For weeks, Félix Melgar could do nothing but wait, feeling trapped in his modest home in Carabayllo. COVID-19 wasn’t the only challenge he was up against.

There was the epilepsy. The empty pill bottles. The seizures. And underneath it all, an unsettling quiet. As if the world had come to a standstill. As if no one was truly there.

“Nobody comes,” he recalls. “Nobody visits you.”

Melgar is one of thousands of Peruvians who faced an impossible choice during the pandemic: go to the clinic for his medications and risk contracting a deadly new virus or stay at home and live with a chronic disease, unmedicated.

Melgar chose to stay at home—and that meant suffering from seizures, again.

Diagnosed with epilepsy at 18 years old, after a serious blow to the head during his military service, Melgar had lived with medication for years, staving off the worst symptoms of the disease and regaining some amount of freedom and control.

A baker by trade, he was used to working long hours, selling fresh bread to make ends meet for his family. But that was before the pandemic struck. And before the unthinkable happened: Melgar’s own bout with COVID-19.

Unexpected Results

Doctors had warned him a positive test would be dangerous. It wasn’t just the epilepsy they were worried about. Melgar also lives with obesity and high blood pressure—underlying conditions that put him squarely in the high-risk category for serious complications should he fall ill with COVID-19.

But still, nothing could have prepared him for the moment when his and his family’s test results came back.

“When I found out that I had contracted coronavirus, I felt desperate,” he recalls. “My wife, my daughter Elena, and I began to cry.” His wife and children had also tested positive.

Health wasn’t the only concern on his mind. Food and housing also loomed large—as the mandatory weeks in quarantine put him and his family out of work, financial ruin felt like only a matter of time, given they had no savings to pay for groceries and rent.

Then came another twist that Melgar wasn’t expecting: medical care and essential resources were available in his community, free of charge. The help came from an organization called Socios En Salud.

More Than Clinical Care

Socios En Salud has been working in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis (MDR-TB) in Carabayllo, an impoverished neighborhood about 20 miles north of the capital of Lima.

Since then, Socios En Salud has expanded to provide medical care and support across a range of clinical areas, from mental health to child health, in coordination with Peru’s Ministry of Health and community health workers —local residents trained to provide basic health services, such as the delivery of medications, and to help patients navigate Peru’s health system.

“We focus on far more than clinical care,” says Genaro Anco, who coordinates Socios En Salud’s social protection program. “We also seek to accompany the patient and the family during the process of treatment and overcoming disease.”

As the pandemic strained Peru's health system and put marginalized communities at risk, Socios En Salud sprang into action, conducting COVID-19 tests for more than 41,330 people, with 18,066 testing positive. To counter the financial burdens imposed by the pandemic, Socios En Salud provided 1,605 families with food vouchers and 1,679 with socioeconomic support.

Throughout the pandemic response, Socios En Salud’s community health workers have been pivotal in reaching patients at risk of falling through the cracks, especially those in Carabayllo’s impoverished hillside communities—patients like Melgar and his family.

‘They Were Always Calling Me’

Over the next several weeks, Socios En Salud helped Melgar get back on his epilepsy medications and access essential supplies, such as masks and hand sanitizer. He also received food and housing assistance through Socios En Salud’s social support program, relieving the family of the financial burden imposed by COVID-19.

Additionally, community health workers regularly called and, when safe, visited Melgar to check in with him and make sure he was getting the support he needed.

“When I was sick, they were always calling me,” he says. “Truly, they did care.”

That care made all the difference.

Now, Melgar and his family have recovered from COVID-19. For his epilepsy, Melgar receives treatment and medications from the Hospital de Apoyo in Carabayllo. He is also part of Socios En Salud’s chronic diseases program, giving him access to clinical, nutritional, and psychological support.

Even after his recovery, Melgar says, Socios En Salud continues to call and check in on him and his family—a gesture that means more than they can ever know.

“I feel much better…little by little, I am recovering,” he says. “I will always be grateful for Socios En Salud’s help.”

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On June 19, 1865, enslaved Africans in Galveston, Texas, found out they were freed—more than two years after the Emancipation Proclamation. That day became known as Juneteenth and has been celebrated by Black communities across the United States ever since.

Understanding this holiday and what it represents—both in the past and present—is crucial to understanding U.S. history. It offers a time of celebration for Black communities, while also reminds of the responsibility that all non-Black Americans have for dismantling the white supremacy and anti-Blackness that the country was founded upon and supporting the movement for Black liberation.

Over the past year, Partners In Health has expanded its work in the U.S. through PIH United States, which collaborates closely with communities such as Montgomery, where the legacy of slavery is acutely felt to this day. PIH also works in Haiti and West Africa, where the history of the trans-Atlantic slave trade continues to devastate communities and affect the lives of millions of people.

As Black communities across the U.S. observe Juneteenth and as non-Black people use the time to educate themselves on the progress still to be made toward racial justice, PIH staff have compiled a list of resources—from articles to films to podcasts—to read, watch, and listen to in honor of this holiday.

By Andi Mar Valadez Castañeda, first-year nurse at Compañeros En Salud

Caregiving—the essence of the nursing profession—has been a task assigned to women for millennia, based on traditional gender roles that saw women taking care of the home and family. In Mexico, that gendered concept has influenced the nursing profession since its early days. The very first “nurses” in Mexico were not the professional nurses we may think of today, but women engaged in traditional healing, such as midwives, shamans and bonesetters.

When Spanish colonizers arrived in Mexico in the 16th century, new diseases emerged and many new forms of care were imposed, while traditional forms of care were devalued. That meant that midwives and other women healers were also devalued and harsh restrictions were put in place, severely limiting the care they could provide. The Protomedicato—a group of male doctors and the Spanish empire’s highest authority in medicine and health—decided that the midwives’ knowledge was not correct and that they needed re-education to do things more efficiently.

As a result, in spite of their generations of experience, midwives were denigrated—constantly evaluated by an all-male board of physicians and subject to absurd requirements, such as having to study for four years in approved schools and one year longer than male doctors, presenting a certificate of "purity of blood," and providing testimonies of good conduct. These requirements meant that only two licenses to practice professional midwifery were ever issued during the colonial period in Mexico.

Mexico won its independence from Spain in 1810. But independence didn’t lead to equity for midwives and other women healers. Mexico’s first nursing school was established during the Porfiriato period, as the country underwent a series of reforms aimed at modernization. But even then, nurses—overwhelmingly women—saw their work severely limited compared to their male colleagues and their salaries were much lower, earning 8 pesos compared to doctors’ 166 pesos.

By 1846, midwives were only allowed to assist with childbirth, and even then they were heavily restricted in what they could do. For example, they were forbidden from helping women through difficult or obstructed labor. And after delivery, midwives were only allowed to receive the baby, cut the cord, provide first aid in the event of asphyxia, and indicate when a doctor was needed.

As nurses were valued less than doctors, caring was valued less than curing—a notion that continues to underpin Mexico’s health system today.

To speak of the subordination of nursing within the medical profession is to speak of gender and structural discrimination—from the fact that care is considered a feminine task, underscoring traditional gender roles, to the fact that, since the creation of the nursing profession, nurses were lower-middle class and doctors upper, accentuating the imbalance of political and economic power. These inequities have taken a toll on the nursing profession, hindering the visibility and recognition of nurses, who find their practice undervalued and their approaches, questioned.

Some progress has been made. As nursing has been professionalized in recent decades, many countries have established specialties, master's degrees, and doctorates in nursing—educational opportunities that did not previously exist. These strides forward have not only been a success for nursing, but also a success for women, who still make up the majority of nurses worldwide. In Mexico, such progress has been present, but slow, due to the macho ideology that persists, both in society and in the health sector.

As we look to the future of nursing in Mexico, I challenge us to make the profession visible and to embrace a new generation of nurses, who no longer see themselves as inferior. I invite us to reflect on our health system through a gender lens and identify the “micromachismos” that prevail in our workplaces and that hinder the development of the nursing profession. And I invite us to rethink our own perspectives on nurses, especially those of us who are physicians.

I invite physicians to be aware of their position of power in order to combat the prejudices that have historically underscored the working relationship between doctors and nurses.

Lastly, I want to emphasize that this call to action isn’t about excluding men from the nursing field. This is about eliminating the gender stereotypes that surround the nursing profession in order to create a space free of misogyny, where nursing is seen as a profession for all and not as a women's profession, where care is no longer perceived as an extension of the feminine and is instead validated as a field of professional study.

Andi Mar Valadez Castañeda is first-year nurse at Compeñeros En Salud, as PIH is known in Mexico. She is part of the pasante program at Compeñeros En Salud, which places first-year clinicians in Chiapas’ rural communities.

The little things can easily be taken for granted around a clinic or hospital—like running water in exam rooms and surgical wards, clean drinking water for patients, and accessible toilets for patients and visitors. When absent, as they are in many health facilities across Haiti, the little things contribute to big problems in preventing infection and promoting dignified, quality health care for all.

That’s why Zanmi Lasante, PIH’s sister organization in Haiti, has focused on improving access to water, sanitation, and hygiene (WASH) services within the health care facilities it supports and throughout neighboring communities across the Central Plateau and lower Artibonite. Most recently, that work included an assessment of all 15 health care centers and hospitals that comprise their network to address major needs and start the necessary renovations that will ensure quality care.

“Access to WASH in health care facilities is an integral part of health systems, yet it is often lumped together with general infrastructure,” says Elizabeth Campa, chief of staff to Loune Viaud, executive director of Zanmi Lasante. A WASH expert with 20 years of experience in humanitarian response, Campa has seen first-hand its importance in health care facilities and its impact on patient mortality. “Without access, research shows time and time again how infections are more prevalent, leading to unnecessary illness and death.”

Today, more than half of the world’s population does not have access to improved sanitation, and an estimated 3 billion people do not have access to handwashing facilities with soap.

These alarming statistics are unfortunately the daily reality for many Haitians. According to the World Bank, Haiti is the most underserved country in the Americas when it comes to water, sanitation, and hygiene. The situation became even more critical after the 2010 earthquake destroyed much of existing infrastructure.  Between 1990 and 2015, the share of the population with access to potable water decreased from 62% to 52%. 

Today, more than half of the country’s rural population still lacks access to potable water, while only about one-third of Haitians have access to basic sanitation.

Neglected facilities, gaps in care

Health facilities are frequently the only points of care in remote, rural regions of Haiti. For more than 6 million Haitians living on less than 2 dollars per day, these crucial institutions promote good health practices; provide primary, maternal health, and pediatric care; and respond to infectious disease outbreaks, such as COVID-19, typhoid, and other infectious diseases.

Despite that, with only 4.3% of Haiti’s budget allocated to health care, these public facilities receive minimal government funding; more than 95% of them are in urgent need of major repair due to normal deterioration and decades of neglect. Many of them lack plumbing, improved sanitation, adequate infectious waste disposal, sterilization equipment, electricity, or access to a basic running water supply. 

This situation has serious consequences for patients, including the risk of developing a life-threatening infection during their stay at an under-resourced health facility. No less severe is the indignity suffered by patients who need to relieve themselves or bathe and have no proper place to do so.

Renovations in WASH

Zanmi Lasante clinicians and staff are acutely aware of this situation, as they work and serve patients within public clinics and hospitals every day. Still, staff’s assessment highlighted key areas of improvement. According to Dr. Ralph Ternier, director of programming at Zanmi Lasante, the sanitation infrastructure in many health care facilities is beyond renovation and must be rebuilt altogether. The geographic location of some makes it impossible to drill boreholes. Since they are not connected to the national water supply, these already severely underfunded facilities have to purchase water of questionable quality every day.

“It’s it unacceptable that in 2021, patients are faced with the dilemma of either buying their own drinking water or staying thirsty until they return home,” Ternier says. “If health care workers can't wash their hands [with soap], provide clean water for their patients, or have access to decent toilets, the facility becomes a breeding ground for disease.”

Zanmi Lasante prevents infection across its network of supported facilities by regularly supplying soap, updating existing plumbing, and replacing toilets and handwashing stations. Facilities are also constantly cleaned and maintained.

Nonetheless, much more could be done to strengthen WASH infrastructure. Zanmi Lasante leadership plans renovations to begin on a handful of facilities this summer. The many priorities include: installing new plumbing and piping systems, which will be connected to a clean water supply through underground cisterns and water tanks; adding handwashing stations with soap throughout health facilities—more important now than ever in the time of COVID-19; building handicap-accessible sanitation blocks with separate, private toilets and showers for men and women; and installing solar-powered lamps to light up pathways at night and prevent falls.

Zanmi Lasante also plans to completely revamp the electrical system in many facilities, install air conditioning in the medicine stock rooms to regulate temperature, build water tanks, repair incinerators, and improve areas dedicated to medical waste management.

The hope is that, with these improvements in WASH and other infrastructure, Zanmi Lasante clinicians and staff will be able to provide better quality of care, reduce the risk of patient infections, increase patients’ use of health services, and improve employee morale.

Model in Kay Liz

Zanmi Lasante can already point to one example at University Hospital in Mirebalais of this improved WASH model. In February 2017, it opened Kay Manmito, a maternal waiting home on the hospital’s campus that hosts women with complicated pregnancies and mothers whose newborns are in the neonatal intensive care unit (NICU). The facility houses a sanitation block with a laundry space, showers, and toilets solely dedicated for the mothers’ use.

Just next door is Kay Liz, or Liz’s House--named after Campa, a proud advocate of toilets and accessibility. The sanitation facility provides an average of 500 people each day with access to bathrooms and showers, with a regular stock of clean water and soap. This meets the needs not only of patients, but also friends and family members, who travel with them and often must stay to receive care for days and weeks at a time.

Campa is proud of Kay Liz and sees it as a model for future work in Haiti.

“Toilets have been a passion of mine since my days in the U.S. Peace Corps, over 20 years ago,” Campa says. “There is so much taboo surrounding the subject of sanitation, but by talking about it regularly, we begin to remove these negative feelings about toilets. Everyone goes to the bathroom; everyone should have the right to improved sanitation.”

Partners In Health is not an average NGO. PIH founders established the organization more than 30 years ago based on a simple, yet radical, idea: Health care is a human right. We believe everyone deserves the right to live a healthy life, regardless of income, geography, or identity.

At PIH, our mission is to provide a “preferential option for the poor” in health care, meaning that those most in need are first to receive care and support. In partnership with local and national governments, we bring the benefits of modern medical science to some of the most marginalized communities around the world, while also integrating local, culturally relevant, and traditional forms of care. From Haiti to Rwanda, our global teams do whatever it takes to make our patients well—just as we would do if a member of our own families or we ourselves were ill.

None of this work is simple--but none of it is impossible. And all of it is essential. Here are five elements that make PIH unique:

1. Accompaniment

Accompaniment means being there, together, for as long as it takes. We accompany first and foremost our patients, whom we often refer to as “our bosses.” We believe that any meaningful social progress is only born out of true solidarity and partnership, and so our style of accompaniment is rooted in shared experiences and meant to support whomever needs assistance, for as long as they need it.

At PIH, accompaniment has no time limit. Only by keeping an open commitment to collaboration can we aspire to solve problems caused by centuries of oppression—due to colonialism, the slave trade, and systemic racism—and find the hope needed to overcome seemingly insurmountable hurdles.

When PIH began working in Haiti in the early 1980s, among the first employees hired were accompagnateurs, or community health workers (CHWs) in Haitian Creole. These accompagnateurs put our accompaniment model into action.  Recruited from their communities, they are intimately aware of the challenges their neighbors, friends, and family members face on a daily basis--first-hand experience that helps them connect patients to local clinics and form the bridge often missing to quality health care.

Their work reflects how we accompany all our partners—from leaders of global health organizations and ministers of health, to lab technicians and local clinicians—focused on our overarching goal of achieving a universal right to health care.

2. Partnership

Since the beginning, PIH leaders knew that real advancement toward a universal right to health would only be possible through strong partnerships. Our goal is not to expand across the globe, but to partner with governments and organizations who invite us to the work. Together, we prove what is possible in resource-poor settings, among the most marginalized communities, and offer it up as a model for replication. Then, we dare the world to look the other way.

We partner with national governments, local districts, the private and public sectors, civil societies, as well as some of the world’s most prestigious academic institutions, such as Harvard Medical School and Brigham & Women’s Hospital. These partnerships, of public officials and clinicians, scholars and scientists, advocates and community members, are what drive all our work, everywhere.

3. Equity

PIH is a social justice and global health nonprofit, with both elements  intertwined. We see social justice as the continuous push to create a more fair and equitable society, one in which everyone has the right and opportunity to live a life filled with dignity and purpose.

Our social justice work is focused on creating a new universal standard of health care and is anchored in a preferential option for the poor.  We refuse to accept the global health norm, where all that is imagined for those with the least resources or power are the cheapest options. This is a failure of imagination.

We reject that paradigm and propose a different model of care—one rooted in equity. At the clinics and hospitals that we support, care is driven by patients’ needs. And often, that care isn’t solely medical; it includes resources for food, shelter, employment, and transportation to and from health facilities. The entire package of medical care and social support is necessary to care for patients, fix broken health systems, and right historic wrongs. 

4. Research + Advocacy

PIH has decades of experience in global health care and deep academic and research partnerships in the United States.

Some of the most brilliant scientific minds in global health work within our ranks. Fordecades, PIH has partnered with world-renowned institutions, such as Harvard University, to deliver groundbreaking research. Our work has informed hundreds of peer-reviewed, scientific papers that in turn form the base of our global advocacy and inspire lasting change.

Some concrete examples:

• In the 1990s, our community-based treatment of multidrug-resistant tuberculosis (MDR-TB) in Peru proved so effective that the World Health Organization (WHO) revised its global treatment recommendations.
• Years later, our HIV Equity Initiative helped deliver antiretroviral therapy to patients in Haiti, eventually saving hundreds of lives. Our initiative was so successful that it inspired the Global Fund, PEPFAR, and the WHO to fund the fight against HIV in rich and poor countries, alike.
• In 2012, our cholera vaccination campaign in Haiti set a precedent for outbreak response and inspired the WHO to create a global stockpile of the oral vaccine, which has since been used to control and prevent outbreaks in Yemen and Sierra Leone.

Ultimately, we measure ourselves not only by how many people we have served directly, and how well, but also by how many people we have served indirectly, through our efforts to change minds, laws, and policies.

5. “The Five S’s”

Around the world, PIH builds up local health systems alongside its partners, strengthening these systems to respond to disasters and meet the daily needs of patients and their families.

We believe all strong health systems must have five essential elements, which we call “the Five S’s.”

PIH's Five S's

• Staff: Well-trained, qualified staff in sufficient numbers to respond to the need
• Stuff: Proper and ample medication and supplies
• Space: Safe, appropriate spaces with reliable electricity and clean water
• Systems: Universally shared best practices for care delivery and administration
• Social support: Essential resources to ensure effective care, such as food, transportation, housing, and education

Even before care resource coordinators in Massachusetts make their first phone calls, they take a pledge: “Our commitment is to accompany patients on their journey to health and wellness and link them to available social supports,” the workers assert. “Health is a human right we are all entitled to, irrespective of our ZIP code.” 

As pandemic response efforts like contact tracing ramped up last spring, it became clear that simply identifying people with COVID-19 and their contacts, and explaining the latest health and safety guidelines, was not enough for many people across the country. Individuals and families often required far more help to safely isolate and minimize transmission: they needed food, or a safe dwelling, cash assistance to pay bills, or cleaning supplies -- and they needed someone committed to helping them acquire these basics. Care resource coordinators, individuals who ensure that cases and contacts have the social, material, and other supports they need to safely isolate or quarantine, filled that crucial gap.  

The importance of connecting people to social support during a pandemic was made apparent in a series of case studies that detail care resource coordination in action. Written by Partners In Health’s U.S. Public Health Accompaniment Unit, in collaboration with public health teams around the United States, the studies include deep-dive examinations of programs in Massachusetts, New York City, Immokalee, Fla., and North Carolina. Each reveals a unique snapshot of how resource coordination programs have been designed and scaled up in different regions each operating within their own specific contexts.

Approaches, models, funding streams, and community partnerships vary from state to state and across cities. Even job titles often differ, for example “care resource coordinators,” “resource navigators,” “health promoters” and “community health workers” can all fulfill a similar function.  But the main goal of each of these social support specialists remains consistent across sites: to connect vulnerable individuals and families to the basics they need to stay safe and healthy, and to build trust in local community health systems.

“This system just feels different now,” said one migrant worker from Immokalee, commenting on the resources made accessible to his community through local health promoters. “They speak to me in my language and in a way that shows they understand and actually care; it just feels like family.”

Door-to-Door, Family-to-Family

Immokalee, located 25 miles northeast of Naples, Fla. is home to a large population of migrant and essential workers who have long endured the brunt of systemic health and economic inequalities.  COVID-19 only further exposed and exacerbated these disparities as many residents live and work close to others, putting them at risk for COVID-19 infection and transmission, and have historically faced barriers to accessing healthcare, making them more likely to suffer poor health outcomes after infection. As the virus took hold, the case study says, the “state’s COVID-19 response efforts did not adequately meet the needs of Immokalee’s residents, leaving significant gaps in access to testing, comprehensive contact tracing and case investigation programs, resources to allow individuals to safely isolate or quarantine, and equitable access to vaccination.” 

To help bridge these gaps, Immokalee’s community leaders relied on partnerships between community-based organizations, notably, the Coalition of Immokalee Workers, Healthcare Network, Misión Peniel, Partners In Health, and the Collier County Department of Health.

Unlike some other programs, the Immokalee partners decided to recruit and train a new cadre of health promoters, or promotoras (Spanish for community health workers) specifically to connect farmworkers, laborers and other vulnerable populations in the area to critical resources that would help them safely isolate and quarantine during the pandemic. These new promotoras, fluent in the language and culture of their communities, have become trusted sources of health information and other supports. They travel door-to-door, from family-to-family, providing individualized help to members of the community, from securing transportation to testing and vaccination sites, to food deliveries, housing support, labor protections, and cash assistance to cover costs during isolation.  

Indeed, between July 2020 and early April 2021, Immokalee promotoras visited more than 2,800 households and reached approximately 9,000 people; they helped with disbursement of $482,000 in cash transfers to 400 households, site leaders said.  

Immokalee promotor Osman López Hernández said COVID-19 has devastated his community.

“Sometimes, I will go to a house and the entire family is sick,” he says, speaking through a Spanish interpreter.  “They haven’t gone to the clinic because they don’t have money or transportation, or they think they can’t access services because they don’t have ID.”  

López Hernández, a former community health worker in Guatemala before moving to the U.S. with his wife and three children, says the problem isn’t a lack of education; rather, it’s simply that people don’t have clear, accurate information. They don’t know, for instance, that transportation to the clinic is available or that food can be delivered right to their homes. 

Among the many cases he manages, López Hernández is currently helping a family of five, all with COVID-19. Three of them have died, he said, and one is at home on oxygen. Each week, López Hernández brings them food, bottled water, and financial assistance. But even with all of the illness and death he has seen up close, López Hernández says, “it hasn’t made me more depressed. It has given me more experience, and it helps me continue to do this work for the people here.” 

The virus’ toll on the community has also opened his eyes.  “What is really surprising,” he said, “is that this is happening in America.”

Navigating New York City

In New York City, with more than 8 million residents, the sheer scope of the workforce and response to the pandemic is staggering: 200 to 300 resource navigators employed by 10 community-based organizations completed 195,000 referrals for basic needs as of late February 2021, the case study says. More than 220,000 free “Take Care” packages with masks, hand sanitizer, a thermometer, snacks, games, educational resources, and a pulse oximeter for COVID-19 positive patients were sent to households under NYC’s Test & Trace Corps Take Care Program, funded through federal and city support. Approximately 10,000 individual cases and contacts were able to isolate or quarantine in a free hotel room through the NYC Isolation Hotel Program and many families received food through the Get Food NYC Emergency Home Food Delivery Program.   

When the pandemic hit, Suzan Lam’s community-based organization, the Chinese-American Planning Council, was called into action, and she became deputy director of the group's contingent of NYC’s Resource Navigators. Lam was among the first teams of navigators to staff one of the city’s rapid testing sites, in Sunset Park, Brooklyn, which offered people who tested positive for COVID-19 immediate resource connections, helping them get rides to hotels for isolation, for instance, or setting up food deliveries. 

In these high positivity, high-need areas, Lam said, “finances were a huge struggle,” with people concerned about whether they could go back to work. Amidst the fear and so many unknowns during the early stages of the pandemic, Lam said people were grateful to connect with navigators who spoke their language, explained medical protocols, and also guided them to the services they might need, from childcare to support for survivors of domestic violence. All of this occurred right at the testing site. 

Lam said one of the major challenges was the shifting health guidance around isolation and quarantine. “As we learned more, the resource navigators had to be sure we were providing accurate information. We had to be constantly updating, educating ourselves with the latest guidance. The need to continually adapt was challenging,” she said. 

A Layered Strategy in North Carolina

North Carolina’s approach to resource coordination is unique in its use of multiple interrelated programs, the case study says, including direct financing of social supports, and assistance for COVID-19 cases and contacts outside contact tracing systems.  The state’s Department of Health and Human Services leaned into “layered interventions that built on the state’s successful, pre-existing investments and work,” such as addressing the nonmedical drivers of health and combining identification of social support needs with dedicated financing to help. The USPHAU’s North Carolina team supported this work by helping expand the state’s community health worker program in vulnerable communities, connecting partners to hyper-local community-based organizations and providing overall program evaluation with an eye towards racial equity.

For Idalia Arellano, a community health worker hired in the midst of the pandemic, the most astonishing shift has been a new level of communication, responsiveness, and partnership created between the state, county, and the region’s most vulnerable communities.  Before the pandemic, she said, it was not always easy to get attention and resources for the state’s Latinx and Black communities.

“COVID-19 was for sure a wake-up call. Honestly, if the pandemic wouldn’t have happened, I don’t think the movement toward equity would have happened.”

With the pandemic, she said, “people had to listen, not because they wanted to, but because communities of color were the ones getting sick. Now, they want to hear from people of color, from the grassroots in the trenches, the organizations that are actually doing the work.” 

This new, more powerful support network plays out in important ways, Arellano said— expanded weekend hours at testing and vaccination sites so that poultry and migrant workers have access; culturally appropriate food deliveries to families in isolation; and guarantees that neither identification, nor social security information, be required so that undocumented people can begin to trust the health system. 

Arellano, who works for Southeastern Healthcare of North Carolina, one of the organizations partnering with the state on COVID-19 efforts, added: “There’s so much more work to be done, but at least now we’re moving toward a shared goal.” 

Her field supervisor, Blanca Borceguin, also a CHW, agreed. “I don’t want to say COVID-19’s a blessing in disguise, but one thing it has done is made the state know its community’s needs on a deeper level.”  That means CHWs can help families secure rent or utility assistance in the short-term, for example, as well as support them in negotiating longer-term payment plans with the electric company. 

This stronger statewide partnership gave Borceguin the freedom to visit a local pastor, and, ultimately, plan a mass vaccination event next month with 21 pastors and their congregations at the church with the biggest parking lot.  For the event, Borceguin said, the CHWs are taking care of all the logistics; arranging for free transportation, bags of non-perishable food, securing the vaccines for delivery, staffing the clinic with multilingual workers. She said she told the pastors: “You don’t have to do anything but spread the word that vaccines are here for your people.”

A Patchwork of Programs

Mounting an efficient, equitable response that serves those most in need during a pandemic, is, of course, complicated and rife with obstacles. All of the case studies lay out some of the barriers administrators and resource coordinators faced: Lack of funding or sufficient resources to meet community needs, integrating new and different systems, managing fluctuating caseloads.

It’s worth noting, too, that not all care resource programs are equal. 

A survey of state contact tracing programs conducted by Johns Hopkins, NPR and PIH found that only 52% included scripted questions assessing people’s needs for specific items, such as food, housing, medicine, or personal protective equipment. An analysis of the survey also found that only 39% of contact tracing teams included dedicated care coordinators; and nearly a third of these programs don't do systematic follow-up with people to make sure their needs were met.

A Pioneering Program in Massachusetts

In April 2020, the Commonwealth of Massachusetts, in collaboration with PIH, launched what would become one of the most extensive statewide COVID-19 contact tracing programs in the country. From the beginning, the Massachusetts Community Tracing Collaborative (CTC), which helped support local health departments’ efforts, prioritized care resource coordination as a central component of the program. 

Over time, as the benefits of resource coordination were apparent, the program expanded to accept referrals from sources beyond the contact tracers and case investigators who were part of the CTC, the case study says. Local public health officials, community members, and higher education staff began referring people to CTC resources coordinators. Through all of its work, the CTC prioritized diversity and equity at every level. Recognizing the “historical and ongoing legacies of structural violence and inequality that were laid bare by the COVID-19 pandemic,” the program was “intentionally designed to build strong, diverse, multidisciplinary teams to test, trace, protect, and support communities across MA. Cultural, geographic, and linguistic diversity is especially important for the Care Resource Coordination team, as is deep experience and familiarity with local context and communities.” This focus allowed care resource coordinators to provide the hardest hit cases and their contacts a lifeline to the essentials they needed but could not readily access. 

Since the program launched, Massachusetts care resource coordinators have connected more than 100,000 people in the state to food, housing, medicine, mental health support, and other basics. 

“I think what was the most helpful,” said Nikkia Watson, a care resource coordinator in Massachusetts, “was providing people with support to know they were not alone in feelings of fear and isolation. Many people, especially in the beginning, were so anxious and would often say, ‘I don’t know what’s wrong with me. I’m never like this.’ We assured them that this time was hard, and lots of people were also feeling overwhelmed. That helped to calm some nerves.”  

While COVID-19 has highlighted deep, structural inequities in the U.S., Watson said, the pandemic also offered a unique moment to rethink our current systems. 

“I think there is a real opportunity here for advocacy work and resource coordination for the many people we see struggling with the long-term, non-medical impacts of COVID-19,” she said. “People have lost jobs, housing, and loved ones. Those things mixed with systems of oppression and lack of support for immigrant families need to be addressed and that’s a great place for health care workers and promoters to step in. Targeting these issues will help limit the long-term effects on these communities.”

Explore the COVID-19 Resource Library

Racial violence, police brutality, and other forms of racism don’t just affect the physical safety of Black, Asian, Latinx, and Indigenous people—racism also affects mental health.

Yet, for many people of color, mental health care remains costly, hard to access, and stigmatized.

Panelists discussed these challenges and more during a virtual event organized by Partners In Health on May 20, in light of Mental Health Action Day and Asian Pacific American Heritage Month.

The panel included Eric Nam, singer-songwriter and entrepreneur; Tracy Chou, founder and CEO of Block Party; Dr. Ksakrad Kelly, PIH cross-site mental health psychotherapy technical advisor; and Dr. Mary Yang, PIH psychiatrist consultant. The conversation was moderated by PIH writer and editor Janissa Delzo.

“Systemic racism is something that is quite violent and traumatizing,” Kelly said during the virtual event. “It is something that is embedded in every aspect of our society and culture—from where we live, to the food we eat, to the resources we have access to…it’s a constant presence.”

The panel comes amid ongoing racial violence in the United States, from the murders of Black people by police to COVID-related violence against Asian Americans. Across the U.S., COVID-19 has disproportionately impacted Black, Latinx, and Indigenous communities, as well as low-income Asian Americans, due to decades of systemic racism.

The panelists discussed how systemic racism, colonialism, and the legacy of the trans-Atlantic slave trade affect the mental health of people of color, translating to racial stress and trauma that is carried in the body and mind.

“Because of the rise of hate crimes…when we have all these things coming together, I think we all right now, as AAPI in the States, we live with high anxiety, stress, and paranoia,” said Nam. “I think it’s all been exacerbated by COVID-19.”

The panelists also interrogated the word “resiliency”—a term that is often used to describe marginalized communities, but that shifts the focus to the individual, rather than the system that created the harm.

“People who we think of as the most resilient rarely see that as a compliment,” said Yang. “I think people want justice.”

For Chou, that justice includes grappling with the complexity of anti-Asian racism, shaped by decades of colonialism, imperialism, and war in Asia, as well as the model minority myth in the U.S.—an insidious lie that claims Asians are more successful than other races, particularly Black people, due to their work ethic. The myth actively harms Black communities and obscures the real challenges that Asian Americans face.

"It really is an anti-Black racist tool that’s meant to sever communities of color and pit Asians against Black people,” said Chou. “So there’s still that white supremacy underlying all of these conversations.”

Panelists left the audience with a simple yet crucial message: You are not alone.

“I just want to encourage whoever may be going through difficult times, to really reach out for help, and not be afraid of it,” said Nam. “If you’re struggling, ask for help. If you’re not struggling, look to help somebody.”

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On the streets of Lima, 86% of transgender women have faced discrimination. And more than half have experienced domestic violence.

That’s according to a recent survey by Socios En Salud, as Partners In Health is known in Peru, and Féminas Perú, a grassroots organization focused on transgender rights.

The research comes as part of Socios En Salud’s recent efforts to improve access to health services and quality of care for transgender women—one of Peru’s most marginalized groups.

“Through the Féminas intervention, we are trying to end the stigma and discrimination against this population, long neglected by society,” says Giuliana Hernandez, Socios En Salud’s coordinator of the Féminas project. “We must protect health care as a human right. All people deserve access to quality health care.”

‘We Continue To Be Invisible’

For the thousands of transgender women living in Peru, discrimination, stigma, and fear of violence mark daily life.

“Being a trans woman in Peru is very difficult,” says Lesly Quispe, a transgender activist and member of Féminas. “It has impacted my life, from the moment I’ve realized my identity and made the decision to be who I am.”

Across Latin America, most transgender women don’t live past their 35th birthday. HIV prevalence among trans women—whose job prospects are often limited to sex work due to systemic barriers—is as high as 38%. And more transgender people are murdered in Latin America than on any other continent—violence that is routinely un- or under-reported.

That discrimination and violence extends to the health care system, too.

Many transgender women don’t feel safe seeking care at clinics and hospitals where discrimination runs rampant, according to Hernandez. Peru’s health system lacks comprehensive training and protocols for clinicians around sexual and gender diversity, making health centers potential sites of abuse and prejudice.

For the vast majority of transgender women, these challenges are compounded by a lack of national identity documents that reflect their gender identity.

National IDs are required to access health care, social services, and formal employment in Peru. Despite years of activism and even proposed legislation, Peru does not allow people to change their name, gender, and photo on their national identification cards through an administrative process.

In order to update their IDs, Peruvians must resort to a lengthy and costly judicial process that includes a background check, psychological evaluation, and witness interviews—requirements that effectively bar most transgender people from being able to change their IDs.

Without IDs that match their gender identity, transgender people face even greater levels of discrimination and harassment, as well as exclusion from most jobs—forcing many to take up sex work.

“We continue to be invisible as trans women,” says Leyla Huerta, one of the founders of Féminas Peru.

Taking Action

Socios En Salud has provided health services to transgender women for years through its medical care and social support for sex workers, people living with HIV, and other at-risk groups in Lima and Carabayllo.

Just months before COVID-19 strained Peru’s health system and highlighted the gaps between rich and poor, cisgender and transgender, documented and undocumented, Socios En Salud began strengthening its efforts to reach Lima’s most marginalized—including transgender women.

Step one was to ask the women what they needed.

To accomplish this, Socios En Salud partnered with Féminas Peru to conduct several months of surveys, focused on transgender women living in Lima; the results were recently released, after the data was validated.

The first survey, an online questionnaire sent to 701 transgender women in the city and conducted from October to December 2019, found that 86% had faced discrimination, 52% had suffered from domestic violence, and nearly 61% had felt unhappy in the last two weeks.

The second survey, conducted in-person among 301 transgender women from September to October 2020, found that 73% of the women were unable to update their national IDs, 33% didn’t have any health insurance, and 49% suffered from depression.

The results were a call to action.

In the coming months, Socios En Salud will use the survey results to inform its strategy moving forward, as it provides clinical support for transgender women, accompaniment through the national ID process, and a mental health support program. It has already begun to implement peer support groups and psychological first aid sessions.

There’s a long road ahead, and the surveys were just the first step. But Quispe is hopeful the research will pave the way for meaningful change.

“For Socios En Salud and Féminas, these results are a call to establish strategies to reduce the limitations for the development of this population,” she says. “We will continue to work to strengthen health systems in Peru and accompany patients in each and every step of their journey.”

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When picturing the people who work in global health, doctors, nurses, and clinical staff likely come to mind. Those standing in labs, sitting at desks, or answering the phone are much less visible—but no less important. From research to fundraising to data collection, these non-clinical workers make the day-to-day work of global health possible, equipping clinical teams worldwide with the resources and support they need.

Megan Striplin is one of those workers. As a lab program associate with PIH’s Clinical Operations team, she has helped labs around the world develop operational plans, track their progress, and coordinate the flow of lifesaving supplies—work that has become all the more crucial during the global response to COVID-19.

In this edition of our Working In Global Health series, we caught up with Striplin. In our wide-ranging conversation, she reflected on why she changed career paths, what’s been the most meaningful part of her work at PIH, and why diversity matters—in global health and beyond.

You’ve been with PIH for more than three years, starting as a Project Coordinator with endTB and now as a Lab Program Associate. Before that, you were with the Clinton Health Access Initiative (CHAI). What inspired you to work in global health? And how did you end up at PIH?

Ten years ago, I was working as a microbiologist in the lab and realized that I did not want to work on the bench for the rest of my life. Then in 2013, the Boston Marathon bombing overwhelmed the city with grief and reminded me that life is short and that it is worth pursuing what fulfills you, even if you have to backpedal from your current trajectory. I knew I wanted to dedicate my work to social justice and addressing inequity, so I returned to school and got my MPH from Columbia University, specializing in Population & Family Health with a concentration in Global Health. I met so many smart people doing wonderful things, including during my time at CHAI. As I continued in my studies, I knew I had finally found my niche and was developing a skillset where I could contribute to the field.

After school, I returned to Boston. I was already familiar with PIH – I had volunteered here in the past, supporting the cholera vaccine work in Haiti. Luckily, I was able to join PIH as a member of the endTB team and from there, able to marry my backgrounds in lab work and public health, which is how I came to be a lab program associate with PIH’s Clinical Operations team.

What’s been the most meaningful part of working at PIH? Any campaigns or projects that really resonated with you?

Hands down, working one-on-one with colleagues from the care delivery sites is the most meaningful part of my work. I have learned so much from them, and their perspectives are invaluable to what I do. Visiting Botsabelo Hospital in Lesotho was an honor and an inspiration – seeing patients, not just an MDR-TB drug regimen, and reading the outcome “cured” in their medical chart is an experience I will never forget.

Also, the Lab team recently hosted the 4th annual PIH Laboratory Workshop, last month. This event brings together PIH lab managers from all the care delivery sites in order to provide training and updates related to lab performance, foster connections between the cross-site team, and provide the opportunity to showcase the work they have done over the last year in their respective labs.  Of course the event was held virtually this year, but that allowed us to expand to additional members of the lab team, as well as our counterparts from various Ministries of Health and team clinicians. It felt so good to re-connect through this event and share our experiences with the pandemic and support one another through the common challenges we are all experiencing.

When we think of global health practitioners, we often picture doctors, nurses and others in clinical roles. But administrative roles are vital to the work. Can you talk about your work now, and how that ties into PIH’s mission?

Yes! The more I engage in this work, the more I see how operational support is vital and often overlooked. Community-based care consists of clinical care, of course, but at PIH we also focus on health systems strengthening.  The 5 S’s (staff, stuff, space, systems, and social support) cannot happen without input and collaboration from teams like Labs, Procurement, Monitoring & Evaluation, and Advocacy, just to name a few.

This month is Asian American Pacific Islander (AAPI) Heritage Month in the U.S. What does AAPI Month mean to you? Are there any ways you celebrate it?

That is a good question and something that continues to evolve with my identity. Growing up in Northern Virginia as a Korean American adoptee, I didn’t reflect on this much as I was fortunate to have a racially diverse group of peers. However, due to years of accumulated micro-aggressions and the recent hate crimes amid the pandemic, I have come to realize that I do strongly identify as AAPI and that is something to be celebrated. I haven’t traditionally engaged in anything specific to recognize AAPI heritage during the month of May, but I am practicing self-love and consciously appreciating being a member of this community and how that helps me understand the complex heterogeneity of our society.

Asian American history isn’t routinely taught in the U.S. education system, or the history that is taught is woefully inadequate. What do you wish more people understood about Asian American history? Any people or events you want to call our attention to?

Growing up, the only Asian American history I was taught in the classroom was a brief mention of the Japanese internment camps during World War II. But in college at the University of Washington, there was a hip hop group (The Blue Scholars) that had a tribute song to the remarkable civil rights activist, Yuri Kochiyama. Influenced by her family’s internment in the 1940s in California, she went on to advocate for the rights of Japanese-American internees and support for Malcolm X and the anti-war movement. In 2014, the White House honored her for dedicating her life “to the pursuit of social justice, not only for the Asian American and Pacific Islander (AAPI) community, but all communities of color.”

On a personal note, my own father was raised in the same California town as Kochiyama, at around the same time. The internment of Japanese Americans compared to my white family (who like many others in a place of racial privilege, found success in the postwar years) serves as a tragically stark comparison of the direct and downstream effects of institutional racism. This has helped me recognize the ways I have benefited from generations of white privilege (as an adoptee raised by white parents and grandparents), in my own family, and how that perpetuates further inequities and imbalance of power in society.

The global health field has historically been led by white men in North America and Western Europe, and white people hold more than 80% of leadership roles in the nonprofit industry. As an Asian American woman working in global health, do you have any advice for women of color looking to pursue a career in this field?

Don’t give in to the feelings of imposter syndrome and have confidence in yourself. It’s not easy, I know, but remember that you bring your unique perspective and background to the table and that holds incredible value. We cannot serve underrepresented communities without diverse perspectives.

For many of us, living through a global pandemic has warped our sense of time—it can feel like there’s too much and not enough. What has your working-from-home experience been like? And when you’re not working, what are you up to these days?

So true. For me, working-from-home has been an experience with all the feels. I appreciate the extra hours I have in my day to spend quality time with my family and, considering so many who have been out of work due to the pandemic, I am grateful to even be able to work-from-home. It doesn’t come without challenges though, which, for me is unplugging and “turning off” work-mode. I also miss my PIH coworkers, incredibly – it’s just not the same inquiring about their families or keeping in touch, virtually. It will be so nice to see smiles again and joke around, in-person. When not working, I try to spend as much time outside as possible. If indoors, I like to try new recipes in the kitchen, read, or knit something that I will most likely not finish.

In honor of Asian Pacific American Heritage Month (APAHM), Partners In Health (PIH) staff in the United States shared their favorite books, movies, songs, and podcasts that share the lives and experiences of the Asian American and Pacific Islander (AAPI) community. Their recommendations, below, highlight works that provide inspiration, historical context, and insight into the Asian American experience. Since 1992, May has been federally designated as APAHM and is a time to recognize and celebrate the history, culture, achievements, and contributions of the AAPI community—with whom we stand in solidarity at PIH.

When Partners In Health opened a new oxygen plant at a Lesotho hospital in December, with potential uses including support for the pandemic response, tuberculosis patients, and a few targeted health facilities, clinicians almost immediately made a decision: 

Keep it running, non-stop. 

As a devastating second wave of COVID-19 struck the southern Africa nation in January, just weeks after the plant was installed, oxygen production quickly switched from new luxury to urgent, vital necessity. Dr. Melino Ndayizigiye, executive director of PIH in Lesotho, said every hospital in the country has contacted PIH, known locally as Bo-mphato Litsebeletsong Tsa Bophelo, to request medical oxygen. Concentrated, high-purity medical oxygen is vital for patients struggling to breathe normally.

“We decided to operate the plant day and night,” Ndayizigiye said. “However…we couldn’t meet demand.” 

Day-and-night production has continued at the plant, a retrofitted shipping container on the campus of PIH-supported Botsabelo Hospital in Maseru, Lesotho’s capital. The plant produces several hundred liters of concentrated oxygen per day. For comparison, bedside oxygen concentrators—wall-mounted units placed beside hospital beds—can dispense about 10 liters of medical oxygen per minute. While some patients may need just 5 liters per minute, people with severe breathing difficulties can need much more, making even bedside concentrators not optimal for all patients, and making oxygen plants very necessary.

Ndayizigiye said he’s hoping to upgrade to boost production even further and supply oxygen to more health facilities, and ideally, add more oxygen plants in rural parts of mountainous Lesotho.

The situation reflects both the dire global shortages of medical oxygen and the lifesaving race—of supply chain teams, maintenance technicians, clinical staff, and global health leaders—to provide oxygen where it’s needed most. Devastating impacts of shortages are tragically playing out in India and other countries where COVID-19 is surging, outpacing medical capacity and infrastructure, and filling hospitals to overflowing.

“Gasping for air and not being able to breathe have become the norm for impoverished people around the world struggling with COVID-19, and that is unacceptable,” Dr. Joia Mukherjee, PIH’s chief medical officer, said at a recent webinar about strengthening global supplies of medical oxygen. 

Forrest Shroyer, associate director of facilities on PIH’s clinical operations team, said PIH has focused on bedside concentrators, buying and shipping hundreds of them over the past year to supply hospitals and health facilities in Lesotho, Malawi, Peru, Haiti, Liberia, and Sierra Leone. 

“We are working to move as much as we can, as fast as we can to respond to the pandemic, and to use this opportunity to strengthen health systems,” said Jesse Greenspan, PIH’s director of supply chain and logistics. 

Those shipments have faced enormous obstacles during the pandemic. Seyfu Abebe, PIH supply chain manager, said lockdowns and global surges in demand led to limited availability of COVID-19-related goods, especially for poor countries, and resulting high prices. National export bans, shipping woes and decreased flights also have snarled PIH’s supply chain, for everything from gloves and facemasks to oxygen plants and equipment. 

“The global supply chain was broken in so many ways,” Abebe said of the past year. 

Nonetheless, PIH made more than 700 international shipments—including all goods—between March 2020 and March 2021, up from about 400 annual shipments in non-pandemic years.

Oxygen Systems, Not Just Tanks

Country-specific challenges arose, as well. Shroyer said major manufacturers of oxygen concentrators don’t offer products for Peru, for example, because of the country’s electrical specifications. PIH supply teams have had to find other partnerships to support Socios En Salud, as PIH is known in Peru. 

“We were working on advocacy campaigns to try and pressure suppliers to see if they could make some for us,” Shroyer said. “We’ve really tried to push from every angle possible to get these concentrators to Peru.”

Meanwhile, oxygen demand in the country has been skyrocketing. Dr. Leonid Lecca, executive director of Socios En Salud, said in April that Peru’s consumption had reached 200 tons of oxygen—300% of levels before COVID-19—amid the nation’s second wave of the pandemic. 

Socios En Salud has made expanding the availability of medical oxygen a priority during its pandemic response. Lecca said that while “there is still a long road ahead of us to reduce the oxygen gap,” his team also is working on a new program to deliver oxygen directly to homes, to support COVID-19 patients receiving care in isolation.

Other signs of progress are emerging, as well—a PIH-ordered oxygen plant similar to Lesotho’s recently arrived in Malawi, where it’s been installed at a PIH-supported facility in rural Neno District.

And every new oxygen concentrator or plant is a long-term investment in the health system it serves, long beyond COVID-19. PIH buys recommended spare parts for every concentrator, while supporting maintenance and trained technicians around the world to keep the equipment running.

Because medical oxygen, of course, is about far more than COVID-19. Treatment of pneumonia, traumatic injuries and heart problems, for example, all require oxygen, as do safe childbirths and simple surgical procedures.

And because oxygen equipment and supplies must be tailored to their specific health facility, environment, and even climate—humidity in tropical regions, for example, can require additional ventilation and air dryers to maintain oxygen infrastructure—supplying oxygen is about far more than tanks and nozzles; it’s about building strong systems for its use.

Mukherjee noted that oxygen development in rural Liberia was rooted in the Ebola response more than five years ago, and since then, has served the country through outbreaks of measles and Lassa fever, as well. She noted that the key trifecta of saving lives—airway, breathing, and circulation (ABC)—makes oxygen a universal need.

“As we think about strengthening health systems, that ABC is always in our mind,” she said.

It’s in patients’ minds, too. Dr. Shada Rouhani, PIH senior adviser for clinical operations, said patients, of course, are not thinking about global supply chain disruptions or equipment maintenance when they arrive at a health facility. Having oxygen ready in that moment can be the difference between life and death.

“All they can think about it is, ‘I can’t breathe,’” Rouhani said. “For critical illness, time matters, and minutes matter.”

As we reflect on the violence against Asian Americans that has come to light in recent weeks, it’s crucial to understand historical context—including how that context affects the present, and how bold new action is required to change the future.

“There’s a lot of reasons why that [violence] is happening. I think one of them is a misunderstanding of who we are, and our important role in the history of this country as fellow Americans,” said Dr. Paul Park, a director at PIH and the son of Korean immigrants.

“We continue to be seen as the perpetual foreigners,” Park said of Asian American communities. “People don’t understand U.S. history, and our very deep role in the fabric of that history—instead, we’re just seen as these foreigners who are not American.”

Park, 39, is Partners In Health’s director of implementation for NCD Synergies, overseeing programs that care for people with non-communicable diseases such as insulin-dependent diabetes, sickle cell disease, cardiovascular disease, and more. He’s been with PIH for eight years, is an instructor at Harvard Medical School, and a faculty member in the division of global health equity at Brigham & Women’s Hospital in Boston. He also is a physician with the Mashpee Wampanoag Health Service Unit, where since 2017 he has practiced one or two days a week with the Indian Health Service in Mashpee, Mass. A Korean American, he was born and raised in Indiana after his parents emigrated to the U.S. in the 70’s from Taegu, South Korea.

As the U.S. celebrates Asian American and Pacific Islander Heritage Month, amid repeated hate-driven attacks against Asian Americans across the country and devastating COVID-19 surges in Asian countries such as India, Park noted that all of his work, whether in global or community health, is rooted in fighting inequity and intolerance.

“It’s not a coincidence that most of our patient populations are communities of color,” Park said. “To me, our work against health care disparities is a fight against racism.”

Asian Americans are the fastest-growing racial group in the U.S., numbering more than 23 million and tracing their roots to more than 20 countries, from East and Southeast Asia, to South and Central Asia, and West Asia. While some Asian Americans are economically well off, many live in poverty. Income inequality is growing faster among Asian Americans than any other racial group—reflective of a community that includes refugees from U.S. wars across Asia, as well as an influx of new immigrants who work low-wage jobs, often in dangerous conditions.

“When we talk about the idea of decolonizing global health, I do think that decolonizing the U.S. is part of that process,” he added. “Decolonizing the work we do abroad is not enough. I think there are elements of the colonization mindset everywhere.”

That mindset supports systemic policies and structures that pit communities of color against each other, Park said, relating racist public policies to divide-and-conquer tactics.

“By throwing scraps to different minority groups, we end up essentially fighting for those scraps, instead of all having an equal opportunity for forward progress, where the system is not set up to be primarily advantageous for white Americans,” he said.

Changing centuries of violence and structural racism requires conversations that not only unify communities of color, Park said, but also overturn cultural contexts—or myths—such as the “model minority myth,” which perpetuates the false narrative that AAPIs are universally successful due to, in part, their quiet, reserved nature. 

“Understanding that concept of ‘the first and second generation’ is very important,” Park said, describing his parents as part of a “first generation” who came to the U.S. with a cultural belief in working hard, keeping your head down, and providing for your family.

In other words, not “causing trouble,” so to speak, by opposing oppressive, racist policies and systems. 

Park said those beliefs debilitated political and social progress for “second generation” Asian Americans such as himself,  contributing to the stereotype that Asian Americans won’t create conflict and leading to the institutional abandonment of Asian American communities, including those that suffer from poverty, over-policing, and structural violence.

For example, less than 0.5% of charitable giving from foundations goes to Asian American organizations, despite the fact that some Asian American communities live in deep poverty, such as the Mongolian and Burmese communities, whose poverty rate of 25% is more than twice the national average.

“It’s up to our generation to course correct, and make noise, and show passion and fight against social injustices against us and other communities of color,” Park said.

That means stepping outside of comfort zones and engaging with people of diverse backgrounds and communities different from your own.

Park has been leading such conversations since he attended Indiana University, where he became the first chair of political advocacy for the university’s Asian American Association. Park attended IU from 2000-04, and now serves as president of its Asian Alumni Association.

He said conversations about racism and inequity must happen internally, within communities, as well.

“Like all communities, we are not perfect—we also have faced challenges around our relationships with other communities of color,” Park said. “I think that’s also something that we as the AAPI community need to discuss among ourselves.”

While his mother always told him to ignore racism, Park, who got married in October, said he plans to take a different approach, should his own family grow.

“You have to say something—otherwise my future kids are going to face the same problem,” he said. “You have to say something, be loud, be vocal. You have to push back."

Yesterday, the Biden Administration announced a $7.4 billion investment in a public health workforce, to be drawn from the American Rescue Plan Act recently passed by the United States Congress. This follows an earlier announcement of $250 million for community-based organizations, also drawn from the American Rescue Plan Act. 

Partners In Health (PIH) applauds the decision to invest in our critical public health and community health workforces while we continue to battle the COVID-19 pandemic and the underlying inequities in the U.S. health system through our U.S. Public Health Accompaniment Unit. PIH has been working and will continue to work with key partners to advance policies that will enable investment in new public health and community health jobs across the country.

This announcement couldn’t have come soon enough. Over the last decade, the nation has lost at least 38,000 public health jobs, while state and local public health budgets have dropped by 16% and 18% per capita, respectively.

Systemic under-funding since 1980 has slashed the state and local public health workforce from nearly 500,000 jobs to under 200,000 today. Especially hard hit are poor communities and communities of color, which have been continually passed over and neglected due to entrenched inequities. This undermines health in all communities. As a result, hospitalization rates of Black people in the U.S. due to COVID-19 are almost three times those of white people, while COVID-19 related death rates are twice that of white people.

The new public health jobs announced by the Biden administration make clear that there is a concerted priority to advance equity in the response to COVID-19 and beyond, reflected in the following key aspects of the plan:

Investing in Local and State Public Health

The administration is setting aside $3.4 billion to hire staff in state and local public health departments to further respond to COVID-19, and $500 million for the hiring of school nurses—critical members of a community-based health care response—who can offer vaccine information to parents and students as availability increases for younger people. These priorities fill critical gaps in public health and build toward a stronger infrastructure for years to come.

Investing in the Future and Greater Health Equity

The administration allocates $3 billion for modernizing the public health workforce and building toward better health equity beyond the pandemic. Funds will be distributed through a new grant program—designed by various federal, state, local, and territorial public health experts—aimed to support health departments in lower-income and under-resourced communities. This grant program will increase hiring of community health workers and provide an opportunity to continue in their role beyond COVID-19.

Elevating Community Health

The Biden administration is investing $250 million for community-based organizations to work with those hardest hit by COVID-19. Half of these funds are expected to reach programs by mid-June, with the other half in a future funding opportunity for smaller community based organizations. This funding is crucial for building a larger cadre of community-based workers and social support specialists, who help connect the most vulnerable individuals and families to basic resources like food, medicine, and housing assistance. These programs will help to address inequities by building capacity in communities with need and trust in vaccines; however, we hope to see these investments grow.

These community-based responses are essential to delivering on vaccine equity, the COVID-19 response, and stronger public health systems. PIH estimates that the U.S. needs to create more than 500,000 community health worker jobs alone to address underlying inequities. Community-based organizations have been pivotal in the work to combat COVID-19, and have developed  strategies to work side by side with officials to tackle COVID-19 and more. 

Diversity, Equity, and Jobs 

To best serve the communities that face the greatest inequities, PIH and partners have encouraged the federal government to recruit and hire from those same communities. This is critical because the workforce plays two distinct roles: a means of delivering services to communities, and a jobs program for communities grappling with the intersecting crises of unemployment and a disproportionate impact of COVID-19 illness and death.

Diversity and equity are a clear focus in the Biden administration’s workforce plans. These efforts include launching the Public Health AmeriCorps, which has the stated purpose of building a diverse pipeline for the public health workforce and providing direct service to communities across the country. The administration’s efforts also include recruiting and training public health professionals with backgrounds from minority serving institutions and universities, encouraging all grant awardees to hire from communities served, and a focus on recruiting from backgrounds that are underrepresented in public health professions.

Long-Term Goals

Too often, U.S. policies have undervalued and devalued the vital work of community health and public health workers, leaving them to earn below living wages. In a March 2021 letter to Department of Health and Human Services Secretary Xavier Becerra and Centers for Disease Control and Prevention Director Rochelle Walensky, U.S. senators call for workforce members to be well-compensated and hired from those communities hardest hit by COVID-19. We believe all public and community health jobs should be good jobs, backed by strong labor standards.

We recognize these funds from the American Rescue Plan are a down payment on what must be a broader, sustainable investment in our public health infrastructure and community-based workforce. Efforts in the American Jobs Plan, American Families Plan, and future priorities of the administration must build on these investments so we can create a more equitable system and prepare for the next pandemic. PIH and our partners look forward to the long-term project of making that aspiration a reality.

Sita Chandra has dreamed of working in global health for as long as she can remember. As the daughter of Indian immigrants who are physicians, she grew up hearing stories about her parents’ medical work both in the U.S. and globally, seeding her passion for global health at a young age. That passion has since led her to Partners In Health, where the North Carolina native has put her dreams into action as a development coordinator and, now, as a clinical operations associate.

We caught up with Chandra, who is currently based in her home state, as part of our series Working In Global Health, which spotlights PIH staff who have dedicated their careers to making a global impact. During our conversation, we chatted about what drew her to a career in global health, why we must decolonize global health, and what she’s been up to in her spare time—including her wildly popular coffee vlog and “the perfect drink for summer.”

You’ve been with PIH for two-plus years and have worn a couple different hats—starting as a development coordinator and then transitioning to clinical operations associate. How did you find PIH, and what makes you excited to work here? What have you learned through your roles?  

It is hard to believe it has been over two years! When I found PIH, I had just graduated from my master’s program and was excited to officially begin my career in public health. In the midst of searching for global health positions, I stumbled upon PIH’s website, and it was the mission of “we stay” that pulled me in.

What makes me excited to work here? It’s the people—it is always the people. From my team to our donors to our patients to our volunteers, I am continually reminded of the amazing community I get to be a part of, as we push forward the mission that every human deserves the right to quality health care. Through my roles in both Development and Clinical Operations, I’ve learned that we can only do this work well with the mutual understanding that it requires solidarity, trust, and supreme empathy.

What drew you to the global health field more generally? Was there a person, moment or experience that really crystallized your interest?

Growing up with parents who are physicians definitely shaped my interest in global health. My parents immigrated to the United States in the ‘80s and they’ve shared their unique perspectives as physicians practicing medicine both stateside and globally. Growing up, I always knew I’d pursue global health in some way. As a high school student, I got a glimpse of it in the summer of 2011, when I volunteered at the Casa Materna in the mountains of Calhuitz, Guatemala.

My classmates and I found out that a mother we had gotten to know was in labor with a breached baby. We were all outside the delivery room watching the doula, midwives, and community health workers going in and out of the room. It was a long, stressful night, until we heard the baby crying many hours later. Overwhelmed with emotion, we got to meet her the following morning and I remember all of us looking at this newborn as a beacon of hope. This experience stuck to my bones as I grew into adulthood. 

This month is Asian American and Pacific Islander Heritage Month (AAPI) in the U.S. The term “Asian American” has always been political—it was coined in the 1960s by Asian American activists in solidarity with the Black Power movement and all oppressed people of color in the U.S. and worldwide. But in the decades since, as it has entered the mainstream, the term hasn’t always been understood in its political context or used in an inclusive way. As a South Asian, what does this term mean to you? Do you feel that it captures your experience, or confines it?

First and foremost, I am proud to be an Asian American and as it has entered the mainstream, I’ve found that it isn’t used in an inclusive way. Whenever I identify myself as an Asian American, I am almost always met with “but you’re not Asian” because people often forget that Asian American includes Indian ancestry too. I believe this response is a consequence of microaggressions and the way Asian American experiences are portrayed by the media. For me, “Asian American” means capturing the experience that comes with being Asian AND American – two separate identities merged into one.

Second generation Asian Americans carry a very nuanced and complex experience when it comes to identity, language and a sense of belonging. I have experiences in the United States, the country I was born in, where I’ve been told I am not American enough, while also having similar experiences whenever I visit India and hear that I am not Indian enough. I, myself, know that I am Asian American and that is more than enough.

As global health practitioners in a U.S.-based nonprofit, we often talk about the importance of decolonizing global health. But global health leaders, disproportionately based in North America and Western Europe, often ignore Asian contributions to health and medicine, despite the fact that these approaches have existed for millennia. How do we make global health a truly global enterprise? Why is it important to de-center Western approaches to medicine and uplift approaches from Asia, Africa, Latin America and other non-Western contexts?

We need a balance and in order to achieve that balance, we have to create a space to welcome, listen to and deepen our understanding of Eastern medicine. I was raised with both Eastern and Western medicine, so it was normal for me to incorporate both, until I ventured out into the world and realized they weren’t commonly integrated. Western medicine focuses on reactive care and Eastern medicine focuses on preventative care – both are different, both are valuable and both deserve a place in global health. We have to de-center Western approaches to make room for the Eastern practices and perspectives. We can start with inviting experts in the field to share their knowledge and practices, whether that’s through webinars, social media or conferences. We have to make room because Eastern medicine deserves a larger place in the global health landscape.

The pandemic has disrupted daily life, including work routines, for millions. As a PIHer working from home, what has your experience been like? Can you tell us about your daily routine?

I’ve decided that I am an office person – I thrive off of being in the presence of other people’s energies. As a person with congenital bilateral hearing loss, the pandemic has challenged me tremendously, especially in the virtual office. I rely on lip reading, facial expressions and body language to carry me through conversations, but those resources have been lost due to the pandemic, whether the conversation is happening virtually or behind masks. I am grateful to work with colleagues who understand the resources and accommodations I need to do my job well. 

After my lease ended in Boston, I decided to spend a season at home in North Carolina with my family, and it has been incredibly special to have this time with them. My daily routine changes every day and I’d have to say it has been such a luxury to turn my southern childhood home into my office—the joys of more space in the South! I begin every morning with lemon water, a few minutes of meditation and a cup of coffee, before starting my workday. Though, it does get quiet, so one of the things I am excited for is the day we can safely gather around the lunch table in the PIH office’s commons and chat about the latest Netflix show we are binging or laugh until we cry over each other’s witty jokes. That is what I’m looking forward to.

And we hear you have a coffee vlog! What inspired you to start this? Any coffee concoctions we should try?  

Oh goodness, it is so wonderful to have the support of so many PIHers! It started off as a quarantine project to try and perfect my latte art and share it with my friends. Then I decided to share it with more people, in the hopes that I could get advice on how to better my latte craft. From there, I was having so much fun with it and continued to post new recipes, review oat milks, and learn different ways to make coffee. It’s been fun to collaborate with different coffee brands and make new friends who enjoy the art of coffee as much as I do. My newest coffee obsession is Vanilla Mint Espresso Soda by coffeewithmaggie. It has mint leaves, smoked vanilla syrup, 2 shots of espresso and sparking mineral water – it sounds bizarre, but it works and it is the perfect drink for summer!

Phebian Sondufu-Sowa’s shift at Koidu Government Hospital (KGH)—the only hospital in Kono District, Sierra Leone—technically ends at five o’clock. But on any given day, at any given time, she’s on call, ready for her phone to ring with a patient on the line.

“Sometimes, I’m here until eight or nine at night,” Sondufu-Sowa said. “Then, sometimes as soon as I reach home, a patient will call me, saying ‘Ma, I’m not feeling bright.’ And I have to rush back.”

Sondufu-Sowa occupies a singular role at the Partners In Health-supported hospital. As the nurse managing its adolescent and youth-friendly services (AYFS) clinic, she is often the only person young adult patients truly trust—not only at KGH, but in their lives as a whole. Usually, the phoning patient isn’t facing a physical crisis that any clinician could handle; more often, they’re in need of a sounding board, or a shoulder to cry on.

Since PIH and hospital staff established the clinic in May 2020, Sondufu-Sowa has spent her days providing medical care for 10- to 24-year-old patients’ most intimate health needs, and emotional support through their most pressing challenges—around relationships, school, poverty, and planning for the future.

Sierra Leone has one of the highest maternal mortality rates in the world—women face a 1 in 20 lifetime risk of dying in pregnancy or childbirth—and, relatedly, some of the world’s highest rates of teenage pregnancy, HIV, school dropout, and sexual- and gender-based violence. Specialized, comprehensive care for reproductive health and psychosocial wellbeing is essential—especially in Kono, one of the poorest regions of the country.

AYFS services are wide-ranging—from family planning, prenatal care, and care for sexually transmitted infections, to nutrition education, career planning, and counseling around healthy relationships. The clinic also serves as an access point for young people who need other hospital services, such as the mental health unit or PIH’s social support program.

Many patients—the vast majority of them young women—arrive at the clinic hesitantly, without much practice vocalizing their experiences around seemingly taboo, and unjustly gendered, topics such as sexual health, birth control, and intimate partner abuse. Nor do they want to be seen by any older relatives or neighbors.

The clinic—a small room attached to KGH’s maternity ward—was constructed with a separate entrance and waiting area to promote patient privacy. But patients’ comfort truly relies on Sondufu-Sowa.

Her overarching tactic is meeting patients where they are—even when that entails a late night phone call and clinic visit.

“Some are really, really nervous when they come in. I want to take nerves away, so I counsel them, encourage them, ask how they are doing. I’ll be at home, they will call me and say, ‘I’m coming to the clinic,’ and then we sit here and talk, talk, talk,” Sondufu-Sowa said. “And then, they are free. They’ve opened up.”

A Purpose to Fulfill

During those conversations, Sondufu-Sowa isn’t afraid to challenge her patients—to expand their ideas of what is possible for themselves and their futures. She advocates for family planning; encourages every patient to remain in school and strive to attend university; and consistently tells her female patients to bring their male partners on their next visit, in order to expand the clinic’s reach and in the spirit of normalizing sexual health as a shared responsibility.

“You have a purpose to fulfill,” is her common refrain with patients. “You have good things to offer to fulfill the world. Don’t stop here. Go further.”

Her advice is considered radical by many patients, and is sometimes hard to embrace when living in a patriarchal context in which parents or elder relatives commonly forbid family planning; limited money to pay school fees is often reserved for sons; and many women’s only feasible pathway to basic survival is—somewhat ironically, given the persistent dangers of giving birth within a weak heath system—through pregnancy and marriage. Ultimately, Sondufu-Sowa’s goal is to let her patients be in charge of their own health and life decisions—by withholding judgment, and keeping them talking and visiting the clinic.

“I recently had a 15-year-old come in for family planning, and then a few months later, she called me to meet at the clinic at night to tell me, ‘I want to remove my implant. I want to get pregnant because I don’t want my boyfriend to get married to another.’ I talked to her, prepared food for her, tried to explain her other options,” Sondufu-Sowa recalled.

But the patient’s decision was final; and Sondufu-Sowa respected her wishes.

“So,” she continued, “the next week we removed the implant. And I told her that if she got pregnant, she should come to AYFS. And she was happy.”

Offering this kind of nonjudgmental care comes naturally to Sondufu-Sowa, who decided on nursing as a career during her own adolescence.

“For my mother, when I was growing up, even providing our daily bread was a big issue,” Sondufu-Sowa said. “At one time, she got sick, and we rushed her to the hospital. Everything was money—for the doctor to see my mother, for treatment. She was admitted for two days. We couldn’t even think about paying hospital bills. I’m the elder daughter, and was asking God, ‘What can I do?’ But there was a particular nurse who cared for my mother. I told her, ‘Auntie, we don’t have money now.’ And she said, ‘Okay.’ She was a mentor, she stood by us, she provided everything for us. She was practicing real nursing.”

Sondufu-Sowa’s mother recovered—and instantly heard about her daughter’s determination to become a nurse.

“I said to her, ‘The disadvantage is too much. There needs to be somebody in the hospital who can interact with people,’” Sondufu-Sowa said.

Support, Counseling, Encouragement

Sondufu-Sowa now is serving as the nurse she long hoped and endeavored to be: not just a medical provider, but also a friend, confidant, and advocate for some of the most at-risk, marginalized patients a hospital sees. The AYFS clinic is promoted in classrooms and afterschool clubs throughout Kono District, with KGH staff presenting on the services available and engaging students. But it’s Sondufu-Sowa’s approach to caregiving that has steadily grown the young clinic, with 737 patients visiting for care in the first three months of 2021—up from 377 in the three months previous. In total, the clinic has thus far served 1,427 young adults in Kono.

One of those patients is Isatu Mondeh, 20, who is due to deliver her first child in May. She already is spreading news about the services.

“I tell my friends who are pregnant to come to the hospital, and I tell every teenager around that there are family planning services here,” Mondeh said.

Mondeh first visited KGH for prenatal care when she discovered she was pregnant—and at her first appointment, also discovered she was living with HIV. Given her age, clinicians referred her to the AYFS clinic.

“When I met Isatu, she was wasting away, and she was emotionally down and avoiding her friends,” Sondufu-Sowa recalled. “I encouraged her, saying, ‘All is not lost. We have seen many people living long lives with this illness. It only depends on you taking your medication every day.’”

She supported Mondeh through the process of enrolling in free antiretroviral therapy, and enrolled her in social support programming: for nutrition, to ensure she could tolerate her new daily medication regimen and regain her health, especially as a pregnant woman; and for transportation, to ensure distance from the clinic or the cost of a motorbike would not prevent her from attending her prenatal appointments.

“The food packages have helped me a lot,” Mondeh said. “I have enough to eat with my medication, and have money left over to spend on other things.”

“I hope for a healthy baby—and I would prefer to have a girl,” she continued, smiling. “I’m nervous, but excited.”

During Mondeh’s regular visits to the clinic, Sondufu-Sowa is an outlet for these feelings.

“I’ve been talking to her and encouraging her since the day I met her,” Sondufu-Sowa said. “Support, counseling, encouragement...that is what young people need from this place.”

A Three-Generation Bond

This level of bond is commonplace at the clinic. For 20-year-old Zainab Sesay, all hope had been lost after she gave birth to her second child prematurely—at 24 weeks, her daughter weighed less than two pounds. Sesay then struggled to care for her at home, living in extreme poverty. Though her daughter had received care at KGH’s special care baby unit and been discharged healthy, Sesay avoided naming her.

“I did not think she would survive,” Sesay said. “It was scary.”

The turning point came, she said, “when I met Phebian.”

Knowing the dire circumstances to which Sesay would return home—kicked out by her family, receiving no support from her children’s father, food insecure, and on the brink of eviction—a community health officer at KGH recommended Sondufu-Sowa reach out to the young mother.

Sesay readily accepted Sondufu-Sowa’s invitation to the clinic and, on behalf of her and her baby’s health, confided in the nurse.

“She told me she didn’t have enough food and wasn’t producing breast milk,” Sondufu-Sowa recalled. “She was giving her baby water.”

So began a partnership between the two women. Sondufu-Sowa immediately enrolled Sesay in social support similar to Mondeh, with PIH providing her food packages and transportation stipends, as well as cash assistance and a postnatal package consisting of items like reusable diapers, soap, and lotion.

That tangible support was supplemented, of course, by what Sondufu-Sowa refers to as “passionate care”—a listening ear and constant encouragement.

“She was really emotionally down,” Sondufu-Sowa said. “She needed someone she could talk to.”

Sesay visited the clinic multiple times a week to spend time with Sondufu-Sowa, as her and her baby’s physical health gradually improved. She soon decided on a name for her daughter: Phebian.

Today, with young Phebian now seven months old, the trio still see each other several times a week. Sondufu-Sowa continues to monitor their health, including family planning; Sesay opted for an implant. And Sondufu-Sowa is serving as an advocate for Sesay as the two prepare to speak with her family to let her return home.

The hours, it sometimes seems, are never-ending. But for Sondufu-Sowa, there’s no choice but to answer her calling.

“The other nurses at the hospital say, ‘Ah, Phebian, I pity you,’” she said. “I say, ‘Sister, this is my job. I have to stand by my patients.’”

In August 2014, Dr. Mohamed Bailor Barrie got a phone call from Partners In Health Co-founder Dr. Paul Farmer—and immediately began dancing.

“Paul called me and said PIH made a commitment to come to Sierra Leone. I started dancing through the whole house,” Barrie recalled.

Barrie had long envisioned PIH in his home country. Years prior, when starting his own clinic for the rural poor, he read about the organization in Tracy Kidder’s Mountains Beyond Mountains and got in touch with Farmer and Dr. Joia Mukherjee, PIH’s chief medical officer, for technical guidance. He’d kept in contact since then, always advocating for the organization to work in Sierra Leone, an impoverished country where health outcomes are among the worst in the world and life expectancy is a mere 54 years.

“I had it in the back of my mind that if I was ever able to bring PIH to Sierra Leone, I would be the happiest man,” Barrie said. “They think about health care differently, and see patients and poor people differently—holistically, and through an eye of social justice.”

The good news was coming at a painful time. West Africa was at the height of history’s worst Ebola outbreak, and the government of Sierra Leone was looking for partners to help quell the virus as deaths rose, both from Ebola itself and disruptions to health care in general. Still, Barrie was full of hope visualizing the future of PIH Sierra Leone.

“I couldn’t sleep that night,” Barrie said, “imagining what we would do, and thinking, ‘Are we going to create an impact? A huge impact?’”

Today, Barrie continues to ask these questions—in a new capacity. Previously PIH Sierra Leone’s strategic advisor, Barrie stepped into the role of executive director in May—fulfilling a dream decades in the making.

A Dream Deferred, and Reignited

Growing up in Makeni, a three-hour dive from the capital city of Freetown, one of Barrie’s heroes was a nurse who lived in his neighborhood, whose home everyone visited for care. Admiring this clinician from a young age, Barrie knew he wanted to be a physician.

“I started playing doctor as a kid,” Barrie said. “I would go to the bush, pick different seeds, put them in a cup as pills, and have honey and syrups. On Saturdays and Sundays, the kids in the neighborhood would come with their dolls and I would pretend to treat them. That's how I spent my childhood. Every weekend I would do my clinic and see patients.”

His dream seemed unlikely to come true, however, as Sierra Leone had no medical school. The only option for the country’s aspiring doctors was to study abroad—an impossibly expensive pathway.

“My father was a tailor and made less than one dollar a day,” Barrie said. “I had one meal a day, and my brother and I had to sell things—cigarettes, candy, roast meat, kerosene—to support our education. We’d go to a village seven miles away to get mangoes and to the swamp to get leaves to sell at the market, so that at least we could get something to eat in the morning.”

Barrie planned instead on following in his older brother’s footsteps and studying engineering. But when Sierra Leone’s medical school opened in Freetown, and he learned a national scholarship was available to the top two students in the country, his dream was reignited.

“I studied hard—because that was my hope for becoming a doctor. Fortunately, I was the second best student. And that took me to medical school,” Barrie said.

Of course, tuition wasn’t the only expense to worry about. The costs of food, housing, transportation, and school necessities like textbooks were not covered in Barrie’s scholarship.

What’s more, Sierra Leone was in its sixth year of civil war. Just as Barrie began medical school, the Revolutionary United Front attacked Freetown and held it under siege for nine months.

Barrie coped. He took refuge in Guinea during the coup, staying safe but prolonging his education. Upon returning to Sierra Leone, he lived with a friend’s family, eliminating the cost of rent but, with the cost of transportation as another barrier, walking 14 miles to and from school each day. And he relied on friends—and a deep well of patience—to access textbooks.

“On weekends, I would borrow textbooks from my friends and hand copy them. Before each semester, I’d have all of the books handwritten,” Barrie explained.

“At some point,” he continued, “I nearly gave up. I wanted to leave school and work with my uncle at his pharmacy. But I had the scholarship and friends who were very supportive, and my brother went to the United States and started sending me money. He bought me my first textbook in my fifth year. Then, things started changing.”

With this new cushion of basic social support, in 2004, Barrie achieved his lifelong goal: He graduated medical school and was officially a doctor.

“What Can I Do To Help?”

But as a brand new physician, working at Sierra Leone’s public children’s hospital, Barrie quickly found that the reality of practicing medicine did not match his expectations from his make-believe clinic. All aspects of health care had a fee attached, making it inaccessible to his patients.

“One day,” Barrie recalled, “a woman brought her sick child into the hospital. I looked at the kid, sent him to the lab, and prescribed the drugs for his diagnosis, malaria. Without thinking about: ‘Can this mother afford this?’”

“She couldn’t,” he continued. “I gave her the prescription not knowing she had paid our consultation fee, paid for the lab test, and all she had was finished. She came back three days later with her child convulsing; he had developed severe malaria in the time she was trying to get the money together to buy the medication.”

That patient, Barrie said, represented a personal turning point.

“I went home and thought: ‘The health system is deplorable. What can I do to help?’” he said. “I made the determination that day to start a clinic to provide free health care to poor people.”

Barrie’s initial plan was to work in the United States as a doctor, save money, and return home to begin his clinic. But then he was connected to Dan Kelly, an American medical student doing a global health fellowship in Sierra Leone.

The two began talking—about “health and poverty and social justice”—and easily found common ground in Barrie’s goal to provide free health care to marginalized populations. Together, they embarked on a tour of Sierra Leone’s amputee camps, scattered across the country to resettle displaced Sierra Leoneans whose limbs had been chopped off during the horrific, 11-year civil war.

At all of the resettlements, mistrust was palpable as Barrie and Kelly tried to conduct interviews.

“They did not want to talk to us,” Barrie said, “because they said NGOs had gone there so many times to interview them, show them on CNN, then leave without doing anything.”

But people soon opened up—all with the same needs.

“One hundred percent of people said what they needed was food, education for their children, and health care,” Barrie said.

“Let’s Just Start”

For Barrie, nowhere was this need more acute than in Kono District, a rural region in the country’s far east, bordering Guinea. Home to West Africa’s largest diamond mine, Kono had been, in Barrie’s mind, “the Europe of Sierra Leone.” But its natural riches made it a massive target in the civil war; four years after the conflict’s end, in 2006, Barrie was shocked to find that “everything looked like the war had just finished.”

“I told Dan, ‘This is the place we should work. Of all the districts we have visited, this is the worst district,’” Barrie said. “I hadn’t even seen the hospital yet. But just standing on the main road, I could see and feel how health care would be a huge problem in a place like this.”

The two established Wellbody Clinic the following month, as a source of free health care for Kono’s amputees. What started as a one weekend per month mobile clinic seeing 50 patients a day rapidly grew to 200 patients a day within a couple months. Within the year, with funding from the Kelly family, Wellbody was constructed as a permanent clinic on the rural outskirts of Koidu, Kono’s capital, and its first staff members were hired.

Primary care was soon extended, for free, to all patients. And health services eventually expanded to include a community health worker program (with guidance from PIH) for patients living with HIV, the training of traditional birth attendants to recognize labor complications and refer women to health facilities, and the construction of a maternity unit.

Today, Wellbody is recognized as one of the best health care facilities in Sierra Leone; between 2016 and 2020, it saw zero maternal deaths. It is supported by PIH alongside five other rural clinics and Koidu Government Hospital, now considered the best public hospital in the country—in the place Barrie once deemed the worst for health care.

“Honestly, it’s overwhelming,” Barrie said. “We used to have one building; now I look around and there’s a whole campus and a whole health system. We started Wellbody not knowing where it would head. We didn’t even have money for a full year—but we said, ‘Let’s just start.’”

A New Narrative

With Barrie’s facilitation, this same spirit of optimistic urgency characterized PIH’s entrance into Sierra Leone, as the organization began fighting Ebola and investing in long-term health system strengthening.

“Bailor is an engine of positivity,” said Jon Lascher, PIH Sierra Leone’s former executive director, from whom Barrie is taking the reins. “During the most difficult days of the Ebola outbreak, Bailor was a source of energy and inspiration to everyone on the team. And how could you not feel motivated after knowing Bailor’s story?”

Partners In Health Chief Executive Officer Sheila Davis echoed this sentiment.

“I met Bailor in 2014 during the Ebola outbreak and immediately was drawn to him as a thoughtful, passionate and strategic leader,” Davis said. “From day one, Bailor was thinking about what was best for the people of Sierra Leone; he has never deviated from his goal to build health systems that ensure people have long term access to quality care.”

Barrie not only advised Lascher and the organization as it has expanded its footprint in Sierra Leone, but also led a number of its emergency responses alongside the government: from designing PIH’s Ebola strategy, to implementing a historic cholera vaccination campaign, to training Sierra Leone’s national force of COVID-19 contact tracers.

“Bailor is generous and patient, and that is what has made him such a great mentor and guide to me as we built the organization together nearly seven years ago,” Lascher said.

But as he steps into the role of executive director, Barrie said he’s now the one looking for advice.

“I want to listen, and to lead as a servant rather than like a boss,” he said. “Be it the cleaner, the nurse, the program director—I want to listen and learn from my teams, to face challenges and find solutions together.”

For all of his passion for PIH, ultimately Barrie’s longstanding leadership is about something much larger.

“For me, it’s not about Wellbody, or PIH, or any organization,” Barrie said. “It’s about the people of this country, and seeing a health care system we can be proud of, where nobody dies a preventable death.”

And, he said, it’s about rewriting Sierra Leone’s narrative.

“I think Sierra Leone is viewed as a very corrupt country, somewhere it’s not possible to do good work. But it’s not in the making of this country. It’s a history of slavery and colonialism.

“Sierra Leoneans can do good work,” he continued. “But most of us are always engaging our brains to think about survival. How do you think about development and innovation when your stomach is empty?”

The problems may seem complicated, but the answer, Barrie said, is simple.

“We need to care for people.”

Partners In Health’s mission to radically reduce global maternal mortality has entered a new chapter with the groundbreaking of the Maternal Center of Excellence (MCOE)—a state-of-the-art teaching hospital in Kono, Sierra Leone, that will not only provide a new level of health care to Sierra Leonean women and families, but also set new standards for what’s possible in women and children’s health around the world.

Leaders of PIH and the governments of Kono District and Sierra Leone gathered April 23 on the facility’s future grounds to usher in and celebrate the MCOE’s construction phase, after nearly four years of planning the facility.

Speakers included PIH Co-founder and Chief Strategist Dr. Paul Farmer and Sierra Leone Minister of Health Dr. Austin Demby, who shared a personal connection to the project.

“My daughters helped fundraise for the MCOE, collecting a little bit of money out in their neighborhood,” he said. “I can’t wait to come home and tell them their work is helping build a 166-bed hospital, and that the people of Kono and of Sierra Leone say thank you.”

Attendees at the groundbreaking—an occasion years in the making—celebrated much more than a building, as the MCOE represents overdue progress toward feminist health care in Kono, across Sierra Leone, and globally. Here are some of our favorite photos from the event.

Virtual Groundbreaking

With the safety of travel still in question amid COVID-19, PIH and supporters of the Maternal Center of Excellence gathered for a virtual groundbreaking ceremony, hosted on YouTube by longtime project partners John Green, Sarah Green (not shown in screenshot), and Hank Green. PIH Sierra Leone leaders Isata Dumbuya, Jon Lascher, and Dr. Bailor Barrie told the Greens all about the event, and answered viewers’ questions about the MCOE. And with a cheers to the momentous milestone, the group reflected on all that’s left to accomplish in Sierra Leone.

“We started this project wo years ago talking about the importance of health care systems and how we often don’t think systematically when it comes to health care interventions, and that has resulted in lots of these vertical interventions that haven’t strengthened health systems in the long term,” John Green said. “This is an attempt to take a different way, to help fund a health care system in an ongoing way, and to see a stronger health care system in Kono. …If we can make the case in Kono, we can also make the case that we shouldn’t accept weak health systems anywhere in the world, and we don’t have to.”

In a sunlit room in Carabayllo, a woman grasps a strand of yarn and slips one of her needles through it. Between the needles is more than the tiny sweater she’s knitting. Wound up in the yarn are years of hopes and dreams, and not just for her own future.

The woman is one of several mothers who are part of Wawa Pacha, a knitting cooperative for new and expectant mothers organized by Socios En Salud, as Partners In Health is known in Peru.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis in Carabayllo, an impoverished district about 20 miles north of Lima. In the years since, it has expanded its programs throughout the district, providing a range of health services and social support for the mothers, children, and families of Carabayllo’s hillside communities.

Wawa Pacha is one of those programs. From sweaters to blankets to beanies, the co-op has many products, but one mission: to help mothers earn income to keep their families healthy. It’s a mission that the co-op has called “knitting knots of love.”

Knitting Knots of Love

When Diana Hernández joined Wawa Pacha, she had never knitted before. The 34-year-old from La Flor started the classes when she was six months pregnant, with three kids at home, and she had never threaded a needle in her life.

In just a few months, she was making clothes for her children. And she didn’t stop there. Among her creations are dresses, pants, sweaters, and toys.

“Since I learned to knit, I consider it to be an art,” Hernández says. “Now I consider myself an artist.”

That artistry has paid off in ways she wasn’t expecting. She estimates that she’s sold as many as 100 products since she took up knitting—funds that she has used to put food on the table and keep her family healthy.

Although women are essential to Peru’s economy, they are underpaid and make up the majority of the population living in extreme poverty. In communities such as La Flor, women not only face physical and mental health issues, domestic violence and food insecurity, but also the fear of not knowing when or where their next paycheck will come.

Helping women like Hernández generate income has been one of Wawa Pacha’s main goals since it began as a pilot project in 2017, as Socios En Salud was expanding its maternal health services in Carabayllo.

Wawa Pacha began with 15 mothers, all from Carabayllo’s hillside communities. Each week, the women would gather for knitting classes, where they learned to make baby clothes, accessories and toys. Then, they sold those products online and at local craft fairs.

By 2019, Wawa Pacha was incorporated into Socios En Salud's maternal and child health program and achieved its highest rate of production and sales of baby clothes yet, in partnership with the La Flor y Su Majestad Hiroito Health Center, where spaces were set up to create and sell the products.

The results were promising, especially in a district where nearly one in four families lives in poverty, and every last dollar counts.

Between folds of fabric, the future began to take shape, one stitch at a time.

More Than A Business

In the years since, Wawa Pacha has grown into an established cooperative. While membership has fluctuated during the pandemic, currently hovering around eight women, the co-op has become a space where new and expectant mothers can develop their knitting skills, sell products, and learn the basics of entrepreneurship—all on their own schedule.

“This project allows us to generate income without disregarding the health of our babies,” says Elvir Dominguez Soto, a 37-year-old mother in La Flor. “It’s difficult to keep a fixed work schedule when you have a baby in its first months of life.”

The women manage their own schedules and coordinate group meetings via text, giving them autonomy and control over their money and how they earn it.

And they’ve grown their business skills, too. The co-op advertises its assortment of handmade products on social media and in glossy online catalogs. And it ships the products across Lima, delivering dresses, pants, dolls and more directly to customers’ doors.

But Wawa Pacha has always been more than a business endeavor.

“We support each other,” says Soto. “We work as a team.”

Soto has been part of Wawa Pacha since the beginning. The co-op has been a source of community and support for the mother of three, who wakes up at 7 every morning to check on her baby.

The past year has been immensely difficult. Just as Soto found out she was pregnant with her third child, her husband lost his job and got sick. As health and financial concerns burdened her family, Wawa Pacha—and its built-in network of peer-to-peer support—was a lifeline, as well as Socios En Salud’s mental health care, nutritional support and other health services that she and her family accessed.

“The maternal and child care through Socios En Salud has helped answer my questions, which makes me feel more at ease,” says Soto, whose son was delivered via cesarean section and has since been healthy.

Mental health support is crucial for women at all stages of pregnancy. Globally, mental health conditions like depression affect as many as 10% of pregnant women and 13% of women who have just given birth, according to the World Health Organization. In developing countries, those numbers are even higher, affecting 15.6% of women during pregnancy and 19.8% of women after childbirth. As many as 22% of the pregnant women in Wawa Pacha suffer from depression and receive mental health support from Socios En Salud.

At each meeting, the women of Wawa Pacha share stories, laughter, and tears. They are mothers, new and seasoned, and each gathering is an opportunity to exchange far more than yarn and needles.

Their knitting skills have improved, too.

It used to take the women seven days to make just one product, because they had to look after their newborns, Hernández recalls. But nowadays, they can make the products much faster. She’s especially proud of a toy llama she made in just one day—an accomplishment she couldn’t have imagined a few years ago.

“Since I started to knit clothes for my baby, I haven’t stopped,” says Hernández. “When I finish a product, I feel happy and I keep doing more, because each one is better than the last. Knitting and Wawa Pacha gives me a feeling of peace.”

In honor of National Nurses Week, the following essay was co-authored by Partners In Health CEO Dr. Sheila Davis; Cory McMahon, deputy chief nursing officer; and Judy Khanyola, chair of nursing and midwifery at the University of Global Health Equity in Rwanda.

As individuals, as communities, and as a society, this past year has forced us to reflect on many things with new perspective—not least of which the importance of nursing globally. COVID-19 brought into sharp focus the critical role nurses have played in confronting this pandemic.

Think of the array of images shown on a daily basis. Nurses held their patients’ hands as they took their last breath, isolated from friends and family. Nurses helped the mother in labor deliver her baby safely. Nurses gave chemotherapy to grateful patients, because cancer does not pause for COVID-19. Nurses visited patients’ homes to ensure they received essential care, linking them to social services and referring them to hospitals when needed. Nurses managed with makeshift personal protective equipment when there was not enough at hospitals and clinics.

Always, nurses were—and are—the first to jump in, giving themselves wholeheartedly during a very challenging and uncertain time.

COVID-19 has wreaked havoc on our health care systems across the world, demonstrating our interconnectedness, exacerbating health inequities, and giving visibility to the essential role of nurses. The nursing workforce is the world’s largest occupation in the health sector—at 27.9 million strong and 59% of health personnel. Nurses are essential to delivering on the promise of universal health care, as they provide an overwhelming 90% of health services globally.  

At Partners In Health, 50% of the clinical workforce are nurses and midwives. Nearly 90% of our more than 1,200 nursing and midwifery staff are female. They are leaders and decision-makers, patient advocates and care providers, cherished colleagues and good friends. They are there when disaster strikes, and they are there for life’s everyday emergencies.

Early on in the pandemic, nurses were deeply involved in assessing and putting into place infection prevention and control measures and readying facilities and systems to care for an exponential increase in patients. For more than a year, they have been caring for the critically ill, working in uncertain conditions against a relatively unknown virus, all while lacking essential PPE and putting their own and their families’ lives at risk to care for others. Meanwhile, nurses have remained trusted members of their communities, often serving as the bridges between patients and health care systems.

As we enter this next phase of the pandemic, nurses are additionally being asked to take on massive global vaccination efforts. Rwanda exemplifies the lift required of nurses in that effort. The country plans to vaccinate a third of the population in 2021 and reach 60% by the end of next year. Within three weeks of the first vaccine’s arrival in Rwanda, more than 348,000 people had received their first dose. The majority of those vaccinations was administered by nurses.

By 2030, it is estimated that there will be a global gap of 5.7 million nurses. That number was arrived at pre-pandemic—before nurses suffered what should have been an unbearable level of personal and professional stress and burnout—and is likely now much higher.

Despite its challenges, nursing has always been a profession that is united; we rise together and support each other for the betterment of our patients. For us, one of the highlights of this past year has been watching PIH nurses and other health care professionals from Liberia, Rwanda, Haiti, Lesotho, Sierra Leone, Malawi, Mexico, Peru, and the United States learn from each other and engage in a meaningful exchange of ideas, successes, and challenges. This pandemic has helped us, once again, intimately understand the interconnectedness of our work. And that’s why we must continue to fight for the rapid and equitable global rollout of COVID-19 vaccines, because no one is safe, until everyone is safe.

We know our most powerful pandemic preparedness efforts are to educate, employ, and invest in nurses as essential care providers within health systems. This means ensuring nurses receive a quality education, are fairly compensated, have career pathways, and are able to practice to the full extent of their licensure. Nurses must also serve as critical members of decision-making teams, ensuring patients’ concerns remain at the center of care.

Nurses have been essential to quality care from the early days of this pandemic, stayed steady—though strained—through surge after surge, and remained standing in solidarity with each other and their patients. Let’s remember, when these long days are over and we reach a new normal, that nurses are more than first responders in times of emergency; they are natural leaders who, regardless of conditions, get the job done.

In Mexico, there are 15,000 traditional midwives, 100 professional midwives and 16,684 graduates in Nursing and Obstetrics, according to 2016 data from the Institute of Public Health. But for many, midwifery is more than just a job.

For many years, midwifery in Mexico has been understood as a gift that some women are born with and a source of national pride.

"Midwifery is a cultural heritage, or at least it should be considered so; the knowledge midwives have is incredible, it's almost like doing magic" says Adriana Fabián, a 22-year-old professional midwife from Oaxaca, who is currently doing her social service year with Compañeros En Salud.

Midwives are essential to the work of Casa Materna, a maternal health center that Partners In Health, known locally as Compañeros En Salud, has supported since 2017.  There, midwives help women before, during and after delivery, providing dignified and culturally competent care.

‘Every woman is my teacher’

Midwifery wasn’t always the path Fabián saw for herself. But after studying with a traditional midwife in Michoacán, she began to see a future for herself as a midwife. After graduating from university, she decided to do her mandatory year of social service with Compañeros En Salud through its pasante program for first-year clinicians, inspired by Casa Materna and its model of respectful maternity care.

It was there, in Casa Materna, that Fabián began to see the differences in how women in labor were treated by midwives, who took into account the women’s preferences and comfort, as opposed to hospitals, where women would sometimes suffer from obstetric violence and over-medication.

At Casa Materna, midwives work alongside nurses and doctors, combining traditional and modern forms of care for women at all stages of pregnancy in Chiapas. While modern care includes things like medications and facility-based treatment, traditional care includes abdominal massages and allowing women to choose the birthing position they feel most comfortable in.

Since it opened in 2017, Casa Materna has helped more than 360 women give birth in a state with one of Mexico’s highest maternal mortality rates.

As a midwife pasante, it didn't take Fabián long to recognize the intimate and personal bond that traditional and professional midwives build with women in the birthing process. It’s a bond that she, too, has felt. She learns something new from each woman she cares for.

"Every woman is my teacher," she says.

Delivering a baby requires a deep connection between the caregiver and the mother. It is a bond that often cannot be explained in words. But, as Fabián and other midwives know, it is vital that caregivers understand the vulnerability that women in childbirth are experiencing and to express unconditional care and support.

Midwives have been crucial to the fight against COVID-19. During June and July, the most critical period of the COVID-19 pandemic in Mexico, many traditional and professional midwives who had been on hiatus returned to work to deliver babies. As hospitals and clinics closed across the country, many women became interested in home births, and midwives were there to answer the call.

Empathy that nurtures

Midwives have been central to shaping maternal care in Mexico, from those who have opened their doors to women in labor for centuries to those who have, in recent decades, transformed the work to a professional level.

Despite their cultural significance, midwives have often lacked support in Mexico’s health system—a trend that has only intensified in recent decades. There are fewer and fewer midwives, they are less recognized, and they face more barriers to professional development than doctors and nurses, as more women shun traditional medicine in favor of a hospital.

Fabián recalls that some of her classmates at midwifery school were verbally threatened by clinical staff, worried that midwives were taking jobs and money away from their institutions. In some cases, these midwives were forced to stop working and look for new opportunities. Fabián has faced similar challenges herself.

"Sometimes when the women I am attending find out that I am a midwife they are surprised because I am so young," she says. "Most of the recognized traditional midwives are around 50 years old."

But despite these barriers, midwives continue to be a vital force in Mexico’s health system and in the care that Compañeros En Salud provides, drawing on ancestral tradition to usher in new life, as they have done for centuries.

Fabián is hopeful that one day midwives will receive the level of support and recognition they deserve.

"What I like most about being with Partners In Health is this model of respectful childbirth at Casa Materna. Women are in control of choosing the most comfortable way to give birth,” says Fabián. "To change the world, you have to change the way we are born."

Update (May 5, 2021): Pres. Joseph R. Biden’s administration announced their support for the COVID-19 TRIPS waiver. "The Administration's aim is to get as many safe and effective vaccines to as many people as fast as possible," according to a statement from the Office of the United States Trade Representative.

To end the COVID-19 pandemic, Pres. Joseph R. Biden’s administration must support the TRIPS waiver.  

The Trade-Related Aspects of Intellectual Property, or TRIPS, waiver is a way to temporarily release patent rights of COVID-19 vaccines and the first step in allowing them to be more widely produced and distributed throughout the globe. This move is critical to ensure that low-income countries, including ones where Partners In Health (PIH) works, have equitable access to vaccines.   

"For generations, the status quo has meant that lifesaving vaccines and drugs reach impoverished countries years or decades after rich ones. It's time for us to give the whole world a fighting chance,” says Justin Mendoza, PIH’s U.S. advocacy manager.  

The provisions in patent law serve a purpose and can be waived during a national emergency, Dr. Joia Mukherjee, PIH’s chief medical officer, explains in an article published by WBUR. In April 2021, more than two million individuals—including politicians, labor, public health, and civil society leaders—signed a petition delivered to Biden, calling for support of the TRIPS waiver that was originally proposed by India and South Africa to the World Trade Organization (WTO) in October 2020. In addition to PIH, many other health and health rights NGOs have supported the TRIPS waiver, including Doctors Without Borders, Human Rights Watch, and Oxfam International, according to The New York Times.  

The United States has yet to commit. 

However, during the WTO meeting on May 5, Biden has a chance to correct that and support the TRIPS waiver as one key step toward vaccine equity. We urge him to do so. 

In much of the world, contact tracers pick up the phone. But in places like Chiapas, Mexico, they knock on doors.

That’s because phone and internet service are hard to come by in Mexico’s southernmost state, where more than 75% of the population lives in poverty. That makes contact tracing a complex and challenging process—but not impossible.

In fact, new research published in The Lancet Global Health and presented in the Consortium of Universities for Global Health's 12th Annual Global Health Conference as a poster in March shows how Partners In Health supported hundreds of people in Chiapas with contact tracing, medical care, and essential resources over the past year, mounting an effective COVID-19 response despite structural barriers.

The research demonstrates the value of PIH’s approach worldwide: building long-term relationships with local communities and strengthening health systems, before disaster strikes, so that patients receive the care they need, when they need it most.

“We, through the community members, have built a contact tracing force,” says Zeus Aranda, a research coordinator at Compañeros En Salud, as PIH is known locally, and co-author of the Lancet Global Health abstract. “At the end of the day, the people who know the community best…are the community members.”

Responding In Rural Chiapas

When the pandemic struck Chiapas in March of last year, the case count was low at first, hovering in the single digits. But then the surge came. Between March 2020 and January 2021, the state of 5.2 million recorded 8,745 positive cases and 1,259 deaths from the virus.

Even as case counts soared, critical resources—such as COVID-19 tests and oxygen concentrators—were in short supply. And in Chiapas’ rural communities in the Sierra Madre region, where Compañeros En Salud works, disinformation spread, along with the disease.

Despite these challenges, Compañeros En Salud was able to mount an effective response in the communities where it works, detecting and supporting 287 suspected cases and 1,111 of their contacts through its contact tracing program and providing groceries and hygiene products for 650 households.

But that success didn’t happen overnight.

In the Lancet Global Health research, authors Dr. Ariwame Jiménez, Dr. Bruno Vargas, and Zeus Aranda describe Compañeros En Salud’s COVID-19 response in rural Chiapas—and how its impact could reach far beyond the Sierra Madre.

“It’s such great news that this abstract is being shared in a journal that has such a large impact,” says Laura Martinez, who supported the research as Compañeros En Salud’s contact tracing coordinator. “What was undertaken here in Chiapas is something that a lot of communities with similar characteristics can reproduce and adapt to their contexts.”

‘Contact Tracing Is Possible’

Compañeros En Salud has been working in Chiapas since 2011, and its decade of work building relationships and operating programs there made it a trusted partner in the Ministry of Health’s COVID-19 response. But it had never run a contact tracing program before.

To accomplish that, it enlisted members of one of its longest-running programs.

“Community health workers have been the bridge between the clinic and the community for years,” says Jiménez, who coordinates Compañeros En Salud’s community health program and served as a first-year doctor in the community clinic in Soledad.

A cornerstone of public health programs worldwide, community health workers are local residents who are recruited, trained, and then dispatched throughout their communities to provide a range of basic health information and services, medications, and social support.

Compañeros En Salud’s community health workers have been knocking on doors in Chiapas’ Sierra Madre communities for nearly a decade, checking in on patients and becoming familiar faces in areas where paved roads and nearby clinics are few and far between.

That track record of building trust with the community made them a natural fit for the contact tracing program. Each community that accepted support was assigned one or two community health workers for contact tracing efforts. These community health workers followed a careful set of protocols. First, a check in with the local clinic for a list of suspected cases in their area. Then, door-knocking to follow up with the cases and their contacts. Finally, collecting and entering the data in a centralized database.

As COVID-19 intensified in the region, these trusted residents became a lifeline and, for the researchers, proof of an important concept.

“Contact tracing is possible, no matter how hard the context is or the conditions in that specific area,” says Jiménez.

It wasn’t always seamless.

In the early days of the pandemic, Compañeros En Salud’s workforce of community health workers halved, plummeting from 84 to 43 people. Two communities declined to participate in the contact tracing program due to skepticism and misinformation about the pandemic. And many community health workers have only basic literacy skills, complicating data collection.

But the program moved forward, undaunted.

As the pandemic became less novel and more detailed health guidance was released, the vast majority of community health workers returned to work, eventually bringing the staff to 80. Jiménez and her team, along with the infection control and prevention team, met with the communities that declined contact tracing to discuss other ways to provide support. And community health workers without literacy skills found other ways to record their data, often with the help of their supervisors or facility staff.

The pandemic is far from over, and Compañeros En Salud continues to battle the virus in Chiapas. But for the researchers, the Lancet Global Health abstract shows that an effective pandemic response is possible, even in the most rural and under-resourced settings. And it taps into another resource that has, at times, felt scarce: hope.

“What was done is possible in similar contexts around the world. So many communities are very similar to where we work,” says Martinez. “It’s really motivating and inspiring.

The following op-ed was written by Dr. Joia Mukherjee, Partners In Health's chief medical officer, who is helping lead the organization's efforts to stop the spread of COVID-19 in the United States, through the U.S. Public Health Accompaniment Unit, and across 11 PIH-supported countries around the world. This op-ed was inspired by research Mukherjee conducted and published in the Harvard Health Policy Review.

Racism is the chronic and foundational crisis on which our country is built. The death toll of COVID-19 further reveals the deep racial injustice in America’s health care, housing, and employment systems. 

America’s abysmal response to the pandemic was not a failure per se, but a political choice: wealth over bodies, specifically white wealth over Black, indigenous, and Latinx bodies. In the first year of the pandemic, among the 550,000 deaths, Black, indigenous, and Latinx people have suffered two to three times the mortality rate of white Americans. Similarly, the staggering economic pain and hardship of the fiscal freefall has had an outsized burden among these same communities.

The root cause of the disparities is clear: racism is embedded in our justice system, economic system, education system, and health system. 

That is why a universal response to COVID-19—the same plan for everyone—will continue to exacerbate inequity.  Rather, racial justice in our response to COVID-19 demands that we acknowledge that current inequalities are based on a racist system.  And that we work together with people who suffer racial oppression to materially resource our response.   

At Partners In Health, a global health and social justice organization, we have more than 30 years of experience working with affected communities to develop and deliver targeted approaches to achieve health equity and the plagues that disproportionately affect victims of historical and present day injustice. Whether fighting tuberculosis in Peru, HIV in Haiti, or Ebola in West Africa, resources for critical necessities such as food, transport, and housing are as necessary as are policies such as decarceration and community-based outreach.

Risk mitigation in the pandemic requires social distancing—this is most effective when people can stay at home. Yet so-called essential workers, 50% of whom are people of color, were required to be at work, often in the over-crowded conditions such as meat packing plants and farm worker camps. These jobs in food, agriculture, and transportation are often compensated at minimum wage or less and are without sick leave or benefits. In many European countries, people were compensated to stay at home. Yet in the U.S., only one payment was afforded to people in the first year of the pandemic.

The pernicious effects of racism on housing, food security, and political marginalization result in a much higher rate of pre-existing medical conditions in communities of color.  And racist policies since the founding of the nation result in poor access to health care in Black, Indigenous, and Latinx communities. The impact of the social forces and the lack of health care access results in lower testing rates, higher case positivity, and delayed presentation with COVID-19.  And now, with the vaccine rollout underway, we see yet again the stark inequities. An analysis in early March found the vaccination rate for Black Americans is half that of white people, and the gap for Latinx people is even larger.

Then there was Donald Trump. The former president’s racist policies and the blame he leveled at China -- describing the virus as the “Kung Flu” -- resulted in attacks against Asian Americans, such as the horrific Atlanta spa shootings in March. 

Amidst a longstanding void of federal leadership in the Trump Administration, some local communities laid the path for the way forward in targeting assistance to the most vulnerable.

In rural Immokalee, Fla., the Coalition of Immokalee Workers, an organization of migrant and essential workers disproportionately hit by COVID-19, partnered with Healthcare Network, the local Federally Qualified Health Center, to establish a new community health workforce to go door-to-door supporting those most at risk, to expand access to testing, and to register and help transport eligible individuals to vaccination programs. 

In counties across North Carolina, community health workers and organizations providing social supports, partnering with the state, have reached 35,000 households with bags of groceries, prepared meals, masks, hand sanitizer, thermometers, and relief checks. Preliminary findings from an ongoing statewide analysis suggest that N.C. counties with these social supports have lower COVID-19 case positivity rates.

Lifesaving vaccines are now available, but distribution has been chaotic at best, deeply unfair at worst. Many communities need help developing equitable vaccine distribution plans and community engagement strategies to establish public trust, especially in historically marginalized communities. Cook County, Ill., is working to identify “vaccine deserts” in impoverished neighborhoods and then mobilize resources to remove this barrier to care. In Newark, N.J., the city is deploying pop-up vaccination sites to homeless shelters and senior housing buildings, making vaccination accessible and bringing doses directly to communities so that those at higher risk can easily roll up their sleeves to receive protection.

At PIH, via our U.S. Public Health Accompaniment Unit, we’ve been pleased to support urgent requests for targeting assistance to the most vulnerable in communities across the country. Without community-level interventions to resource those impacted by the structural racism of the United States, current systems will exacerbate inequities and further shift the burden of COVID-19 to people of color. 

Efforts that restore equity and focus on justice must continue.

To improve health, bolster our public health systems, and truly be prepared for future outbreaks, we must undo racist policies and focus on repairing the harm that has already been done.

Every adult in the United States is now eligible for COVID-19 vaccines -- a critical milestone. As the nation races against a fourth wave of the virus and increasing spread of variants, vaccinating the entire population is as urgent as ever.

But eligibility alone does not guarantee access.

Already, among equally eligible people within states, the wealthy are getting vaccinated far faster than others. Eligibility won’t improve health disparities, and it could perpetuate long-standing inequities rooted in this country’s structural racism

In a new white paper on vaccine equity, Partners In Health’s U.S. Public Health Aaccompaniment Unit (USPHAU) leaders make a powerful case that both epidemiologic evidence and justice demand the prioritization of certain groups in the ongoing vaccination process, specifically older adults, communities of color, and essential workers.

An Inequitable Rollout

According to a Kaiser Family Foundation analysis of vaccination uptake in 43 states, “the percent of White people who have received at least one COVID-19 vaccine dose (38%) was 1.6 times higher than the rate for Black people (24%), and 1.5 times higher than the rate for Hispanic people (25%) as of April 26, 2021.” Following the same trends seen throughout the pandemic – from access to testing sites to acquisition of personal protective equipment -- vaccination rates remain low in many of the hardest-hit communities. Without intervention, vaccination rates in these communities will continue to lag behind and worsen inequities.

The intersection of marginalized identities, including race, age and employment, compounds poor health outcomes. The risk of death from COVID-19 increases sharply with age, with greater than 80% of reported deaths in the U.S. among those 65 and over. Risk-based vaccination also dictates prioritizing Black, Indigenous, and Latinx communities, who have experienced two- to three-fold higher hospitalization and death rates from COVID-19 than the white community. Though the majority of U.S. COVID-19 deaths have been in the oldest age groups, the death rate among Black an Hispanic patients aged 65 and older has been a significantly higher share of those populations than compared to white patients, the paper notes.

Similar disparities in risk are evident among frontline essential workers, half of whom are from communities of color, with over-representation among jobs in major industries like energy, agriculture, and childcare that form the backbone of our society. Black workers in particular are more likely to have jobs with the highest risk of exposure to COVID-19. Essential workers are at heightened risk of both contracting and transmitting COVID-19 based on the nature of their work, making them a clear priority for vaccination.

A Social Justice Imperative

Racial and social justice reinforce the epidemiological evidence: historically marginalized groups have disproportionately suffered from COVID-19 and therefore deserve priority protection, the paper authors write. Whether discussing cancer, diabetes, or maternal mortality, the burden of disease born by communities of color is disproportionately greater in the U.S. Indeed, in the first half of 2020, non-Hispanic Black people had a six-year lower life expectancy than white populations in the U.S. Systemic injustices embedded in many U.S. institutions, which were initially built on slavery and codified by legislation, continue today, including in public health.

Generations of structural inequity and racism have culminated in limited access to health care in certain communities, the paper authors write. Already limited access is further compounded by logistical barriers. Take access to COVID-19 care as one example. Vaccine sites often operate with limited hours and are in difficult-to-reach locations with limited connection to public transportation. These barriers disproportionately affect essential workers who must balance job demands against opportunities to be vaccinated. Additionally, there are many barriers to vaccine access among older, non-English speaking, and disabled populations: internet access, advanced technology, and mobility are often requirements for scheduling and getting to appointments at most vaccine sites. 

Population immunity is only achievable if every community has access to vaccines.

According to the white paper authors, the nation’s leaders have to ensure 70-90% of the population is vaccinated. To do this, they must eliminate structurally racist barriers and invest in community partnerships to achieve vaccine equity and to reduce transmission and disease burden throughout the country, especially in systematically marginalized communities.

From Theory to Practice, Making Vaccine Equity Work

Equitable vaccination is possible. PIH’s USPHAU, which provides technical support, assistance, and resources to tackle the COVID-19 pandemic, is collaborating with partners in cities, states, and communities across the nation where vaccination activities are in process. The shared goal is to address supply and demand challenges in equitable vaccination, while beginning the process of correcting historical health injustices. Many of these approaches are drawn from PIH’s global experience with community health, vaccination campaigns, and emergency response over the last three decades, from addressing the cholera outbreak in Haiti to the Ebola epidemic in West Africa.

Listening to Communities

Access to accurate and transparent information about the development, safety, and efficacy of the vaccine—as well as how to access it—is a critical element when attempting to build trust between community members and the public health system. Ultimately, all messaging and communication strategies must be tailored to specific community needs, questions, and concerns, and they should be developed in partnership with community members.

In Montgomery, Ala., USPHAU is working with the mayor’s office, the department of health, a social impact creative firm, and community leaders to develop a public engagement campaign, Level Up, that is specific to local needs. Key community members were interviewed to gain their perspectives on COVID-19 and vaccines. Their answers then informed surveys, social media, and other local messaging wrapped into the campaign, which launched as the state’s vaccine eligibility expanded. In addition, USPHAU helped launch a free rides program that offers transportation for community members, and a cadre of community vaccine ambassadors who provide vaccine education and appointment scheduling to navigate challenging sign-up systems.

Mind the Gap

Spatial mapping within communities and regions offers another way to identify gaps in access. This visual approach can spark discussion and drive collaborative planning for improving community access. 

In  Ohio,  for example, USPHAU is  helping  coordinate  across community, government, and academic  partners  to  comprehensively  document and visualize the resources and vaccination needs of communities most vulnerable to COVID-19. Because of this work, the team has identified where gaps in coverage exist and public transportation is insufficient, as well as proposed areas where mobile vaccination units are necessary to meet local vaccination goals. 

In  New Bedford, Mass., USPHAU is supporting  vaccine site operations that focus on specific vulnerable communities, using low-tech tools and local knowledge to register and vaccinate individuals who lack access to technology and English language proficiency. 

Building Long-Term, Equitable Health Systems

Ultimately, vaccination is just one part of a robust and effective COVID-19 response, and even the most optimistic predictions have domestic and global population-level immunity months and years off, respectively. Vaccination and booster campaigns will continue long after. While leaders continue to drive vaccine resources where they are most needed, they must also double down on other aspects of response, recovery, and reimagining public health.

On the Navajo Nation, where vaccination coverage has outpaced states, USPHAU is supporting contact tracers who incorporate questions on vaccination status into regular calls and training staff to solicit feedback, answer questions, and make referrals for COVID-19 vaccination.

In Pima County, Ariz., USPHAU is also incorporating vaccine messaging into contact tracing and case investigation calls to bolster community response to the vaccine. The team has helped the health department craft strategies, in collaboration with local community organizations, to reach vulnerable sub-groups of the population – including individuals experiencing homelessness, American Indian and Alaskan Natives, refugees, and those who are homebound.

Cecelia Rose English, the USPHAU senior team leader in Arizona, said that alongside local partners, her unit’s plan is to “ensure [a] vaccine is available to everyone in Pima County by May 2021.”

Breaking Down Barriers

In Immokalee, Fla., USPHAU and partners work at testing and vaccination sites to connect those in need to social supports, including food vouchers and unconditional cash transfers, to help them through isolation and quarantine and to alleviate the disproportionate impact of the pandemic on the community.  

And in North Carolina, USPHAU is working with state partners to focus on the needs and barriers of vulnerable populations and ensure social and health services screening by community health workers becomes a standard practice during vaccine registration so that community members have what they need to stay safe and healthy.

Devin Worster, senior project lead in North Carolina, said the state is taking vaccine equity a step further. Officials are working with partners to encourage community health workers and community-based organizations “to provide vaccine education, schedule individuals for vaccine appointments, and host community vaccination events to best target marginalized populations in the communities where they live, at locations they will trust, and at the hours that are most convenient to them.”

Vision for the Future

In order to stop COVID-19 and achieve a new normal — opening businesses, schools, and communities — no one must be left behind, the authors argue. Population immunity can only be achieved with successful vaccination programs in every community, at the global, national, and local levels. Critically, these strategies cannot be one-time initiatives; they must be part of a durable effort to empower communities, as the most experienced and best positioned to advocate for structural, logistical, and educational resources that will not only increase vaccination coverage but also improve long-term health.

Learn More at the Webinar

Every day, contact tracers dial unfamiliar phone numbers, never quite sure what they might confront on the other end of the line. It could be an anxious, homebound senior who has run out of medicine. Or an immigrant mother worried whether her child’s labored breathing is an asthma flare-up, or COVID-19, or both.

Over the past year, workers have reached out to countless strangers offering help through the Massachusetts Community Tracing Collaborative (CTC), a statewide program launched last April through a partnership between the state and Partners In Health. Contact tracers have made more than 2 million phone calls to adults with COVID-19 and their contacts, explaining the latest medical guidance to prevent transmission of the virus. And care resource coordinators have connected more than 90,000 people to food, housing, and other essentials for safe isolation or quarantine.

But what’s the emotional toll on these contact tracers and care resource coordinators, who deal daily with illness, fear, and—sometimes—death. The stress is hard to quantify, but there’s no doubt the work leaves its mark.

That’s why in July 2020, acknowledging that these outreach workers might need to vent, or cry, or even scream once in a while, PIH—with the state’s support—established a unique Wellness & Peer Support program open to every CTC staff member.

Through case surges and lulls, the program has offered a range of supports. There are one-on-one sessions with trained peer support providers, CTC members themselves who listen, share pragmatic solutions, and refer people to mental health professionals when needed. Since the program’s launch, about 1,000 individual peer support encounters have taken place.

And there are one-off and longer-term “Wellness Zones,” which are peer-led gatherings ranging from grief workshops and yoga classes to poetry, cooking classes, and guided meditation.

Dayhana Schlosser, a registered nurse, child and family therapist, and director of the CTC support program, helped build this work from the ground up, including training staff volunteers. “These are people who understand the nature of this work and the personal toll it can take,” she said.

Seeking a Wellness Zone

At first, Wellness Zone uptake was slow, Schlosser said, in particular during surges when it seemed impossible to take time away from the pressing work. By September, though, CTC staff members—possibly feeling the need to bond with others and make meaningful connections—began flocking to the sessions. A survey at that time found that more than 90% of respondents reported that participation had positively impacted their overall health and wellness. That compared to a survey four months prior, in which 20% to 30% of the workforce said they had no idea where to turn for work-related mental health support.

Since the fall surge, there’s been a “significant” increase in Wellness Zone participation, said Schlosser, who started at the CTC as a care resource coordinator. About 500 people joined in around the time of the U.S. Capitol riots on January 6. The average session draws 45 to 50 people.  

“I think this has been hugely helpful for many people,” Schlosser said. “There is just a myriad of feelings to process, from needing help talking through a tough call, to facing the huge disparities in the circumstances of the cases, to the personal stuff. A lot of folks in this workforce are grieving themselves, and navigating the work when you've had someone pass away is really tough.”

Indeed, these workers are in a unique—and uniquely stressful—situation, said Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health. They were hired quickly, during a crisis, and placed in the position of being quasi-health workers, when many were not actually health workers. Raviola says early on there was an aggressive push to provide Psychological First Aid training for contact tracers so that they could effectively address the acute mental health and psychosocial needs of people affected by COVID-19. But it soon became clear that some contact tracers themselves were “enduring significant distress” as they supported people remotely and dealt with high levels of physical illness, economic challenges, and personal losses caused by the pandemic.  These new hires, he said, needed a dedicated space “to buffer them and provide initial support.”

A Breaking Point

Paula Bowden Alayne, of Sacramento, CA, was among the first cohort of contact tracers hired in mid-April 2020. She’s no stranger to on-the-job stress; she previously worked as a training officer in San Quentin prison teaching corrections staff how to treat death row inmates more humanely. 

But after six months as a contact tracer, Bowden said, the reality of the work became oppressive. “Talking to people who are sick and potentially dying was getting to be too much,” she said. “It got so it was hard for me to get out of bed. I felt overwhelmed. I think I was getting depressed—like mine was part of a community depression. It was bad and getting worse.” 

There were some cases Bowden just couldn’t shake, like one couple on her call list. He was positive, she was waiting to see if she’d been infected. Bowden checked in daily. On Monday, Tuesday, and Wednesday, things were stable. On Thursday, no one answered the phone. Same on Friday. On Saturday, the wife picked up. Her husband had died that morning. “That was kind of my breaking point,” she said.  But she’d committed to the job, and she needed the income.

Bowden reached out for help and was quickly connected to a CTC peer support person. “We had a conversation, she listened and empathized,” Bowden said. “She gave me a choice: ‘You can walk away from this, or stay.’ It was so powerful to sit with someone who had done this job, knew the ins and outs. She gave me permission to do what I needed to do. That permission and our conversation gave me all the power back, my depression lifted, and I got my energy returned. I kept doing the job.”

Soon after, Bowden applied to become a peer support person herself. She says this position has allowed her to lean in even further to the meaningful work of helping people, both at the individual level and through the groups she leads, such as a six-week session on managing grief.

Bowden recalled working with a staff member who was feeling hopeless, with tremendous difficulty making calls due to a death in the family.  Bowden, with her experience practicing meditation, helped this individual begin to work through the personal grief and feel more grounded, she said, “like life had meaning again.”  

Rising Depression and Anxiety

To be clear, members of the peer support team are not trained psychiatrists, therapists, or counselors; when they suspect even the slightest indication of more serious mental illness in a peer, they can elevate concerns to Schlosser and also refer people to professionals and follow up to make sure no one gets lost in the system.

The mental health toll of COVID-19 has been pervasive, with about 4 in 10 adults in the U.S. reporting symptoms of anxiety or depressive disorder, up from 1 in 10 in the pre-pandemic period, according to a Kaiser Family Foundation survey. Many adults report a range of negative impacts on their mental health and well-being, such as “difficulty sleeping or eating, increases in alcohol consumption or substance use, and worsening chronic conditions, due to worry and stress over the coronavirus.” Among adolescents, rates of suicidal thinking and attempts were up by 25% or more during several months in 2020 compared to similar periods in 2019, an analysis of patients, ages 11 to 21, found.

This rising stress is a worldwide phenomenon. Since the start of the pandemic, PIH global staff have expressed similar concerns about the increasing distress faced by health care and other providers, Raviola said. So, the peer support model developed in Massachusetts is now being adapted to meet the needs of global colleagues, from Lesotho and Peru to Mexico and Malawi.  

Raviola said with the inequities that COVID-19 has further exposed, from structural racism to political extremism and economic disparities – in combination with various stresses related directly to COVID-19 itself – all sites should have staff support programs in place: “We can't afford not to do it since health care workers will continue to be at the convergence of these issues.”

Emotional First Aid

Accompanying patients through some of their toughest moments has kept Nikkia Watson, 28, motivated over the past year. A graduate student in clinical social work at Simmons University, Watson signed on to be a care resource coordinator with the CTC in late April 2020 while also interning at a VA facility outside Boston in the hospice and palliative care unit. By July, Watson had joined the peer support team, devoting half of her time to offering emotional aid to a range of people. 

“Mostly, I provide concrete steps to calm anxieties,” Watson said. “This work is really hard, plus all of us are dealing with emotions and issues in the lives we live outside of this.”  In this role, Watson has worked on confidence-building skills with a young contact tracer having trouble coping with competing demands, and she helped an older woman struggling in secret with anxiety to connect with a mental health provider. “I have definitely referred people to get professional help,” Watson said. We’re not here to be therapists, we are here to make people feel better about the work.”

All of it, even the moments that are crushing, have been deeply satisfying, she added.

“For me personally, and for the folks we’ve helped, it’s the first time people have seen a work environment that is caring—not only caring about productivity, but caring about their mental health. Most folks are coming from a setting where it’s, ‘Do your job and whatever your problems are, deal with that on the outside.’ What’s unique here is we care about what’s going on; how can we make you feel seen, validated, supported. Those aren’t things you usually get at a job.”

As the pandemic appears –perhaps – to be winding down in Massachusetts, Watson has been considering her own future goals. “I’ve seen a lot of grief,” she said. “I’ve seen people just diagnosed and then I’ve seen them hospitalized, and also in the end, going to hospice and dying. It’s a full circle experience that you don’t often get to see. I talk to them at the beginning and see them at the end, and all of this makes me want to be part of the healing profession even more. I think hospice is going to be my new thing.” She adds: “It’s amazing to support people in their darkest times. It’s laborious sometimes, but it’s also so gratifying.”

The morning of April 23 marked a turning point for women and their families in Kono District, Sierra Leone, as Partners In Health (PIH) and Sierra Leone’s Ministry of Health & Sanitation officially broke ground on the Maternal Center of Excellence (MCOE).

A state-of-the-art teaching hospital dedicated to women and children’s health, the MCOE now enters its construction phase on the grounds of PIH-supported Koidu Government Hospital, where PIH and the Sierra Leonean government have focused their efforts on radically reducing maternal, child, and neonatal mortality in Kono and in the country at large.

Sierra Leone is one of the most dangerous places in the world to give birth: Women face a 1 in 20 lifetime risk of dying in pregnancy or childbirth—compared to a 1 in 3,800 chance in the United States.

The MCOE will address this injustice by providing clinicians the fully equipped spaces they need to save patients’ lives—including an oxygen plant, blood bank, intensive care unit, neonatal intensive care unit, surgical suite, outpatient clinic, and pharmacies. Crucially, the facility will contain 163 beds, dramatically expanding Koidu Government Hospital’s current 48-bed maternity ward and special care baby unit, which daily run out of adequate space for all the women and prematurely-born infants in need of care.

What’s more, the facility will be a response to the dire shortage of trained clinicians in Sierra Leone, where there is currently no option to specialize in such areas as obstetrics, gynecology, neonatology, or pediatrics. Specialized medical training programs—and infrastructure like simulation labs, lecture halls, and student housing—will provide never-before-available clinical education opportunities to the next generation of doctors, nurses, midwives, and other equity-minded health care workers.

The MCOE’s construction is estimated to take two years and will be completed with PIH’s longtime partner, Build Health International. Once fully operational, the facility is projected to increase facility-based deliveries by 121%, multiply by five-fold family planning visits, and reduce the rate of still births to under 2% in Kono District.

And beyond measured impact, the MCOE will serve as a model health facility, provide a blueprint for future investments in women and children’s health, and stand as a global testament to women’s rights as human rights.

“It will be a place where women will feel treasured,” said Isata Dumbuya, nurse-midwife and manager of PIH’s maternal and child health programming in Sierra Leone. “For women to feel that they count, where they will come and say, ‘This was done because of me, because I matter. I am worthy, and I've been treated with the highest level of dignity.’”

For Dumbuya and her colleagues in Sierra Leone, the groundbreaking is a historic moment for PIH and for the country—and a step toward a dream come true.

“In 2017, the first conversations started in Kono between PIH, the district health management team, and Koidu Government Hospital administration about the most impactful ways we could work together to reduce maternal and child mortality,” said Jon Lascher, executive director of PIH in Sierra Leone. “Quickly, the strategy came to include not only excellent clinical services, but a true training institution, linked to Sierra Leone’s universities and universities around the world. And soon the idea was born for the Maternal Center of Excellence.

“The MCOE is and will be founded on all of the critical investments we’ve made, and the trust we’ve built, in communities, clinics, hospitals, and government buildings across the country,” he continued. “It promises a truly bright future for women and children’s health. The people of Sierra Leone deserve nothing less.”

Help Build the MCOE

Dr. Tommy Rock grew up in Navajo Nation, just miles from uranium mines where the radioactive element was once extracted for nuclear bombs. The mines have been closed for decades, ever since the end of the Cold War. But the past has a way of lingering.

In Monument Valley, Utah, where Rock still lives, reminders of that past lurk everywhere—from the air he breathes to the water he drinks. He has watched friends and family become sick from the pollution.

“It’s all personal,” says Rock, an environmental researcher and activist who has collaborated with COPE, Partners In Health’s sister organization in Navajo Nation. “My grandfather was a uranium miner and he died of cancer. I have a lot of relatives who died of cancer—they were all former uranium miners.”

Uranium mining is just one of many human activities that have contributed to climate change. The earth’s surface has warmed since the 1800s, coinciding with the Industrial Revolution—a process connected to chattel slavery and, in the U.S., the genocide and theft of land from Indigenous people. Since the 1950s, that warming has happened at an unprecedented rate due to the skyrocketing consumption of oil, natural gas, and coal, known as “fossil fuels.”

That unchecked consumption has put people and the planet in danger, drastically altering weather patterns and leading to extreme temperatures, more powerful natural disasters, and widespread pollution. As PIH has seen firsthand in its work around the world, climate change isn’t just a threat to our environment—it’s a threat to our health.

As Indigenous people around the world have always understood, our health and the health of our planet are interconnected. Our survival depends on each other. Climate change is a global health emergency.

A Health Crisis

Anushka Bhaskar used to visit Delhi, India, every year to see her grandfather. Bhaskar, formerly involved with PIH Engage, is a climate activist, Harvard student and founder of Avritah, an intersectional platform focused on health equity and environmental justice. She remembers being inspired by her grandfather as a young girl, especially by his work researching the pollution of the Ganges River and partnering with the Indian government to clean it up.

Then, unexpected news came: he was diagnosed with colon cancer. The diagnosis didn’t make sense to Bhaskar, for a man she knew to be so health-conscious that he once ate only porridge for weeks. But she had her suspicions.

“There’s a lot of pollution in India and there’s a lot of work to be done on an environmental level in Delhi, where we live,” she says. “I used to go visiting every year pre-COVID, and I would sometimes get very, very sick just from breathing in the air.”

Air pollution, worsened by extreme heat, is just one of the ways that climate change is impacting human health. As climate change intensifies, health experts warn that no clinical area will be unaffected. Between 2030 and 2050, climate change is projected to cause as many as 250,000 additional deaths per year.

“The environment has such a direct impact on people’s health,” says Bhaskar. “I want future pre-meds, future doctors, future health care policymakers...to have this understanding that their work to improve health is so linked to environmental advocacy.”

Take malnutrition, for example—a condition that already affects billions of people worldwide. As temperatures rise and rainfall patterns become uneven, farmers in the world’s poorest regions will struggle to produce staple foods, heightening the risk of malnutrition and undernutrition. Warmer temperatures have already worsened diet quality and increased malnutrition among young children in Asia, Africa, and South America.

As PIH has seen in its work around the world, malnutrition worsens epidemics such as HIV and TB. And flooding and drought in Malawi, for example, has led to poor crop yields, putting more people at risk of malnutrition and making PIH’s food and housing support there, in addition to medical care, critical.

Heart and lung disease are other clinical areas where climate change is expected to take a toll. As extreme heat becomes more common, air pollution will worsen and more people will die from cardiovascular and respiratory disease. Those suffering from airborne infectious diseases, such a tuberculosis, will further struggle to breathe. And increasing wildfires mean that more people will be exposed to dangerous levels of smoke, putting them at risk for lung disease and other respiratory issues.

Infectious diseases are also projected to become more common as climate change escalates. Floods create breeding grounds for mosquitoes and contaminate water supplies, putting people at risk of insect- and water-borne diseases, as PIH has seen in cholera outbreaks in Haiti and Sierra Leone.

Over the past few decades, the number of emerging infectious diseases has skyrocketed due to warming temperatures and the destruction of forests and wildlife, bringing humans into increased contact with disease-carrying animals. The origins of COVID-19 remain unclear, but a World Health Organization inquiry is investigating the possibility of animal-to-human transmission.

“Our human and environmental health comes back to the way that we as human beings restructure environments and ecosystems,” Bhaskar says. “We denaturalize the checks and balances that nature has put into place to protect us.”

An Unequal Burden

Ask Rock about environmental justice and he’ll tell you about an open-pit mine about five miles south of Oljeto, Utah. It’s where his grandfather went to work every day.

The Moonlight Mine is one of more than 500 uranium mines that the U.S. government built on Navajo Nation, as it was stockpiling nuclear weapons during the Cold War. Nearly 30 million tons of uranium ore were extracted from Navajo lands.

Rock remembers a story his grandfather told that still haunts him. His grandfather and a few men were hauling ore out of the mine when, suddenly, the entrance collapsed. His grandfather watched helplessly as a boulder fell on the man behind him, crushing him.

The mine was closed after that. But the damage didn’t end there. Years later, his grandfather came down with cancer from his exposure to uranium—an injustice that still affects Navajo Nation today.

“It will take many generations for that to be cleaned up,” says Rock, who has testified to U.S. Congress about the issue. “It’s not going to happen in my lifetime.”

In the United States, the genocide of Indigenous people, the theft of their land, and the desecration of their sacred sites paved the way for the environmental injustice that marks daily life for communities of color, where toxic waste sites, garbage dumps, oil pipelines, and other sources of pollution are more likely to be built.

“From a political standpoint, people listen less to the communities of color on the frontlines of this crisis,” says Bhaskar. “And we know, for example, that policymakers are less likely to legislate against petroleum plants and other toxic burdens being placed in those areas, because they’re definitely not going to be placed in a white suburban community.”

These inequities exist on a global level, too. Just 100 companies are responsible for 71% of the world’s greenhouse gas emissions. But it is the world’s poor who will suffer most, unless bold action is taken.

Africa, which is the least responsible for climate change, will be hit the hardest. As climate change ushers in warmer temperatures and more destructive natural disasters, millions of people across the continent are at greater risk of displacement, famine, malnutrition, and disease. By 2050, crop yields could drop by 13% in West and Central Africa, 11% in North Africa and 8% in East and Southern Africa, according to the United Nations.

In countries such as China and India, where the West has outsourced its production, pollution claims hundreds of thousands of lives. In China, at least 108,600 premature deaths in 2007 were linked to consumption in Western Europe and the U.S, according to a study published in Nature in 2017. Western consumption habits, such as upgrading a mobile phone every six months, comes with a hefty health cost, oceans away.

‘We’re Up Against Goliath’

Sanders, Ariz., sits on a rural stretch of land along I-40, once part of Route 66, dotted with sagebrush and flanked by the mountainous Puerco Ridge. It’s a quiet town of some 630 people, mostly Navajo. When Rock decided to test the town’s water supply in 2015, as part of his federally-funded environmental justice research, he didn’t realize he’d cause an uproar.

Rock, who holds a PhD in earth science and environmental sustainability from Northern Arizona University, conducted this research with Tolani Lake Enterprises, a Navajo grassroots organization. And the findings were jarring: Residents of Sanders, whose water source was a well in a rundown wooden shack, had been drinking water laced with uranium for more than a decade—without any notice from the state.

Those findings set in motion a months-long campaign, led by Sanders residents and supported by Rock and his colleagues, to demand that the town’s water source was changed to a nearby utility. The campaign was a success—eight months later, Arizona and the Navajo Nation agreed to let Sanders switch its water source.

The underlying issue was not lost on Rock—the U.S. government, once again, failing to take responsibility for the ongoing harm it was causing to Indigenous people, on land that it stole from them and had mismanaged ever since.

He knows that the fight for climate justice has spanned generations and will continue for generations more. But the moments of victory, no matter how small, matter.

“We’re up against Goliath,” he says. “But every little win motivates me and keeps me going.”

As a young mother faced with parenting during a pandemic, Sol Prieto worried about her 9-month-old and whether he was hitting all the milestones in child development. They spent all day at their house in Carabayllo, Peru. She wondered if it was coming at a cost.

“Since I became a mother, I have always been very interested in and concerned about the well-being of my little one,” she says.

Fortunately for Prieto, the 26-year-old mother was not left to face these challenges alone. Support came from an unlikely place: a telehealth app.

The app is called CASITA, and it’s one of seven telehealth apps developed by Socios En Salud, as Partners In Health is known in Peru. These apps vary in focus, but all have a common goal: to help patients connect with care during the pandemic.

Quality Care, At Home

Socios En Salud has worked in Carabayllo, an impoverished community 20 miles north of the capital of Lima, since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. Then and over the decades since, SES has partnered with Peru’s Ministry of Health to deliver medical care and social support, strengthening Carabayllo’s health system.

When COVID-19 struck, Socios En Salud was ready to respond with testing, contact tracing, and resources for those in quarantine, drawing from its deep experience fighting TB. It also adapted its clinical programs to keep patients safe, shifting to a virtual format whenever possible—a shift that called for technological innovation.

That’s where telehealth came in. As cases mounted and virtual programming became a necessity, Socios En Salud developed seven mobile apps, corresponding with ongoing clinical programs. All of the apps connect patients with a chatbot—and, eventually, care—from the comfort and safety of their homes.

“Chatbots are an alternative to provide tele-advice and tele-monitoring in health and to connect people at risk of a health problem with health professionals,” says Karen Ramos, director of Socios En Salud’s community health program. “Chatbots allow us to accompany and follow-up at a distance and allow the participant to have an alternative response to their health problem.”

Some of the apps focus on mental health, such as Bienestár, which offers a free screening and connects patients with a network of specialized psychologists. KUSKA follows a similar model, but in Quechua, an Indigenous language that can be a barrier to quality care for Peru’s historically marginalized Quechua communities.

Other apps focus on chronic diseases. Soy Qhalikay helps identify people at risk for Type 2 diabetes or hypertension and alerts a nursing and nutrition team for follow-up. Chatea con tu Nutri connects patients with health professionals to improve their diet and physical activity.

Still other apps focus on maternal and child health. ALMA enables women at risk for breast cancer to access a free preventative mammography. And GESTamor helps identify women who may be pregnant and refers them to a health facility for prenatal care and monitoring.

A Patient-Centered Approach

For Prieto, it was an app called CASITA that made all the difference. Connected to Socios En Salud’s CASITA program, the app offers a free screening, educational resources, and, if needed, enrollment in the program, which identifies infants at risk for developmental delays and provides training and support for their caregivers.

Prieto first heard about CASITA from her neighbor, whose family is enrolled. After speaking with a Socios En Salud community health worker, she decided to give the app a try. As she spent her days at home with her son, she wanted to know whether he was showing any signs of developmental delays.

When she logged on, the chatbot asked a series of general questions about her and her child. Then, it shared information about the stages of child development, including pictures, and asked more targeted questions about her child’s behaviors.

As she answered the questions and saw the pictures of children—pictures that resembled her son—she felt a sense of relief.

“Through the CASITA chatbot app, I was able to rule out signs of delay or risk in his child development,” she says.

Over the past several months, Socios En Salud’s telehealth apps have helped hundreds of people like Prieto access education, resources, and support—including those previously unserved. The Bienestár app, for example, has helped identify more than 111,540 people in need of mental health support—enabling Socios En Salud to connect them with psychologists and specialized care.

The process has had its challenges. Most of Socios En Salud’s community health workers are women over 50 years old who may not have had technological savvy—at least, before the pandemic.

“They have had to learn and adapt to the use of chatbots, messaging, and video calls through WhatsApp and other applications,” says Ramos. “This pandemic has allowed them to explore their abilities and know that, regardless of their age, they can continue to learn new things that strengthen their abilities.”

As a young mother, learning new things has been a constant for Prieto. But she knows she’s not alone.

Just the other day, she watched her son try to sit up on his own—another sign of progress, one that she recognized from the CASITA app.

“I feel much calmer now,” she says. “I want to create a healthy space for the development of my youngest son. I always keep an eye on him, so that he can be healthy and happy."

More than three months ago, COVID-19 vaccines began to roll out and a 91-year-old woman in the United Kingdom became the first person—outside of a clinical trial—to receive a vaccine. Six days later, a nurse in New York City became the first person in the United States to get vaccinated. Since then, more than 400 million doses have been administered around the globe.  

Yet, there are still dozens of countries that haven’t received a single dose. 

This list includes countries where Partners In Health (PIH) works, such as Haiti. While it’s great news that communities are getting vaccinated, it is vital to recognize that if we don’t vaccinate the most poor and vulnerable communities, everyone will continue to be at risk. 

“No one is going to be safe until everyone is safe,” says Joel Curtain, PIH’s director of advocacy. “We can’t have an approach where only rich countries are vaccinating themselves. A successful strategy requires vaccinating the whole world—it’s both a moral and pragmatic imperative.” 

A majority—about 75 percent—of all the vaccines delivered across the globe have been sent to 10 countries: the U.S., China, the U.K, Israel, the United Arab Emirates, Italy, Russia, Germany, Spain, and Canada.  

This is not an equitable or ethical approach, which is why PIH is pushing to make sure vaccines are accessible to everyone as soon as possible.  

A Push for Increased Vaccine Supply 

PIH supports a two-pronged approach for ensuring equitable access to COVID-19 vaccines, which includes increasing the global supply of vaccines and their equitable global distribution. 

When it comes to supply, PIH advocates for a People’s Vaccine, which provides protection freely and fairly available to all, prioritizing those most in need globally. The initiative calls on governments and pharmaceutical companies to share  COVID-19  technologies and knowledge free from patents. Additionally, PIH joined other organizations and countries to urge the World Trade Organization to waive intellectual property rights to increase the production of COVID-19 vaccines and treatments. 

“We need to remove the intellectual property for vaccines,” says Dr. Evrard Nahimana, PIH’s Africa region policy and partnerships advisor. “It’s not something fancy that will cost a lot of money to do. It’s a pragmatic solution to come together and save lives. We don’t want to wait until 2025 and continue to see people dying.” 

Many rich countries and pharmaceutical companies say there are too many technical barriers to ramp up production, but these are the same arguments used 20 years ago during the movement for access to HIV treatment, notes Curtain, who says we’re currently experiencing a “global vaccine apartheid.” 

“We’re hearing the same arguments from pharmaceutical companies about it being too difficult to produce these vaccines in facilities around the world, all in order to protect their large profit margins.” says Curtain. “There are many steps governments can take to invest in global production to break this vaccine apartheid, and prioritize people not profits.” 

Collective Vaccine Purchasing and Distribution

COVAX is another key initiative that PIH supports for collective purchasing and distribution of COVID-19 vaccines. It’s a collaboration co-led by the Coalition for Epidemic Preparedness Innovations, Gavi, and the World Health Organization to help develop, manufacture, and distribute COVID-19 vaccines in bulk at low-cost. Public and private partners, governments, foundations, and others donate to COVAX, then COVAX negotiates prices to buy vaccines in bulk. The vaccines are then sent to countries with limited resources. Ultimately, COVAX aims to deliver two billion doses to low- and middle-income countries by the end of 2021. This goal includes the vaccination of at least 20% of the population in the world’s poorest countries.  

“COVAX is a wonderful initiative, but 20% is not enough. We need at least 60% to reach collective immunity and be able to control the pandemic,” Nahimana says.  

COVAX partners aren’t immune to vaccine nationalism, when countries prioritize vaccinating their own communities first. It has already led to delays in supplying vaccines to countries, including to sites where PIH works. PIH will continue to fight for equitable vaccine access for all at local, national, and international levels of government, knowing that more widespread commitment toward global vaccine equity will help the most vulnerable communities get vaccinated as soon as possible. 

“We’re positioned to reach the last mile at PIH,” Nahimana says. “At the national level there are a lot of players to support the government in general. But in the most remote areas with the most vulnerable people, that’s where PIH steps in to advocate and support those people.” 

As of late March, all PIH-supported countries in Africa—Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone—have received their first batch of vaccines from COVAX. Most countries have kicked off their vaccination campaigns, and they’re all prioritizing health care workers, including community health workers, then individuals older than 65 and those with chronic conditions. As of March 26, about 10,000 people in Sierra Leone had been vaccinated with a single dose; 13,000 in Lesotho; 348,000 in Rwanda; and 71,000 in Malawi.

Former President Donald Trump got it. His lawyer Rudy Giuliani got it. This winter, Ken Wells of Arizona got it too: an infusion of monoclonal antibodies, one of the only effective treatments available for high-risk patients with COVID-19.

Wells said that the therapy made a big difference in his recovery from the virus. “If the purpose of it is to keep people out of the hospital,” he told ABC reporters, “it’s helped me.”

The story of how Wells received a treatment that many have never even heard of connects back to the director of the Pima County Health Department: Dr. Theresa Cullen, a family physician, former assistant U.S. surgeon general, and one-time volunteer with Partners In Health in Sierra Leone.  Now, Cullen is once again collaborating with PIH, this time to alleviate COVID-19’s toll in hard-hit Pima County.

A COVID-19 Hot Spot

Cullen’s first day as health director in this southern Arizona county on the U.S.-Mexico border was May 1, 2020. “I wasn’t planning on coming into a pandemic,” she said.

But that’s exactly what she did. In less than a year Arizona would become “the hot spot of the world,” during the January surge, with the worst new infection rate of any state in the nation.

In Pima County, Cullen says, 1 in 450 residents have died of COVID-19:

“Everyone knows someone who knows someone.”

But Cullen suspected that promoting “aggressive access” to monoclonal antibody therapy as part of the county’s overall pandemic response might help curb those numbers. In national studies, these antibody treatments were shown to reduce hospitalizations and death by up to 70%. Of the many hundreds of patients who received it in Pima County, only a handful have been hospitalized, according to anecdotal reports from administrators.

Monoclonal antibodies are synthetic drugs that mimic the body’s natural antibodies, amping up the immune response to SARS-CoV-2, the virus that causes COVID-19. When VIP patients like Trump and Giuliani received the therapy last year, it wasn’t yet approved for the general public. In November, though, the FDA granted the drugs emergency use authorization for the treatment of patients with mild to moderate symptoms at high risk of being hospitalized.

Removing Barriers

But obstacles have plagued this treatment from the start.

First, the drugs must be delivered intravenously at a medical facility, with appointments taking two to three hours from start to finish. Many hospitals and health centers, already at capacity and overwhelmed by emergency cases during the winter surge, did not have the staff, space, or logistical support to establish these infusion centers. Also, to be most effective, the antibody therapy must begin within about 72 hours after the onset of symptoms (though it can be administered up to 10 days after symptoms start). 

Although the drugs are costly, the federal government sought to remove this barrier, buying one million doses this winter so that local health providers could more freely offer it to patients. Still, uptake remained sluggish.

Enter Dr. Cullen and her team. Once the drugs became available, she mobilized the health department to help coordinate the state’s supply that was being distributed to Pima County, reaching out to hospitals and care facilities.  At first, she said, there were few takers. Facilities and health care networks were overwhelmed with providing acute care. Cullen kept at it, connecting with an old friend, Dr. John Redd, the chief medical officer and assistant secretary for preparedness and response with the U.S. Department of Health and Human Services. In January, Cullen helped negotiate a pilot program, which has since been extended, at Tucson Medical Center. It was the second such program in the nation. Now, other facilities in the state and across the U.S, have extended the provision of the therapy, increasing accessibility.

Access and Accompaniment

Cullen says the key to high quality treatment and care for all patients -- and to her view of public health in general  -- is access and accompaniment. These principles, she says, came into sharp focus for her during the 2014 Ebola outbreak in West Africa, when Cullen, volunteering with PIH, helped set up a specialized unit for pregnant women exposed to Ebola so they could safely receive care and treatment.

That experience, she said, crystallized her commitment to public health at the community level. “If not for that, I wouldn’t be here today.”

To ensure that every patient in Pima County knew about the effectiveness and availability of monoclonal antibody treatment, Cullen partnered with local officials and others to amplify the message: her team organized a press conference held outside the medical center which was covered by TV, radio, and print media.

Dr. Redd, who also knew Cullen from their time in Sierra Leone, where he worked for the CDC overseeing the U.S. response during the Ebola outbreak, traveled to Arizona for the clinic’s opening event. He implored residents to use the monoclonal antibody therapeutics “avidly, quickly and as widely as possible.”  The drugs, he said, were “bought by the United States government for the people of the United States. These are meant for everyone and they are cost free. There is no ID check.”

Most critically, Cullen said, the health department decided to alert every positive case in the county to the free monoclonal antibody therapy if they qualified. That meant rewriting the scripts used by health workers handling contact tracing and case investigation. The task went to colleagues at PIH assisting with COVID-19 response in Pima County.

Cecelia Rose English, PIH’s senior project lead in Pima County, said as soon as the antibody treatment became available, her team added language to the scripts explaining the therapy and its eligibility requirements, both in English and Spanish.

That’s critical in this county, where nearly one-third of the population identifies as Latino and/or Hispanic and approximately one-fourth of residents speak Spanish at home; about 20% of the county population lives below the federal poverty line. Pima county also encompasses the Tohono O’odham Nation and the Pascua Yaqui Tribe with approximately 34,000 Native American residents; nearly one-third are unemployed, nearly 40% have less than a high school education, and 40% of Tribal members on the Nations live below the federal poverty level, according to census data.

PIH, through its U.S Public Health Accompaniment Unit (USPHAU), has been supporting the county’s overall pandemic response on several fronts -- from training contact tracers and case investigators to testing and equitable vaccine planning -- since shortly after Cullen arrived.  Launched last May, the USPHAU is currently working with cities, states, and communities throughout the country that have borne the brunt of the pandemic.

Racism as a Public Health Crisis

Beyond any particular treatment, Cullen says, COVID-19 has forced a nationwide reckoning: illness can’t be fully understood outside of its larger social and political context. The virus has exposed the deep, long standing economic and medical inequities in the U.S. fueled by this country’s history of racism. Cullen said it’s important to call this out explicitly. That’s why, in November, the health department supported the Pima Board of Supervisors in passing a resolution declaring racism a public health crisis. Joining about 70 other counties across the country, Pima administrators concluded that “racial and ethnic health disparities and income inequality in the county” has become an emergency. The resolution pledged, among other things, to expand the county health equity program and ensure a more just, fair pandemic response and future recovery.

PIH is deeply involved in these efforts and, says Cullen, critical to their success. English, the senior project lead, said her team helped forge the partnership between the health department and the Tucson Indian Center, which offers health and other essential support services to nearly 20,000 urban indigenous residents of Pima County who, because they do not live or work on one of the two Tribal Nations there, can’t access needed resources.  The USPHAU is also assisting the health department to coordinate safe back-to-school plans.  And, with USPHAU support, Pima County care resource coordinators helped more than 10,000 individuals and families connect with essential health and medical resources, from keeping the electricity on to coordinating mental health services for people suffering from anxiety and depression. 

Now, English says, while her team continues to support the emergency response, including vaccine messaging and access, they’ve also been asked to collaborate on Pima County’s ambitious new plan to “recover and rebuild” a resilient public health department of the 21st century that is stronger, more equitable and better attuned to the community’s needs.

English says what’s exciting about the Pima County engagement is the collaboration alongside a broad, diverse group of partners.

“Some days we are ‘in the weeds,’ working on a specific challenge such as scripting and data fields,” she says. “Other days we are helping the health department leadership white board a ‘Post-COVID Recovery Strategy,’ or providing policy recommendations that would impact all of the county’s 1.1 million community members. We are constantly learning and adapting our approach to ensure health equity is always front and center."

"Yes, we are working on COVID-19 response, but perhaps more importantly, we're also helping to transform the culture of the health department.”

Restoration and Resilience

To that end, Cullen recently met with Black church leaders about vaccine rollout plans. She was peppered with questions for about an hour. Why should people trust the vaccine when it hasn’t been studied long term? What about the new variants? Why is Bill Gates involved? Does it alter your DNA? (It does not.)

With each question, she responded calmly and earnestly, frankly acknowledging the health system’s profound flaws. “We know that people of color have suffered more than other people,” she said. “We just have to acknowledge that African American, American Indian, Alaskan Natives, Hispanic populations have died, and gotten the disease at a much higher rate than any other group in the county and in the country. And those groups are the same groups that have had less access to the vaccine.”

Cullen closed the discussion by noting a few “good things” about COVID-19.

“The one I’m struck by is that COVID-19 has given us this opportunity as a health department to reach out and engage with communities that we probably skittered by...but didn’t have a true collaboration with," she said. "I'm hoping that this is the beginning of that as we move forward...There is a time after COVID-19, and [with] restorative justice and resiliency, we can work together to build a healthier community.”

Just weeks ago, Erick Alarcón spent his days racing motorcycles, working in construction and providing for his family. But a diagnosis of tuberculosis brought everything to a standstill.

“I already knew that something was wrong,” recalls the 20-year-old. “I felt a little nervous, worried, and ashamed. I had heard about this disease, but I never thought I would get sick.”

Alarcón is one of thousands of people who recently received free TB testing from Socios En Salud, as Partners In Health is known in Peru, through a new tool called Mochila TB, or “Backpack TB.”

As of early March, Mochila TB became the latest tool in Socios En Salud’s decades-long fight against tuberculosis, bringing testing to people in hard-to-reach areas and helping them take the first step on a cumbersome but crucial road to wellness.

Backpacks and Blue Trucks

Before COVID-19, tuberculosis was the world’s deadliest infectious disease, despite being curable and preventable. Each year, 10 million people contract the airborne, respiratory disease and as many as 1.4 million die—a burden that disproportionately impacts low- and middle-income countries due to centuries of global health injustice.

Peru has one of the highest TB incidence rates in the Americas and one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB) in the world. Socios En Salud has been fighting tuberculosis in Peru for decades, ever since it responded to an outbreak of MDR-TB in Carabayllo, a community outside of Lima, in 1994.

In the years since, Socios En Salud has expanded its work fighting TB, partnering with Peru’s Ministry of Health to train clinicians, hire community health workers, and launch active search strategies such as TB Móvil, which uses campers known as “blue trucks” to bring TB testing to more than 210 people per day. These vehicles set up in streets, squares, parks, markets and health centers and offer free testing for TB and, within the past year, for COVID-19.

But these “blue trucks” can’t reach every patient, especially those in prisons, human settlements, shelters, and rural hillside communities not accessible by car. That’s why Socios En Salud recently began using Mochila TB, a tool that takes testing directly to patients, wherever they may be.

“We expect Mochila TB will become a necessary tool to reduce the gap in TB cases without diagnosis and to reach the most remote places, where the population needs it most,” says Karen Tintaya, director of Socios En Salud’s tuberculosis program.

Mochila TB gets its name from the backpack-like machine at the heart of the intervention. The machine is compact and portable, can test as many as 80 people per day, and emits less radiation than a conventional x-ray machine.

It’s a marriage of digital radiology, artificial intelligence, and molecular biology—and it’s already made an impact. Since early March, Socios En Salud teams have used Mochila TB to serve 3,491 people in some of Carabayllo’s most impoverished communities, helping them access testing, a diagnosis, and care.

‘All I want is to get better’

When Alarcón heard about Socios En Salud’s health campaign in his neighborhood, he went to the local health center, where he received a sputum test and chest x-ray. Days later, the diagnosis came: sensitive pulmonary tuberculosis.

It was daunting news. But he wasn’t alone.

As soon as Alarcón was diagnosed, community health worker Cristina Capristano was there to support—helping him book appointments, get medications, find mental health care, and access social support.

It’s a task that the seasoned community health worker finds both challenging and rewarding.

“For many years, I have seen tuberculosis patients recover,” she says. “That is the most gratifying thing I can receive [from my work], because they are also my family.”

In the months ahead, she will regularly check in with Alarcón, making sure he has access to his medications as well as the mental health support and material resources needed to complete a months-long treatment regimen that is, for many, painful and demanding.

Alarcón knows the process won’t be easy. But the young father is determined to recover, and not only for his own sake.

“I do everything possible to keep my family healthy and whole,” he says. “All I want is to get better.”

The tide of violence directed at the Asian American and Pacific Islander community is a deeply disturbing trend that has been rising significantly over the last year. Between March 2020 and February 2021, nearly 3,800 hate incidents—including verbal harassment, physical assault, and online harassment—have been reported to the Stop AAPI Hate reporting center. That number undoubtedly represents only a fraction of hate incidents that occurred, but went unreported. This most recent wave of racism has brought to the forefront discrimination against the Asian American and Pacific Islander community that has existed for centuries.

We share the collective grief and anger that our Asian American and Pacific Islander community members are experiencing and recognize their exhaustion and frustration at the ways in which public and private sector leaders—including those who govern, educate, and stand to protect and serve communities—have been ignoring and downplaying such acts of violence and racialized misogyny.

Facing a global pandemic together has proven the interconnection and interdependence of our communities. Nevertheless, the pandemic has been used as a platform for disseminating a poisonous anti-Asian sentiment to incite and justify hateful acts of violence against people based on their racial or ethnic background. As a country that seeks to value human life and the dignity of all individuals, the recent escalation of racialized hate crimes in the United States demonstrates that this is far from the day-to-day reality.

We support meaningful actions around anti-Asian racism in our community. We applaud the critical work that has been and continues to be done by NAPAWF, Stop AAPI Hate, Chinese Progressive Association, Asian Americans Advancing Justice - Atlanta, and GBLS Asian Outreach Project--to name a few.

As we stand in solidarity with Asian American and Pacific Islander community members and condemn the recent crimes driven by hate, we are reminded that racism, xenophobia, and misogyny are structurally embedded in our society. We are mindful that our collective struggle for freedom, liberation, and justice is intersectional. Anti-Asian racism, anti-Black racism, and gender-based violence are all in service to white supremacy and the oppressive system it operates — a system that must be confronted and systematically weakened until it is abolished.

We remain hopeful that, through collective advocacy and action in support of and alongside the Asian American and Pacific Islander community, we can turn the tide of violence, hatred, and bigotry and—together—build a stronger, more just, and equitable society.

The COVID-19 pandemic has severely disrupted care and services for people living with tuberculosis—until recently the world’s deadliest infectious disease—draining or diverting resources and potentially costing hundreds of thousands of lives that could have been saved with adequate screening and treatment.

“Modelling work suggests that if the COVID-19 pandemic led to a global reduction of 25% in expected TB detection for six months, then we could expect a 26% increase in TB deaths, bringing us back to the levels of TB mortality that we had in 2012,” reads a December statement from the World Health Organization. “Between 2020 and 2025 an additional 1.4 million TB deaths could be registered as direct consequence of the COVID-19 pandemic.”

The WHO added that those “are likely to be conservative estimates” because of other pandemic-related impacts on TB care, such as treatment interruptions and potentially greater transmission of the disease.

Dr. Michael Rich, senior global health physician for Partners In Health and co-leader of the international project known as endTB, acknowledged those impacts—saying the numbers could translate to 400,000 additional deaths from TB this year alone—but also noted that the WHO estimates are just one possible scenario.

“Now it’s our duty to make sure that doesn’t happen,” Rich said.

As the global health community marks World TB Day on March 24, Rich reflected on the past year and praised PIH and endTB teams around the world, who have kept clinical trials afloat despite health systems stretched beyond capacity. It’s vital work: the endTB partnership is a multi-year, international effort that is running the biggest trials in the world for severe TB, led by PIH and conducted in partnership with Médecins sans Frontières, Interactive Research & Development, and financial partner Unitaid.

EndTB’s overarching goal is to find better, shorter regimens for hard-to-treat, multidrug-resistant TB (MDR-TB) through greater use of the first new TB medications in nearly 50 years—bedaquiline and delamanid. The partnership is working to improve MDR-TB treatment in 17 countries, including six that are involved in clinical trials.

Rich said teams in those six countries—Kazakhstan, Lesotho, Peru, India, Vietnam, and Pakistan—marshaled resources last spring to keep the trials going, while using lessons from one deadly respiratory disease to help the world respond to another.

“Once COVID hit, there was an all-out heroic response from the teams involved in these clinical trials, to keep TB staff and patients safe from COVID, and to keep the trials intact,” Rich said. “The trials are going to be delayed about a year, but they haven’t been compromised, and that is due to the work of all the teams on the ground, and Unitaid support.”

Regional Impacts on TB Care

The effects from COVID-19 have varied among endTB countries. But the pandemic has hit hard in Peru and Kazakhstan, two of the three endTB countries—along with Lesotho—that PIH supports on a long-term, systemic level, working with the government to strengthen health systems.

“Our highest-enrolling country for endTB trials was arguably the worst-hit country for COVID-19 in the whole world,” Rich said, referring to Peru and pointing to the very high COVID-19 mortality rates it suffered for much of the past year.

EndTB teams in Peru, he said, worked with Socios En Salud, as PIH is known there, to support high-quality testing for COVID-19. Teams also adapted many TB screening measures, such as door-to-door visits and mobile testing units, to the COVID-19 response. 

On the other side of the globe, Kazakhstan remains among countries with the highest MDR-TB burdens in the world, and has been hit very hard by COVID-19. In fact, in the largest city of Almaty, a TB hospital had to be fully converted to take care of COVID-19 patients.  PIH and endTB clinical teams have met those challenges by conducting screenings on roadsides or open fields, among other measures, to maintain social distance, continue TB treatment and keep patients and health care workers safe.

Some countries have seen setbacks. South Africa was involved in the endTB clinical trial, Rich said, and had to stop enrolling new TB patients because of the pandemic, choosing instead to only follow up with those currently enrolled.

“There’s a real risk that COVID is going to set research in a lot of diseases way back,” Rich said. “We have to preserve research and keep things moving forward.”

Testing, Diagnosis for TB and COVID

Some of that ongoing research, for example, is examining effects of COVID-19 on active TB patients. Rich said that, while “we know it’s not as bad as we feared,” much remains to be learned about how the diseases interact and how to best screen and test for both.

Because symptoms can be similar—persistent cough, fever, and shortness of breath, for example—a patient suffering from TB could get an inaccurate diagnosis, Rich said, because clinicians are focused on COVID. That patient could then unknowingly spread TB.

“There’s a super-strong case that we should be doing concurrent testing for both,” Rich said. “Many people who have symptoms of TB also meet the criteria for getting a COVID test.”

Scientists are still working out specifics of concurrent testing, such as whether you can test for both diseases on the same sputum sample.

“Right now, we’re mostly taking two different samples—a nasal sample with a swab for COVID, and a sputum sample for TB,” he said.

But, born out of these challenges, there is real promise for innovation in respiratory disease diagnosis and treatment.

“There’s a clear, feasible mechanism to really scale up molecular testing for TB based on what we’ve seen done for COVID,” Rich said. “It’s really allowed us to leapfrog what we think is possible.”

The massive global need for COVID-19 tests has exponentially increased demand for diagnostic equipment, Rich said, ultimately building long-term testing capacity that could bring prices down and lead to new innovations. Those could include screening for multiple diseases from single samples and applying methods of testing for TB drug resistance to COVID-19, as new strains emerge that could require targeted vaccines.

Overall, Rich said, the COVID-inspired global scale-up of molecular testing and diagnosis is creating lab capacity “in a much higher degree than even our imaginations were taking us.”

Improved Safety Protocols

A second silver lining of COVID-19, he said, is the dramatically heightened awareness of public health and safety protocols, such as wearing personal protective equipment (PPE) to prevent illness, and considering solutions for better ventilation in buildings.

In emergency rooms across the U.S., doctors now are in full PPE for patients who have so much as a cough. 

“Maybe they should have been using more universal PPE before,” Rich said, comparing COVID protocols to TB care, which requires broad, standardized use of masks and PPE.

“The most dangerous part of TB care can be when people walk into a clinic to get diagnosed,” Rich said. “If protocols aren’t followed correctly from the start, those clinicians and other patients are just sitting there, getting exposed to TB. … We now have an opportunity for better infection controls and protocols everywhere.”  

Additionally, he said, new emphasis on ventilation, bacteria-killing UV lights, and administrative practices such as proper triage all could have lasting impacts for reducing infections far beyond COVID-19.

“All of those areas have been significantly boosted because of COVID, and that can be a good thing,” he said.

Fast Vaccine Development

Lastly, he said, the creation of COVID-19 vaccines within a year—granted, building on science that had been in the works for decades—shines new light on the potential for curtailing disease outbreaks when global interests and resources are aligned.

“That is a silver lining for the medical community—that we now have the ability to get a vaccine for a disease within a year,” he said. “What’s the list of diseases that we should now put out the full, same effort for?”

While not all diseases are appropriate for a vaccine, the COVID-19 response suggests that, when the next pandemic strikes, people might more willingly quarantine and slow the spread of a virus knowing that scientists can quickly develop medicines and vaccines.

Building that confidence, though, will require new levels of sustained, global collaboration, from academic institutions to national governments and international organizations.  Better surveillance systems looking for the next pandemic, and functioning globally, also will be critical.

“We now understand that clinical researchers need to be more collaborative,” Rich said. “The more people you have working on a problem, the better.”

Partners In Health and Lesotho’s Ministry of Health marked World TB Day with two distinct actions: conducting community tuberculosis screenings in rugged Buta-Buthe District, one of the most mountainous regions of the world’s only country entirely above 1,000 meters; and launching intensive TB screening programs in factories and prisons in Maseru, Lesotho’s capital.   

Factories, prisons, and other crowded, unsanitary areas with poor ventilation can be hotspots for TB, one of the deadliest infectious diseases on the planet. PIH, known locally as Bo-mphato Litsebeletsong Tsa Bophelo, has supported the Lesotho government’s fight against TB since 2006.

PIH’s work is strengthening public health systems and improving outcomes for patients in the rural, southern Africa nation with one of the highest TB burdens in the world. PIH collaborates with Lesotho’s Ministry of Health to run the national program for multidrug-resistant tuberculosis (MDR-TB), a severe form of the airborne, respiratory disease.  

The center of that program is PIH’s Botšabelo Hospital. The growing campus in Maseru is the nation’s only hospital for people with MDR-TB, and reaches patients nationwide. PIH’s TB outreach programs offer resources, screening, and health services to families and communities in hard-to-reach districts of Lesotho, connecting people to lifesaving treatment and care, conducting contact tracing, and providing preventative TB therapy to people who have been in contact with TB patients.

Meanwhile, clinicians and staff on the hospital campus provide lifesaving care and support for patients, who very often are battling severe TB along with HIV, hypertension or other diseases.

Such as COVID-19.  

As we mark World TB Day on March 24, Botšabelo Hospital has expanded over the past year to support care for COVID-19 patients across Lesotho, while also improving care for TB patients.

A new oxygen plant installed at the hospital in December is the first such facility in Lesotho and will save lives during the respiratory COVID-19 pandemic and beyond.

PIH also has laid the foundation for an expansion of Botšabelo’s lab, and is building an isolation and treatment center for MDR-TB patients who are co-infected with COVID. PIH teams have added an on-campus wellness center for staff, and renovated outdoor space where patients can spend time safely with visiting family and friends.

And, as Lesotho starts receiving COVID-19 vaccines—the first batch arrived earlier this month—PIH supported the vaccine rollout and provided transportation for vaccines and health care providers in five districts. PIH’s frontline staff also have received the first dose. PIH also is helping the Ministry of Health oversee the national vaccine rollout.

Dr. Melino Ndayizigiye, executive director of PIH in Lesotho, said ensuring that vaccines reach all corners of the country is vital for the eradication of COVID-19. Botšabelo Hospital’s warehouse and supply chain teams are ready to support that work, and help Lesotho spread COVID-19 vaccines across the country.

All of that work, at Botsabelo and beyond, will boost PIH’s TB care and health services for years to come, so Lesotho can continue fighting TB while preparing for the next pandemic, and ensure all Basotho people have access to health care and a stronger future.  

While pregnant with her second child, Maral Shorayeva began experiencing symptoms that felt like a cold or flu, but when she went to give birth to her daughter, doctors recognized that something was wrong. They suspected she had tuberculosis. Shorayeva, who was 25 at the time, says a nurse took her newborn away immediately, without giving her a chance to hold her daughter. She had already gone through more than a year of TB treatment while pregnant with her first child, her son Bagdad, who was born in 2016. Three years later, she faced her second uphill battle against the airborne infectious disease.

Before COVID-19, TB outpaced HIV as the deadliest infectious disease globally, accounting for 1.4 million deaths in 2019 alone, according to the World Health Organization. In Kazakhstan, where Shorayeva and her family live, TB—and in particular multidrug-resistant tuberculosis (MDR-TB)—is all too common.  According to the WHO, Kazakhstan is among 30 high MDR-TB burden countries, with an MDR-TB incidence of 22 per 100,000 people.

For more than 30 years, Partners In Health has fought TB—in all its forms—and helped thousands of patients reach a cure for this deadly disease, which often affects marginalized communities, such as those experiencing homelessness, living in crowded homes, or the incarcerated. In Kazakhstan specifically, PIH has been treating MDR-TB across 65 percent of the country since 2009, in partnership with the local and national government.

Some of PIH’s recent and most impactful work in Kazakhstan falls under the Expand New Drug Markets for TB, or endTB, project, which aims to find shorter, less toxic, and more effective all-oral treatments for patients suffering from MDR-TB. As the lead implementing partner, PIH works with Médecins Sans Frontières, Interactive Research & Development, and financial partner Unitaid across 17 countries with high TB burdens.

EndTB is bringing relief—and much-longed cures—to hundreds of people, some of whom have battled the disease for years. As one example, 675 patients in Kazakhstan had been treated as of last January for drug-resistant tuberculosis with Bedaquiline and Delamanid, the first new TB drugs to have been developed in half a century.

The current endTB clinical trial, which is part of the endTB project and is being conducted across 7 countries—including Kazakhstan, evaluates the efficacy of new combinations of drug regimens for the treatment of MDR-TB. So far, the PIH team has enrolled 150 patients, 51 of whom have completed treatment and are in post-treatment follow-up.

“Being in the study gives patients a good chance to get shorter treatment with new TB drugs,” said Nataliya Morozova, program associate who works with PIH in Kazakhstan and Russia.

TB Care, and Food Coupons

Shorayeva was among those treated and cured. She agreed to participate in the endTB clinical trial, which meant she would receive treatment for only nine months, in comparison to the standard 20 to 24 months that is currently worldwide protocol for MDR-TB, Her daughter was sent home with her husband, who—with help from his sister and brother-in-law—managed to care for both the infant and older child.

Shorayeva, who suspects she caught TB from her father, stayed in the TB ward at the National TB Center  for three months. Even after being cleared to go home, she and her family preferred not to reunite mother and children for another month, erring on the side of caution.

“I was a bit scared that the baby wouldn’t recognize me,” said Shorayeva, “but everything went smoothly.” Her son, who was just 3 at the time, was very happy to see her again.

Shorayeva said she now feels fine and enjoys caring for her children. Still under observation, she continues to receive support in the form of food coupons and transportation passes. Though small, the weekly coupons, worth approximately $5, make a difference for her family, who rely upon her husband’s earnings as a handyman.

Gulnara Zhumakairova, the ambulatory coordinator for PIH in Kazakhstan, is responsible for ensuring patients adhere to treatment and have the support they need to get and remain healthy. Some cases are more complicated than others, such as patients dealing with substance or alcohol addiction, those needing psychological support, or others facing obstacles related to housing.

Food, Shelter as Medicine

Zhumakairova shared the story of a 58-year-old endTB patient she met in 2019 who had fallen on particularly hard times. Takhir Mavliyev needed psychological support, had tested positive for TB, and was living with diabetes. He was also homeless and lacked a valid ID.

“When a person doesn’t have registration, he cannot be employed,” Mavliyev said. “I could have found a job as a janitor, but even that requires registration.”

Assessing Mavliyev’s situation, Zhumakairova got to work. She referred him to psychological support and to Sanat Alemi, a local organization that had experience helping undocumented people get registered for an ID.

During the beginning of his treatment, Mavliyev stayed at the TB Center in Almaty. Once the COVID-19 pandemic started, the TB Center was converted to a specialized treatment facility for COVID patients, so Mavliyev was transferred to a different TB hospital where he completed treatment. However, the patient was homeless and did not have a place to go once he was ready to be discharged.

PIH stepped in, about a month before that date arrived. The doctor leading Mavliyev’s treatment and PIH staff started looking for accommodations for him. PIH eventually arranged and paid for a hotel room for a month.  Mavliyev said he was happy with the accommodation and appreciated having a room to himself, complete with a television, shower, and breakfast every morning.

During that time, Mavliyev got his ID and started rebuilding his life. “One month in the hotel really helped me,” he said. “I’m really grateful for the help I received from PIH. Otherwise I wouldn’t have known what to do.”

Now, Mavliyev is living in a room he rents in a hostel and driving a taxi. He continues to receive weekly food coupons, which he said buy him basic foods like buckwheat, oatmeal, coffee, and cottage cheese. At 5’4” and 116 pounds, he was severely underweight when he enrolled in the endTB clinical trial. But during the course of his treatment, he gained more than 30 pounds.

Food is important for MDR-TB patients, and an essential part of PIH-supported treatment, as TB drugs are more tolerable when patients are properly nourished.   

“Participation in the program helped me a lot,” he said. “The treatment wasn’t that long, and I got cured. I’m grateful to the doctors and health staff that helped me at the hospital.”

At the center of the campus of Lakka Government Hospital, a mango tree stands, its wide branches offering a shaded gathering spot for patients looking for conversation and camaraderie. Many of them have lived at the hospital for months, with even more challenging treatment still ahead.

“They call each other outside, gather under the tree, chat, talk about personal issues,” said Dr. Girum Tefera, Partners In Health’s clinical consultant at Lakka: the only dedicated tuberculosis hospital in Sierra Leone, located on the outskirts of capital city Freetown.

For one patient at the hospital, however, the tree was a symbol of anguish and adversity, rather than a source of comfort or connection. In June 2019, Saffiatu Sesay was brought to Lakka paralyzed from the waist down and unable to breathe easily. After two battles with tuberculosis the year prior, a lab test indicated that the disease had reemerged in its deadlier, harder to treat form: multidrug-resistant tuberculosis (MDR-TB). And based on her paralysis, it had worked its way into her spine.

Forced to abandon school in order to undergo inpatient treatment—and with zero mobility and exhausted by her illness—the 26-year-old, when she wasn’t sleeping, spent her time staring outside, watching groups of patients underneath the mango trees.

“Each time I looked outside my window, I felt bad—remembering how I was before, realizing I was unable to do anything for myself,” Sesay said. “I could not go out and see the world.”

A Hospital Transformed

When Sesay arrived at Lakka, clinicians were optimistic about her prognosis.

Tefera, who joined PIH Sierra Leone shortly before Sesay’s admission, brought years of experience from working in one of Ethiopia’s MDR-TB Centers of Excellence and with PIH’s endTB project. He had successfully treated cases of spinal TB before and had not only the necessary knowledge and experience, but also the tools to do so at Lakka.

Just three years earlier, this wasn’t the case: It wasn’t until 2017 that such treatment existed in Sierra Leone, when PIH and the government’s National Leprosy and Tuberculosis Control Program established the country’s first MDR-TB treatment program at Lakka, and partnered to improve and expand care there. The National TB program introduced never-before-available MDR-TB drugs, as well as diagnostic equipment and additional clinical staff to deliver this new kind of care.

PIH supplemented these lifesaving resources with ongoing support in supply chain, stocking pharmacy shelves with ancillary drugs to treat TB complications; infrastructure, renovating wards to make them more comfortable and dignified; social support, ensuring access to care; and clinical mentorship from experts like Tefera.

Such investments have ushered in further growth: Whereas the partnership’s sights were once set on establishing infrastructure as basic as 24-hour electricity and running water, last year PIH and the National TB Program opened a high-dependency unit, providing clinicians the necessary space and equipment to care for critically ill patients. And whereas any MDR-TB medications used to be completely novel, together PIH and the government recently revised national treatment protocols to prioritize bedaquiline, the most newly developed oral tuberculosis drug, proven in part by endTB to be less toxic, more humane, and therefore more easily adhered to and effective.

All told, in a country where for decades MDR-TB was a death sentence, the National TB Program and PIH have built up Lakka as a tuberculosis hospital that cures 75 percent of its MDR-TB patients—a rate significantly higher than the global average of 57 percent, and one that would include Sesay.

“Waiting, Waiting, Waiting”

Even with the most modern of health care, however, tuberculosis is a brutal disease whose treatment remains notoriously punishing. This is all the more true of its drug-resistant form, whose second-line treatment requires patients to increase their medication intake from the standard three or four daily TB pills to up to 20 daily pills, with a litany of uncomfortable and complicating side effects for up to two years.

Drugs and medical infrastructure are crucial to the success of treatment. But equally important, says Tefera, is care and support for patients’ mental health.

“In MDR-TB care, whenever we receive a new patient, the first thing we need to do is address their headspace,” Tefera explained. “What I usually do is pick one or two exemplary patients who came bedridden and now are mobile after getting the treatment, and call them to share their experiences and give the new patient advice in their same language.”

That support is vital for patients, especially those who are nervous or skeptical about the treatment.

“Because they come very sick, and having been through two or three phases of tuberculosis treatment that didn't work out, they believe this time also not will not work out,” said Tefera.

It’s also difficult for patients to overcome the stigma that persists in Sierra Leone and around the world against tuberculosis—even with the cure rates seen at Lakka.

“During previous eras, people knew that a patient who contacted tuberculosis was going to die, because of absence of treatment and limited access to health care,” Tefera said. “And because of the infectiousness of the disease, when people realize a patient has tuberculosis, they no longer want to live with them. Most patients coming to Lakka don't have adequate family support. They are typically poor and abandoned.”

In this way, Sesay was an exception: As she moved into the MDR-TB ward to begin inpatient treatment, she had the support of her older sister, Isatu, whom PIH helped move into a free room on hospital grounds. But as Isatu cooked, did laundry, and helped her sister bathe, the rest of the Sesay family agonized over the future.

“My mother was always crying, telling people, ‘Saffi will not come home again,’” Sesay said.

Confined to her bed and swallowing 15 pills a day, she too had little hope.

“The doctors, especially Dr. Girum, constantly encouraged me and told me I would stand again and be okay. The nurses would talk with us, laugh with us, make us their best friends. And my sister was with me all the while,” said Sesay. “But I never thought I would walk again.”

“When TB involved with the bone, the progress you see is very slow. You don’t take the medicine today see the response tomorrow,” Tefera added. “Saffiatu was waiting, waiting, waiting, with nothing happening. There were times she was asking us to just go back home.”

To the Mango Tree

The turning point came three months into treatment: Sesay wiggled her toes and, soon, her entire foot.

“She then started fighting,” Tefera said. “She was optimistic. We started giving her instructions on how to move, physiotherapy; we encouraged her to go outside with wheelchair. I promised her, ‘The first day I see your feet on the ground with no assistance, I will buy you a dress for you to wear out to dinner.' At seven months, that was what happened.”

After seven months of treatment—sooner than Tefera predicted, or considers standard in a case of spinal MDR-TB—Isatu rushed to tell him and other Lakka clinicians the news: Sesay was standing on her own and, with support, could walk.

“It was not easy; I felt serious pain in my knees and legs, and I would fall down,” Sesay said. “But I was so excited.”

The rest of the hospital shared in her happiness.

“No one will forget that moment,” Tefera said. “It was a different day. We ran over and saw Saffiatu’s smile, and every patient was gathered, shouting and clapping, encouraging her, ‘Now you can join us outside.’ Starting then, nothing could prevent her from going out. She's always outside, mixing with other patients, chatting with friends.”

The next month, Sesay was discharged to continue treatment at home, with monthly visits to Lakka for check-ups and medication refills. As part of standard care for Lakka patients, she received a stipend to pay for a taxi or motorbike ride to these appointments—an essential resource for patients facing poverty and distance as barriers to care. For Sesay, who returned home to her family, a four-hour drive away from the hospital, that social support was a lifeline.

“Even without the money from PIH, I would have looked for other ways,” Sesay said. “I would have sold my belongings just to come for my medicine—because I know what I went through at the hand of MDR-TB. I take it every day, since the doctor told me if I skip a day, the illness will reoccur.”

Her dedication paid off: After 14 months of outpatient care, on February 25, Sesay was declared cured of MDR-TB.

“Something to Look Forward To”

Sesay, now 28, is looking ahead to the future.

PIH, including PIH Program Officer Armah Quist, is there to support her as she takes her next steps. Quist, who manages social support programming at Lakka, is an advocate and confidant for many patients at Lakka. Her bond with Sesay endures, and she frequently thinks back to a conversation they had:

“There was a time she sent for me, and when I arrived at her room, she said, 'After here, I don't know what my life will look like. I’ve lost almost everything.’ I told her, ‘Coming out of this hospital, you will be a better person. You will be healed again, you will be whole again, and you will have something to look forward to.’ And I asked her, ‘What do you want to do?’”

Sesay responded that she wanted to return to school—and in a later phone call, got more specific.

“She said, ‘I want to be a nurse.’ So we’re pushing that forward,” Quist said. “When Saffiatu thinks all hope is lost, that's why we are here as PIH. We come to support these kinds of patients to give them hope again. I'm here for her. We are all here for her.”

Quist is currently working with Sesay on plans to restart her education—with funding from PIH and an eye towards eventually entering a nursing course. One day, Sesay hopes to deliver the same lifesaving care and support—material and moral—she received at Lakka.

“If it hadn’t been for the help of the good health care workers at Lakka, it would have been a different situation for me. I want to give back to other sick patients,” she said. “One thing about this health condition is: If you have people who encourage you a lot, you will survive."

Abelino Hernández is originally from Guatemala, but he has worked in neighboring Chiapas, Mexico, for several years to make a living and support his loved ones. He used to work on coffee plantations during Chiapas’ harvest season, from about October to March, and it was common for him to develop a cold due to the frigid weather in the mountains. But during the past year, he began to have a strong cough that felt more severe than a cold.

"It hurt a lot to cough," Hernández says. "My throat bothered me a lot. I couldn't even eat anymore because it burned when I passed saliva."

His employer at the coffee farm suggested that he go to the nearest hospital, about a three-hour trip from the community where Hernández worked. But he was hesitant to go, due to rumors he had heard—during the pandemic, misinformation about health services has run rampant in Chiapas’ rural communities.

"They said that in the hospital they killed people, and I didn't want to die," Hernández says.

But each day, Hernández became weaker. Within weeks, he could no longer stand up, eat alone or go to the bathroom. It all came crashing down one day in a hotel room, when Hernández, feeling faint, asked the hotel owner for a glass of water. Before they could hand him the glass, his vision blurred and he lost consciousness. He woke up in a hospital room at Ángel Albino Corzo Community Basic Hospital, in the Chiapas city of Jaltenango de la Paz.

Looking for answers

For many people in Latin America, it is difficult to find jobs to support their families—a challenge that has only worsened with the COVID-19 pandemic. This prompts them to try their luck in other countries and take a leap of faith in an unfamiliar place, often putting their own lives at risk through heightened exposure to violence, high-risk jobs, and lack of social support.

Partners In Health has worked in Mexico since 2011 and is known locally as Compañeros En Salud. Its programs include mentorship of first-year clinicians; training and support for community health workers; and support for a birthing center, rural primary care clinics, and the Ángel Albino Corzo hospital in Jaltenango—where Hernández was rushed for emergency care.

"I opened my eyes and I didn't know where I was," Hernández says. "I asked a doctor and she told me we were in the hospital. Then I started crying."

The diagnosis wasn’t clear, at first.

Hernández had a cough and fever, so doctors thought it could be COVID-19, since there had been a surge of infections in Chiapas that month. But when they asked more questions, they discovered that he had been suffering from his symptoms for six months. Compañeros En Salud’s clinical team took a chest X-ray, which revealed the diagnosis: Hernández had tuberculosis.

Tuberculosis is the world’s most deadly infectious disease, killing 1.4 million people in 2019 alone, according to the World Health Organization. In Mexico, new cases of tuberculosis arise every year in more than half of all municipalities in the country. Although the mortality rate in Mexico has decreased in recent years, many people continue to die from TB because of a lack of access to medicine.

Treatment for tuberculosis can last between six and nine months, and is intense. For Hernández, it was going to be difficult to take the drugs and cope with their side effects for so long without family, money or belongings in Mexico—his employer had burned all of  Hernández’s clothes and possessions, out of fear that he was infected with COVID-19. And Hernández had nowhere to go—the Mexico-Guatamala border was closed due to the pandemic, and staying in the hospital would be impractical and damaging to his mental health.

Fortunately, Compañeros En Salud was aware of these challenges—and ready to respond.

Compañeros En Salud offered Hernández free housing in a guest house normally used by volunteers. CES also formed a support team of doctors, interns, and volunteers who mobilized to take care of Hernández. Members of this team took turns bringing him food, giving him his medications, and staying to talk with him.

Specialized care and attention are vital to successful TB treatment. To help patients maintain the grueling treatment regimen and manage side effects, PIH teams from Lesotho to Kazakhstan utilize treatment supporters and health care workers—often assigned to a single patient at a time—to make daily checkups and help ensure healthy recovery.

With the support of Compañeros En Salud’s Right to Health program, Hernández was able to visit specialist doctors and carry out lab tests at a specialized hospital in Tuxtla Guitérrez, complementing the treatment he received in Jaltenango thanks to the Health Jurisdiction of Villaflores.

The Right to Health program supports patients with transportation, food, accommodation and accompaniment when they have to travel for several hours to the state or country capital for medical consultations with specialists. This support relieves the burden on patients as they navigate Mexico’s health care system.

And Compañeros En Salud’s care for Hernández was more than just medical.

"Doctor visits became social visits," says Dr. Martha Arrieta, coordinator of primary care at CES, who followed Hernández’s treatment closely. “It was incredible to get to know him and to be able to know his life experience, where he came from and what had happened in his life. Visiting him was one of the most beautiful parts of my day.”

As he recovered in the guest house, Hernández and Compañeros En Salud staff shared stories, discussed their worries and frustrations, and learned from each other. He learned to cook, read, and paint with the rest of the team. They also sang, watched movies, and listened to music. Little by little, he was recovering—not only learning to manage his symptoms, but learning to enjoy life again.

A path to wellness

Recovering from an illness is never a linear process. On different occasions, Hernández got sick again, had a fever or developed gastrointestinal problems. His case was challenging and complex for the Compañeros En Salud team to manage, as they mobilized not only in response to tuberculosis, but also COVID-19.

TB will continue to be a vital issue in Mexico, and around the world, long after the COVID-19 pandemic subsides. With proper treatment, the disease is perfectly curable; but many people struggle to access lifesaving medicines and medical services. It is vital to focus on awareness, prevention and treatment to eliminate stigma and prevent deaths.

Accompaniment is also vital, giving patients the support they need to recover.

Hernández always believed in his ability to heal. Day by day, he became more self-sufficient and regained his strength. In December 2020, he finished his treatment regimen—and a few weeks later, returned to Guatamala to be with his family.

“Now that I return to Guatemala, I am happy to see my cousins,” he says. “But I'm also sad to go. Nothing will be the same. They have taken good care of me here. "

At Partners In Health, Earth Day is a moment to reflect on the intersection of climate change and global health, in that those most affected by natural disasters and disease are often marginalized communities.

That’s why PIH, more than ever during the COVID-19 pandemic, is urging greater global collaboration so that work toward climate justice prioritizes the world’s most vulnerable and addresses health concerns that extend far beyond clinical care.

“All rights and social justice issues are interdependent and therefore require collective action,” said Joel Curtain, PIH’s director of advocacy. “Achieving health equity also requires environmental, social, racial, and economic justice.”

As a social justice organization that strengthens health systems, provides and supports medical care, and trains local health care workers in 11 countries around the world, PIH has a firsthand view of how the global climate crisis affects human health—from the increased frequency of devastating natural disasters to rising air pollution, food insecurity, and clean water scarcity.

PIH staff and clinicians see the evidence through cholera outbreaks after devastating floods; HIV and tuberculosis epidemics fueled by malnutrition and air pollution; and rampant malaria amid severe rainy seasons, floods, and deadly storms.

And now, as the world battles COVID-19 and scrambles for resources like clean water to maintain good hygiene, it has never been more evident that pandemics highlight inequality and injustice on a global level—and the communities that bear the greatest burdens are those that systemically have received the least support.  

In recognition of Earth Day, PIH strongly believes that we can cure the world's worst injustices, together, by addressing planetary health as essential to humanity’s health—and ensuring health as a human right.

During a global pandemic, an infection can happen anywhere—a church, a car wash, a grocery store. But not every setting ends up spreading the virus far and wide.

That’s why Bridget Hanna spends her days looking at maps. For Hanna, an outbreak specialist with the Epidemic Intelligence Unit, these maps of Massachusetts towns don’t just give directions—they tell stories.

“Every COVID case is connected,” she says. “Which is to say, at a basic level, that everybody got it from someone else. But most people will get it from somebody who gave it to a couple of people. And that’s what really makes it a cluster.”

Partners In Health has staffed and supported the Community Tracing Collaborative (CTC) since April 2020, in partnership with the Commonwealth of Massachusetts and local health departments. Since then, the CTC has boosted contact tracing across the state, following up with positive cases and their contacts and connecting them with essential resources for quarantine.

But standard contact tracing isn’t the only tool in the CTC’s toolbox. Through the Epidemic Intelligence Unit, it’s looking to pinpoint the sources of multiple infections, or “clusters,” and use those insights to stop the spread.

Plotting a Pandemic

In public health circles, it’s called “cluster-busting.” The idea behind it is simple: most people will get the virus from someone who gave it to multiple people, or at a place or event where multiple people were infected.

So while standard contact tracing is important, it sometimes can be like playing catch-up. Cluster-busting, instead, looks at the bigger picture and offers a chance to get ahead of the virus—by finding out where a person became infected, who else was there, and what person, place or event was doing the spreading.

Cluster-busting has proven effective in Asian countries such as Japan and South Korea, where average daily cases sat at 1,556 and 421 respectively, compared to the United States’ 68,123, as of late February. In Massachusetts, where average daily cases sat at 1,707, public health leaders have been watching these countries closely—and taking notes.

The Epidemic Intelligence Unit (EIU) was launched in August 2020 as a specialized unit within the CTC, tasked with investigating COVID-19 clusters and delivering intelligence to health officials. The unit includes 40 case investigators and outbreak specialists.

Hanna is one of those specialists.

Her day often starts with reviewing tips from contact tracers—notes about people who tested positive and who reported being at a place or event with several others.

These settings can include workplaces, restaurants, birthday parties, funerals, and more. Since the vast majority of infections occur in a household, the Massachusetts Department of Public Health differentiates between clusters in the home, in long-term care facilities, and all other types. Generally, it defines a “cluster” as two or more confirmed cases with a common exposure.

“If a case investigator sees something like someone went to a wedding, we want to understand right away all the other contacts who were at that wedding,” she says. “Potentially, other people got infected there.”

She dives into the data, pulling reports from the CTC’s database of COVID-19 cases sent by local health departments. She wants to see whether other cases were recorded around the same place and time. That’s where the cluster maps come in.

“We can look at the report of every town and see that, ‘Okay, there are four employees of one auto garage who’ve been infected in the past three days…if we can figure out what’s happening quickly, maybe we can intervene to stop the spread,’” says Hanna.

She uses this data to plot the cases onto maps of Massachusetts communities, pinpointing the locations where the clusters occurred. That intelligence is then shared with local health departments, equipping them to take action.

Importantly, the data is always anonymized and all personal information is kept private. Outbreak specialists are ultimately looking for patterns.

“You get to learn so much about how the virus behaves in different environments,” says Ana Sanchez-Junkin, another outbreak specialist with the EIU. “I feel like we’ve learned a lot of things that help us with community outreach and educating groups in our community on how they can keep themselves safe.”

Working Smarter

Cluster-busting tackles COVID-19 not only retrospectively, but also prospectively. In other words, outbreak specialists don’t just look back in time, at clusters that occurred in the past—they also look ahead, anticipating where clusters may form and taking action to prevent them.

For example, if a person who tests positive is employed at a local business, Hanna can contact the business owner in hopes of preventing a cluster from forming, as contact tracers connect the employee with health care and essential resources. Or, if someone passes away from COVID-19 and a funeral is planned, Hanna and the team can proactively reach out to the funeral organizers and try to prevent the event from becoming a super-spreader.

Both kinds of cluster-busting provide crucial intelligence for health officials, equipping them with the data they need to shape their COVID-19 response.

Sometimes, the next steps are relatively straightforward. One of the first cases Hanna mapped was at a car wash in Chelsea. After detecting a cluster, she met with the local board of health to share her findings and they worked with the business owner to find a solution together—in this case, improving the car wash’s safety protocols, such as cleaning a touchscreen more often.

Other times, outbreak specialists look beyond a cluster of cases and broaden their focus to entire industries, such as retail or manufacturing, delivering intelligence that helps industry leaders and policymakers better understand how transmission occurs and take action.

Each case helps outbreak specialists deepen their understanding of the virus and how to stop it—offering a sense of hope amid a pandemic that has devastated communities and disrupted daily life for millions.

“What keeps us going are the success stories,” says Sanchez-Junkin. “For example, where you can help a business better understand how to stop an outbreak in the workplace…or, I had cases with some churches where they were able to go virtual for a few weeks and then help their communities understand how to keep themselves safe. I feel like those types of success stories are what makes the frustrations and the more technical aspects of the job worth it.”

For Hanna, the work feels both new and familiar. A longtime health advocate, she began her career as a human rights activist, spent years researching the epidemiology of the Bhopal gas disaster for her PhD, and taught global health with PIH Co-founders Dr. Paul Farmer and Dr. Jim Kim at Harvard University.

But this work takes her back to her undergraduate years, when she wrote her thesis on the industrial history of Massachusetts—a chapter she never expected to revisit, much less in the context of a pandemic.

“I know all this stuff about the old, industrial history of the state, which is useful to me as I’m making these calls to different industries and companies,” she says. “I’ve had a very unusual career path. But I feel like everything in my life has prepared me for this moment.”

Dear friends, 

One year ago today, the World Health Organization declared COVID-19 a pandemic—a word that, from its roots, means all people.

At the time—March 11, 2020—PIH teams in 11 countries had been preparing to face the novel coronavirus for weeks. Counting hospital beds, ventilators, and oxygen canisters, we already knew that this illness would most hurt those who already had the least—marginalized people, communities, and entire countries.

One year later, our world stands changed. 

The WHO reports at least 2.6 million human beings lost to the virus—and we know that the true toll, measured in those lost and those left behind, is certainly much higher.

We have witnessed bravery and selflessness in the face of danger and uncertainty, and we know more will surely be needed.

We have found new ways to care for one another—some as simple as a face mask, others as complex as global vaccine delivery—and we know we must do more.

Now we must add this pandemic’s lessons to all we’ve learned in decades of responding to injustice with care. Together, we have the knowledge, experience, and energy to shape our shared future.

Let us make permanent the systems of care we improvised, let us make real the promise of health care as a human right, and let us press forward to stop this tragedy, for everyone, everywhere.

In solidarity,

Dr. Sheila Davis
Chief Executive Officer
Partners In Health