting countries around the globe, including ones where Partners In Health (PIH) works. 

The most recent wave, which is when there is a surge in the number of cases over a period of time in a particular region, has been documented in Haiti, Lesotho, and Sierra Leone, among other countries. While there are many factors that contribute to waves, one currently is the emergence of virus variants, such as the highly contagious Delta variant identified in 92 countries, as of June 21. First detected in India in October 2020, the variant continues to spread.

PIH’s approach to building strong health systems and responding to emergencies relies on the five S’s: staff, stuff, space, systems, and social support. In Haiti, a lack of “stuff,” namely vaccines, has had a significant impact on the country’s 11.5 million residents. As of June 30, COVID-19 vaccines have yet to become publicly available in the Caribbean nation. Additionally, “space” has posed a challenge, as some hospitals have reached their limit on the number of COVID-19 patients they can accommodate. Within the the network of hospitals and clinics supported by Zanmi Lasante, PIH’s sister organization in Haiti, there are 73 beds—33 of which were occupied, as of June 28— for COVID-19 patients at Hôpital Universitaire de Mirebalais and Hôpital Sainte-Thérèse in Hinche, which are the only two ZL-supported facilities providing direct care to patients with COVID-19.

Across Africa, COVID-19 cases are surging by 20% on a weekly basis and are quickly approaching numbers documented during the peak of the first wave in July 2020. In Lesotho, where an influx of people are crossing the border from neighboring South Africa—which has the highest number of COVID-19 cases on the continent, cases are rising and particularly affecting Leribe and Butha-Buthe districts, which are supported by the country’s national health reform, and Maseru district, where the central office is based. In response to the current wave, PIH Lesotho continues to supply oxygen to hospitals; provide logistical support to transport vaccines and health care providers throughout the country; run a mental health and staff wellness program to help health care workers cope with COVID-related stress; and get more rapid antigen test kits, in addition to the 10,000 they recently donated to Lesotho’s Ministry of Health.

In Sierra Leone, COVID-19 cases are increasing and are at their highest since the beginning of the pandemic. There is a significant need to increase surveillance, prevention, and case management.  As PIH Sierra Leone responds to the current wave, the team is focused on treating patients and providing social support, as they prepare for anticipated challenges, including oxygen and ICU bed shortages. Amid the third wave, new restrictions including a curfew, suspended religious ceremonies, and limited occupancy on social gatherings, were announced on July 1.

The number of COVID-19 cases, and the resulting death toll, will only continue to rise in countries unable to properly prevent the virus’ spread, care for and support the sick, and conduct comprehensive vaccination campaigns. PIH continues to advocate for equitable global COVID-19 vaccination distribution, especially considering only 0.9% of people in low-income countries have received at least one dose of a COVID-19 vaccine compared to 45% of people in high-income countries. 

At PIH, we believe that no one is safe from COVID-19 until everyone is safe.

This April, Elizabeth Momoh delivered her fifth child at Sewafe Community Health Center in Kono District, Sierra Leone.

“Ah so gladi,” she said in Krio, during her last prenatal appointment before her due date. “I’m so happy.”

Momoh, 28, has been visiting this health center her whole life. She grew up in the small town of Sewafe, which is a 45-minute drive outside of Koidu, the capital of Kono. In 2011, she delivered her first baby there. With four children at home, she’s made countless trips to the clinic for pre- and postnatal care and for check-ups when one of her kids has a fever or rash.

It was only in the last year, however, that Momoh and her family began receiving high-quality care at Sewafe—because of comprehensive investments from Partners In Health in the health center’s staff, stuff, space, and systems.

“We suffered,” Momoh recalled of the previous decade. “There was only one building. There were no laboratory tests. There was no medication. They would write you a prescription and you would have to go buy it. This was very difficult for those of us without money.”

This was—and still is—the reality at community health centers throughout Kono. And it’s partly why, for years, the district was widely considered the worst place in the country—and among the worst places in the world—for health care.

The tragic irony wasn’t lost on Sierra Leoneans: Koidu Government Hospital (KGH)—the only hospital in the country’s rural, eastern-most district, with a population of 500,000—went without running water, consistent electricity, trained doctors, and stocked pharmacy shelves, even as it stands in the shadow of West Africa’s largest diamond mine. Though home to a wealth of natural resources, Kono is impoverished due to decades of colonialism, the slave trade, and civil war—and its health system is no exception.

Today, this reality is changing. With support from Partners In Health, KGH is now widely considered the best public hospital in Sierra Leone, and the nearby Wellbody Clinic serves as a model for health clinics across the country. Patients from Kono and across Sierra Leone, as well as from neighboring Guinea and Liberia, flock to both facilities to receive never-before-available health services, from primary care to complex surgeries, at little to no cost.

Yet availability does not mean access. In rural communities like Sewafe, social and economic barriers prevent thousands of families from accessing this high-quality health care. Living in extreme poverty, commonly as subsistence farmers, many would-be patients cannot afford to take time away from work to make a sometimes hours-long trip to KGH or Wellbody. Nor can they afford the cost of a motorbike ride to and from Koidu—typically, some 20,000 leones, the equivalent of two dollars. Nor is that motorbike ride always possible—during Sierra Leone’s months-long rainy season, already cumbersome dirt roads become flooded to the point of impassability.

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Because of these obstacles, local community health centers offer the most convenient, least disruptive path to health care. But all too often, stepping inside these small clinics is like stepping into the past. Electricity is fickle. Plumbing is nonexistent. Pharmacies and laboratories are nearly empty. And clinicians are undertrained.

Proximity to home was the main reason Momoh chose to attend Sewafe Community Health Center—and even then, she is part of a minority. Most families in Kono skip visiting their local clinic altogether, knowing the facilities are unequipped to deliver adequate, affordable health care.

As such, for most rural families in the district, high-quality care remains catastrophically expensive, or out of reach entirely.

That’s why, starting in 2019, PIH deepened its commitment to strengthening Kono’s health system top-to-bottom and began supporting community health centers with tried-and-true investments in staff, stuff, space, systems, and social support. PIH’s goals are two-fold: first and foremost, to widen access to quality health care for more of Kono’s population, especially those most marginalized by poverty and geography; and, relatedly, to relieve pressure from Wellbody Clinic and KGH by creating more options for patients to choose from.

Sewafe is the first of six local health centers to have received comprehensive support from PIH, through partnership with local health leaders. Such support over the course of 2020 has led to vast improvements to care—even amid the COVID-19 pandemic, when many health facilities saw the quality of their care decline due to global supply chain disruptions and the need to divert drugs and medical supplies.

Standing outside the health center after her appointment, Momoh said she has observed Sewafe only getting better.

“It’s very different now,” she said. “Many people are coming now because there is free treatment for you and your children. They’ll give you your diagnosis and treat you. That wasn’t happening before.”

Below, see how the health center has transformed, from under-resourced and sparsely attended to ever-improving in quality and impact.

In 2019, PIH conducted a baseline assessment of Sewafe’s clinical capacity to understand its strengths and weaknesses in providing health care. Staff used a globally-standardized scoring system that produces a “service readiness score,” taking into account the availability of basic amenities, medicines, and equipment; the center’s infection prevention and control capacity; and diagnostics.

In other words, they measured whether Sewafe had the staff, stuff, space, and systems to deliver quality health care.

In 2019, the facility scored a 62%. (For comparison, Wellbody Clinic’s service readiness score was 82%.)

One of the major barriers to effective health care was pharmacy and laboratory capacity. Pharmacy shelves remained nearly empty, and the lab lacked equipment to do most tests. As Momoh pointed out, patients could rarely get a diagnosis, let alone the medication they needed to heal or to manage a chronic condition.

Patient attendance reflected these limitations. In 2019, before PIH’s renovations, a total of 5,972 patients visited Sewafe. On average, clinicians saw fewer than 20 patients per day.

Starting in September 2019, PIH’s infrastructure team set to work and completed a host of renovations, including: installing solar power to allow for 24-hour electricity; digging a new well for access to safe water; introducing plumbing; improving air circulation, for better infection prevention and control; installing air conditioning for the safe storage of medications; and completely redoing building interiors.

These infrastructure improvements converted Sewafe into a safer, more dignified health center.

Improvements weren’t limited to the building itself. John Cooper Combey, a community health officer and PIH’s primary care clinical manager, has coordinated and led trainings for staff at Sewafe, from nurses looking to improve their skills in the delivery room to lab technicians eager to learn how to conduct never-before-available tests.

Clinicians also gained access to the drugs they long sought to prescribe to patients. Through PIH’s support, Sewafe has stocked its pharmacy shelves with essential medicines, all of which are provided to patients free of charge.

With new equipment and supplies from PIH, Sewafe’s diagnostic capacity also improved. Lab Manager Aiah S. Mbayoh, who has worked at the health center for nearly 20 years, noted these positive changes.

“We started lab operations in 2006, and we were only concentrating on tuberculosis, maybe stool and urine tests,” Mbayoh said. “But with the intervention of PIH, we have so many other things we can focus on: hepatitis, typhoid, HIV, malaria, sickle cell, diabetes.

"Patients are happy, as tests are now happening that did not happen in the past. And I’m happy because learning is good for me.” 

Nurse Ramatulai Sewaneh has also seen first-hand the changes in patients’ opinions of Sewafe—and in the sheer number of them. “The biggest difference,” she said, “is that we’re seeing plenty, plenty, plenty of patients now. And they’re coming from other districts, too.

"They are praising the clinic, saying the medicine here is good, and telling others to come.”

The data confirms these observations: In 2020, a total of 9,470 patients visited Sewafe—a 59% increase from the previous year. In November 2019, staff saw only 453 patients; the following November, they saw 2,339 patients.

Much of the increase in patients has been related to maternal and child health: Sewafe saw a 19% increase in patients arriving for prenatal care and a 45% increase in patients under 5 years old.

According to Margaret Bundo, a maternal and child health aide who has worked at Sewafe for six years, “Everything is in our possession now. So we take care of patients better, and more women are coming. It’s almost like a mini hospital now.

“I like to help my people,” she added. “That’s why I rise to be a nurse. Not for money, but to help and save lives.”

A year later, another assessment confirmed what all of these clinicians had been observing: Sewafe’s service readiness score—its ability to provide effective health care—had climbed to 84%.

There are still many more improvements to be made. But with this 22% increase, Sewafe’s foundation is now set, thanks to support from PIH and the Ministry of Health.

In Momoh’s words, “They care for us well, and kindly.”

At 27 years old, Alondra Esquinca is head nurse at the Center for Respiratory Diseases in Chiapas, Mexico, where Partners In Health is known as Compañeros En Salud. Esquinca has helped lead the COVID-19 response in Chiapas, strengthening the local health system and saving dozens of lives. But even with her enormous positive impacts on her community, she lives in constant fear for her safety and faces discrimination regularly.

Esquinca is one of more than 360,000 transgender people in Mexico. The term transgender describes someone who does not identify with the gender they were assigned at birth. Despite years of advocacy for trans rights, stigma, discrimination, and violence against trans people are a part of everyday life for thousands in Mexico.

It’s a reality that Esquinca knows all too well.

"When you are like me, you feel the stares and hear the whispers of the people around you," she says.

She has felt those stares for years—from the halls of a hospital ward to the dirt roads of her home town.

‘They’re Always Going to Judge You’

Content warning: rape

Originally from Villaflores, Chiapas, Esquinca was assigned male at birth and raised as a boy. But from a young age, she knew this gender identity didn’t resonate with her.

“Since I was 7 years old, I already knew that I wasn’t a boy,” she recalls.

As a teenager, she came out as queer. A few years later, she identified as a cross-dresser. In her 20s, she identified as a transgender woman and transitioned, while she was studying to become a nurse.

Even as it offered some amount of freedom, openly expressing her gender identity came with a cost. After Esquinca came out as transgender, her family rejected her. In her community, she was singled out and discriminated against at nearly every turn. And for years, she struggled to make ends meet—a predicament that put her safety at risk.

One of the biggest problems faced by transgender people in Mexico and worldwide is a lack of job opportunities.

"Many of us have professional training, with a lot to contribute," she says. "Unfortunately, employers don't give us that opportunity and exclude us. Most transgender people in Mexico do sex work, which, despite being an honest job, is risky for us."

Esquinca took up sex work during nursing school, in order to pay bills and put food on the table. She knew the arrangement wouldn’t last forever—just until she had her nursing degree. But the work placed her in a vulnerable position, and she suffered acts of violence.

"One day, I got into the car of a man who I thought was a client like any other," she recalls. "But a block later, five other men got in. They took me to the outskirts of town, and they raped me. I really thought I was going to die that day."

Violence against trans women is extremely common in Mexico, which has the second-highest rate of transfemicides in Latin America. Life expectancy for trans women in Mexico, who face systemic barriers to accessing care, is only 35 years.

Esquinca survived the encounter. But it left her traumatized.

"I'm very grateful that I was able to get out of there, but it's not easy at all," she says. "Anywhere you go, they're always going to judge you and put labels on you."

An Opportunity to Grow

Years ago, Esquinca never would’ve pictured herself as a head nurse. But that’s one of the reasons she accepted the position.

She wanted to forge a new path.

Now, Esquinca is the first openly transgender employee at Compañeros En Salud. She supervises a team of nine nurses at the Center for Respiratory Diseases—a six-bed facility opened last year, to care for patients with severe COVID-19.

As she leads her team through a deadly and uncertain pandemic, Esquinca uses her position to advocate for gender diversity, equity, and inclusion, building strong relationships with the nurses on her team and implementing training around gender identity and sexual orientation.

“As a clinician and a leader, Alondra exemplifies the best that CES has to offer,” says Ana Laura Rodríguez, a medical team coordinator who works closely with Esquinca. “She’s always looking for new ways to improve her work, knows the importance of team work, and has patients as her priority.”

Esquinca knows the burden isn’t hers alone to carry—it is the responsibility of all cisgender people, or those who identify with the gender they were assigned at birth, to advocate for the health and human rights of transgender people. But after so many years of silence and struggle, she feels compelled to speak up.

"It is a public health issue," Esquinca says. "Even in hospitals, there should be more information [about gender diversity]. We need to educate people about the types of gender that exist; they are no longer just male and female. Everyone has the right to live as they feel most comfortable."

Looking back, Esquinca didn’t have any examples of transgender women in leadership to follow and learn from. And she knows change won’t happen overnight. But as she looks to the future, she is hopeful.

"The message I want to give to those who are in a situation like mine is not to be discouraged. Keep discovering yourselves little by little, and when you look back, you will be in a much better situation," she says. "It's hard at the beginning, but nothing is impossible. I know that with effort and dedication, we will manage to live in a dignified manner.”

Partners In Health remembers Father Fritz Lafontant, who died on June 28 at his home in Haiti. Lafontant was an Episcopal priest, lifelong advocate for the marginalized, and a founding member of Partners In Health and founding director of Zanmi Lasante, PIH’s sister organization in Haiti.

It’s with great sadness, but great pride, that we share the news of Father Fritz Lafontant’s passing. He succumbed to COVID-19 in his home, surrounded by his family, his household, and his closest friends. The reason for our sadness is obvious—we will miss his forceful nature and indomitable spirit. But these are also reasons for pride, even in this moment of loss. He leaves behind a legacy measured not only by all that he built, which remains sturdy and beautiful, but even more so by the generations of students and trainees that he cultivated over his more than 60 years as a priest and educator.

“Pa Frico,” as we all called him, never stopped believing that education was the golden ticket for children in rural Haiti. He dedicated all of his time to this mission, for he believed, as he liked to say, “that there is great genius out there in the hills of Haiti.” Pa Frico’s ministry with, and for, children of modest means lives on, quite literally, in thousands of Haitian professionals—many of them the leaders of Zanmi Lasante today. Others remain scattered within the nation of Haiti, across the Caribbean, and in the United States. This is the legacy he cared about most, and we, as Partners In Health, will strive to honor it as he did.

We can’t honor Pa Frico without also thinking of his worldwide legacy as a founding member of Partners In Health, and the founding director of Zanmi Lasante.

We know there won’t be another Fritz Lafontant, but we also know that he put his time and treasure into making Haiti a place where children and young people, as well as the ill and infirm, had a decent chance to become agents of change. For that we give thanks in a moment of sorrow, and extend our profound sympathies to his family, which is, thanks to Pa Frico, our family too.

May he rest in peace.

This reflection was provided by Dr. Paul Farmer, PIH co-founder and chief strategist; PIH’s CEO Dr. Sheila Davis, Loune Viaud, executive director of Zanmi Lasante; and PIH Co-founders Ophelia Dahl, Todd McCormack, and Dr. Jim Yong Kim.

When Shanon Smith, a New Bedford, Mass., epidemiologist, saw there were 10 extra vaccine doses near the end of a health department vaccination clinic, she took to the streets. 

“I put on a vest, grabbed a clipboard, and started knocking on doors and even stopped cars encouraging people to get vaccinated,” said Smith, who works at the city health department through a collaboration with Partners In Health’s U.S Public Health Accompaniment Unit (USPHAU).  

Eventually, with help from residents who pointed out neighbors’ houses and colleagues who called on friends, Smith accompanied enough people over to the clinic for vaccinations. A few even took selfies at the station the department set up to make the experience more fun. It was, Smith said, a small victory: “We did not want those doses to go to waste.” 

Across the United States, public health workers and community leaders, businesses owners and President Joseph Biden are rolling out innovative strategies to gain the attention of people who remain unvaccinated -- and nudge them to roll up their sleeves for the shot. 

A Race Against Time 

From barbershop conversations in Alabama to guest appearances at cupcake-baking classes in Chicago, there is a race-against-time effort underway to increase national vaccine rates and stop the spread of disease. Some approaches might seem a little headline-grabbing, like the Howlin’ Wolf bar in New Orleans promoting its “shot for a shot” night with free drinks for the vaccinated, or Washington State’s, “joints for jabs” with weed as a lure, or Krispy Kreme’s free donuts with a vaccination card. 

But the motives behind these efforts are deadly serious. COVID-19 has killed 600,000 people in the U.S., and while death rates nationally have dropped since their peak, it’s the remaining unvaccinated people who are getting sick and dying. The only path to “normalcy,” experts agree, is by vaccinating most of the public.  

Indeed, the current moment calls for urgent action, and that means getting creative, said Dr. Bram Wispelwey, senior technical lead in charge of clinical operations at the USPHAU. With fewer than 50% of people in the U.S. fully vaccinated, and inequities plaguing the health system in which Black and Hispanic Americans’ vaccination rates are still lagging in almost every state, there is no time to waste. “We're at a crucial moment where cases are lower than they've been in many months and continue to drop,” he said. “So, there's an opportunity here.”   

The USPHAU, collaborating with partners around the country, is seizing that opportunity by helping to support hyper-local efforts aimed at populations facing the greatest barriers to vaccination. 

The Brother’s Chat 

In Montgomery, Ala., where only 35% of residents have had their first shot, Pastor Richard Williams of the Metropolitan United Methodist Church launched the first “Brother’s Chat Round Table Discussion,” at the Legacy Barber and Style shop on a recent Monday night. Six men participated, all of them Black, including the barbershop owner, a local mural artist, two business leaders, and a doctor, who joined via Zoom. For nearly an hour, they talked with the pastor about the pandemic’s toll on their families and community, how long-standing racial and systematic inequities played out over the past year, and the many reasons why some people don’t want the vaccine. “It’s difficult to be able to receive help from a system that doesn’t acknowledge its issues against your existence as a Black man,” said Williams, who also partners with USPHAU on several other vaccine initiatives. 

“I get the point about being hesitant as Black folks and not trusting the government,” said Dr. Ian Moore, attending on Zoom wearing a sweatshirt from his alma mater, Tuskegee University. “But you can’t do stuff like that against your own best interest, and saving your own life, protecting yourself against something you know is killing folks, and it’s killing us disproportionately compared to our white counterparts.” 

By the end of the gathering, two participants who’d been undecided going into the event agreed to get vaccinated.  

Pastor Williams isn’t the only leader thinking about barbershops and vaccines. President Biden recently announced a “month of action” -- including a wide range of activities meant to drive vaccine uptake so that 70% of the population gets at least one shot by July 4. These actions range from “Shots at the Shop,” a vaccination and outreach effort aimed at Black-owned barbershops and beauty salons across the country, to free childcare for parents getting vaccinated and extended evening pharmacy hours to help workers.  

Cupcakes and COVID-19 Shots 

The USPHAU-supported Chicagoland Vaccine Partnership (CVP) was created to combat extreme inequity in the response to COVID-19. For example, while 59% of Chicagoans are Black or Latinx, in the first week that vaccines were available “only 18% of COVID-19 vaccines went to Black or Latinx Chicagoans,” according to city data. That stark gap has closed, but not completely. As of June 13, the official breakdown of fully vaccinated residents was 37% Latinx, 30% Black, 53.9% white, and 52.6% Asian. 

The CVP, a community coalition of more than 135 members--including health, government, philanthropy, and neighborhood leaders, has been working to close those racial and health gaps, ensure access and equity in COVID-19 vaccination distribution, and strengthen the Chicagoland area’s public health infrastructure for the future. When it became clear that the “messengers” delivering vaccine information would be critical to uptake, the Vaccine Partnership created a Speakers Bureau of trained public health professionals who could effectively address a wide range of audiences and community concerns. To date, the speakers have facilitated more than 30 events with over 630 people.  

No venue is considered too small.  

Recently, USPHAU’s Dr. Pranali Koradia, who specializes in emergency medicine, appeared via Zoom at a children’s cupcake-baking class hosted by the community-based organization, It Could be Your Kid, and led by local cook Dominique Lyric. As the young bakers awaited their cupcakes in the oven, Koradia shared vaccine information and answered questions for both the kids and their parents. 

To further engage people in vaccination, Malcolm X City College and the Chicago Department of Public Health, in partnership with the CVP, are also offering a free online training that helps community members speak to their neighbors about vaccination. After taking the course, newly minted Vaccine Ambassadors can earn credits at City College and continue to receive support to bolster their skills and public health training, through an online learning community managed by USPHAU. So far, more than 2,400 people have signed up for the course. 

Call the Aunties 

The USPHAU’s work extends to Toronto, a city with the largest Indigenous population in Canada at over 80,000. The team is partnered with a nonprofit, Seventh Generation Midwives, to support their Call Auntie program, which started as a hotline at the beginning of the pandemic. These urban Indigenous aunties became a COVID-19 information resource for their community, providing culturally safe navigation of public health guidance and problem-solving that is not written for the reality of Indigenous families, 87% of whom live below the poverty line. To date, there have been about 500 calls to the hotline. This partnership expanded, establishing Auduzhe Mino Nesewinong, an Indigenous-specific testing and vaccine clinic providing an integrated public health response to COVID-19. The Aunties continue to provide support, such as food assistance, Indigenous-specific case investigation and contact tracing, and direct support for families who are self-isolating or COVID-19 positive, said Cheryllee Bourgeois, a midwife with Seventh Generation. 

“Using kinship models to center self-determination and extended family well-being, Indigenous people in Toronto always have an Auntie they can call,” she said. 

An All-Hands-on-Deck Moment 

When it comes to vaccination efforts in Pima County, Ariz., the health department is taking an all-hands-on-deck approach, launching events wherever people congregate. There are pop-up clinics at dog racing facilities and casinos, the mall, and even the zoo. To leverage the energy (and social media savvy) of young people, the health department hosted a “Vax Truth Challenge” in which 16- to 24-year-olds submitted videos addressing various vaccine themes for a grand prize of a Nintendo Switch or a Chromebook.  

The winning video, by 23-year-old Amelia Jimenez, was inspired by the TikTok trend juxtaposing images of people getting vaccinated with clips of their favorite memories. This, Jimenez said, “was a representation of that hopeful state of mind that life will one day return back to normal again.” She said the video, which also speaks to the dangers of misinformation shared on social media, has received a mixed response.  

“Going into this competition, I knew that some people wouldn’t like my video,” she said. “But I didn't let that stop me. If I could just impact one person, and that one person decided to get vaccinated because they saw my video, then I have succeeded. No step is too small towards change.” 

Pima County isn’t just trying to appeal to TikTok users. The health department has started offering long-term care recipients the option of requesting a “vaccine house call,” with vaccinators arriving right at the door. 

Similarly, in Newark, N.J., USPHAU has worked with the health department and its partners to send pop-up vaccination sites to homeless shelters and senior housing buildings, communities at particularly high risk for COVID-19.

The Ethics of Incentives 

The range of incentives used by USPHAU and partners is intentionally modest.  

Large cash incentives -- like the $5 million prize lotteries in states such as New York and New Mexico -- could set a dangerous precedent, according to a recent article in The New England Journal of Medicine. “It’s important to consider that booster shots will probably be required down the line,” the authors write. “Offering incentives now may set a costly and undesirable precedent, causing people to expect — and wait for — an incentive the next time around.” 

Ric LaGrange, a vice president at the behavioral science company ideas42, one of USPHAU’s partners on vaccine messaging, said: “Incentives should not be so large as to create coercive influence on an individual's decisions. Free doughnuts are one thing but giving out $100 might cross the line into coercive influence, particularly among low-income populations.” 

So, in Montgomery, where USPHAU is working with Mayor Steven Reed and other partners and leaders on a community-inspired vaccination campaign called “Level Up,” the team recently hosted a food drive and vaccination clinic where people were offered $50 gift cards once they received their first shot. At this and similar events around the city, a total of 200 people were handed a strategically worded ticket which said: “Your second shot is reserved for you.”  

Grace Lesser, USPHAU’s senior lead in Montgomery, said this language was used for a reason. Researchers at the University of Pennsylvania found that telling people a vaccination was “reserved” for them boosted adherence. (The Penn study focused on flu shots, but researchers said the findings held true for vaccinations in general, including for COVID-19.) The idea, researchers suggest, is that telling a person that a particular dose “belongs to them” underscores the notion that if they don’t claim it, they will be losing something important.  

LaGrange added that “vaccine hesitation is complex,” and sometimes seemingly small considerations can shore up the goal of greater vaccination uptake. In Montgomery, for example, “we leveraged behavioral science principles to support integrating a vaccination clinic with a local church’s regularly scheduled food pantry/clinic,” he said. “Appointments were not required, trusted messengers in the community spread the word, and volunteers distributed hot breakfast and dry goods and discussed concerns with visitors. These may sound like small features but reducing potential hassles (like the need to make an appointment or travel to an unfamiliar location) and building trust through one-to-one interactions impact decisions.”  

At the end of the day, each of these initiatives hinges on local connections and trusted relationships built over time.

“There is no one-size-fits-all generic plan that will succeed in addressing all vaccine access issues,” Wispelwey, of USPHAU, said.  “Eligibility for vaccination is not access, and access looks different everywhere.”  

“We are at a stage where the inequity in COVID-19 risk may further increase along the fault lines of poverty, race, and ethnicity unless we can find ways to successfully reach unvaccinated teens and adults in the communities that are both hardest hit and suffer the most limited vaccine access.”