On Human Rights Day, December 10, governments are convening at the World Trade Organization (WTO) to discuss whether to suspend patents and other barriers on medical tools dedicated to COVID-19 response. International human rights law understands intellectual property to be a social construct that cannot interfere with health and other rights, and this measure is key to increasing access to treatments and vaccines so people around the world can be protected from the virus. Unfortunately, the United States, the European Union, United Kingdom, Japan, Australia, Switzerland, Norway, and Canada are all blocking this waiver.

Partners In Health, together with Oxfam, Public Citizen, and other organizations, has argued to the U.S. government for a People’s Vaccine, which would be free and available to all. The decision taken on December 10^th will reveal national commitments to an international order based on universal human rights, which depends upon recognizing that our own humanity is bound up with that of others across the world. 

The U.S. Trade Representative must make the right decision in support of suspending patents and other barriers that would prevent an equitable response to the COVID-19 pandemic.

In addition, the incoming Joseph R. Biden administration can demonstrate much-needed global leadership by mobilizing greater resources for expanding access to vaccines and therapeutics), using provisions in existing legislation to share knowledge and technologies related to COVID response, and strengthening manufacturing and distribution of treatments and vaccines in the Global South. 

These measures are imperative not just for specific vaccines or for this pandemic, but for future pandemics the world will inevitably face. These structural injustices systematically deprive people around the world of lives of dignity and are incompatible with the realization of universal human rights.

Each day from 9 a.m. to 1 p.m., Leini Escalante works at a community clinic in rural Chiapas, Mexico, helping clinicians care for COVID-19 patients. In the middle of the day, she returns home to feed her two children. Then, she heads out again to do home visits with patients who are in isolation.

What may feel like a packed day for some is just a typical day for Escalante, a community health worker with Compañeros En Salud, as Partners In Health is known locally. And her work is critical, especially these days.  Since early March, at least 7,874 people have become infected with COVID-19 in Chiapas, a state in southeast Mexico where 76% of people live in poverty.

Compañeros En Salud works with nine rural communities in the coffee-growing Sierra Madre region of Chiapas. As part of that work, CES hires and trains local residents like Escalante to serve as community health workers, helping patients manage their medications and understand their health status. Currently, CES employs 99 community health workers.

Escalante has been a community health worker (CHW) in the community of Honduras de la Sierra for about four years. She was inspired to become a CHW after living in front of the clinic and constantly seeing other women in her community participating in trainings, visiting patients’ homes, and developing the knowledge and skills to provide care. For many years, she focused on maternal health. But in September, when the pandemic reached its peak in rural Chiapas, Escalante’s work took a new turn—she decided to shift her focus entirely to COVID-19 patients.

In the months since, Escalante has spent her time caring for COVID-19 patients in isolation and supporting the community clinic. She is one of two CHWs entirely focused on COVID-19 patients. In Chiapas—a historically marginalized state with barriers to accessing quality health care, few PCR tests for accurate COVID-19 diagnosis, and a three-hour ride to the closest hospital—her work is essential.

When patients have respiratory symptoms and arrive at the clinic, they are screened and sent home for isolation; there, Escalante visits them regularly. If they have risk factors like diabetes or hypertension, she visits daily; otherwise, she visits every 3 days.

Escalante also supports PIH’s contact tracing team in Chiapas, identifying people who have been in contact with a confirmed or suspected case and keeping an eye on them in case they present symptoms.

“I really like my job, because I feel like I’m doing something worthwhile,” says Escalante. “I help my patients, I talk to them, their families, answer their questions, and earn their trust. It has also been very helpful for me, as it keeps me busy. I used to stress a lot at home, but being a CHW has definitely improved my sense of peace.”

Escalante recalls meeting a patient and identifying some signs of depression in her. As she kept visiting her, the patient started to open up and talk about her personal life, mentioning that she was happy to have someone caring for her and taking an interest in her health.

“I felt very satisfied to know that I was helping someone else, and not just physically, but emotionally as well,” says Escalante. “I’m very grateful for my job. I’ve grown and learned so much.”

A COVID-19 diagnosis is disruptive, not only threatening physical and mental health but also, for many, putting jobs, housing, and food at risk. When Partners In Health launched its contact tracing partnership with the state of Massachusetts in April, supporting local health departments across the state in contact tracing, it was grounded by a simple vision: No patient should have to navigate COVID-19 alone.

Since then, the Massachusetts Community Tracing Collaborative (CTC) has spoken with 124,535 cases of individuals who have tested positive for COVID-19 and their contacts and made roughly 750,000 calls across the state—statistics that speak to the strength of PIH’s approach, informed by decades of global experience responding to infectious disease outbreaks.

The CTC follows a time-tested model: It reaches out to all COVID-19 patients and their contacts, advises them on testing and quarantine, and connects them to the resources needed to stay home and healthy.

CTC staff include contact tracers, case investigators, and care resource coordinators, who provide comprehensive and culturally relevant support rooted in social justice, focusing on communities hardest hit due to systemic inequities in areas ranging from housing to health care. The CTC is more than a contact tracing program—in many ways, it’s a lifeline, connecting patients with advice, resources, and a listening ear as they navigate a daunting and uncertain pandemic.

Watch the video for first-hand accounts from contact tracers. Patients’ identities have been kept anonymous out of respect for their privacy.

Marlene Nez won't let anything get in the way of helping her community, including COVID-19—despite challenges including exposure and needing to quarantine.

As a Community Health Representative (CHR) on Navajo Nation, it is Marlene’s job to ensure individuals and families have the resources—clean drinking water, food, medication—and assistance they need. Though she’s been a CHR for 3 years, her daily home visits look much different these days due to the pandemic.

“We are not able to go into homes. And if we do have to deliver food, then it’s really hard to just stand in the doorway and say that we are just here to drop off these items,” says Marlene. Her elders really want to be able to spend time with her, but she has to let them know she can’t because of the pandemic.

As much as Marlene would like to spend time with those in her tight-knit community in Greasewood Springs, Arizona—a small, rural area west of Gallup, N.M.—she knows that it’s in everyone’s best interest to keep their distance from each other.

“She is always very careful in her work and is very compassionate,” says Olivia Muskett, Community Outreach Specialist at Community Outreach and Patient Empowerment Program (COPE), Partners In Health’s (PIH) sister organization on Navajo Nation. “You can really see how much she cares for her community and how she’s always thinking about others before herself.”

Marlene has always sought ways to help others, long before becoming a CHR. She previously worked in the health field, and most recently has worked helping support many patients. With a desire to give back to the community where she grew up, she applied for a CHR role, which involves robust training including being a Certified Nurse Assistant.

She is one of about 100 CHR program staff on Navajo Nation, who work under the Navajo Nation Department of Health, and form the community foundation of Navajo Nation’s health system. COPE was established in 2009 as a collaboration with the CHR Program, but CHRs have been working with community members since 1968.

Because of the pandemic, CHRs’ role has become even more essential across Navajo Nation, which experienced the highest rate of COVID-19 infection in early months—outpacing even New York City’s. Most recently in the second surge, Navajo Nation is again experiencing one of the highest incidence rates in the country. Marlene and her colleagues have consistently connected families in quarantine or isolation with the essentials they need to remain healthy or overcome illness.

Deliveries, Decisions, and Delegating

When Marlene isn't on the road delivering essentials, she is busy working to find out what individuals need and how to get it to them. Usually, she’s able to offer direct support, but oftentimes it has involved bringing in other key groups, such as St. Mary’s Church, the Navajo-Hopi COVID-19 Relief Fund, and World Central Kitchen.

Marlene explained additional challenges that affected her community this summer, “I ran into one of my clients at the grocery store and asked how she was doing, and she informed me that they were really struggling with water because the well dried up, so I had to go back to my chapter and let them know that community members may be in need of water.”

In came the Water Warriors United team, who were able to distribute water and water barrels. The efforts didn’t stop there though. Marlene also took it upon herself to notify the chapter manager of how the Navajo Incident Command System (ICS) could assist community members. While ICS worked to fill the chapter’s request, the chapter used their own funds to purchase about 100 cases of water.

“It was a real surprise and blessing for our community members,” says Marlene. “I’m glad that I was able to work with the chapter manager on this and that I have a good working relationship with the chapter.”

Marlene remains optimistic and hopeful. Even though the pandemic has had a disproportionate impact on Navajo Nation, she has seen that families are so dedicated to caring for each other and that has been incredibly meaningful during this difficult time.

This essay was written by Partners In Health staff directly responding to the COVID-19 pandemic around the world. Dr. Daniel Bernal is tuberculosis project coordinator at Compañeros En Salud, as PIH is known in Mexico; Dr. Melino Ndayizigiye is executive director of Bo-mphato Litsebeletsong Tsa Bophelo, as PIH is known in Lesotho; and Katie Bollbach is director of the U.S. Public Health Accompaniment Unit, leading contact tracing efforts across the United States.

It is commonly noted that this pandemic has swept the entire world but has affected countries—and populations within countries—in dramatically different ways.  Indeed, initially hailed as the “great equalizer,” COVID-19 has exacerbated scandalous inequities both within and between countries across income levels, as well as the effects of under-financing public health systems.  

For Partners In Health, which has been working to address such inequalities for more than 30 years, it has also reaffirmed the critical importance of local health systems in determining the response to major health threats—in this current pandemic and beyond.   

Our work varies widely, but one major theme emerges: the impact of COVID-19, on health as well as economic and social life, is inextricably related to the capacity of local health systems that has been carefully built—or dismantled—over the years.

For example, Lesotho is one of the poorest countries in the world, entirely surrounded by South Africa, with some of the worst health statistics in the world: 1 in 4 people are living with HIV. Each year, there are 654 new TB infections per 100,000 people each year—the highest TB incidence in the world. And 1 out of 97 women die during childbirth.

At first glance, the country was not spending insufficiently on health—total expenditure on health was 11.5% of the country’s gross domestic product, according to the WHO. However, 51% of the health budget was already committed, going to pay the debt on a World Bank loan acquired to build a high specialty hospital through a “public-private partnership,” which therefore left much less for remaining care—and for responding to the urgent and sudden COVID-19 crisis.

PIH was invited to Lesotho by the government in 2006 to work in rural health clinics to find and treat HIV cases at a time when rates were some of the highest in the world. The government had seen PIH’s track record in Haiti, where sister organization Zanmi Lasante was providing lifesaving care to previously untreated rural communities, and hoped to achieve similar success. When PIH arrived, we found empty clinics, no full-time staff, village health workers (VHWs) not managed or linked to care delivery services, and a lack of basic services, labs, or medicines.

We made it our mission to turn that around by investing in local health systems. From 2007 to 2014, PIH worked to steadily improve quality of care by ensuring the clinics had drugs, staff, and increased space. In 2020, when COVID hit, Lesotho’s health system was far better prepared to manage cases in both the community and in facilities. Currently, PIH is working with the government to establish an oxygen plant that will produce oxygen for COVID-19 and other patients who need it across the country, as well as other ways in which to mitigate the negative impact of COVID-19 on routine health services. For example, the country is now decentralizing lab services from hospitals to health centers and conducting more community outreach to promote integrated primary health care services. 

Improved engagement with the community—creating an atmosphere where patients and their families can exercise agency over their own health and well-being and see access to the health system as their right as members of society—has been critical throughout our COVID-19 response, in Lesotho and elsewhere.

Indeed, community engagement within COVID-19 treatment and prevention strategies—and all health care—has been absolutely critical to establishing trust in health systems within the many communities that PIH works, across different income levels. This has been especially true as we work with historically excluded communities, such as indigenous communities in Chiapas, Mexico.

Despite Mexico’s status as an upper middle-income country, vast disparities in wealth—and health indicators—remain. As of September 2020, the country led in health care worker deaths globally and ranked 4th in total COVID-19 deaths and 7th in confirmed cases worldwide.

Politics has obstructed Mexico’s COVID-19 response as the country reckons with a health system fragmented by employment status, underfunded public institutions, and a failure to mount a coordinated government response, fueling disjointed and ineffective COVID testing, tracing, treating and prevention. 

To fight COVID-19 in Mexico, PIH, known locally as Compañeros en Salud (CES), works with rural and underserved communities. CES has not only had to combat political dysfunction and health system-wide fragmentation. It has also had to address how years of inequality and neglect that have put these populations at greater risk of direct and indirect harm from COVID-19. Residents face high risk of developing chronic conditions, such as hypertension, obesity, and diabetes, and have developed distrust of the formal health system. 

As we worked in Chiapas, one thing became clear: this predicament further underscored the need for effective community engagement to show that the local public health system is genuinely committed to listening to and understanding the needs of diverse populations it serves. In Chiapas specifically, PIH’s strategies have included radio programs, de-stigmatization campaigns, and conversations with the Pan-American Health Organization, community leaders, town mayors, and local and state health authorities to promote awareness and education around COVID-19. 

Another lesson from our work is that building trust in care delivery is always based on both historical context and the construction of relationships over time; it cannot happen overnight when a pandemic breaks out.

We have found that when diverse communities are engaged and involved in decision-making in a meaningful and equitable manner, radically different responses to the pandemic emerge.

In Lesotho and Mexico, PIH made community engagement a central pillar in our COVID-19 response. Both teams focused on training and equipping community health workers with up-to-date information on the virus, personal protective equipment, and contact tracing tools. This community health approach—closely coordinated with local government systems—played a crucial part in connecting people to care effectively and reducing the toll of the disease on their lives.

Perhaps the most striking case study from our global response is the United States, which was ranked as first in pandemic preparedness before COVID-19 struck. For those of us who were familiar with the U.S.’s disinvestment in public health over the years, that ranking had always seemed at odds with reality. The U.S. has more of a string of hospital networks than a comprehensive public health system. Further, despite medical care costs increasing steadily over the years, the U.S. has divested from public health, spending less in 2008 than in 1966.

This divestment has led to devastating consequences in an unrelenting pandemic and lack of vital infrastructure for testing, contract tracing, and isolation with social support. It also reflects the country’s indifference to community engagement and history of systemic racism, as the hardest-hit populations and areas across the U.S. have disproportionately been communities of color. 

As PIH responds to COVID-19 in the U.S., we bring lessons learned from our infectious disease work globally, including our work with contact tracing during the Ebola outbreak in West Africa. At each and every turn, we seek to demonstrate that actionable public health knowledge does not emanate from the North, as has been the predominant view in global health. Rather, we must ground ourselves in knowledge and lessons learned from diverse contexts. By turning to historically marginalized communities as the experts and following their lead, we can uncover universal truths about health systems as social institutions that, with support, can enhance inclusion and equality rather than reaffirm discrimination and promote distrust.

In Sierra Leone—a country unjustly accustomed to infectious disease outbreaks—COVID-19 has impacted one group particularly hard: Ebola survivors.

Years after the world’s largest outbreak of the virus, between 2014 and 2016, those who beat the odds and emerged from Ebola Treatment Units continue to contend with odds stacked against them, as chronic health side effects, poverty, malnutrition, and mental health challenges like addiction linger.

“People are still suffering,” said Sherry Bangura, program officer for Partners In Health’s community-based programs team in Port Loko District—the former hotspot of Sierra Leone’s Ebola epidemic.

The COVID-19 pandemic has exacerbated these struggles: Many survivors have experienced PTSD amid another infectious outbreak, and are behind in their medical care, education, and wages as they take every precaution against yet another deadly virus—often without an adequate social safety net.

Bangura knows better than most what the convergence of Ebola and the current pandemic looks and feels like. Not only are he and his team of four Port Loko-based colleagues in their fifth year operating a district-wide social support program, continually learning and responding to the unique needs of community members—many of them Ebola survivors. Bangura has also experienced COVID-era PTSD—as an Ebola survivor himself.

An Ebola diagnosis

In late 2014, Bangura was at the beginning of his young professional life: he’d completed his secondary education, moved into his own apartment in his home district of Port Loko, and was in his fourth year as a paralegal, with the ambition of eventually attending law school.

Then Ebola arrived in Sierra Leone, with Port Loko among the hardest hit areas. Everyone’s life was uprooted, including Bangura’s. The nonprofit he worked at ceased operations, and he returned home to his “second family”—the family of a classmate with whom he’d lived since he was 11 years old, in order to be closer to school. Amid the outbreak, he took on a new job as a community health worker supervisor.

Ebola—like COVID—is known as a caregivers’ disease, since it disproportionately infects doctors, nurses, and other frontline health workers. In the words of Dr. Marta Lado, who fought the outbreak alongside Partners In Health from 2014 to 2017, “It’s one of those most ungrateful diseases that affects the one who cares more about others.”

Bangura was doing just that: helping educate households about how to protect themselves from infection, and leading people to health facilities when ill.

“That’s where I got myself infected,” he said. “During the course of helping others go for care and understand the outbreak.”

In the weeks that followed, optimism was difficult to hold onto.

“I just felt that…that would be the end of everything,” Bangura continued. His two weeks in the Ebola Treatment Unit is a time he “doesn’t ever want to imagine.”

“Everybody you saw died. Mothers. Children. Important people. It was so sad,” he said. “To see someone surviving was a very rare thing. I lost hope thinking I could make it.”

But after two weeks—the time it took for Ebola to kill most patients—Bangura tested negative for the disease and was discharged with some clothes, food, cash, and a driver to take him back to his second family. On their doorstep, he received a second piece of devastating news.

“They were not at the house at the time I came, but left a message that if I happened to return, I should not be allowed to enter the house,” Bangura said. “I had a feeling in me, that maybe they didn’t think I’m a human being anymore.”

Dealing with social stigma

As the Ebola outbreak raged throughout Sierra Leone, survivors of the disease didn’t just have to deal with the trauma of life-threatening illness or losing their homes and possessions to infection prevention and control measures. (When a person was confirmed infected with Ebola, health officials would cordon off their homes and burn their belongings, sometimes along with the house itself, as part of attempts to curb the disease’s spread.)

They also had to deal with social stigma—severe fear within communities, and sometimes even between friends and within families, that survivors may carry the virus. Not to mention blame and shame.

“Nobody wanted to come close to [survivors]; communities rejected them,” Sherry said. “There were a lot of blame games: ‘You brought Ebola into our village, you survived while others died, you caused the death of our relatives.’”

Many survivors internalized this stigma and many relocated, leaving behind the homes they’d forever known but that were now painfully unwelcoming, whether because of community hostility, lingering memories, or both. Women, he notes, were hit hardest, as caregivers who either suffered the brunt of blame for spreading Ebola, or were crushed under the weight of all those they’d cared for and lost.

When Bangura returned to Masiaka, the town where he was living before the outbreak, no one knew about his status as an Ebola survivor; though his chosen family had rejected him, he had the opportunity to resettle into the community where he’d for years served his friends and neighbors. He could blend back in.

He did the opposite.

“I had to speak,” he said. “I had to let people understand my status and why I got infected.”

Bangura wasn’t considering only himself in this decision. He also thought of all those less privileged than him, and how he could use his statuses—as an educated, respected community member, and now as an Ebola survivor—to become a better advocate for them.

“If I kept myself isolated,” he continued, “I would have deprived other people of getting the service they need from me. Maybe my case is better because I can read and write, and honestly, I had been someone the community respected. As a paralegal, people brought their problems to me. So what about a poor, innocent woman who cannot speak for herself, who cannot do anything, maybe she's the only person left and she's back to her community. How can she respond to [stigma]?”

Bangura’s solution was to found his own organization, with the purpose of collecting survivors’ stories to see what they needed in the aftermath of Ebola. With some savings, plus the money he’d been given upon discharge from the Ebola Treatment Unit—money meant to help him rebuild his life—he began Rescue Team.

Rescue Team soon gained the attention of Partners In Health, which had begun working in the country in October 2014, during the height of the Ebola outbreak. The two joined forces, with Bangura leading a program in which every teenager and adult discharged from Ebola Treatment Units had a job offer from PIH to work as an Ebola social mobilizer.

PIH’s social mobilization team worked to ensure that survivors in even the most remote communities could continue to access the health care and social support they needed. And, importantly, they worked to find out what else survivors needed.

Support for survivors

Seeking out people’s stories—and being unafraid to share his own—still defines Bangura’s approach to running PIH’s social support program in his home district. Lived experience leads the way.

“There is still trauma in the survivor community—I sense it more highly during coronavirus, because it gives flashbacks, reminds them of their past,” Bangura explains. “Even myself. And it affects their livelihoods.”

Through the COVID-19 pandemic, Bangura has himself provided material support to his survivor community, and counseled and accompanied them through a shared worry that, with this outbreak, they might not again get so lucky.

“That’s why I’m still pushing on,” he continued. “I do believe we have an impact and change people’s lives. And as a program, we have to think big for the future. You can never understand people if you don’t come close to them. If you want to be great, you have to let others be great. If you want to be a leader, you have to let others be leaders.”

When Dr. Yerkebulan Algozhin heard the first reports about COVID-19 early this year, he said, the news didn’t worry him much. After all, similar viruses including SARS, bird flu and swine flu had passed without inflicting heavy losses on Kazakhstan, where he is the country director for Partners In Health (PIH).

But when COVID-19 started spreading rapidly across the country, he became scared. He thought about his tuberculosis patients, whose lungs already were weakened.

“I was worried about my relatives, friends, colleagues and patients,” he said.

Algozhin and his PIH colleagues are part of the endTB partnership, a global effort to test new treatments for tuberculosis. As they continued that work with new safety protocols for COVID-19, they didn’t anticipate that they, themselves, might become infected with the novel coronavirus.

COVID-19 was first detected in Kazakhstan in March. Authorities were quick to enact a shutdown, closing borders and setting up checkpoints around the capital, Almaty. PIH began holding meetings remotely and worked to limit doctor-patient contact, delivering medicine to patients at their homes and communicating mostly online. When in-person meetings were necessary, health workers conducted medical exams outside, often on roadsides.

“Our nurses and doctors continued their work during the pandemic. Despite the risk, they regularly delivered medications to [TB] patients in different parts of the city and performed patient examinations,” Algozhin said.

PIH co-investigator Dr. Amanjan Abubakirov, a TB doctor who also works at the National Scientific TB Center, began treating COVID patients in April, after the hospital released TB patients in order to accommodate more people with COVID-19.

Fortunately, not many of the TB patients involved in the endTB study have been affected by the pandemic. A few have showed symptoms, but the one confirmed case was a mild one, Algozhin said.

However, by April, the disease started spreading quickly among medical personnel. In one Almaty hospital, almost 200 doctors and nurses tested positive for COVID-19, including all of the surgical staff. The hospital was closed and patients were transferred to other facilities.

Still, the government considered overall rates of infection low enough to lift the emergency restrictions.

In June, Algozhin himself fell ill, as did Abubakirov. Since many members of PIH’s Kazakhstan staff began showing symptoms, the whole staff was given mandatory sick leave and sent home.

COVID-19 Care at Home

Algozhin said he had a mild case of the disease. His symptoms included loss of smell and taste, bronchitis and fatigue. His wife and mother also fell ill. He and his family convalesced at home.

His son, also a doctor, provided treatment for them, including for Algozhin’s mother, who was seriously ill with pneumonia for two months.

Fortunately, they all recovered.

But sadly, Algozhin’s good friend, a doctor who worked in one of the TB dispensaries, succumbed to COVID-19. Algozhin said his friend was a devoted physician who was “working with patients, almost to the end.”

Abubakirov’s symptoms included pneumonia, high fever, shortness of breath, and loss of smell and taste.

His treatment included antiviral and hormonal medication, anticoagulants, cough medicine and vitamins, he said.

Six days later, his 75-year-old father fell ill.

“His oxygen saturation dropped to 44 percent,” Abubakirov said.

 With hospitals overloaded at that time and medical workers working 18-hour shifts, Abubakirov and his sister, also a doctor, agreed to treat their father at home. As Abubakirov recovered, his father began having problems with his heart, kidneys, and central nervous system.

“We thought we would lose him,” Abubakirov said.  

But the care he and his sister provided was successful, and their father recovered.

COVID-19 cases started decreasing across Kazakhstan. By the end of August, the TB hospital had discharged its last COVID-19 patient and returned to treating TB patients.

Second Wave

Kazakhstan’s Ministry of Health said 59 doctors in Kazakhstan have died of COVID-19. The government has offered financial compensation for doctors’ families.

Across Kazakhstan, doctors are now better equipped and more knowledgeable then they were at the beginning of the pandemic, Algozhin said. They are better prepared for a second wave, having procured new supplies of personal protective equipment, disinfectants, pulse oximeters, thermometers and ultraviolet lamps.

Moreover, the PIH team in Kazakhstan learned how to work remotely while maintaining teamwork.

“We became more united and learned how to work in emergency situations,” Algozhin said.  

Sierra Leone has one of the highest maternal mortality rates in the world, making it one of the most dangerous places for women to give birth. The country sees 1,120 maternal deaths for every 100,000 live births—a number that far outpaces the global average of 211. But it doesn’t have to be this way.

Since 2014, PIH has focused on improving maternal health care in Sierra Leone, where it originally began working in response to the Ebola outbreak in West Africa. PIH has not only provided care to patients but has sought to strengthen the country’s health system in partnership with the Ministry of Health, laying the groundwork for accessible, quality care for future generations. In November, PIH announced plans to build, staff, and resource a Maternal Center of Excellence in Kono District in the eastern part of the country.

Bestselling author John Green recently sat down for a virtual conversation with PIH leaders to reflect on the past, present, and future of PIH’s maternal health work in Sierra Leone. These leaders included Dr. Joia Mukherjee, PIH’s chief medical officer; Isata Dumbuya, a nurse midwife who leads the reproductive, maternal, and child health program at PIH Sierra Leone; Jourdan McGinn, deputy executive director of PIH Sierra Leone; and Armah Quist, program officer with PIH Sierra Leone at Lakka Government Hospital.

Below are highlights from the conversation, edited and condensed for clarity.

Green: When I first started learning from you and your colleagues about the work that was being done in Sierra Leone around maternal mortality, what was explained to me is that it's not an issue with ambulances or blood pressure cuffs or medications or running water –the issue is that if the system does not get stronger, then there is no way to make lasting change. And I think that is really powerful.

Mukherjee: None of these problems started today and they're not going to be solved today. But if we really look at the history and invest in the places that were so historically impoverished—that's why you use the term impoverished instead of poor, because it's an extraction—nowhere is that more clear than in Kono District in Sierra Leone, where the very hospital is literally in the shadow of a diamond mine, where resources are being just sucked out of the community, as Paul explains in his new book (Fevers, Feuds, and Diamonds).

As we started to look at Ebola, it wasn't a question only about a virus. I'm an infectious disease doctor. I went in the Ebola treatment unit, many of our great colleagues were in their PPE in the unit, but we weren't the ones getting Ebola . It was the people who were living 10, 12 people in a house, the people who didn't have the opportunity, the privilege to isolate and quarantine. The things that we're hearing now with COVID that drives the inequality so high. These things are what make people very susceptible. And then when you go to get care, there's no care for you.

So we started to treat Ebola. But we rapidly understood that Ebola was just one piece of the overall suffering of people we saw. One of the district directors said, ‘I'm glad you're here helping us do Ebola. But if a kid falls out of a mango tree and breaks his arm, what am I gonna do?’ Regan Marsh, who was our chief medical officer in Sierra Leone for a number of years, wrote about how, in the middle of the Ebola crisis, a pregnant woman who came seeking care was bounced, hither and yon, because no facility had adequate supplies to take care of her. And she ended up dying. And that wasn't because of Ebola directly, but it was indirectly because of the impact of this terrible disease on a health system that was absolutely unprepared.

So we saw during our Ebola work that Sierra Leone had the highest maternal mortality in the world and that really became our focus—if we could focus on maternal mortality, that would prepare the system for Ebola, that would prepare the system to fix that broken arm of that kid. And so really we look at our maternal health work as a battle horse that will bring attention to this human rights issue and feminist issue but at the very same time elevate the standard of care.

Green: We're also joined by Isata Dumbuya, a nurse midwife who has been leading the maternity ward at Wellbody Clinic and also at Koidu Government Hospital in Kono District since 2018. Isata, I wonder if you could first tell us what inspired you personally to work in Sierra Leone? And when you first came to Koidu Government Hospital, what was the situation there as compared to, say, the United Kingdom?

Dumbuya: I was born in Kono District and I grew up between Sierra Leone and the U.K. So I spent quite a number of years in Sierra Leone, including going to secondary school. In the U.K., I trained to be a nurse and then a midwife. I finished my midwifery training in 1999.

When I came to Sierra Leone to work with PIH, it was very different from the United Kingdom. In the first week of my arrival, two women died. This was a shock—a real eye-opener—because where I came from in the U.K., women did not die as a result of pregnancy, they did not die as a result of wanting to give birth. In Sierra Leone, you see these young women come in and, in front of your eyes, they die, from preventable things.

Over the years, it's taken us time to try and change this picture. And it is changing, because we now have systems and services in place that do make a difference. We have a working blood bank. We've got pharmacies and labs. We've got drugs that we can be able to give them to improve their conditions and improve their chances of survival. And we have well-motivated and trained staff. We've got a high dependency unit which is set up now to make sure that when sick women come in, we're able to treat them. The same for their babies because we have a special care baby unit now where small, premature babies, sick babies can get care.

At Koidu Government Hospital, more women are coming—we've seen a 38% increase in uptake in antenatal care. We've also seen that the delivery rate has increased by about 69%. Women are coming in and having babies. So we're doing a great job and we'll continue to do that, but we need to do more because there are still women out there dying. There are still women out there that do not access these services. There are still women out there that, for whatever reason, do not come to us and they still die. This hurts and breaks us, because we feel that every woman has a right to live; they shouldn't be dying just because they want to have a baby. This is not accepted in other parts of the world. And this is something that we all need to fight within Sierra Leone.

Green: When I talked to you recently, I asked you what you felt like was the next critical step and you immediately answered the Maternal Center of Excellence. I wonder if you can talk about why you see that as such an important next step in such a transformative moment for health care in Kono.

Dumbuya: The Maternal Center of Excellence will be a place where women are going to be able to access cervical cancer screening, family planning, a safe place for adolescents and youth friendly services. We've already started doing that. But the Maternal Center of Excellence will be able to provide this on a wider basis. We're going to have three surgical theaters. So anyone coming in for a Cesarean section won’t need to wait. And we have a special care baby unit now, but this will be upgraded to a neonatal intensive care unit. So we will be able to offer even higher level treatments for sick neonates and sick babies. And this is going to be a place where staff can come and be trained and receive all the sort of resources from experts.

This is going to be like the blueprint to show that in Sierra Leone, where for many years we've had the highest maternal mortality rate in the world, we can also have a state of hospital where people can come not just from within Sierra Leone but from neighboring countries to access this care. I believe this will just be the beginning and together we're going to change this picture because these women, they deserve this. Our staff, our clinicians, they deserve this. This is our dream.

Green: That's so inspiring. Thank you so much for sharing that. Every time I get to talk with you, it feels like my heart grows three sizes. I'm going to move now to Jourdan McGinn, the deputy executive director of PIH Sierra Leone. Since we've been talking about the Maternal Center of Excellence and how transformative this can be in Kono and beyond, I wonder if you can talk about the origins of the idea for the Maternal Center of Excellence, what the planning process has looked like so far, and what the initial inspiration was.

McGinn:  This Maternal Center of Excellence is really a product of the success that Isata spoke about. We wanted to think a little bit more radically to say, ‘In one of the countries with the highest maternal mortality rates in the world, how could we radically reduce this?’ Almost exactly three years ago today, a group of us sat in a small conference room and we asked ourselves, ‘What would it take to accelerate the reduction of preventing these women of dying from causes they don't have to? What if we didn't just accept incremental progress? What if we didn't just add a few more beds? What if we rethought what was possible?’

We re-imagined building really an entirely new ecosystem to address what, John, you said at the beginning really is a crisis of maternal death. And so the MCOE is exactly that—it's a re-imagining of what is possible for women in poor and under-resourced communities like Kono District. And it's far more than a building. It's a part of this ecosystem—about the community connecting to the clinics, connecting to the hospital.

We've partnered with Build Health International to design a 120-bed facility, which will triple the number of beds we have now on the existing campus of Koidu Government Hospital. And it's important that it's on this campus because this is a government hospital and this Maternal Center of Excellence will be a government facility. It will be managed by the government of Sierra Leone. We've designed it with them from the beginning. So really this is a collaboration.

Green: We're going to move now to Armah Quist, a program officer at Lakka Government Hospital, which is the only dedicated tuberculosis hospital in Sierra Leone. Armah is also an activist and organizer. When we spoke previously, Armah, you mentioned that, having put all of this work into building a feminist movement among young women in Sierra Leone, you had so many hopes for the Maternal Center of Excellence and that it was something that you so dearly wanted to see happen. I wonder if you could talk about what your hopes are for this center.

Quist: The Maternal Center of Excellence has a lot of potential to push women’s rights in Sierra Leone, especially Kono. This is exactly why the Maternal Center of Excellence needs to exist—because women and girls in Sierra Leone deserve better. They deserve a youth friendly space where they can go and ask questions about their bodies. The place I never had. And if they get pregnant, they deserve to go to a hospital that will treat them with dignity, whether they are married or unmarried, whether they are young or old, whether they are rich or poor. They deserve a place where they have a good chance of surviving childbirth.

This is what the Maternal Center of Excellence will create for all women and girls in Sierra Leone. It will create a place where the next generation of women can be empowered. The Maternal Center of Excellence is about far more than health care—it’s about feminism. It’s about women realizing their potential. And it’s about giving women the dignity and voice they deserve.

For the sixth year, PIH staff from around the world shared their favorite works they watched, read, or listened to in the past 12 months. In light of the many challenges 2020 has presented, we asked staff to specifically highlight books, podcasts, or movies that provide hope and inspiration. We hope that you, too, will see the light in the recommendations below. Although this holiday season may feel much different than previous years, one thing remains constant: PIH's commitment to strengthening health systems around the globe. 

How is mental health connected to history? And what can one hospital teach us about it? In Unchain, a new podcast miniseries from Partners In Health, doctors, patients and historians in Sierra Leone tell the story of Sierra Leone Psychiatric Teaching Hospital—the oldest psychiatric hospital in sub-Saharan Africa—which marked its 200th anniversary this year.

This miniseries dives deep into Sierra Leone’s history—including slavery, colonialism and civil war—to explore how the past holds implications for mental health.

Sierra Leone Psychiatric Teaching Hospital—once an impoverished facility that, due to lack of resources, used chains to keep patients from harming themselves and others—tells a story of both trauma and transformation: how the past never fully leaves, but can inform our present and future.

Below, a selection of archival photos offer a special glimpse into the hospital's past and present.

In a room full of people, Dr. Patrick Ulysse is usually among the last to speak. He sits, cross-legged, taking notes and listening with his whole body. He chooses his words carefully and, when he does speak, everyone in the room listens, wishes he would do so more often, and leans in to appreciate what the soft-spoken leader has to share.

Ulysse, born and raised in Haiti, had been a doctor for five years when the devastating 2010 earthquake struck. At the time, he was working for Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti, as the medical director in Centre Medical Charles Colimon at Petite Riviere, a two-hour drive north from the capital Port-au-Prince. His quick actions in the hours and days following the earthquake and, over following months, his steady management of camps for the displaced, marked him as an innovative, caring leader.

Like many Haitian clinicians before him, Ulysse took the lessons he learned at Zanmi Lasante and applied them in another country—Liberia, where he worked with partners in the national government to rebuild an ailing public health system further weakened by the Ebola epidemic. In 2019, Ulysse transitioned from his executive director role in Liberia to PIH’s chief operating officer. Over the past year, he has helped PIH navigate our global COVID-19 response and led the development of a new five-year strategic plan.

In the interview below, Ulysse shares lessons he’s learned over the course of his career in an ongoing series we’re calling Ekip Solid, or “Strong Team” in Haitian Creole. These PIH global leaders are all experts in their fields, and each interview will address how they approach leadership, share what drives them to global health work, and provide an inside look at their professional and personal passions.

You started your career with PIH in 2006 in Haiti, working as a general practitioner and managing the HIV and TB programs at a Zanmi Lasante health center. Can you tell us what you saw, heard, and experienced that drew you into this work? What about it made you want to stay with ZL, and PIH in general?

In 2005 I had just finished my medical training and was working with a medical NGO in rural Haiti providing care for persons living with HIV. The hospital where I worked did not have anti-retroviral drugs, and so I would routinely refer patients to a nearby hospital that had a supply. If these patients lived outside the hospital’s catchment area, they had to pay for the drugs. So in reality, the drugs were not available to the majority of patients I was caring for, because they could not pay.

There was one patient who was in the advanced stages of HIV and desperately needed antiretrovirals. A colleague told me they thought someone from ZL might be able to help. The physician I spoke to did not ask me who the patient was or where they were from; instead, they asked what the patient needed in addition to the medicines, and when I said food, they sent food. This was first time I had encountered a program in which components like food support were part of the care package provided to patients. After providing support for this one patient, ZL started supporting the hospital where I was working by supplying free drugs. 

As a young physician, ZL was my introduction to a model of medical care in which the humanity of patients – in all its dimensions – was embraced. ZL staff did not see the person only in terms of their disease, but assessed their socioeconomic realities, their families, and their emotional health. And then, most importantly, ZL provided a system and mechanism to provide the support needed to address the social forces directly or indirectly causing illness.

I stayed with ZL over the years because I found that the mission of PIH and ZL aligned with the physician and person I wanted to be. I had become a doctor to provide care for those who most needed it, and PIH showed me what a “preferential option for the poor” could and should look like.

You’ve talked about how PIH has built a generation of physicians “who, when they see a patient, don’t just see a disease or pain, but the patient’s living situation, the patient’s social challenges, the patient’s emotional health.” Why do you think this approach is so critical? And how do we cultivate this at a structural level?

Any health care provider in the communities where we work can describe how tremendously social forces impact health. PIH has trained a generation of providers to understand the structural violence that underlies the diseases we are treating. The PIH approach is historical and anthropological and demands that we ask the hard questions about how these realities came to be.

PIH cultivates this approach at a structural level in different ways in different contexts. In many of the places where we work, we support the ministries of health in training clinicians in a year of “social service.” During this year, clinicians work through a curriculum in social medicine while embedded in a PIH clinical site where social and economic support are delivered as an essential component of comprehensive medical care.

As PIH grows and strengthens training and teaching facilities at all of our care delivery sites, such as Hôpital Universitaire de Mirebalais in Haiti, we continue to institutionalize and disseminate our approach. With our partners in Rwanda, PIH helped create the University of Global Health Equity, which is reimagining health education for doctors, nurses, researchers, and public health and policy experts, and teaching health care delivery grounded in a social justice approach. Finally, we continue our advocacy efforts at the global level, working to disseminate the knowledge gained from our experiences and transform global health policy.

In your 14-year career with PIH, you’ve responded to crises across continents—from the earthquake in Haiti as a physician to Ebola in Liberia as executive director of the country program. Now, we’re in the midst of COVID-19, and you are helping lead PIH's response as its chief operating officer. Does this moment we’re in feel at all familiar? If so, in what ways?

This moment feels familiar in several ways. First, we see in every global health crisis – from the earthquake to Ebola to COVID-19 – that the most vulnerable people are disproportionally affected. Time and time again, marginalized communities bear the greatest burden and suffer exponentially more across all contexts. Second, each of these crises has exposed the pre-existing vulnerabilities of health systems. A health system cannot be prepared for an emergency if it does not already have functional, accessible, and equitable services. PIH focuses on strengthening public health systems so when disaster strikes, communities, districts, and countries are able to respond equitably, and do so quickly and efficiently. In each of these crises I have seen PIH respond more quickly than I thought possible and always preferentially for the most marginalized communities. At the same time, these crises affirm the importance of humility in continuously recognizing where we can and could have done better, and that there are always lessons to be learned.

As viruses and global crises always do, COVID-19 has exposed the cracks in our societies in a way that begs us to question how we treat one another and how we choose – or choose not – to recognize that our individual health is intimately connected to and dependent on the health of others, in our neighborhoods, in our countries, and around the world.  

This summer, we saw renewed calls for racial justice and intersectional equity across fields, including calls to decolonize global health—a field that has historically been complicit in systemic racism, colonialism, and exploitative narratives about poverty that obscure the role of unjust systems in creating it. As a global health professional who has not only lived and worked in Haiti, but is from the Haitian community, what are some ways you’d like to see the global health field change?

PIH’s work is grounded in the philosophy and practice of accompaniment, in which people share a journey, walking alongside each other, neither one in front of or behind the other. As Paul Farmer has written, accompaniment “does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges… [accompaniment] requires cooperation, openness, and teamwork.”

We aim to be accompagnateurs in every facet of PIH, and this model helps us to break down the harmful paradigms of giver and receiver, of expert and amateur. We work hard to understand the context and the needs in the places we work and if and how mutual collaboration can be beneficial. We recognize and name the power dynamics that have conventionally existed and work together to develop measurable, tangible steps to reverse and deconstruct them. 

Global health practitioners and organizations in centers of power must recognize their historical place at the table and question whether they are reinforcing or disrupting the legacies of colonialism. We must make the table bigger, decentralize its location, diversify the kinds of seats, and add more seats – only from there can we begin to have more equitable decision-making in the field of global health. We must recognize the interconnectivity of health outcomes with racism, climate change, gender discrimination and work toward liberation and justice in all dimensions.

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COVID-19 has radically shifted ways of communication and working around the world. How have you seen PIHers rise to this new challenge--any lessons learned about how we can operate better because of this experience?

COVID-19 has greatly limited the amount of travel between our sites. This has shown me that even when we cannot be physically with each other as a team, we can still feel connected and show up for each other and for the patients we serve. I find that our spirit is still just as strong – a testament to who we are at PIH and how we believe in our mission. Like millions of others across the globe, we have become more reliant on virtual connection. We have found that with this we have had the opportunity in many ways to increase cross-site sharing. This has also reinforced the tremendous importance of strengthening internet connectivity in the more remote places we work – Cerca la Source, Haiti; Maryland County, Liberia – as remote connection becomes the new normal.                                 

This moment of increased isolation has some of us picking up new hobbies or rekindling old ones, while others have been in a funk. Still others are somewhere in between or experiencing a mixture of all these things. How has this period been for you? What’s been getting you through? 

At this time when so much is changing nationally and globally, I have been reflecting on the questions taking shape that are and will affect our care delivery sites and our role as PIH. I have been deepening my understanding of the climate change crisis; imagining what climate emergencies will mean for the communities where we work reinforces the urgent need for all of us to incorporate climate justice principles into our daily work. I have been educating myself about global agriculture and thinking about the potential impact of COVID-19 on food insecurity across the globe. And like many, I’ve returned to a few long-neglected hobbies: I have been practicing the saxophone and teaching my daughter to play chess.

When a woman in labor arrives in a maternity ward with signs of obstetric distress, health care workers face a crucial choice: whether to pursue an emergency c-section. Because as soon as they decide a c-section is needed, it’s a race against the clock. If health care workers aren’t able to begin the operation soon enough, the life of the mother and her baby could be at risk.

This critical interval is known in the medical field as “decision to incision”—or, more specifically, the time from the decision to pursue an emergency c-section to the operation itself. Ideally, this period should last no longer than 30 minutes, according to the World Health Organization.

But in impoverished settings, that time can be prolonged by a host of factors, including a lack of staff and resources. A doctor might be far from the hospital. An operating room might need preparation. In Sierra Leone, where 1 in 20 women run a lifetime risk of dying prematurely during pregnancy or childbirth, Partners In Health launched an ongoing initiative that has dramatically reduced decision to incision times and strengthened maternal health care.

Isata Dumbuya, program manager and midwife, and Jourdan McGinn, deputy executive director, help us understand what this term means and why it matters for maternal health—in Sierra Leone and beyond.

When is an emergency c-section needed and who makes that decision?

When making their initial assessment of a woman in labor, health care workers take a variety of factors into account, including if the woman has started bleeding, if she has eclampsia and if the labor has become obstructed.

“If you come to the hospital with any of these conditions, you are an emergency case,” says Dumbuya. “We are now thinking, ‘we have to deliver this baby in order to save the woman’s life.’”

Typically, a doctor makes the call. But at PIH-supported Koidu Government Hospital (KGH) in Sierra Leone, where until recently, only one doctor worked in the maternity ward, an experienced midwife can make this decision, inform the doctor and start preparations.

The clock starts ticking from the moment a health care worker decides to pursue an emergency c-section—ideally, the operation must begin within 30 minutes or less.

What clinical and structural challenges influence the decision to incision time?

Decision to incision time depends not only on the training and skills of health care workers, but also what resources they have access to.

It’s a high-stakes situation in any hospital, but especially in Sierra Leone, where decades of colonialism, slavery and global exploitation led to widespread poverty and lack of investment in the health care system. KGH is the only facility offering c-sections in all of Kono District, which is home to more than 500,000 people.

Historically, a range of clinical and structural challenges prolonged the decision to incision time at KGH.

For example, the hospital’s maternity ward was severely under-staffed, often having only one doctor, two nurse anesthetists and a few scrub nurses. None of them stayed at KGH overnight, meaning that if a woman in labor arrived in the middle of the night, she would have to wait for a health care worker to commute to the hospital. Additionally, KGH’s cleaning staff didn’t work overnight, meaning in late hours, the operating theater often could not be immediately sanitized for use.

The hospital also lacked material resources needed to shorten its decision to incision time. The pharmacy wasn’t open 24/7, so the nurse anesthetist might be unable to access the drugs needed for an emergency c-section. Another hurdle was a lack of phones that were consistently charged or supplied with minutes, known as airtime, without which critical phone calls—to the OB-GYN, drivers, cleaners—would be impossible, causing major delays in care.

How has PIH improved decision to incision time in Sierra Leone?

Before PIH launched its Decision to Incision Initiative, the decision to incision time at KGH could last more than four hours. But in the years since, that gap has narrowed. Now, on average, the decision to incision time is less than 45 minutes.

These dramatic improvements come from PIH’s Decision to Incision Initiative, launched in 2016. The initiative aims to improve staffing and resources at KGH as part of broader efforts to improve maternal health outcomes in Sierra Leone.  

Through this initiative, the number of nurse anesthetists at KGH has risen from two to four, and scrub nurse staffing has increased to eight, ensuring coverage of the maternity unit both day and night. Additionally, health care workers on-call are required to sleep in the unit, avoiding the possibility of delays from transportation. PIH also set up an overnight shift for cleaning staff, so the operating theater could be sanitized at any time.

To tackle the lack of resources, PIH has made key changes to the maternity ward, including the installation of a medical cabinet, so clinicians can access drugs at any time, regardless of pharmacy hours. PIH also has made sure that health care workers have the resources to maintain airtime and charges on their phones, allowing them to be reached at a moment’s notice.

Beyond these clinical and structural improvements, PIH also has introduced accountability measures to make these changes sustainable in the long run. Staff in the maternity ward hold weekly meetings to examine case studies and stay up-to-date on best practices. If something goes wrong with a c-section, every staff member involved—from the doctor to the driver—reflects on what challenges they faced and how they might improve to avoid mistakes in the future, building a culture of continuous learning and improvement.

Throughout the initiative, PIH has collected critical data, tracking the program’s successes—and areas for growth.

“We didn’t massively change the hospital workflow,” says McGinn. “It was about looking at the data consistently, asking how we could improve, and creating shared momentum around improving this goal.”

Why does this concept matter for maternal health?

While adding a medicine cabinet and hiring more anesthetists may seem like subtle changes, their impact has been major.

PIH has dramatically reduced the decision to incision time at KGH, helping mothers access lifesaving emergency c-sections quickly and efficiently. The improvement comes as part of PIH’s larger efforts to improve maternal health outcomes in Kono District.

Dumbuya has seen that progress firsthand. In the early days of the initiative, she’d wake up in the middle of the night to her phone ringing, with desperate, under-resourced nurses on the line. But now, she says, she can sleep through the night, knowing that the maternity ward is running smoothly.

Still, she urges her team to stay vigilant.

“You need to be willing to push yourself and to always think: ‘This baby today could be my baby. It could be my sister’s baby. And my mother’s baby,’” she says. “This is not just someone else’s baby. It’s someone else’s life—someone’s future.”

In Sierra Leone, 1 in 20 women run a lifetime risk of dying prematurely during pregnancy or childbirth.

To tackle this injustice, and many more, Partners In Health is working with Sierra Leone’s Ministry of Health to construct, equip, and staff a world-class center dedicated to maternal and child health.

PIH, the Ministry of Health, and architectural partner Build Health International plan to break ground on the Maternal Center of Excellence in April 2021, with health care services slated to begin in early 2023.

Attached to PIH-supported Koidu Government Hospital—Kono District’s only secondary care provider—the new center will serve as a state-of-the-art referral facility for women and children in Kono and across Sierra Leone and West Africa. It will also become a center of innovation in reproductive, maternal, neonatal, and child health—offering clinical training, mentorship, and research opportunities for Sierra Leone’s current and future clinicians.

Since 2014, PIH has led targeted programming to radically improve health outcomes for Sierra Leoneans, with a focus on maternal health.

Improved maternal health care is a dire, longstanding need in Sierra Leone where colonialism, slavery, civil war, and foreign exploitation have impoverished the country and its health system. Despite the early successes of PIH’s efforts, Sierra Leone remains one of the most dangerous places on earth for women and children to live. In addition to the country’s maternal mortality crisis, its  infant mortality rate is 81 per 1,000 live births—the highest in the world.

The Maternal Center of Excellence will serve as a replicable model for how to systematically reduce maternal deaths throughout the country—and worldwide.

Preventable, premature death among these marginalized groups persists around the world not because of lack of knowledge, but because of lack of investment. The new center is one step toward curing this injustice and will stand as a testament to the inherent value of every human life. Making motherhood safer is more than just a health initiative—it is a human rights imperative.

In November 2014, Partners In Health Co-founder and Chief Strategist Dr. Paul Farmer was in Freetown, Sierra Leone, breaking bread with a group of Ebola survivors as the world’s largest epidemic of the virus raged across the country.

“It was the night I met Ibrahim,” Farmer recalled, referring to one of the survivors. “We started talking and he told me he’d lost 23 members of his family to Ebola. I was shocked into silence. And what he said next was: ‘I’d like you to interview me about my experience.’”

“I've been an anthropologist as long as I've been a doctor, and it's very rare that someone says that,” Farmer continued. “I thought, ‘If I'm going to interview him about such an awful experience, it better be for someone other than just myself.’”

That, Farmer said, is when he decided to write a book.

Fevers, Feuds, and Diamonds: Ebola and the Ravages of History was released on November 17 and details the Ebola outbreak’s origins and aftermath; the stories of patients, clinicians, and caregivers; the international response; Farmer’s own memories from Ebola treatment units; and the historical chapters underpinning it all.

And in a book about a historic epidemic, published during a historic pandemic, Farmer writes about where we go from here, in the thick of COVID-19 and ongoing, extreme health inequities across the world.

“I think the big story,” Farmer said, “is that we have to keep pushing forward health system strengthening, whether we're talking about Sierra Leone or the United States.”

In the interview below, Farmer provides an inside look at the book and talks about grief, joy, history, and the role of proximity in global health.

This is an expansive work—you take us through the 2014 crisis as well as an in-depth history of West Africa. And perhaps one of the most moving parts of the book is personal accounts you share of Sierra Leonean Ebola survivors. Can you tell us about the process of constructing this narrative?

Writing is a solitary endeavor, right? But you can make it a bit more social. And for this book, it had to be a social process. Of course, very saliently, I was writing with the people whose stories and history are told here. They all had knowledge that was unfamiliar to me, and I just decided that every time one of them said something that triggered that tingly feeling of unfamiliarity, I would make it my business to learn more. When I heard something I didn't understand—which was all the time, every day—into my notebook it went.

One of the things I wanted to do was to read (with Bailor Barrie’s help) parts of this book to Ibrahim, Yabom, Chairman—all of these people in the book—and see if I was getting it right. They understood that they should interrupt me, correct me, explain where I'd gone off on a false track. That was an emotionally rich if sometimes painful way to write. I learned a lot with them.

People will learn many people’s stories when they read the book. But can you give everyone a preview of some of these stories? You dedicate two full chapters to Ibrahim and Yabom, both of whom survived Ebola.

Ibrahim was 26 when he got sick. He was working as a motor taxi driver, and everything kind of hit his family at once, in the summer of 2014. His mother’s side of the family, and his mom, were felled, root and branch. But the thing that I wanted to underline in telling his story was his desire to help other people. I was just getting to know Ibrahim when he met Mariatu, a young girl who was really still dying of Ebola, even though her bloodstream had no evidence of ongoing infection. He worked with her and her father and others as an accompagnateur, someone helping address the social needs and provide support—psychological and material.

I find Ibrahim to be a wonderful, engaging, thoughtful person. Others may have found his experience ordinary, but they would've had to have been Sierra Leoneans if they felt that way. I mean, the guy survives Ebola and most of his family does not. And like all of our adult patients, he also survives a war, during which his father and other relatives died.

Yabom, who was 38 when she narrowly survived Ebola, had just lost a dozen family members, including her husband and children. Her story was an important part of West African history. When she, over the course of almost three years, shared this story with me, there were all kinds of indications that it was important. Not just because everybody's story is important, but because she survived, with enormous losses, Ebola and a brutal civil war that disrupted all of West Africa. And because she is a rural woman, mom, daughter, sister—I mean, if you don't have a gendered perspective on caregiving, you're not going to learn a lot about caregiving.

What is it like to collect these personal histories?

I usually have a very hard time with it. I find hearing these stories more brutal than uplifting, at least at first. It's amazing to some people to hear that, because I write about human suffering all the time. But there were days when I found it easier to work in Ebola-ridden Port Loko Government Hospital than to talk to Yabom about when her husband and children died. I remember putting off that discussion for months, maybe a year. It was hard for her and hard for me. I'm not confused about who's who here—who lost family to Ebola and who did not—but it's tough material.

I realized that I was getting to know her husband who had died of Ebola. I'd never met him, of course. But after about two years of hearing about him, I realized that I actually missed him. That said to me that I’d scaled that empathy wall and was feeling things that I would never have felt without spending a lot of time talking to Yabom and learning about her family and her experience. And if you can convey how much she and her husband cared about each other and how much they survived together before Ebola, I can't imagine that somebody else can't scale that empathy wall.

You write in the book that grief was “a subject obliterated from much expert discourse during the first month of the epidemic, when many pontificated about ‘local beliefs’ about sickness, death, burial, funerary ritual, and the afterlife." Can you talk about the role of grief in the epidemic—and why it was erased from so many narratives?

I'll bet it has nothing to do with misanthropy, of not caring about other people's grief. But when we start looking for the reasons that it was erased, obscured, or underplayed in reports from West Africa, think about the reporting and writing that happens in the middle of an outbreak. There's no space in this short news cycle to have in-depth explorations—unless people do something remarkably good or remarkably bad, which results in a sort of social flattening. Grief and mourning are anything but flat.

I will be thrilled when Yabom and Ibrahim write their own autobiographies, and in the language that suits them since they both speak several. But in the interim, what I tried to do was unflatten them, give them a voice, and get their story down the way they wanted to tell it. And that involved exploring grief.

And there’s another, more psychological answer: These are very, very hard subjects, and it's easier to talk about funerary rituals and who's throwing cowrie shells or doing incantations or prayers or wrapping the body in a shroud.

Let’s talk about funerary rituals and all the stereotypes that were swirling about while the outbreak was happening. You point out that many people were examining the spread of Ebola through a lens of exoticization. How do you hope that the book adds nuance to blameful images associated with Ebola?

I have never not encountered this distorting interpretive grid. Go right through the list of places that PIH has worked, places I've seen and written about, and I've never not seen it.

One of the things that occurred to me was that, when my father died suddenly at 49, our traditional funerary ritual included laying out his body in a suit and kissing him on the brow. In discussions of Ebola, this sort of ritual was rendered as cultural insanity: Why would anyone waste time attending to the burial of the dead in the middle of such a catastrophic epidemic?

The answer is: Because we always do that. We always care about our families and friends. Humans do that. And what is the last act of caregiving if not burial of the dead? What so many were describing as bizarre and incomprehensible is not bizarre any more than it is incomprehensible.

So that was really my goal, to bring nuance through sharing lived experience as it was reported. And I don't think that can fail you. Look right now at the division in the United States: Are we just going to say, of the other side, ‘There's no way we can understand such cultural lunacy,’ or are we going to figure out what leads to these discrepant views of the world?

Speaking of the United States, I think it’s easy for many Americans to feel disconnected from the countries where PIH works, Sierra Leone included.

This book is all about revealing connections. How do you understand what is still convulsing our nation—what's going on with COVID, or what happened to George Floyd, Breonna Taylor, Ahmaud Arbery, Tamir Rice—without understanding history? How do you understand American history without understanding the history of racism? How do you understand that history without understanding slavery?

Americans have intimate connections to the continent of Africa. So do Europe and South America. That history is the history of our world, of our social reality, current and past.

I was in Montgomery, Alabama, for the launch of the Equal Justice Initiative’s National Memorial for Peace and Justice and the Legacy Museum. I remember standing right near the office of Bryan Stevenson, the organization’s founder and a long-time PIH board member, and I could see the mighty Alabama River. I could see the former slave docks; they're right by Bryan’s office. I’d thought about this history on every visit to EJI. But this time, because I'd already been working in Sierra Leone for a while, I thought about those ships departing from somewhere around Freetown or Bunce Island—the site of a major British slave trading post—and ending up in Montgomery. I’m happy for that little visual map, which came to me unbidden. I'm glad that there was some restoration of historical memory for me, and happier I can share it in this book. We can all have those little epiphanies.

This book is a pleasure to read, but is also very painful. Not just because the physical descriptions of Ebola are difficult to take in, but also because of the extent to which the virus forced people to make really unfair choices between their humanity and their health—holding their loved ones close, versus giving in to the very real threats of the virus. I wonder how you observed that, but also how you observed people leaning deeply into their wells of humanity and hope.

I saw much more of the latter. I was very moved by the work I saw and stories I heard. I was unhappy about the quality and purpose of the “international response,” which seemed to replicate colonial priorities of disease control over care. But the friendships we made are enduring gifts and a reflection of all that was beautiful during those times, when so many people really did try to look out for each other.

I struggled a lot with how many of the grisly details to include. And I knew for sure that I didn’t want anything gratuitous. There are many episodes that I removed because they were so graphic and didn’t add to that corpus of sentiments and enlightenment and wonderment I experienced and wanted to share with the reader.

I'm hoping people won't mind that it's a very difficult book emotionally, because there's a great deal of proximity to suffering in these pages. But I really hope that the ultimate message is one of uplift.

You’ve been a pioneer in the global health field for decades. How do you manage the emotional pendulum in this work between very real sadness and very real joy?

It’s very hard, but there are lots of reasons to allow yourself to be buffeted by those extremes. The most important one is because they are precisely the extremes that are our friends, patients, and co-workers have experienced directly.

I think those staffing the global health apparatus could stand to be more battered by sadness, in fact. It's the bloodiness and bureaucratic nature of a lot of public health, the lack of proximity to patients, that probably spares the control-over-care paradigm from reform. Because people are just too distant from it. I don't think of PIH as part of the public-health machinery so much as part of the global health equity machinery. Understanding equity and inequalities implies the obligation to understand context, to look back in time to understand how social history came to be.

Some people have a rich life of faith, others have distracting hobbies, others are doing such varied work that their sadness is leavened by a lot of satisfaction—like when the team in Sierra Leone gets the Maternal Center of Excellence up and running, you'll be floating on that happiness, right? Years and tears later, I'm still happy about University Hospital in Haiti, still thrilled about Butaro Hospital in Rwanda, and the University of Global Health Equity next door.

All three of those things are meaningful to me: spiritual engagement, distracting hobbies—mine happens to be gardening—and that network of friends who stick together in this work long enough to see the progress and joy that invariably attends this work. It's really more about joy and progress once you stick with it. If I go back to my hypothesis that a lot of people in global health could stand a little bit more sadness, it’s not that I wish sadness on them. But I wish the kind of passion that we have on all of them. And I think that, for most, passion comes from proximity.

You mentioned before the “control-over-care paradigm.” Can you share more about this idea?

Even when I was still a medical student, I found hard-core disease control unnerving—all of your attentions are focused on stopping spread of a pathogen without adequate attention and resources for treating people suffering from said pathogen.

Where in the world was the priority most reliably placed exclusively on disease control with little interest in the care afforded the natives? This paradigm came into being during colonial rule. Year in, year out, epidemic this and epidemic that, I could find some undercurrent that said: ‘Good, high-quality medical care is for us—not for you, Black people and brown people. We got disease control for you.’

With Ebola, people would misinterpret the international community's response. They said, "Billions of dollars were put into Ebola care." That's bullshit. There weren’t billions of dollars put into Ebola care—if there were, we would have had similar case fatality rates to what we saw in Europe or in the United States.

We found plenty of people in the public health community saying, “It matters a great deal to me that people get better care.” But early on in the epidemic, the mediocrity of the quality of care was not raised militantly and persistently. And by the time these massive investments—which were a lot smaller than we were led to believe—were made, it was too late. The majority of purpose-built Ebola treatment units never saw any patients.

Can you update us on Ibrahim, Yabom, and the rest of the survivor community you feature in the book?

They are all still working with us. And one of the things that happened with the survivors’ program was that fellow Ebola survivors became close friends. Today they still constitute a community—not just a collective working to improve the care that people who survived Ebola are receiving, but also as a social collective able to confront other problems, like COVID-19.

I believe that the greatest problems faced by the people we're calling survivors are material problems: housing, jobs, food, insurance. They say, "I need a phone, I need a laptop, I need to go to school, my kids need to go to school, I want to go to university." So we really have to keep asking hard questions about inequality: how it's sustained, how it can be addressed. And that's not going to go away in Sierra Leone or the United States without sustained and passionate commitment to health equity.

You didn’t know that this book, about a historic epidemic, would be published during a historic pandemic. How do you think this moment can perhaps benefit from the book?

When things like COVID-19 come along, people are suddenly more aware of the fragility of our grasp on flourishing. So the solutions that are proposed in this book, which include such concepts as health system strengthening, building safety nets, and building out insurance for unemployment, catastrophic illness, and funerals—all of that can be viewed through the lens of COVID, too.

Our work, which is around health system strengthening and all of what I just mentioned, never enjoys adequate financial support. A book like this isn't going to generate the resources. But if it generates the understanding that leads to corrective investments, that would be a great thing to have contributed to.

Was writing this book cathartic?

Yes, it was. It wasn't just catharsis, as in, "I'd like to exorcise some of these terrible images and thoughts from my mind and maybe writing about them will help." It was also getting to know the other side of these individuals, whom I'd known as patients, as fully fleshed-out people with joys and victories as well as losses. And getting to know Sierra Leone, which I'd seen as a battle zone between a virus and poverty and people. You don't want to go away from a place and a people with only grim and gory stories. You want to understand the rest of their experience, too.

Gedeon Ngoga said several global factors—the COVID-19 pandemic, a new report on health inequities, and World Diabetes Day, which is Saturday—all have a common thread: the importance of nurses.

“Nurses make a difference in so many facets of the work,” Ngoga said. “They make up the vast majority of the health care workforce, especially in low-resource settings, and for that reason they are counted on for much of care delivery. Ninety percent of care delivery is provided by nurses.”

Ngoga added that nurses make it possible to integrate and decentralize care delivery for non-communicable diseases (NCDs) such as diabetes, helping PIH serve patients in rural areas where specialists may not be readily available. 

Ngoga is Partners In Health’s cross-site nurse educator for NCDs. His comment aligns with this year’s World Diabetes Day theme, “Nurses Make the Difference.” The theme rings incredibly true for PIH’s growing NCD programs, including diabetes. PIH nurses around the world are ensuring diabetes patients receive sustained, comprehensive care—including in community settings—from diagnosis to clinical treatment and connection to specialists.

That care particularly focuses on type 1 diabetes, which predominantly affects younger patients in low-income settings and requires advanced skills in specific areas—such as insulin management—to prevent life-threatening consequences.

Ngoga said this year, PIH’s more than 1,200 nursing and midwifery staff—nearly 90 percent of whom are women—also have been supporting COVID-19 responses while maintaining routine services and chronic care across PIH’s clinical areas, from maternal and child health to malnutrition, malaria, HIV, and more. 

“Nursing sits at the crux and at the margins of many intersecting operations, and vast clinical areas,” said Julia Vance, a cross-site nursing coordinator for PIH. “They can pull together many different tendrils of care, and also are actors in changing people’s relationship to health and health behaviors.”

Melissa Ojemeni said that breadth of influence—and the level of skill and autonomy required of nurses—often is overlooked. Ojemeni is program manager for PIH’s Global Nurse Executive Fellowship, a yearlong program that just launched its second cohort. This year’s 10 nurse fellows come from six PIH-supported countries: Haiti, Sierra Leone, Liberia, Rwanda, Lesotho, and Malawi.

The fellowship is expanding the leadership capacity of nurse executives, building their skills and providing mentorship for leadership roles. It’s also changing perceptions, Ojemeni said, that nursing is only about administering medicine or handling mundane tasks.

“We’re often not recognized, we’re often not at those tables that are making decisions, but slowly and surely that is changing,” she said.

PIH is helping lead that effort. In the World Health Organization’s Year of the Nurse and Midwife, and with Dr. Sheila Davis, RN, as CEO, PIH’s global advocacy for nurse leadership is growing.

Equitable, Integrated Care

A recently published report demonstrates the importance of nursing in delivering equitable care for NCD patients in settings of poverty.

“The Lancet NCDI Poverty Commission: Bridging a Gap in Universal Health Coverage for the Poorest Billion” was published in September. The report is the result of a massive, multi-year collaboration by NCD experts around the world, including many PIHers. The first-of-its-kind analysis examines NCDs and injuries, which deeply affect millions of people in the world’s poorest settings and cumulatively represent one of the planet’s biggest and most glaring health disparities. 

Every year, NCDs and injuries cause 560,000 avoidable deaths for people who are younger than 40 and among the world's poorest billion. That total is greater than the avoidable deaths caused by HIV and maternal causes combined, for that same population.  

Pandemic safety measures and social distancing did not stop work on the Lancet report, which includes country-level findings and recommendations for more equitable NCD interventions and policies. The report was co-chaired by Dr. Gene Bukhman, PIH’s senior health and policy advisor for NCDs. Its commissioners included Dr. Agnes Binagwaho, vice-chancellor of the University of Global Health Equity in northern Rwanda; Dr. Gary Gottlieb, former PIH CEO; and Chelsea Clinton, global health advocate, PIH Trustee, and vice chair of the Clinton Foundation.

One of the report’s key recommendations is investing in integrated NCD care delivery, including a nurse-led model for severe, chronic NCDs such as type 1 diabetes. Through the leadership of nurses, clinical officers, and other mid-level care providers who specialize in NCDs, patients can receive advanced services at district hospitals that are much closer to where the care is needed most.  

Innovations in nurse-led NCD care in Rwanda, for example, are informing strategy and training models for NCD services across the African continent and resulting in new partnerships with WHO-AFRO and other regional partners. 

An audience of hundreds viewed a virtual launch event for the landmark Lancet report. PIH’s NCD teams plan to build on the momentum to mobilize greater funding and political commitment for NCDs of poverty.

All of that work is built upon the foundation of nursing care.

“At every segment, every step of the health care system, really the person that’s overseeing things in one regard to another is a nurse,” Ojemeni said. “And I think that’s something that resonates not only in the developing world, but also in the U.S.”

Ojemeni said PIH’s ongoing involvement and advocacy with the WHO will be crucial to elevating the voice of nurses, who number more than 20 million around the world.

“Imagine what that capacity and power could do on a global level to promote change and promote what’s best for our patients,” she said.

In the United States, Native Americans face disproportionate rates of type 2 diabetes, a chronic condition in which the body either doesn’t produce enough insulin or resists the effects of insulin. If untreated, the disease can lead to serious and even fatal complications including kidney failure, heart attack, or stroke.

Diabetes is especially prevalent in Navajo Nation, where about 25,000 people suffer from type 2 diabetes and 75,000 are estimated to have prediabetes. The high rate of diabetes among Native Americans stems from decades of systemic racism, which have led to unemployment, food deserts, lack of running water, and a weakened health system.

That’s why Partners In Health (PIH), Brigham and Women’s Hospital (BWH) and its sister organization in Navajo Nation, Community Outreach and Patient Empowerment (COPE), have worked to strengthen Navajo Nation’s Community Health Representative Program, which hires and trains local residents to provide compassionate, culturally appropriate care to patients in their communities.

Recent research highlights the importance of this work. A study, published last November in the International Journal for Equity in Health, found that patients who received home visits and other care from Community Health Representatives showed an improvement in blood sugar levels and cholesterol levels over those who did not, lowering their risks for diabetes complications, such as heart attacks and blindness.

A Community Approach

The COPE team has strengthened medical care and social support in Navajo Nation since 2010, in partnership with Indian Health Services. Community activities have focused on food access and clean water in addition to training and support of the Community Health Representative (CHR) Program.

But CHRs aren’t a new concept—the program in Navajo Nation specifically has been around since 1968 and was the first such tribally-run program launched by Indian Health Services in Native communities across the United States.

In Navajo Nation, CHRs are trained Certified Nursing Assistants and many come from the communities they serve. In addition to English, they must speak Diné, the primary language for many elders. Their primary job is to monitor and assist chronically ill patients. Each CHRs conducts about 80 home visits per month and serves a population of anywhere from 600 to 5,000, in remote areas.

Despite the essential scope of their duties, CHRs often have to care for their patients with few resources.

Olivia Muskett, now COPE’s Training Outreach Specialist, was one of these CHRs in the early 2000s. In those days, she recalls, many CHRs didn’t have computers and relied on those who did to print and share materials, often borrowing from other programs. The CHRs, she says, couldn’t directly access medical records or coordinate with their patients’ doctors. “We were on the outside looking in,” she says.

Since PIH, BWH, and COPE have invested in the program, she has seen dramatic improvement. Now, many CHRs can manage their patients’ care by accessing their electronic medical records. They receive mandatory training in taking a “whole patient” approach, meaning they consider a patient’s medical and socioeconomic situation to assess their health. And they’re more connected with doctors. As a result, they’re able to serve more effectively as bridges for patients, connecting them to health services, putting in referrals, and helping them enroll in Medicaid.

Navajo leaders wanted to know how much these interventions had affected quality of care, and so the COPE team and partners designed a study focused specifically on the impact made on the lives of patients with diabetes.

Study Proves CHR Program’s Effectiveness

Beginning in 2016, Harvard researchers and the COPE team compared the outcomes of two groups of diabetes patients over a period of four years: those who had the COPE intervention through CHRs, and those who did not.

The team looked at four measures: 1) HbA1c results (reflecting average blood sugar levels), 2) cholesterol levels (low-density lipoprotein), 3) blood pressure, and 4) body mass index.

The results were impressive. Patients in the test group had greater improvements in blood sugar tests and cholesterol levels, both of which lower the risk of diabetes complications, such as heart attacks and blindness. The most significant improvements were seen in patient HbA1c tests, which record blood sugar levels.

Dr. Sonya Shin, associate professor at Harvard Medical School and lead researcher on the study, was encouraged by the results. “Given the fact that American Indians experience disproportionate rates of cardiovascular disease compared with the U.S. general population, we believe this intervention could have an important role in advancing health equity,” says Shin.

The study, while new, has already had an impact. COPE has used the research to advocate for greater integration of CHRs with provider teams, including access to electronic health records and closer care coordination. Meanwhile, patients have benefitted from getting their chronic conditions under control and watched as their blood sugar levels progressively came down. They have also reported eating healthier foods and feeling better.

The research is one small step toward reducing health disparities that continue to impact people’s day-to-day lives in Navajo Nation.

Maritza Sáenz has been a singer for years; but when her mother died of a lung disease, the music lost its meaning.

It was a loss that the resident of Callao, Peru—a rural community outside of the capital of Lima—describes as devastating. Sáenz, a single mother who shares a home with her daughter, grandson, and 85-year-old father, recalls not being able to sleep or concentrate on things that usually brought her joy. It felt like something was missing.

It wasn’t until she began speaking with a psychologist through Socios En Salud, as Partners In Health is known in Peru, that things began to turn around.

“Today, I feel more relieved,” says Sáenz, who speaks with her counselor on the phone. “She understood me, despite the distance, and knew how to treat me.”

Sáenz is one of nearly 5,000 Peruvians who have accessed mental health services through PIH since the start of the pandemic. This mental health support comes as part of PIH’s COVID-19 response in Peru, where PIH has provided more than 22,800 COVID-19 tests and offered more than 3,000 people social support, including medicine, food, and housing assistance.

“When we connect people, both physically and emotionally, within a community or a family [with] the resources they need, we will be providing them better opportunities,” says Carmen Contreras, director of mental health in Peru.

PIH has worked in Peru for more than 20 years. Its mental health work there has included providing tuberculosis patients with psychological support, establishing a safe house for women living with severe mental health conditions, and training local residents as community health workers, who refer patients to mental health centers and connect them with care.

During COVID-19, that work has adapted to also include group and individual counseling for families mourning the loss of loved ones, as well as an innovative messaging app called Bienestár. The app, run by PIH’s team of local psychologists and community health workers, offers mental health screenings and connects patients with care virtually. It currently serves three of the communities where PIH works.

Catherin Rodríguez, who supervises PIH’s work in the Trujillo community, says mental health is crucial for everyone. That’s because it’s never just one person who is affected. Mental health has ripple effects—on a family, a household, and a community.

“It is essential for a person to be concerned about their mental health,” says Rodriguez, “because this action can be replicated at home with their entire family and so, little by little, be concerning for overall health.”

Stigma, says Contreras, is also a barrier to accessing mental health care. Yet people have to realize they are not alone in experiencing difficulties. “Emotions are part of being human,” she says.

Contreras has seen SES’s mental health work evolve over the years. That journey has been both professional and personal—especially this year.

“A close relative of mine nearly died from COVID,” she says. “It was actually very difficult for my family. I spent a month dealing with that…we were all devastated.”

Much of that devastation came from the fact that her family, like many others affected by COVID-19, didn’t know how to tell other relatives when their loved one’s condition was worsening.

“With COVID, we need to work on that,” says Contreras, whose relative has since recovered. “It’s not just oxygen, or saturation, or the lungs; it’s also how we deal with our emotions.”

A pandemic and the uncertainty it brings—from work to health care to housing—takes a toll not only on physical health, but on mental health. That makes a mental health response to the pandemic all the more vital.

For Sáenz, the journey has been difficult. But she is making music again.

“It has been very beneficial for me to have a psychologist by my side,” she says. “Now, I can breathe. I don’t feel pain in my chest. The oppression that I had I was able to lift thanks to the specialist’s help.”

In a rural clinic in Cange, Haiti, Dr. Paul Farmer and Ophelia Dahl came to a troubling realization—people living in poverty were dying of preventable diseases. And it wasn’t because of lack of medicines on the market. It was because the international community had turned its back, essentially leaving them to die.

That was an outcome that these health care advocates and their future colleagues refused to accept. What began in Cange swelled into a global movement, and Partners In Health was born. From sounding the alarm about multidrug-resistant tuberculosis in Peru to launching the HIV Equity Initiative in Haiti, PIH leaders took their fight from the hospital to the halls of international organizations, calling for health care as a human right and inspiring millions around the world.

This extraordinary story is captured in Bending The Arc, a critically acclaimed documentary available on Netflix. The film—directed by Kief Davidson and Pedro Kos—tells the story of PIH’s early years and the global movement for health equity and social justice. For an inside look at the film and its lasting impact, PIH sat down with award-winning writer and producer Cori Shepherd Stern.

Can you tell me about yourself and how you became interested in the story behind Bending The Arc—what drew you in?*

I was a television producer for a long time, was doing a lot of pop culture TV, and needed a break from it. I ended up going and working in Nigeria doing volunteer work muling medical supplies from the U.S., primarily HIV drugs. We would fill suitcases with them and take them over to Nigeria. The doctors there sorted the drugs and then gave the appropriate prescriptions, because people couldn't get them in Nigeria. While I was doing that, I was increasingly interested in why this wasn't available [in Nigeria] when it was available in the U.S.—what was the problem?

I read this article about the HIV Equity Initiative that Partners In Health was doing in Haiti. One of the authors was this guy, Dr. Paul Farmer. I was really struck by the common sense of what Partners In Health had done. That was my first introduction with Paul and the work, honestly.

Later, Mountains Beyond Mountains came out. I first reached out to Tracy Kidder. Then I reached out to Partners In Health to try to get the rights for a scripted film. And they said, ‘No.’ I reached out again. I just kept reaching out, like every few months. It took years. Finally they said they might be interested in doing a documentary. I brought Kief Davidson on board and we finally got PIH to agree that we could have the rights to make a documentary.

Can you talk about how the film narrative came together over the years of production? Did you know how it would turn out, or was it more a process of discovering?

January 2010 was the Haiti earthquake. We had plans to fly to Haiti that month, but we quickly moved those plans up. And I went to some friends – Desi Van Til, Sean Mewshaw, Heidi Lindeleof, and Damon Lindelof  - and said, ‘Look, I know this is last minute – but this is an incredible story. We need to fly to Haiti, like, tomorrow. Can you come on as our first Executive Producers and give us the money to do this?’

We were on the ground for almost two weeks shooting during the midst of the quake. But we couldn't really find the film. It was because Partners In Health isn’t about the acute emergency, right? It's not about the acute emergency of COVID-19 or the acute emergency of the earthquake—it's about the ongoing chronic emergency of global health inequity.

It wasn’t until we were in Rwanda and I was with Paul and [Dr.] Agnes [Binagwaho]. They gave a talk at Rwinkwavu Hospital about global health equity and about the journey of Partners In Health from Haiti to Rwanda. And it was the structure of the film, basically what ended up on screen. It was like, ‘This is what the film is.’ I just heard it. It was incredible.

What are some of your fondest memories from this project?

One really important moment in the film for me was Ebola—we got that on camera and people have asked me, ‘Was that staged? Is that real?’ When Agnes got that call, that was real. That blew me away that we had that moment on camera of her actually getting the call about Ebola. It was a crucial moment.

Another moment was when I showed a cut of the film to Paul for the first time. We were at [PIH co-founder] Todd [McCormack]'s house and I showed it to Paul and Ophelia and everybody. They loved it. But Paul was like, ‘You missed it—you missed the ending. You've got to change the ending.’ Paul knew we had to put Mirebalais in the ending. And he was exactly right. To really bring the story full-circle, we had to put the new hospital as the ending.

In the production notes, you talk about how your team filmed in disaster zones, operating rooms, and a historic blizzard. What were some of the unique challenges you faced while filming?

We began filming just days after the earthquake in Haiti. It was an extremely traumatic time for PIH and for all Haitians—and honestly the last thing we wanted to do was ask someone to let us put a mic on them and follow them around while they were dealing with such devastation. But it was important to capture the work of PIH during that time, so we tried to be as respectful as possible. From a sheer logistics standpoint, we were sleeping in tents (and were grateful to have them) and trying to charge our camera batteries with generators. 

Sound was also a constant issue. In film, if your shot gets messed up you can possibly cover it with other footage—but if your sound is bad, you're completely out of luck. So we had to do everything we could to make sure we had clear, clean sound recordings. In Haiti, the roosters crowed constantly and we had to try to block the sound using mattresses propped up against the windows and doors. We flew from the heat in Haiti straight into the worst blizzard week in Boston—where the heating system kept kicking in and ruining our sound.

Out of all the places we shot, Rwanda was our absolute best because there's a state-of-the-art studio there called ADMA that we were able to use. It was beautiful with all of the best equipment. We used a wonderful Rwandan crew, as well. 

And since the film covers 30 years of PIH’s work, that meant you had to go into the archives for a lot of the material. How did you gather this archival material and how did you decide what to use?

When we first started the film, we were given 13 photos and 30 seconds of footage and told that was the extent of the PIH archive. Paul insisted there was so much more, so we started digging. We contacted everyone we could find who had ever shot with PIH. Andrew Marx was invaluable in helping us get in contact with amazing filmmakers like David Belle and David Murdock, who had so much footage and really worked so hard to gather that footage in the early days of PIH. I also randomly met Fred De Sam Lazaro, a wonderful journalist, in a bar in England, who had shot with Paul and had great footage as well.

We finally got access to the PIH photo archive that had over 30,000 (not 13) photos in it, and it was like being in heaven for a filmmaker. And then, most importantly, I spent days and days at the Countway Library at Harvard digging through 50-odd boxes of archived material from PIH. We found some of our most incredible stuff there, including the tapes of the TB meeting that we included in the film. [Director] Pedro [Kos] and I danced around the library the day that we found those.

Our final and hardest piece of footage to find was the clip of Paul debating the World Bank guy—the "bankers must not be getting any sex" clip. We had heard that it existed—Tracey Kidder told us it did—but no one had a record of it anywhere. Finally, Tracey found it for us! It was on an old VHS tape tucked away in his cellar. We literally started cheering in the office when he called us and said he found it.

The film covers PIH’s decades of work with infectious disease outbreaks—ranging from multidrug-resistant tuberculosis (MDR-TB) to HIV/AIDS. Now, we find ourselves in the midst of a pandemic caused by another infectious disease, COVID-19. What aspects of the film do you think are still relevant today?

I think the film is particularly relevant today because it speaks to the idea that every life is worth saving and that it takes effort to do that, but it's not impossible. I'm horrified that we're just letting the death count tick by in the U.S.—over 200,000—and it doesn't have to be this way.

If PIH could contain an MDR-TB outbreak in Peru that many years ago, surely we can combat COVID-19 right now in the U.S. It's baffling to me that this country—with all of our wealth—is letting people die because we don't have the will to put systems in place to save mothers, fathers, brothers, sisters. I'm grateful to the work that PIH is doing here in the U.S. to contact trace and make sure that we're getting people the care they need.

The film ends with some powerful quotes—Paul Farmer tells us about the need to have hope and to reject despair and cynicism. And Jim Kim talks about “pessimism of the intellect and the optimism of the will.” What made you decide to end the film with these comments?

The idea that these are difficult problems but they do have solutions is the core of this story. PIH refused to look the other way and say, ‘It's too hard, we can't do it.’ It's crucial to firmly counter the belief that it's too hard to provide an equitable world, that it's too hard to save someone's life—when it's a matter of will and imagination. 

What was your hope for the film when you were writing and producing it, and has that changed or evolved in the years since?

My hope with this film was – and is - to have the world know the story of these people, who took on something very difficult but stayed committed to the fight and truly changed the world. And beyond that, for the story to serve as meaningful inspiration for others to truly commit to decency and humanity in their own lives and work.

What’s the one thing you hope that viewers—both those new to PIH and longtime PIHers—take away?

I hope people take away that just because something is hard, it doesn't mean it's impossible. And if you see it can be done, it's your responsibility to do it. I know that's radical to some people—but I do believe it is our responsibility to do everything in our power, to really push ourselves, to make this a more equitable planet for all of us. 

Learn more at bendingthearcfilm.com

*This interview has been edited and condensed

It was the middle of summer in southern Mexico, and the vibrant sun warmed the arms of 10 young clinicians arriving to Chiapas. Little did they realize that their one-year experience ahead would, quite likely, change their lives—and that they would not see the world the same way ever again.

Every year, 10 clinicians arrive in Chiapas to complete their social service year with Compañeros En Salud (CES), as Partners In Health is known locally. This year’s cohort of pasantes—a Spanish word for first-year doctors—will work in marginalized areas of this remote, mountainous region, where access to health care is difficult and challenges have only intensified during COVID-19.

Since 2011, the pasante program has placed newly minted doctors and obstetric nurses in rural communities in Chiapas—the poorest state in Mexico—to live and work. The pasantes go through a rigorous selection process where they are interviewed by the staff of Compañeros En Salud. Those who are chosen serve in the 9 rural primary care clinics that CES operates in partnership with the Mexican government, a community hospital, and Casa Materna—a center dedicated to maternal health.  

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Before CES began its work, many Chiapanecans lacked reliable access to health care for a variety of reasons, including not enough clinicians to cover clinics, irregular supplies of medications, and ill-equipped facilities.

This year, the COVID-19 pandemic has presented additional challenges in access to care. Residents find isolation requirements difficult in multigenerational households. And most cannot work from home should they become sick, as they farm corn and coffee as their main means of income. For their part, pasantes have been trained to use personal protective equipment, distribute masks to their patients, encourage preventative measures such as handwashing, and know protocols for CES’ COVID-19 response. 

When they eventually arrive in their communities, pasantes have been properly oriented and know visiting CES supervisors will be there for support.

Dr. Karen Martín will be serving the community of Plan de la Libertad for the next year. “I want to grow professionally with CES, but I know I will grow as a person too,” she says. “I want to have a better understanding of these communities and their people, getting to know them, how they think, opening up to them, but mostly being able to help them.”

In August, Martín joined the nine other clinicians in her cohort in Jaltenango, the city where CES is headquartered in Chiapas, for three days of orientation. The pasantes met each other and learned about the program, traditions in the community, emergency protocols and safety before heading into their respective communities.

The excitement was tangible.

“I strongly believe the best way to help vulnerable populations is through proper health care,” says Dr. Stephanie Picazo, another new pasante. “Compañeros En Salud has shown me this is possible. I’m excited about living in Laguna del Cofre, meeting the families, learning about their corn and coffee crops and, mostly, impacting this place.”

Many had known about Compañeros En Salud and its mission for years, including the training and mentorship opportunities it provides. And they knew the competition—including the application process—for just ten positions would be intense.

Dr. Carlos Popoca was drawn to the program for its focus on health equity. 

“I decided to come here for my social service year because I am aware of the inequality of my country and the lack of access to basic quality health care services in a place like Chiapas,” says Popoca, who will spend his year in the community of Salvador Urbina. “Taking your knowledge and sharing it with a rural community is something every young physician should do. I want to better understand the context of my patients, their culture and diversity, as well as the situations that lead them to illness, in order to be able to help them.”

Pasantes are often eager to serve, even if it means living far from their families for a full year; most come from the capital of Mexico, or surrounding states, as far as 15 hours away from Chiapas. Many who complete their social service year with Compañeros En Salud are so moved by the work that they request to stay to become full-time staff members.

“I feel like CES is the place where you can make a real change in the world,” says Dr. Karen Gutiérrez, a pasante based in the community of Reforma. “We all arrive here aiming to bring the best type of attention to those who need it the most. This will be a year of constant growth."

People struggling with mental health conditions who have stopped receiving treatment or taking medication—and as a result have seen their conditions worsen and may be homeless—are sometimes called “lost” patients.

In Maryland County, Liberia, Helena Wesley has made it her mission to find them.

Wesley is from Maryland County and has worked since 2015 as a mental health community psychosocial worker for Partners In Health. During that time, she has tracked and connected with more than 20 people, so-called “lost” patients, and reintegrated them with their families, communities, and dignified treatment.

“Because I grew up in Maryland, I know almost every family, and so when I was deployed into the community, I saw it as an important sense of duty to find and help people with mental illness,” she said.

Those 20 represent just her most significant cases. Wesley and her colleagues on the PIH Liberia mental health team collectively conduct more than 520 community visits a month, on average, to support people with mental health conditions and their families.

PIH Liberia’s mental health program is community-based, linked to health centers and enriched by hospitals, with a rights-based approach to building resilient health systems. PIH has helped integrate mental health care delivery across the country by developing an outreach program for the homeless, psychosocial support, and electronic medical records, while piloting quality improvement projects to increase referrals from traditional healers.

Clinicians deliver care within a mental health referral system and have been trained to accurately screen and diagnose people for mental health conditions. The team works extensively at the community level to provide care and educate community members about mental health conditions through patient-led radio broadcasts, training, and engagement with traditional and faith-based healers.  

For Wesley, the job often means talking with her neighbors—and the conversations aren’t always easy.

When Wesley began working with PIH, she regularly visited families who she knew included someone with mental health conditions, or who community members suggested she visit. She soon realized, though, that most of those families didn’t know the whereabouts of their relatives with mental health conditions.

Due to stigma and other factors, people with mental health conditions who leave their homes often don’t do so willingly—they may not be receiving dignified care at home, or even may be forced out by their families.

In such situations, Wesley searches in local marketplaces and public gathering spaces, to find people and try to enroll them in PIH’s mental health program.

When she is able to find someone who has been lost and is struggling with mental health conditions, Wesley says, the first thing she does is call them by their name and offer them something to eat. Helping someone with basic needs goes hand in hand with emotional support.

“I engage them in conversation and use physical contact, like a pat on the shoulder or back, to show them I care and gain their trust,” she said. “After a few of these conversations, I am able to convince them to return with me, back home to their family, in order to gain the family’s support and begin treatment at PIH-supported health facilities.”

Wesley acknowledged that she often faces challenges in her work, as many people with mental health conditions have experienced stigma and discrimination. But she remains determined and does all she can to help people start treatment and get better.

When people are in treatment, Wesley visits them at their homes or a health facility in the morning and evening, every day, to monitor their progress and well-being.

In addition to caring for patients, Wesley also works to raise local awareness about epilepsy, HIV transmission, the importance of adhering to medication, and stigmatization within her community, as part of PIH-Liberia’s community health programming. In the past year, the Liberia mental health team conducted 194 activities with communities.   

Community members trust her, she said, and often refer potential cases to her.  

“PIH’s work in promoting mental health services in Liberia is making an impact. And that is why I am motivated—seeing patients who were rejected and very often abused on the streets due to their mental state accept treatment and reunite with their families gives me so much satisfaction,” she said. “It is very fulfilling to have patients in recovery now call my name and chat with me whenever they see me, or when I visit them at home.”

Dr. Giuseppe (Bepi) Raviola, director of mental health at Partners In Health, shares below how PIH has invested in and incorporated mental health into COVID-19 care around the world, and reflects on the importance of self-care during moments of stress and crisis.

October 10, World Mental Health Day 2020, is this year dedicated to “Mental Health for All—Greater Investment—Greater Access. Everyone, everywhere.” It comes during a year like no other. For many people, it has added the highest levels of stress, strain, and trauma they have ever experienced. The current moment calls for each of us to take individual steps to buffer our mental health, and to together stand up for greater investment in mental health, wherever we live.

Major public health challenges, climate change, racial and political justice movements, as well as the complex evolution of our use of technology are converging now to challenge our conception of “mental health.” Pandemic anxiety takes many forms–physical, emotional, cognitive, spiritual, and existential.

How do we intervene with the stress we are experiencing, and that embedded threat response?

We are each managing our own very personal manifestations of acute and chronic stress that dig deep into our biology, and trigger both our innate and unique threat responses. This is overlaid on our past life histories and experiences, which have already been embedded physically and psychologically, and in the ways that we live our day-to-day lives. For some people, the threat response can inspire constructive action and even inspiration. For some it can evolve to a state of depression. And for others, it can unfortunately increase the capacity for violence.

With personal, professional, political, and economic norms so challenged, we’re justified in this moment to have a sense of existential crisis as individuals, communities, and as a species.

How do we intervene with the stress we are experiencing, and that embedded threat response?

Self-Care in Crisis

Mental health interventions include not only biological treatments for mental illness, which do have efficacy, but more importantly encompass the various attitudes, practices, and "interventions" that we each choose and commit to as individuals living within a broader ecosystem of family, friends, local community, and the natural environment.

I’d like to take the opportunity to share with you some points for optimism, both with regard to the steps we personally can take during this difficult time, and also from the perspective of what can be accomplished in the delivery of mental health care.

On the personal side, each of us—without training in formal mental health treatments—can learn to effectively deliver basic components of interventions to others, and to ourselves; these can be spiritual, physical, psychosocial, and psychological. Many different kinds of interventions, including meditation, yoga, acupuncture, exercise, and time outside in nature, have been proven scientifically to be beneficial for our mental health.

There are little things that we each can do to advance our well-being, starting with simply breathing and putting one foot in front of the other.

One particular psychological treatment delivery model, the Common Elements Treatment Approach (CETA), crystallizes evidence on best practices to address a variety of problems. CETA is a proven and innovative approach that addresses substance use, violence, and mental health problems (such as depression, anxiety, trauma, and aggression) in a single intervention. It is comprised of nine highly studied and effective elements: engagement and education about the problem; thinking in a different way; engaging in activities you enjoy; confronting fears and trauma memories; maintaining safety and self-care; substance abuse prevention and intervention; problem-solving; and anxiety management. The World Health Organization has also endorsed several other approaches that are comprised of similar basic psychological and psychosocial skills, proven by research, and implementable in communities.

The variety and robust evidence for these interventions should give us a tremendous sense of optimism. We don’t necessarily need a mental health professional to cope better. We don’t have to have a degree to be helpful to ourselves or others, and a person doesn’t have to have a mental health “problem” to take advantage of these tools. Not everyone needs “mental health care” packaged as a clinical service. There are little things that we each can do to advance well-being, starting with simply breathing and putting one foot in front of the other. The effects of these small personal transformations can ripple to positively impact our children, partners, families, friends, and colleagues—in person, by phone, or on Zoom.

Investing in Global Mental Health

However, we’re still left with a global gap in the dissemination and sustained availability of all of these kinds of tools and interventions. There are various reasons this is true, including:

• limited budgets to support mental health specialists,
• few non-specialists trained and supported to deliver mental health care,
• limited management capacity for training and long-term supervision,
• a lack of adequate primary care to back community-based mental health care and support delivery for more complex situations

This is why investing in mental health is now so important.

We hope that PIH’s approach to delivering mental health care can serve as a point of hope, that provision of care and support is doable in all contexts, relevant in all contexts, and that it’s a worthwhile investment. The kind of work that we do is not simple; however, it is not overly complicated—or expensive—either. While COVID-19 is changing the landscape of health care delivery, now is the time to look at what works, and commit greater resources to delivering mental health care and support to diverse populations.

Over the past decade, Partners In Health’s cross-site mental health programs have prioritized the direct care of people living with mental health conditions, and have served as a real-world example of what can be accomplished when small investments are made in mental health care.

The shocking and difficult experience of scrambling to develop an organized  mental health response to the 2010 Haiti earthquake and to the 2013 to 2015 Ebola crisis in West Africa clarified for us the need to develop a clear strategy for cost-effective mental health care delivery that wouldn’t leave us as exposed to the inevitable trauma of these and other unexpected events. In essence we’ve tried, at an organizational level, to put one foot in front of another in the face of huge challenges and burdens from humanitarian disasters and a significant burden of illness in the communities we serve. Incredible progress has been made. Over the last year, for example, more than 104 PIH-supported facilities delivered mental health care, more than 65,000 facility-based mental health visits were made, and more than 12,800 people were treated for mental health conditions across PIH global sites.

Adaptation in the Time of COVID

Over the past several years, our global sites have been collaborating to expand the availability of psychological and psychosocial mental health care and are now prepared for exactly the kind of crisis we now face with COVID-19.

Each site has responded decisively and creatively, with a number of innovative new initiatives. Socios En Salud, as PIH is known in Peru, for example, developed a cell phone-based digital technology, a chatbot, through which people are screened and linked to support, if needed. The chatbot is being piloted and scaled up nationally in partnership with the Ministry of Health. The team adapted the chatbot into Quechua to increase access to essential mental health services.

Following PIH’s engagement with the Commonwealth of Massachusetts in developing the Community Tracing Collaborative, our mental health team encouraged an aggressive approach to training in Psychological First Aid for contact tracers so that they could effectively deliver support and address the mental health needs of contacts and people affected by COVID. Early on, we observed that some contact tracers themselves were enduring significant distress supporting people remotely, as high levels of trauma, economic challenge, and personal loss faced by people affected by COVID were naturally transmitting to the contact tracers. Support groups were developed for the contact tracer corps, and a contact tracer peer manager was elevated from that corps to develop a team of peer support specialists for the program.

Meanwhile, PIH global sites were increasingly expressing concern about the significant distress faced by health care providers whose colleagues and themselves were contracting COVID-19. The peer support model developed in Massachusetts, which benefited originally from the PIH global experience, is now being re-adapted back to the global sites, starting with Lesotho and Malawi, for the purpose of supporting health care workers in distress.

Protecting the mental health of our health care providers, who make essential sacrifices every day, must remain a priority.

Envisioning Improved Care

Taking all this into consideration, this is what I would ask of you on World Mental Health Day 2020:

• Take a moment to define for yourself what it means to have good mental health in the current context of rapid and disruptive social change
• Consider what the future of mental health care in society should look like
• Commit to talking about mental health with friends, family, and colleagues
• Push for the political will and change needed where you live to build mental health practice, services, and programs to meet the challenges of the present—and to come

At PIH we talk about “solidarity” in our work as an acknowledgement of a shared commitment to peace, social justice, and equal human rights—including in health—in the face of poverty, structural and actual violence, natural disaster, and political upheaval. If the effects of historical and psychological trauma have become more apparent through the current COVID-19 crisis, then it must be met by a shared vision for mental health care and support to ameliorate the situation for all. We will continue to work toward this goal, and access to quality mental health care for everyone, everywhere.

Content advisory: This article talks about sensitive issues including suicide and mental illness.

Tatiana Therosme gathered herself for a moment before talking about a young woman, born with HIV, who battled severe depression for years because of stigmatization and mistreatment resulting from people’s perceptions of her diagnosis.

Therosme first learned of the woman, Fabiola Noel, through a fellow staff member for Zanmi Lasante, as Partners In Health is known in Haiti.

“I was the primary clinician provider, and the nurse called me because she had tried to kill herself,” said Therosme, community health worker supervisor for Zanmi Lasante.

What followed was a relationship of support and clinical care that has stretched over years, ever since that phone call.

Therosme and other members of Zanmi Lasante’s mental health team quickly began seeing Noel regularly. Therosme learned that Noel’s peers had repeatedly treated her badly, as had a teacher at school.

“Because of the context of her HIV, because of the context of stigmatization…she really faced many, many difficulties,” Therosme said.

Zanmi Lasante’s ability to support Noel and treat her clinically for anxiety and severe depression—caring for her mental health, as well as physical—is a testament to a mental health system that arose after Haiti’s devastating 2010 earthquake, through a partnership with Haiti’s national government.

Over the past decade, that system has grown to serve a population of more than 1.3 million across Haiti’s Central Plateau and lower Artibonite regions, providing care for depression, psychosis, epilepsy, and many other mental health conditions and neurologic disorders.

Between January 2016 and September 2019, for example, Zanmi Lasante’s mental health system delivered more than 28,000 patient visits, and served more than 6,300 patients at supported health facilities.  

A recently published article details those 10 years of growth, and describes the development of a comprehensive, community-based mental health system in the Caribbean nation, where public mental health services previously were not able to match what was needed. Additionally, the article describes challenges to care stemming from Haiti’s ongoing political and social instability, and finds that despite those challenges, high-quality mental health care can be delivered not only in Haiti, but also in other low-resource settings around the world.

The article, “Development of a comprehensive, sustained community mental health system in post-earthquake Haiti, 2010–2019,” was published in February by Cambridge University Press in the journal Global Mental Health. Co-authors include Pere Eddy Eustache, director of mental health and psychosocial services for Zanmi Lasante; Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health; Therosme; and several others.

“The dedication of various staff across Zanmi Lasante and PIH to maintaining the system and improving the model has led to ongoing program growth and longer-term commitment to build a better system, (offering) hope that anyone in Haiti living with a mental disorder can have access to free, quality mental health care,” the study states. “We can expect that the perception of the Zanmi Lasante program’s relevance as an antidote to despair from mental suffering, both in communities and in the health system, will only increase the demand for services with time.”

Noel, whose name has been changed to prevent further abuse, is an example of how much people can achieve when the crushing burdens of mental disorders are lifted.

Therosme recalled that Noel assumed she would die young because of her HIV, so she never believed she could become a nurse or clinician.

“I remember working together to see what her next plan could be,” Therosme said. “She didn’t think she could make it, but she worked and completed her studies.”

Support, not stigma

Eustache said much of delivering mental health care in Haiti is about helping people understand that the trauma they are living with can be alleviated, and that receiving clinical care and local support are positive steps that should be shared, not stigmatized.

“The history of Haiti has been a history of violence. Structural violence, political violence, everything. People are exposed to poverty, and what I call social violence. And the new aspect of violence is what I call environmental, ecological violence,” Eustache said. “Sometimes people are living with trauma, and they are unaware of that.”

Eustache said ecological trauma from many sources can affect Haitians. “For example, every time there is a heavy rain, in the slums, walls collapse, followed by casualties,” he said. “Deforestation is strongly active in the destruction of the environment. This is what I call ecological violence.

“Drought caused by deforestation creates a cycle of hunger, pushing people to cut trees and make charcoal, destroying the environment, which becomes more and more threatening for people who are more and more vulnerable to trauma,” he continued.

Eustache said many of the people who receive mental health care from Zanmi Lasante show behaviors that are related to trauma they experienced in the past, and now appears in other forms.

“This is something we live on a daily basis,” he said.

“People don’t know how to phrase it, how to verbalize it,” Eustache added. “But we need to remain aware that Haiti is a country that has been prone to trauma.”

The earthquake on Jan. 12, 2010, struck about 15 miles southwest of Port-au-Prince, Haiti’s capital. The disaster killed nearly 300,000 people, injured hundreds of thousands more, and devastated social services and health care infrastructure.

In the weeks that followed, Haiti’s Minister of Health contacted Zanmi Lasante to request support in developing a national mental health system.

Service, not scarcity

The ministry’s request, initially made in February of 2010, was based on Zanmi Lasante’s previous success in addressing HIV and TB from a community-based model of care. That model included mental health services, with community health workers playing a key role in providing access and support.  Government and health leaders in Haiti believed the model also could be effective for addressing the growing burden of mental illness, itself, as an independent issue outside the framework of any other disease.

“After the earthquake we were aware that the need for mental health would be huge, and we needed to understand those expectations,” Eustache said. “So, we started thinking about a mental health program.”

Eustache and Raviola worked closely together, starting the week of the earthquake, to bring to reality a model for a community-based program that could be tried and tested in the regions where Zanmi Lasante works.

Therosme took Eustache’s comment a step further, saying that Zanmi Lasante jumped on the opportunity to build a structured mental health program that could fill gaps in staff recruitment, training, development of mental health specialists, and more. 

Those gaps had long been significant in Haiti, where the majority of people addressed mental health care through traditional treatment channels, such as religious leaders and local healers. Language barriers and local customs often enabled religious and community leaders to build trusting relationships with patients, as opposed to doctors in Port-au-Prince or other urban areas, often far from people’s homes. Financial barriers also played a role.

Eustache said that at Haiti’s two psychiatric hospitals, Beudet Hospital and the Mars and Kline Psychiatric Center, both in Port-au-Prince, the government pays clinicians’ salaries, but remaining costs are laid on patients and their families.

That means people from rural areas often cannot afford to not only travel to the capital, but also support a hospitalized family member during extended care. As a result, many people would avoid traveling to Port-au-Prince and instead seek local care from traditional healers.

These were just some of the factors forming the backdrop as an initial assessment, begun in March 2011, examined the setting for mental health programs in Haiti.

Building a system

The project began with an initial assessment of the local context—beliefs, attitudes and perspectives related to mental health care practice, and priorities. It engaged 15 focus groups and included 11 individual interviews with community members, community health workers, facility-based health workers, people living with mental illness and their families, and religious leaders, including houngan or voudou priests, manbo or voudou priestesses, and Catholic and Protestant priests.

The assessment found that, for respondents, the stressful conditions related to poverty experienced in many parts of the country, exacerbated by the earthquake, left everyone vulnerable to all manifestations of sadness and dysthymia, depression, suicide and psychosis.

It also found that traditional healers desired a formal mental health system, including psychological treatments, with which to collaborate.

This informed Zanmi Lasante’s commitment to build a formal mental health system, in large part, as a response to the devastating disaster. The growing team began by developing care pathways and protocols for depression, psychotic disorders and epilepsy, with the support of Grand Challenges Canada. 

“We consider that the earthquake has been an opportunity to raise awareness, and raise funding, to help us maintain the program and make sure that more and more people can get access to care that we are providing,” Eustache said. “We lost 300,000 people—that’s huge for a small country like Haiti. We say that these people shouldn’t have died for nothing.”

Zanmi Lasante’s immediate mental health response after the earthquake was providing care for people who had been displaced and were staying in temporary camps. That work evolved into community-based care, built on the foundation of community health workers and referrals to clinics or hospitals, where clinicians could assess patients and develop long-term care plans.

“What was accomplished by Zanmi Lasante in developing this system has been truly remarkable,” Raviola said. “Clinicians worked under the most challenging circumstances to support people living with unaddressed mental disorders that pre-existed the earthquake, trauma from the earthquake, the effects of additional disasters including the cholera crisis and multiple hurricanes, as well as political violence. The Haiti work also laid the groundwork for PIH’s cross-site learning collaborative in mental health care delivery, which to us represents a model of trans-national dialogue and sharing of experiences and lessons.”

Between 2010 and 2015, the Zanmi Lasante and PIH cross-site teams developed a system based on five key skill sets for delivering mental health care in low-resource settings, and five key implementation rules.  These include:

Skill sets:  

• case-finding, engagement, follow-up, and psychoeducation;
• targeted psychological interventions;
• medication management;
• supervision and consultation; and
• quality oversight

Implementation rules:

• assess context;
• identify and map priority care pathways;
• specify decision support tools;
• use QI practices; and
• address sustainability, management, and capacity-building

This process of describing the essential, effective elements of a basic system of care informed learning processes at other PIH sites in important ways, as the PIH cross-site team developed dialogue across all of the sites to build similar, and different, models of care based on local priorities. The Haiti case, for example, is now a key teaching tool for a course at Harvard School of Public Health called “Case Studies in Global Mental Health Delivery.”

Stability, amid instability

All of the skill sets and implementation rules tested in Haiti are delivered in a social and economic setting that has been turbulent, not just in the earthquake’s aftermath, but also in very recent years and to the present.

Three different presidents have served Haiti since 2015, amid constitutional crises and frequent civil protests, fueled by allegations of electoral fraud and government misuse of billions of dollars.

In 2016, Hurricane Matthew ravaged southern Haiti and displaced 175,000 people, many of whom faced a cholera epidemic, and food shortages brought by widespread damage to crops and livestock.

By 2017, 38,000 people were still living in displacement camps built after the 2010 earthquake. The following year brought more waves of street protests, both peaceful and violent, during a new period of national lockdown, known as peyi lòk. Schools closed, roads were blocked, and the country was brought to a standstill, slowing the economy and worsening poverty.

All of these crises have had significant effects on the well-being of clinical staff and caregivers themselves.

“At a human level, significant challenges currently make service delivery extremely difficult due to the contingencies of the daily reality that providers, coordinators, and managers have been facing over the past decade, a situation that has worsened since 2017,” the 10-year paper notes.

‘We still need to fight’

Despite all of those challenges, Zanmi Lasante’s mental health team has continued to show up, every day, to provide vital care and support—to people including the young woman with HIV.

Therosme said that woman now is a nurse administrator and social worker in a Zanmi Lasante hospital, accompanying people with HIV and tuberculosis, supporting their care and social assistance.

“She’s come far—she never imagined a day when she would be where she is now,” Therosme said. “Now she is talking about having a child.”

Eustache was sitting next to Therosme as she spoke, and noted her emotion.

“Tatiana is moved to tears telling this story,” he said.

Eustache said that Zanmi Lasante’s mental health mission is at its core about connection, in a country that remains essentially divided into rural and urban societies. Rural Haiti, he said, “has been totally excluded in terms of services and access to care,” along with education, public services, and more.

“Historically, Haiti has been going as a nation with two different societies—like two trains going in the same direction that cannot meet together,” Eustache said. “In our work as Zanmi Lasante, we say that our main goal is to make these people part of the whole society, with access to care that has been denied to them.”

Joining those train tracks will require continued collaboration between Zanmi Lasante, PIH mental health programs around the world, and other partners across Haiti.

“All we have accomplished as milestones is a joint effort from the Zanmi Lasante mental health program and the PIH cross-site mental health program,” Eustache said. “This is a joint effort, with a team spirit.

“(And) we have not done enough,” he added. “We still need to fight, to work.”

Bending the Arc, the universally acclaimed documentary that tells the story of Partners In Health’s early years and the global movement for health equity and social justice, is airing on Netflix amid public health crises that have laid bare the inequities at the heart of the film. 

Netflix began offering Bending the Arc to streaming viewers in an international release on Oct. 22, 2020.

Dr. Jim Yong Kim, PIH co-founder and board member, said the film resonates deeply amid the COVID-19 pandemic.

"Today, Bending the Arc is essential viewing,” Kim said. “As COVID-19 continues to spread, we could all do with the reminder that with the right amount of grit, determination, and decency—it’s possible to beat a pandemic. We’ve done it before.”

Kim knows that firsthand. Bending the Arc tells the story of PIH’s origins in Haiti in the ‘80s and subsequent battles against infectious disease outbreaks including tuberculosis in Peru and HIV in Rwanda. The film follows Kim, fellow PIH co-founders Dr. Paul Farmer and Ophelia Dahl, and others as they fight systemic barriers to care in undaunted efforts to serve impoverished communities.

By successfully treating tuberculosis patients who were near death—against World Health Organization protocols at the time—and becoming some of the first doctors in the world to treat HIV patients in rural settings with full regimens of antiretroviral therapy, the trio and their colleagues changed entrenched international policies and norms.

The film features additional PIH leaders, including Dr. Joia Mukherjee, PIH’s chief medical officer; Dr. Agnes Binagwaho, former Rwanda Minister of Health and now vice chancellor of PIH’s University of Global Health Equity in northern Rwanda; and more.

Dr. Paula Johnson, a cardiologist, president of Wellesley College, and friend of Dahl and Farmer, said Bending the Arc is an “inspiring window” into PIH’s efforts to bring the benefits of modern medical science to those most in need of them across the world.  

“The film illuminates the geopolitical realities of the developing countries PIH operates within, the medical challenges providers in those communities face, and PIH's pathbreaking approach to build capacity and strengthen health systems,” she said. “This is a gripping documentary and an incredible teaching tool for anyone seeking a deeper understanding of the complex cultural, organizational, and political conditions PIH must navigate in order to build resilient and sustainable health systems where they are most urgently needed.”

Bending the Arc ultimately is a story of hope in the face of overwhelming obstacles, and the possibilities that emerge when we reject injustice and cynicism in favor of optimism and action. Its true heroes are people such as Melquiades Huauya Ore, a resident of El Agostino neighborhood in Lima, Peru, who was fighting deadly multidrug-resistant tuberculosis (MDR-TB) when he met Kim.

Their friendship and interaction during Huauya’s extended treatment is one of the most powerful story lines of the film. Doctors pronounced Huauya fully cured in 2006, and he has since become a passionate advocate for TB patients worldwide.  

Bending the Arc was written by Cori Shepherd Stern, and directed by Kief Davidson and Pedro Kos. Davidson and Stern also produced the film. It premiered at the Sundance Film Festival in January 2017—with Huauya in the theater—and since has screened at film festivals around the country.

Dahl, who led PIH as executive director for 16 years and now chairs its board of directors, said the battles portrayed in the film continue today.

“We have been hearing arguments for why dignified and quality health care can’t be brought to impoverished communities since we started PIH, and we continue to fight those assumptions,” Dahl said. “Inaction has deadly consequences, that is why we continue to treat, counsel, heal, and advocate for the most marginalized without discrimination. Bending the Arc captures some of the lessons we learned and some of the fights we fought along the way.”

Farmer echoed that sentiment.

“Providing high-quality health care to the poor and underserved has always been a radical act, and in this moment we are again called to radical action,” he said. “Pandemics thrive on division, and Bending the Arc is a timely reminder that when we work together to fight both disease and dogma, healing is possible.”

As a global health organization working in some of the poorest countries in the world, we’ve seen firsthand the importance of the World Health Organization’s (WHO) efforts in promoting global solidarity and an equity agenda for ending the global COVID-19 pandemic.

At this week’s Special Session on the COVID-19 Response, the WHO’s Executive Board has an important opportunity to take a strong stand for broadening access to COVID-19-related health technologies as global public goods. Across the world, many low- and low-middle income countries face significant barriers to accessing diagnostics, medicines, and an eventual vaccine for COVID-19-related conditions. The WHO’s COVID-19 Technology Access Pool (C-TAP) has been sidelined by acceptance of intellectual property regimes that favor pharmaceutical companies in high-income countries. 

But the WHO Executive Board can and must now reaffirm the urgency of sharing technological know-how to address this sweeping pandemic.  In turn, member states should ensure, through TRIPS waivers and otherwise, that intellectual property restrictions do not limit access to Covid-19 technologies.  We call on the WHO Executive Board–– and all Members States– to make these commitments to ensure COVID-19 health technologies as global public goods. The world cannot afford to wait.

In January, University Hospital of Mirebalais in central Haiti, achieved a major milestone: international accreditation as an institution of graduate medical education.  This milestone placed the 300-bed health facility firmly on the map of global teaching hospitals that meet the highest standards in medical education.

To Dr. Giovanni Bordes, a third-year resident in the program at Mirebalais, the news didn’t come as a surprise. “It’s a big step and a proud achievement,” he says. “Even before we learned about the accreditation, this was the best place for a young doctor in Haiti to do their residency. Since I graduated medical school, my biggest dream was to get into the residency program here.”

The teaching hospital’s global accreditation by the Accreditation Council for Graduate Medical Education (ACGME)—making it the only ACGME-accredited hospital in the Caribbean and the only in a low-income country—is just the latest evidence of its impact on current and future medical professionals in Haiti.

'There's Always Someone To Learn From'

Zanmi Lasante, Partners In Health’s sister organization in Haiti, and the Haitian Ministry of Health opened University Hospital of Mirebalais in April 2013. Since then, the hospital has rolled out 6 residency programs, including in emergency medicine, surgery, and obstetrics and gynecology. So far, 123 residents have graduated, and 98% of them have opted to stay in Haiti, contributing to building a stronger health system.

University Hospital is the culmination of three decades of PIH’s work in Haiti, where PIH has partnered with Zanmi Lasante since the 1980s to provide health care to a population of more than 1.3 million people. PIH employs 6,300 staff in Haiti, including 2,500 community health workers, and provides primary care, maternal and child health care, HIV and tuberculosis services and more, in partnership with the Haitian Ministry of Health.

The hospital’s residency programs offer residents access to opportunities and resources that are hard to find elsewhere.

Bordes, whose specialty is obstetrics and gynecology, values the program for its access to medical equipment, such as ultrasounds and fetal monitoring systems as well as the mentorship opportunities it provides.

“In Mirebalais, we have attending [physicians] specialized in gynecology as well as in obstetrics, so we learn skills and procedures that other public hospitals don’t teach,” he says. “There’s always someone to learn from and there’s always someone who has your back.”

Bordes also appreciates the focus on physicians’ well-being. The program offers residents accommodation, hot meals, reliable Wi-Fi and, crucially, for those with a high workload, a work-free, 24-hour period to relax and reset each week.

That set-up is intentional.

“Along with training, one of our priorities is resident wellness,” says Dr. Ornella Sainterant, the hospital’s continuing education coordinator.

Sainterant, a palliative care physician, is a former resident herself who was part of the first family medicine cohort in 2011 Now, she is responsible for coordinating the residency program, where she advocates for improving health systems—starting with patient/physician communication.

“In our residency program we teach residents about the health system and Haiti’s national health policy,” Sainterant says. “We also focus on physician communication skills, because when you listen to your patients, that can also help you to improve the system.”

Social Medicine

Listening might once have been seen as a soft skill but, as Sainterant says, in a busy clinical setting it can be one of the hardest parts of the job.

In the palliative care department, she takes residents under her wing, equipping them with the tools and language to lead difficult family meetings with empathy, break bad news to patients and their families, or navigate situations in which patients are experiencing anger.

“When the residents work with me in palliative care, they can see me in action, and then they can carry out the work in practice,” she says.

One of the key pillars of the program is social medicine—the idea that clinicians must understand the social and economic factors underlying their patients’ wellness and overall health.

“Social medicine is unlike anything I had previously learned in medical school in Port-au-Prince,” says Bordes. “You learn to listen to the patient and what the patient has to say. Now I always ask my patients, ‘What do you expect from me? What would you like? What would suit you?’ and then together you make a decision about the next steps.”

In addition to teaching social medicine in the hospital, the program immerses residents in nearby communities to study the relationship between health and environment—something that serves the dual purpose of building greater trust between doctors and patients and addressing health system gaps.

Between working and teaching on the ward and supervising the residency program, Sainterant spends much of her time thinking about the ways in which clinical care and health systems strengthening intersect. She would like to see new generations of Haitian research doctors emerge, contributing to national and global knowledge bases through their expertise and experience.

Both she and Bordes hope to be role models for future cohorts of residents, inspiring them to commit to building a future in Haiti, using their skills to contribute to strengthening the health system.

“I hope that in the coming years we will have more health professionals staying in the country, and that they can be the leaders for others,” Sainterant says.

The program has already had that deep and enduring impact on at least one resident.

“I could have left Haiti a long time ago, but I decided to stay because I think I can make a difference,” says Bordes, whose parents live in the United States. “Everything I’m learning in the residency program is setting me up for that.”

Contact tracing is about much more than mapping the spread of COVID-19. It’s about lending a listening ear, communicating health information, and connecting people with the social support—such as food and housing—they need to quarantine safely. But contact tracers can’t provide this level of care without an underlying public health strategy and systems rooted in equity.

In Illinois, Partners In Health seeks to support just that. PIH is advising the Illinois Department of Public Health as it scales a contact tracing program to meet the unique needs of the communities it serves.

“Our first priority shouldn’t be, ‘How do we solve the simplest cases?’” says Ameet Salvi, PIH’s project lead in Illinois. “It should be, ‘How do we support the most complex and difficult ones? How do we design a program and implement it in a way that doesn’t leave the vulnerable as an afterthought?’”

PIH began working in Illinois in May, when  Illinois Gov. JB Pritzker’s Office requested help after seeing the success of PIH’s contact tracing work in Massachusetts and learning about its U.S. Public Health Accompaniment Unit (PHAU). The unit, which grew out of PIH’s Massachusetts work, provides technical advising to states, counties, and cities across the U.S. as they fight COVID-19. It also serves as an open-source hub of information and best practices for public health leaders. So far, PHAU is assisting over 10 U.S. partners--from Newark, N.J. to Pima County, Ariz. --with their pandemic response.

For Illinois, PIH’s advisory team has been an important part of the state advisory team as local health officials scale up a statewide contact tracing program.

‘A Microcosm of the Country’

Since mid-July, with the progression of summer and the state’s reopening, Illinois’ case count has been slowly rising. The state’s experience in some ways reflect challenges nationwide, as states across the country reopen to varying levels and as the pandemic has spread from urban centers, hit hard in the Spring, to more rural areas as the summer has progressed.

“In some ways, Illinois is a microcosm of the country as a whole,” says Trent Fuenmayor, PIH’s project manager in Illinois.

Drawing on its global experience fighting infectious diseases, PIH is advising state health officials as they hammer out the nuts and bolts of scaling up a statewide contact tracing program—establishing protocols, developing training materials, and refining public health messaging. For many state employees, these duties come on top of their usual job functions.

Mounting a statewide contact tracing program is no small task for Illinois, where the health system is decentralized and spans 97 local health departments. Involving the community, says Dr. Regan Marsh, is key.

“Everything about COVID needs to be hyperlocal,” says Marsh, a clinical technical advisor for PIH’s work in Illinois and Newark, N.J.. “Even the person giving the training needs to have local recognition. It needs to be from the community.”

“Contact tracing is essential to slowing the spread of COVID-19,” said Illinois Department of Public Health Director Dr. Ngozi Ezike.  “Illinois is a large and diverse state ranging from highly populated urban areas like Chicago, to more sparsely populated rural areas like Red Bud. We want people to know we are working to protect everyone’s health and we need everyone’s cooperation to do that.  Working with PIH has helped inform the best way to build a contact tracing infrastructure so we can reach all of our communities across Illinois.”

And equity is essential. COVID-19 has disproportionately affected communities of color across the U.S., who were already marginalized by decades of systemic racism. Such disparities have emerged in Illinois, too.

In Chicago, Black, non-Latinx cases account for 42.6% of COVID-19 deaths. Latinx residents have the highest infection rate statewide. These disparities emerge due to structural inequities such as housing discrimination, lack of access to health care, higher levels of air pollution, and overrepresentation in essential jobs with little to no workplace protections.

“The people who are already marginalized are also the ones who are going to be the most impacted by this disease and need the most tailored equity support,” says Fuenmayor.

On a practical level, that could mean doubling the number of care resource coordinators—the core staff who connect patients with housing, food, and financial assistance—in areas that are particularly hard hit. It also means making sure that contact tracers represent the racial, ethnic, cultural and linguistic diversity of the communities most affected.

Social support—from meal delivery to rental assistance—is key to creating the conditions necessary for quarantine and stopping the spread. It’s also a core part of PIH’s care delivery, proven to be effective throughout decades of global experience fighting infectious diseases, from Ebola in Sierra Leone to tuberculosis in Peru.

Marsh and Salvi previously worked in Sierra Leone during the Ebola response, where they saw first-hand the need for contact tracing efforts to stem from the community and connect people with the resources they need to survive.

They draw upon their global experience as they advise Illinois health officials launching a statewide contact tracing program amid a pandemic that evolves by the day. The accompaniment that threads through PIH’s work around the world guides their work in Illinois.

“There’s a lot of important learning from the global south for the north, especially now during Covid,” says Marsh, who is also an emergency medicine physician and PIH’s director of clinical systems. “Public health in the U.S. has been terribly under-resourced for decades.”

“The conversations are difficult, and the problems entangled and entrenched,” says Salvi. “But we’re giving our partners that vote of reassurance: ‘This is going to be messy; get ready for it. We’re going to be there by your side to help you get through it.’”

Working in 2015 as a program manager for Inshuti Mu Buzima, as Partners In Health is known in Rwanda, Theoneste Nkurunziza realized many of the preventable patient deaths he was seeing had a common cause: delays in referring patients from rural health facilities to hospitals outside the country or in Kigali, Rwanda’s capital.

Nkurunziza became interested in researching root causes of those delays, which were barriers to lifesaving care. But he knew, like other health care workers across low-income countries (LICs), that attempting to conduct that research could present difficult trade-offs.

Dr. Megan Murray of Harvard Medical School and Dr. Joel Mubiligi, executive director of Inshuti Mu Buzima, recently described those dilemmas in peer-reviewed journal Annals of Global Health:

“Given limited personnel, facilities, and materials, research comes at short-term costs to patient care, and it is often difficult to predict the long-term value,” Murray and Mubiligi said. “Scarcity is not only a factor in prioritizing health care activities; relatively few LIC health care professionals have the opportunity for research training, and access to medical literature is limited by language, technology, and the cost of journal subscriptions. These barriers make it challenging for even the best-trained LIC researcher to effectively compete for funding.” 

The African continent has only 198 researchers per 1 million people, compared to more than 4,000 in high-income countries, a 2019 study found. The disparity persists within Africa itself, with 878 researchers per 1 million people in North Africa but only 88 per 1 million in sub-Saharan Africa.

The Intermediate Operational Research Training (IORT) program in Rwanda, run by PIH and Harvard Medical School, is an effort to change those disparities and create opportunities for new research.

The program has supported 52 researchers over the past five years. Combined, these researchers have led 28 papers that were developed as part of the training. Twenty-seven of those papers have been published, including seven that are part of a special collection published in September by Annals of Global Health.

“Research knowledge and skills needed to produce data-driven evidence for informing routine health care delivery are largely lacking in most low- and middle-income countries,” said Dr. Fredrick Kateera, chief medical officer for Inshuti Mu Buzima. “Through a one-year, hands-on mentorship program, IORT leverages IMB’s partnerships with Harvard Medical School to train health care workers in basic epidemiology and biostatics concepts and practices, using data collected as they manage patients and run clinical programs.”

Additionally, Kateera said, the program supports health care workers “from scientific idea formation to publishing manuscripts,” enabling them to produce scientific evidence that informs clinical and program improvements in locally relevant ways.

 Nkurunziza was part of the program’s 2015 cohort.

“I knew that I had the zeal and the willingness to do research,” Nkurunziza said. “Here was an opportunity that most people never have access to—to learn and work on my research paper with support from dedicated staff.”

The program enabled Nkurunziza and a research fellow to collect surgical data, including on referral processes, and publish a 2016 paper, “Referral Patterns and Predictors of Referral Delays for Patients with Traumatic Injuries in Rural Rwanda.”

They found that remoteness of a health facility, type of diagnosis, and urgency of treatment were predictors of delays, and that limited availabilities of ambulances and surgical specialists in district hospitals were root causes. Nkurunziza used evidence from the study to advocate for better referral systems and practices.

He’s also more than returned the program’s support, by mentoring subsequent trainees and leading an Introduction to Research Training course, all while furthering his own work and education.

Nkurunziza has been part of 15 publications since 2016, has presented his findings in four countries, and now is pursuing a PhD at The Technical University of Munich.

Most importantly, the skills he developed in the training program have helped Nkurunziza contribute to research that improves lives in Rwanda and beyond—and he’s not alone.

Child development

Dr. Christine Mutaganzwa was a district clinical director for Inshuti Mu Buzima, in Rwanda’s eastern Kayonza District, when she began the research training program in 2016. She had been looking for an opportunity to conduct research while receiving support and dedicated research time amid the constraints of her demanding position.

The program enabled Mutaganzwa to study the implementation of PIH’s pediatric development clinic, held at two district hospitals to support parents and toddlers in the region. Her research focused on children at risk of developmental delays because of malnutrition, and showed that implementing pediatric clinics was feasible with non-specialized health providers in rural settings, with mentorship and supervisory support. 

“I want to make sure that this group of children is cared for,” she said. “I truly appreciated the time (the program) gave me…especially through separated, week-long research training time and the junior mentors who enabled me to concentrate on my research project.” 

Mutaganzwa went on to lead the pediatric development clinic, which now features a brand-new facility at PIH-supported at Kirehe District Hospital. Additionally, she has since co-authored 10 papers and recently earned a master’s of medical science in global health delivery at Harvard Medical School. Her thesis explored factors related to follow-up care for parents and children enrolled in the clinics.

Mutaganzwa said the training program is invaluable for nurturing researchers in low-income countries. 

“Everyone who has been a part of IORT learns valuable skills and becomes a mentor,” she said. “Many have gone on to excel in their careers.”

All Babies Count

A year after Mutaganzwa, Marie Claire Abimana also used the training program to study child health, as part of the program’s 2017 cohort. 

Abimana, a registered nurse midwife, had joined Inshuti Mu Buzima earlier that year, as a quality improvement advisor for a program called All Babies Count. She oversaw mentorship of healthcare professionals, supporting postnatal care and early childhood development in two rural districts.

In the training program, Abimana’s project assessed child development outcomes and found high rates of developmental delays among babies born preterm, with a low birth weight, or with stunting. She recommended improving nutrition and promoting early stimulation for optimum growth.  

Abimana said she appreciated the program’s approach to teaching and improving research skills. 

“I loved the fact that all lessons included practical examples and homework,” she said. “The feeling of working hard at my own research project while learning complex research competencies like statistical analysis was incredible.”

Like Nkurunziza, Abimana became a junior mentor for the cohort that followed her own, passing on the mentorship she had received herself.

She also has engaged with the growing network of training program alumni to partner on additional research, demonstrating the value that national research training programs have for growing the pool of Rwandan researchers and strengthening collaborations across institutions.

Abimana's paper is featured in the Annals collection. She's now pursuing a master’s degree in public health, demonstrating how the research training program is providing not only a year of education and support, but also a platform for lifelong development.

Partnership and accompaniment

The IORT is a core program that invests in the careers of research leaders at IMB and partner organizations in Rwanda. Adapted from the World Health Organization SORT-IT model, the training is a cornerstone of comprehensive investments to strengthen research skill, experience, and infrastructure, with the goal of intensive Rwandan leadership on future research work.

As Murray and Mubiligi noted, the training reflects the long partnership between PIH and Harvard Medical School. The training featured in the Annals collection was mentored by Harvard faculty Bethany Hedt-Gauthier and Dr. Ann Miller, who along with IMB and HMS junior mentors provided more than 1,200 hours of mentorship and research support to trainees. The program aims to accompany emerging researchers through the entire journey of their paper, from idea to publication.

The investments pay off not only in published papers that result, but also in nurturing skills and interest in research among trainees, and in strengthening the research partnership between PIH, HMS and other partners.

“Through IORT, research careers have been unearthed, study findings have been used to influence policy and practice, and evidence produced in Rwanda is influencing health care implementation and improvements in comparable LMIC settings,” Kateera said.

Partners In Health-Liberia has implemented electronic medical records at J.J. Dossen Hospital in Maryland County, enabling efficient registration and digital access to patients’ medical histories as part of PIH’s multi-country effort to streamline how health information is collected, stored, and utilized.  

The July launch of an electronic medical record (EMR) system for J.J. Dossen includes the hospital's non-communicable disease clinic, outpatient department, and mental health services, with impacts that already are significantly improving health care delivery for the hundreds of patients who visit the PIH-supported facility every day.

The EMR system is replacing cumbersome paper records. As it expands across the hospital in coming months, the system will enhance workflows for areas including triage, laboratory work, pharmacy services, and prenatal clinics. 

The phased rollout will enable each department to learn from others, building an integrated records system that improves as it expands.

The system, called OpenMRS, is an open-source project co-developed by PIH in 2004 and now used by more than 100 PIH-supported facilities around the world, along with several governmental and partner organizations. PIH Sierra Leone, for example, announced its OpenMRS launch earlier this year.

PIH Liberia Director of Clinical Education and Child Health Dr. Rebecca Cook noted that having the EMR system at J.J. Dossen will enable health providers to enter vital signs, lab results, prescriptions and other diagnostic details during patient appointments, and will further PIH’s goal of establishing Maryland as a model county for Universal Health Coverage in Liberia.

Maryland County health officer Dr. Methodius George and J.J. Dossen medical director Dr. Kolu Davies, both Ministry of Health employees, commended the new EMR system at an event celebrating the launch. 

Emmanuel Debah, supervisor of the outpatient record room at J.J. Dossen, said that before the implementation of electronic records, he and his team manually retrieved charts for patients who visited the hospital. After a patient’s visit, his or her chart would be returned to the record room for storage on packed shelves.  

Debah said the process was tedious and time-consuming, and added that it sometimes did not allow staff to complete all entries for a patient’s records, because of the high volume of patients.

“Predominantly patients suffering from malaria, diarrhea and acute respiratory infections are the ones who visit the facility, and due to the workload, we are unable to complete entries and when the patient re-visits, it becomes difficult to refer (to their records),” he said. “We have been advocating for a solution and now that we have the EMR, our problems have been solved.”

Patients at J.J. Dossen now receive a card with their bio data, a serial number, and a barcode, which hospital staff scan to access the patient’s medical records. 

Joseline Toomey, a Maryland County resident, recently brought her 10-month-old son to the hospital because he was suffering from diarrhea. She said her first experience with the EMR made the visit much faster.

“I was worried I would spend the usual long hours to get checked in today, and end up spending half a day just to get my son diagnosed and given treatment,” she said. “But with this new system in place, my visit has been without any problems, and very fast and convenient.”

Better data, better care

Cyrus Randolph, PIH physician assistant for non-communicable diseases, said electronic records will also help his team provide integrated primary care, as comprehensive records for multiple ailments will be more easily accessible.  

Through mentorship from PIH’s monitoring, evaluation and informatics teams, seven staff from PIH and the government’s Maryland County Health Team have been trained to use the EMR, enabling clinicians to quickly access the medical records of more than 5,500 patients registered to date.

The effort is part of PIH’s global effort to improve data systems to better serve patients and communities and better inform health care delivery, policy, and advocacy, with sustained support from the Wagner Foundation and the multi-year Building Impact Grant.

Dr. Emma Boley, health monitoring, evaluation, and informatics lead for PIH in Liberia, said teams soon will roll out the EMR system in other PIH-supported facilities in Liberia.

“As we roll out the system, we will continuously support hospital staff with training on how to transport old records on paper onto the electronic system, in order to completely go paperless,” she said.  

Annum Sadana has dreamed of becoming a health professional for years. The recent college graduate grew up seeing health disparities both in India, where she was born, and in the U.S., where she was raised, instilling a passion for global health equity from a young age.

But it was in college that she came to realize something crucial.

“I always had this theory of change that one day I would be a part of this and one day I would have direct impact on communities,” she says. “But that time is now.”

Part of what sparked this change for Sadana was learning about Partners In Health, specifically its commitment to social justice. That led her to join PIH Engage—PIH’s grassroots network of community organizers ranging from high school and college students to recent graduates. Now, Sadana is one of hundreds of PIH Engagers across the U.S. advocating for health care as a human right.

“I think my experience with Engage over the past three years has been one of the most empowering, if not the most empowering thing I did in college,” she says.

A Call To Action

PIH Engage began in 2012 and has since grown to 70 teams across the U.S. Recently, the network has expanded to Mexico and Peru. The program has three core components: advocacy, community building, and fundraising.

Sadana started her team at Rice University in 2017, during her sophomore year. In the years since, the team has met with U.S. representatives, shown up at political candidates’ town halls, and organized campus events focused on global health.

“It’s really inspiring to hear how people have been personally affected by these issues but also want to take action in solidarity with others for a broader purpose,” says Nick Seymour, Engage program coordinator for PIH.

While it emerged in recent years, PIH Engage stems from an idea that’s a cornerstone of Partners In Health: health care is a human right. The “preferential option for the poor” that Paul Farmer discusses in Tracy Kidder’s Mountains Beyond Mountains is not a neutral phrase—it’s a moral and political call to action.

That call led students like Queeny Jose to start teams of their own. Jose grew up seeing health inequities in Haiti. After the 7.0-magnitude earthquake struck the country in 2010, killing more than 200,000 people and displacing 1.5 million, Jose and her family lived without a home for about a year and then moved to Miami in 2012. While in high school, Jose was drawn to PIH for its social justice lens and felt the urge to take action—a call that continued into college.

“When I got the opportunity to move here [to the U.S.] and have higher education, I knew that I wanted to help my community some way and somehow,” says Jose.

Building An Intersectional Movement

This school year, she is launching her own team at the University of Florida, where she is a junior. While the team will meet virtually due to COVID-19, she’s hopeful to build a strong and committed team.

The program overall has seen a surge in interest in recent months.

“I think the reason people want to join is that they are realizing, especially with COVID, that there are disparities within their communities,” says Jose. “That has helped us to introduce others to the idea of how this is happening all over the world.”

The spike in interest also comes as the Black Lives Matter movement has mobilized millions of people in the U.S. and globally to call for an end to the systemic racism that has left no corner of American society unscathed—from the institution of policing to housing to health care.

2020 has been a markedly different year for the program—PIH Engage teams aren’t typically active during the summer, while school is out, but this summer, PIH Engage leaders mounted a nationwide advocacy push to secure more federal funding for contact tracing and testing in marginalized communities across the U.S., as well as for the global COVID response.

This academic year, PIH Engage leaders aim to provide a deeper history and understanding of global health issues, grounded in an anti-colonial, anti-racist framework—a theme they discussed at the program’s annual Training Institute, held virtually this summer, where student leaders from across the country meet to strategize for the upcoming year.

Dr. Joia Mukherjee, PIIH's chief medical officer, says those efforts are vital.

“Human rights only change when people have a strategy, organize and demand better,” she says. “I am so encouraged by young people from all around the world who are fighting for, and teaching us all to fight for, an expanded and intersectional view of the right to health that encompasses, racial, economic and climate justice.”

For students like Sadana and Jose, the program has provided something crucial in a time of uncertainty—a sense of community and purpose.

“Forming new connections with people across the country and really getting to know them and seeing how passionate they are is really a source of critical hope for me in this time,” says Sadana. “Every time I talk to somebody about Engage or do something Engage-related I walk away more hopeful than I was before.”

In August, Haiti’s health care system registered a major victory: the first COVID-19 patient to survive intubation and mechanical ventilation returned home to his family after 29 days at the University Hospital of Mirebalais, the state-of-the-art facility that has served as a lifeline for patients from across the country.

Yet even a hospital as well-equipped as Mirebalais can do little to alleviate the psychological effects of crises—from COVID-19 to the devastating 2010 earthquake—that have laid bare systemic inequities and compounded the hardships of daily life.

And as researchers with Partners In Health (PIH) found in a recent study, young people in Haiti are made especially vulnerable by their chronic exposure to stressful life events.

“We are exposed all the time to different types of trauma,” says Father Eddy Eustache, an ordained Catholic priest and the director of mental health with PIH’s Haitian sister organization, Zanmi Lasante (ZL). “Mental illness in Haiti exists on a large scale, and because of the worsening situation, that need for care continues to grow. So, we think the services we provide should be scaled up at the national level.”

Expanding Mental Health Services

Those services began in earnest in the weeks after the earthquake, when “Père Eddy,” as he’s known to friends and colleagues, met with Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health, to plan a coordinated mental health response.

In addition to the post-traumatic stress disorder (PTSD) it exacerbated, the earthquake revealed just how significant the burden of mental health conditions already was, with high levels of depression, anxiety, and stress having developed over decades of unemployment, violence, and political instability—or what Père Eddy has described as the “poverty package.”

It also exposed the severe lack of mental health care at that time—just a pair of psychiatrists for a country of 10 million people—and spurred the government and partners to act.

In the decade since the earthquake, ZL has expanded its mental health team to include 15 psychologists and social workers, who work in 12 clinics across the country. They’ve also trained 156 community health workers to address depression, anxiety, bipolar disorder, epilepsy, and schizophrenia. ZL has also published research around its long-term mental health response to the earthquake, as it built up a comprehensive, sustained mental health system to serve 1.5 million people.

Still, says Père Eddy, they’re fighting an uphill battle and not least because of the persistent stigma associated with mental health conditions. “There’s a lot of fear and shame,” he says. “And as a result, there isn’t the political will to address it.”

The Burden of PTSD Among Youth

That led Père Eddy and colleagues to study the effects of the earthquake on the mental health of Haiti’s youth. In the study, published in 2018 in the Journal of Psychiatric Research, Père Eddy and colleagues analyzed data collected about 4 years after the earthquake from a mental health assessment conducted at a secondary school in Haiti’s Central Plateau.

Although the earthquake had centered in Leogane, a city on the southern outskirts of Haiti’s capital, Port-au-Prince, some 90,000 internally displaced persons migrated to the Central Plateau, including many of those who had been injured.

What the study found was concerning. The mental health assessment had included a Stressful Life Events Checklist—a 13-item questionnaire documenting exposure to a broad range of stressful life events, including sexual abuse, armed conflict, and separation from family.

Of the 120 students who had filled out the assessment, all reported at least one stressful life event; nearly three-quarters reported witnessing others being physically mistreated, and 42.5 percent said they had experienced physical mistreatment themselves. Additionally, just over 58 percent reported that there was a time when they felt that their life was in danger, and nearly 57 percent had experienced the death of a loved one.

To the surprise of the researchers, the study found that exposure to an earthquake or other disaster was not significantly associated with having PTSD. Nonetheless, it offered further evidence of the immense burden of PTSD among youth in Haiti.

“The earthquake did not bring mental illness to Haiti,” says Père Eddy, “but it did present to us an opportunity to raise awareness about the urgent need for quality care—to say to the world, ‘Something has to be done.’”

‘Unity of the Body and Mind’

In January, just as the first reports of the novel coronavirus were surfacing in China, Haitians commemorated the 10th anniversary of the earthquake and its more than 300,000 victims.

Reflecting on the legacy of the earthquake, Père Eddy says it’s crucial for policymakers to understand the importance of mental health—what he calls “the unity of the body and the mind.” Ignoring mental health, he says, will only exacerbate poverty, feeding a cycle that is sure to continue in the absence of quality care.

“Dr. Farmer described the earthquake as ‘an acute and chronic crisis’ that compounded what was already a very difficult situation,” says Père Eddy. “And as our study shows, that’s true of mental health too. The exposure to stress was not a one-time event; it’s a product of the violence and poverty people live every day.”   

Still, he remains hopeful: “We’re taking this opportunity, in the tenth year since the earthquake, to say to all: ‘We want these programs to continue and to grow, so that more Haitians can have access to mental health care.’”

No matter where you are in the world, this school year is bound to be different—COVID-19 has impacted education systems from Kazakhstan to the U.S., moving some schools fully online and others to a hybrid model. And schools around the world are instructing students to wash their hands, wear a mask and stay at least 6 feet apart from others. 

While campuses may be closed, education must continue. PIH has supported students in Haiti, Malawi and Rwanda for years through social support, helping students pay for textbooks, uniforms, tuition and more. And that support continues amid COVID-19.

As schools prepare to reopen on various timetables—or continue academic years with schools remaining closed—we reached out to some students in our social support programs to learn about their hopes, dreams and concerns for the upcoming year. Here’s what they said.

Dr. Sheila Davis has said she never could have foreseen how her career would twist and turn, eventually leading her to where she sits as the chief executive officer of Partners In Health—a position she assumed just over one year ago.

Now, Davis is in another unforeseen situation as a leader in the global fight against the novel coronavirus. While her teams marshal the organization’s response from Peru and Haiti to Rwanda and Lesotho, she has helped launch a new effort—first in Massachusetts and then across the United States—that places PIH as a key technical adviser and partner to government and community partners in a sweeping effort to stop the spread of COVID-19.

Luckily, Davis isn’t a stranger to responding to public health emergencies. Joining PIH as a nursing coordinator in October 2010, she was instrumental to planning and opening University Hospital in Mirebalais, Haiti, in the months following the country’s devastating 7.0 earthquake. As the chief nursing officer, she led the organization’s Ebola response in West Africa from 2014 to 2016. And rising to chief clinical officer in January 2017, she was the first called to coordinate an emergency response when flooding wiped away entire neighborhoods in Lima in the spring of 2017.

In the interview below, she reflects on the current moment—and much more—in the first in an ongoing series with PIH global leaders that we’re calling Ekip Solid, or “Strong Team,” in Haitian Creole. The participants are all experts in their fields, and each interview will address how they approach leadership, share what drives them to global health work, and provide an inside look at their professional and personal passions.

So far, 2020 has been a roller coaster of a year, and it’s far from over. What are some challenges you've faced as PIH pivoted to respond to COVID-19 this year? And what do you hope the remaining months will bring?

Responding to the COVID-19 pandemic has been challenging in so many ways, and we know that we still are not past the worst of it. The silver lining has been seeing how the PIH community mobilized. Our Daily COVID-19 Update calls have been a striking example of the strength of PIH. On these update calls, our colleagues from around the world gather to share knowledge and discuss strategies in a beautiful display of support for one another. So far some care delivery sites, such as Socios En Salud (SES) in Peru, have been hit very hard, and during these calls we have all been able to learn from the experiences the SES team has gone through and offer our support.

You’ve spoken about how nurses have been “virtually invisible” in health care, despite their vital work, and the need for more nurses in leadership roles. How has your decades of experience in nursing shaped you as a leader? What unique skills and perspectives do nurses bring to the table?

In all sectors of health care, nurses are omnipresent. One of the major strengths of nursing is the ability to work within a multi-disciplinary team and continually triage and pivot to the greatest need. Nurses also have the privilege of spending a lot of time with patients through birth and end-of-life care and can share in the joys and sorrows of patients’ lives in a very important way.

You’ve long stood in solidarity with the HIV/AIDS community, both globally and in the U.S. What changes have you seen in care delivery and advocacy over the years and what still needs to change?

Almost 40 years into the HIV/AIDS epidemic, we still do not have an effective vaccine. Huge strides have been made in treatment and prevention of transmission, but over 770,000 people died of HIV in 2018 alone and 32 million died since the epidemic began. The advocacy of Act-Up and Treatment Action Campaign (TAC) changed the way that drugs were researched and approved globally. Treatments in cancer, heart disease, and every other clinical area have benefitted from the advocacy that sped up every part of the process from drug discovery to clinical trials to approval. The advocacy around treatment pricing globally and ensuring that there is access to the newest – and often most cost prohibitive – drugs also benefitted from HIV/AIDS activism, but we still have a long way to go to make treatments for all medical issues available and affordable for the most vulnerable.

We are in the midst of a global movement for Black lives that spans across all areas of society, from the criminal justice system to health care. How can leaders—especially cis, white, straight people in the Western world—amplify the voices of people from marginalized groups and foster systemic change?

Instead of us trying to amplify voices that have systematically been oppressed, we need to get out of the way and let people speak for themselves. Even in instances of well-intended amplification, it implies that someone, usually someone who has been in a position of power and privilege, is needed to be the conveyer of the message. At PIH, we are committed to addressing racial injustice, both internally and externally, and know that we have a ways to go.  We also understand that this process of re-conditioning ourselves is ongoing and are committed to continuing with the knowledge that, for many of us, this will be a life-long commitment.  

Not everyone knows that you’re a single mother who raised your daughter while taking night classes to pursue your masters and doctorate in nursing. What did this experience teach you about yourself and the world?

It is a challenge to juggle work, school, and family, but I was fortunate to have a great group of friends and family that helped with my daughter, Eva, which enabled me to continue to advance my academics and career. I also had great mentors who continually encouraged and pushed me to keep going. It was a delicate balance and I made some mistakes along the way, but there is no perfect roadmap. Now, as I look back at the communities that Eva has been a part of because of my work and education, I am glad that she was such a part of my work and school life. It comes full circle in many ways.

When Eva was at Boston University as an undergraduate, she was the nanny for PIH’s Chief Medical Officer Dr. Joia Mukherjee’s child, Che. Eva and Che had a special bond, as they both had mothers who worked in global health and traveled a lot. One day, when Eva was taking care of Che while Joia was traveling and they were dropping me off at the airport, Che asked Eva who took care of her when her Mommy traveled. Eva told Che that we all take care of each other. I think that says it all.

You live near the ocean and see it as a source of great peace. What inspires your love of nature? 

I have always gravitated toward the ocean, and I moved to a little seaside town outside of Boston a few years ago. I am so lucky to be able to walk on the beach all year long and like it best in fall and early spring, when I often have the beach to myself.  The water is so powerful; the sound of the waves, the beauty of the water, and the smell of the salty air engage all your senses.

Tell us more about what you do in your spare time—we know you write poetry. Have you written anything lately? And have you read any poetry that you find particularly relevant now?

Alice Walker is a poet I have always loved, and her poem, “Women,” seems particularly pertinent for today. Although she is best known for her book The Color Purple that was made into a movie, her poetry is beautifully written, tackles difficult topics, and always makes you stop and re-read passages over and over again. A lesser known poet, Tracy K. Smith, is also definitely worth exploring. She has said, “For me, a poem is an opportunity to kind of interrogate myself a bit.” That is the best example of what poetry means to me. During this challenging time, reading the powerful words of others helps me self-reflect and the subsequent self-interrogation is good for all of us.

Partners In Health in Lesotho received a United Nations award Thursday for its community-based COVID-19 program, with special recognition of PIH’s work to reach people and families in remote, mountainous regions of the country in southern Africa.

The recognition came from the United Nations Development Programme (UNDP), which collaborates with about 170 countries and territories to eradicate poverty and reduce inequalities through sustainable development.

In May, the UNDP requested competitive proposals for its Innovation Challenge Grants, which would support community-based solutions against COVID-19.

PIH-Lesotho, known locally as Bo-mphato Litsebeletsong Tsa Bophelo, developed a proposal that focused on community awareness and infection prevention and control measures, through the involvement of local health centers and village health workers, who connect their neighbors to health care and resources. PIH’s proposal also focused on mobilizing health center committees in the Lebakeng and Thlanyaku areas, and utilizing treatment supporters who already were working with multi-drug-resistant tuberculosis patients across the country.

Lesotho is entirely surrounded by South Africa, an epicenter of the COVID-19 pandemic on the African continent. Lebakeng and Thlanyaku are particularly vulnerable border areas. 

Out of 80 applications from community health and nonprofit organizations throughout Lesotho, PIH was commended by the UNDP on Thursday for “best program design for a community intervention for COVID-19.”

The UNDP’s Lesotho representative presented the award to Dr. Melino Ndayizigiye, executive and clinical director for PIH in Lesotho. Leadership with Lesotho’s Ministry of Health and Ministry of Development Planning were on hand, along with Lesotho’s National COVID-19 Secretariat and representatives of the six other award winners.

PIH has worked in Lesotho since 2006, when the government invited us to support its response to the HIV epidemic. PIH’s work and programs in Lesotho have grown to include maternal health, child health, drug-resistant TB, mental health, non-communicable diseases and more, transforming care and health systems across the country.  

In a sunlit room, a mother shows her daughter a small pink bead, holding it up in one hand and grasping a plastic jar full of beads in the other. The blue and green mat beneath them is sprinkled with pieces of all colors and shapes. Her daughter, a toddler, had been playing with a dandelion yellow bead, but is now fascinated with the pink bead, eyes wide as she watches her mother bring it closer and closer to the mouth of the jar.

This space isn’t a daycare; it’s the home of Rocío Salas and her daughter, Valentina, in Lomas de Carabayllo, a community in Peru’s Northern Lima District. They are practicing skills learned through The CASITA Project.

Valentina is one of thousands of children enrolled in The CASITA Project, a child development program run by Socios En Salud, as Partners In Health is known in Peru. Amid COVID-19, the program has shifted to online sessions. But its mission remains as crucial as ever: equipping caregivers with critical knowledge and skills as they nurture the next generation.

Virtual Learning

The idea driving CASITA is nuanced yet simple—invest in caregivers and, by doing so, help the children in their care reach their fullest potential.

CASITA identifies children ages 6 to 24 months who are at risk of developmental delay, and then trains caregivers in activities that encourage age-appropriate behavior. The program offers 12 free sessions led by community health workers, where caregivers and children learn skills through play, using toys and household items such as bottletops and bedsheets. An important part of the sessions is the practice of “serve and return” interactions between both. This back and forth process is important to the wiring of the brain in the earliest years.

The program began in 2013 as a pilot and has served more than 3,000 children in the communities of Northern Lima, Peru, where poverty and systemic barriers contribute to high levels of malnutrition, chronic illness and domestic violence. CASITA has produced positive results—85 percent of the children in the pilot program showed marked improvement.

When Salas enrolled Valentina in CASITA in January, Salas was reluctant at first. She and her husband hadn’t had access to education about child development due to structural barriers. But as Valentina learned more skills and grew more confident, Salas came to realize just how crucial the first few years of life—and her role as a caregiver—really are.

“At the beginning, my husband thought that it was not important to sing, congratulate or show affection,” says Salas. “But I made him understand that all this is good to strengthen Valentina's confidence and that we must think about her future.”

When the family began CASITA, the classes were hosted at a local health center. As COVID-19 began to spread, the program went virtual to protect the health of staff, caregivers and children.

These days, the Salas family accesses the classes via mobile phone. They watch videos, learn and apply child development concepts, and send photos and videos of their activities with Valentina to the CASITA team, so health professionals can evaluate their progress and provide feedback.

Like other families in the program, they also have access to Chatbot, a mobile app developed by Socios En Salud. The app asks a set of basic questions about a child’s developmental milestones, collect a health children information and connects caregivers with resources related to child development and socio-economic support.

A Community Effort

For CASITA, a program typically hosted in health centers or the homes of community members, the transition to digital hasn’t been seamless.

Caregivers in Peru, as in other countries, must juggle an ever-growing list of responsibilities during the pandemic—a list that, for many, includes work, school and other family obligations that demand their attention.

Technology, too, has complicated the effort. Some caregivers didn’t have access to a smartphone or the kind of data package needed to share media files and access the Chatbot app. But that hasn’t stopped caregivers.

“They are so motivated to participate and learn new topics that will help their children develop properly, that they borrow the cell phone of their husband or a relative to receive the information,” says Nancy Rumaldo, CASITA project coordinator.

And community health workers—in many ways, the program’s foundation—have played a vital role in helping with the transition to digital.

“At this time when we cannot meet, it is important to continue communicating to know how the family is, what they need and if they have any questions,” says Franklin Ruiz, a community health worker with the CASITA team.

Ruiz, a primary school teacher living in Carabayllo, joined CASITA three years ago. He’d seen the program’s impact firsthand when his mother hosted sessions for caregivers and children in her home. Now, he draws on the knowledge and skills he has learned to educate caregivers in his community.

The shift to digital hasn’t been easy, but it has been necessary. Even as a global pandemic puts much of life on hold, children continue to learn, grow and develop, making caregiving just as vital now as ever before.

“CASITA virtual is about providing that accompaniment,” says Ruiz. “It’s telling caregivers 'you can' and 'you are not alone.’”

Nearly six years ago, the paths of Dr. Marta Lado and Dr. Regan Marsh crossed in Sierra Leone, during the height of history’s worst Ebola epidemic. Like many clinicians working together on the frontlines of a medical emergency, they began a lifelong friendship and collaboration. Their shared experience fighting a deadly virus, at the time largely unknown, was formative professionally, too—not least of all because it prepared them for the current fight against the novel coronavirus.

Since April, Lado, chief medical officer for PIH in Sierra Leone and an infectious disease doctor, has been working at 34 Military Hospital in Freetown, the epicenter of the country’s COVID-19 outbreak. So far, Sierra Leone has recorded more than 2,000 positive cases, with a 3.4 percent mortality rate. Not typically a PIH-supported facility, 34 Military Hospital’s infectious disease unit has been serving as the main referral hospital for the country’s most severe COVID-19 cases, with Lado at the helm of patient care in the isolation ward.

Marsh, an emergency physician, has been treating COVID-19 patients at Brigham and Women’s Hospital in Boston, a teaching affiliate of Harvard Medical School and one of the top hospitals in the world. Marsh also serves as PIH’s director of clinical systems, after having worked with the organization in Malawi and Haiti and preceding Lado as the chief medical officer in Sierra Leone.

Massachusetts, whose population is comparable to Sierra Leone’s, is now among the best U.S. states when it comes to controlling COVID-19. However, Massachusetts was at the center of the epidemic in the spring and has surpassed 129,000 cases overall, with a mortality rate greater than 7 percent.

Across an ocean—between one of the most clinically rich corners of the world and one of the most medically impoverished—Marsh and Lado spoke about their respective hospitals’ COVID response, their experiences treating a new virus, comparisons with the fight against Ebola, and how medicine and social justice are as tightly intertwined as ever.

How have the last several months been for each of you and the hospitals you’ve been working in?

Lado: The first two, three months were tough. We had very limited human resources. When the first cases came in the beginning of April, it was only one other physician and myself who were here, covering 24 hours, splitting day and night shifts for 30 beds of critical COVID cases.

We had a decent ratio of nurses, though not so many cleaners and lab technicians. Everybody was just giving 300 percent.

Marsh: The emergency department (ED) where I work in Boston has 120 physicians, including faculty and residents. That is probably more physicians than there are in  Sierra Leone. There are 3,500 nurses at my hospital; there are around 1,000 nurses in Sierra Leone. Several years ago, when our director of operations for PIH-Sierra Leone visited Boston, I showed him around our ED and he said, "There are more monitors and ventilators in this ER than there are in all of Sierra Leone." He was not wrong.

Those are the areas where the U.S. response was really fortunate. With strong leadership from the hospital, we’ve been able to rapidly scale up multiple ICUs and inpatient COVID wards.

And then on the staffing side, whole services were diverted to COVID. Clinicians from surgical and inpatient services that were shut down were redeployed to the ED, testing centers, or the respiratory infection clinics.

Lado: We were super lucky because we got three junior medical officers that volunteered to work with us in June, after two exhausting months of frenetic work. We are getting more resources like pulse oximeters, blood pressure machines, glucometers, oxygen concentrators, medications, etc. We now have two CPAP machines and three cardiac monitors, so we can monitor the most severe patients as an intensive care unit. And we are more experienced now; we’re all learning about the management of COVID-19, so things are improving.

Marsh: As Marta is saying, I think our care ultimately has gotten a lot better too—streamlined, efficient, compassionate. We didn’t have quite the resource constraints, obviously, but at the beginning of the epidemic, there was so much understandable fear about nosocomial transmission, because we had seen, particularly from Europe, how many physicians and nurses were getting infected.

For those of us who had spent time in West Africa, it was a little easier. Back in Ebola, right at the beginning of that outbreak—Marta will remember this—people talked about “no-touch nursing,” because if you touch the patient, you might get Ebola. The beginning of COVID in U.S. was not that bad, but there was such concern about health care worker infections, especially with PPE shortages, we had to think about its impact on our standards of care. But learning from Europe and Southeast Asia, and then seeing it ourselves, people became much more comfortable with the disease.

Lado: Arrogance, in this kind of a scenario, is not acceptable, because nobody knows what is best.

It's a moment that you are like a sponge, trying to absorb as much as you can from everyone and everywhere. Because there was no literature, there was no scientific evidence published yet; so we all needed to create the evidence ourselves.

Probably for Regan and I, this was a little bit less difficult, because we have lived in this context before: We didn't know much about Ebola, and we had to open our eyes and say, "Okay, let's work, adapt and learn."

I think that this outbreak is teaching the medical community worldwide that there's still a lot of medicine that we don't know, a lot of medicine that is not evidence-based, and we need to continue learning.

Was Sierra Leone better prepared for COVID-19 because of Ebola, and in a position to offer lessons to the U.S. and other well-resourced countries?

Lado: After the outbreak of Ebola, 34 Military Hospital had built this permanent infectious disease (ID) unit designed for potential outbreaks. So we were able to start from something very strong: a properly designed ID unit, with a well-differentiated flow of red zone and green zones, and a level-three biosafety lab and radiology department inside of the red zone. That made everything easy to start accepting the first patients with COVID and then setting up the first and only ICU for COVID 19 cases in the country.

Marsh: Marta, correct me if I'm wrong, but all health care providers in West Africa were trained so much on infection prevention control and personal protective equipment (PPE) that it was really easy to, I imagine, re-train people around COVID.

In the U.S., hospitals were rapidly trying to figure out: Do we need to wear masks all the time, or only in patients’ rooms? What type of masks are needed? How do I provide compassionate care and connect with patients while I'm wearing PPE? What's the concept of unidirectional flow for infection control? How do we convert regular floors into ICU floors? It was interesting because we were really building those systems rapidly as the epidemic unfolded here in Massachusetts.

Just before all of this, I was in Liberia in February, and hand-washing stations had popped up everywhere, just like during Ebola. The buckets came out of nowhere again. We have Purell everywhere in the hospital, but the concept of community-based hygiene is where there is real strength in West Africa, based on the previous experience of Ebola.

Testing has, for reasons of poverty or politics, proven difficult in both Sierra Leone and the U.S. How has that aspect of the pandemic evolved?

Lado: At the beginning of the outbreak, we were focused on contact tracing for people who were coming from abroad. Most of them were asymptomatic people, who were completely okay.

But as the outbreak moved forward, the moment we moved testing from just contact and epidemiological links of clusters to people who come to the hospital with difficulty breathing, or everyone with a fever—that is when we started realizing there was huge unnoticed community transmission. People didn't know where they got it from. It's everywhere.

We have been shifting to what has been happening in Europe, in the U.S., and many other places. If you have any symptoms, we will test you. Now my hope is that we can close the band of differences in social and economic status and start identifying and diagnosing people with COVID who are living in the poorest slums in Freetown.

Marsh: In Boston, the first people detected were largely from a biotech conference of, truthfully, mostly wealthy, white people from the suburbs. Most of them were healthy, but got early access to testing at a time that it was really hard. This is the same as Marta's talking about: We were testing people based on this perceived travel risk factor.

Then we started testing higher-risk people. Now we test everyone who's being admitted. And even if you’re not admitted, if you have any symptoms that could possibly be COVID, we test you.

Despite the fact that it has affected everyone, COVID-19 is not the great equalizer. Rather, it is reflecting back at us cruel injustices within our own communities and countries. How have you each observed this as doctors?

Lado: COVID has shown a big breach in society. At 34 Military Hospital’s COVID treatment center, 90 percent of our patients are upper middle- to high-class. Who are the people who get tested? Who are the people who have money to go to health facilities when they get sick?

These are the people who go to foreign countries for their medical checkups normally. They go to the U.K., the U.S., India, even Ghana and other places with better health facilities. They would never step a foot in a Sierra Leonean health care facility in their normal lives.

But then they could not leave the country because airports closed. There’s no other option. I think that these specific parts of society are rediscovering their own country and its challenges. It's exposing people who have been blind and in denial, who didn't want to see the reality of health care in their country.

Marsh: In the U.S., we can see now how COVID has had a horrible effect on poor communities and communities of color.

A lot of this has to do with structural racism in health care, and structural violence and economic injustices in our community that have existed for decades. Longer.

I also work at a community hospital with a strong Latinx community. We’d converted one part of the emergency department entirely to a COVID unit, with six beds. On many shifts, all the beds would be filled with Latinx patients and other patients of color, all with COVID, all with essentially identical symptoms and histories.

Many of my residents in the emergency department have written about their experiences having to intubate, or put in the ICU, immigrants and person after person of color.

In Boston and across the U.S., COVID has deeply magnified the health inequities we all see. It's been devastating in its impact on the populations that PIH serves.

What challenges do you still face?

Marsh: Massachusetts has done a really good job of social distancing, contact tracing, testing, and isolation and quarantine. It'll be interesting to see what evolves through the fall as people are, truthfully, a little tired.

Lado: We’re still very resource-limited. During Ebola, we had the same frustrations, but we had a lot of foreign aid.

Sierra Leone doesn’t have any intensive care department. And the training in intensive care and critical patients is very, very low. These opportunities should teach us that we need to strengthen medical education and clinical training. We are seeing that people are dying because of many reasons, but one of them is that there is not much experience among the health care workers in critical care.

Marsh: Marta is a hero in all of this, to have taken her Ebola lessons and now be applying them to lead the COVID response. It's really incredible, and we're fortunate to have her.

Lado: Oh, don’t say that. You would do the same if you were here! And the truth is that you already did the same while you were here during the Ebola outbreak. We need to continue supporting our communities.

Across the U.S., COVID-19 has disproportionately affected Black, Indigenous and Latinx communities and underlined longstanding health disparities in communities of color—disparities rooted in centuries of systemic racism.

Partners In Health sat down with Thomas Sequist to discuss a recent piece he wrote for the New England Journal of Medicine that examines the impact of COVID-19 on the Navajo Nation and Chelsea, Massachusetts.

In the Navajo Nation, PIH partners with Community Outreach and Patient Empowerment (COPE) to support COVID-19 efforts, a food sovereignty program, cancer care and community health workers. In Massachusetts, PIH leads a statewide contact tracing effort in partnership with state and local boards of health.

Sequist is Chief Patient Experience and Equity Officer for Mass General Brigham, a health network that includes 14 hospitals, including Brigham and Women’s Hospital, which is a leading partner of COPE. Sequist also serves on COPE’s board of directors.

PIH: Thank you so much for taking the time to chat today.  In your piece, you draw parallels between communities of color in two disparate locations—the Navajo Nation and Chelsea, Massachusetts— and their experiences with COVID-19. What led you to make this comparison?

Sequist: So I had, going back to March, been having experiences with both of those communities. The first was immediately within Chelsea—that is one of the communities that we serve in our health system at Mass General Brigham and we, early on, were seeing a very high occurrence of COVID infections for patients showing up at our hospitals who were really sick and patients who lived in Chelsea. I think shortly after that there was the increase in COVID infections among the Navajo Nation. In my role at Brigham and Women's Hospital, where we have a volunteerism and collaboration program with the Navajo area Indian Health Service, on one of the couple of the hospitals on the Navajo reservation—we started partnering with them as well to try to help address any needs that they were having around the outbreak.

And a lot of what struck me in these two interactions is—and I should say for Mass General Brigham, the reason I was so involved with Chelsea is just one of my operational roles was to help lead clinical operations for our COVID response across the system and so, in that, I ended up working and thinking a lot about the outbreak in Chelsea—my initial thoughts after several weeks of experiencing two very different communities, the Navajo nation and Chelsea, is that there are certainly some things that are very, very different between these communities. But a lot of what we were seeing was quite similar in terms of the poverty and the poor health outcomes in these communities that are really linked to structural racism.

PIH: You mentioned in your piece that many people in Navajo Nation lack clean running water, electricity, phone service. In your current role, how do you take these challenges into account? How do you weave equity into the fabric of the pandemic response?

 

Our role, from Brigham and Women's Hospital with the Navajo Nation, was really a very supportive role. So we're definitely not leading any of their pandemic responses. And our goal was, from thousands of miles away, what are the ways that we can support them? And we did it in a variety of different ways. Some of it was purely supply based—personal protective equipment, cleaning supplies, that sort of thing. The other was sort of content knowledge—helping them provide more expertise around critical care management for these patients, having clinical folks actually go out to the Navajo Nation and to the Northern Navajo Medical Center, the hospital in Shiprock, New Mexico, to actually provide care. A good example of that is our nursing staff that have a lot of expertise in critical care actually going out there and helping them in that space. We really tried to sort of bridge whatever gaps we thought they had identified that we could be helpful with.

But to your larger question—how do you address a pandemic in the setting of a place that has experienced decades and centuries of structural racism? That is the real challenge. And I guess what I would say is that the pandemic itself is new, but the issues that it's raising are certainly not new. Many of these communities across the country are simply not equipped to be able to respond to such a global pandemic.

PIH: Yeah. And as we examine why clinical outcomes have been so poor in communities of color, in your piece you urge us to look beyond comorbidities such as diabetes or heart failure and, instead, address the root cause—systemic racism—which can come in the form of food deserts or limited access to health care. What do you wish more public health professionals understood about how poor health outcomes in communities of color are linked to our societal structure?

The thing that I would emphasize the most is that we often jump way too quickly to the conclusion that the circumstances that an individual finds themselves in related to their health are result of poor choices—poor life choices, or decisions that they have made. And what I was really trying to emphasize is that that is not true. That that is not the case. That many times what you perceive as being a choice really wasn't a choice for that person.

So if we think about food deserts or food swamps, you may say, ‘they're making a bad choice in terms of their food.’ Well, if that's the only food option that's either physically available—if you're in a food desert, in a rural area where healthy food supplies may not be available—or in places where there are food options available, but they're all bad food options—like a food swamp—we just have to really recognize that that's not a choice that those individuals are making. And then when you don't have a healthy food supply or you don't have the ability to exercise regularly, because you have to work two jobs to make enough money to survive, because you're a low-wage income earner, it is not their choice that they are choosing not to exercise. And so all of these things, when you put them together, then can lead to chronic disease and to diabetes, and then those illnesses coexisting with an illness like COVID increase your chance of having a poor health outcome.

And what I would really strongly suggest that we all think about is to say, it was really not a choice for them to have this risk for diabetes and really all of this can be traced back to the same set of circumstances around poverty, education, income opportunities, employment opportunities, and many other things that exist in these communities.

PIH: Right. I feel like the conversation in public health has evolved and we're talking so much more about the root causes and there's so much to unpack even within your piece. Were there topics that you didn't have time or space to address in the piece? What are some things we should be discussing more?

I think a couple of things are important. We have to make major investments in core infrastructure and the capacity of these communities to prosper if we're really going to address public health. Otherwise I fear that we are going to be putting band-aids on a very large problem and ultimately they won't be successful.

So we can develop programs that, when individuals have food insecurity, we can try to work on food pantries—and I'm not suggesting that we should not do that—but what we really need to understand is, why is there food insecurity and how do we address that? We can work on issues of trying to create health navigators and other functions and community health workers that increase access to care, but what we really have to think about is, why are there challenges in access to care? A lot of these things get to the core infrastructure and economic prosperity of these communities.

And so as public health experts, we have to really start to drill down and be open about and be comfortable with talking about that structural racism that has existed for years. Why is it the technologies like cell phone and broadband and internet access, why do those things lag behind in these communities? And we may feel initially—well, it's more expensive and if you're in a remote, rural area, it's harder and will be more costly per individual to have this type of technology available. But then when you meet a global pandemic, we shouldn't be surprised when these individuals can’t take advantage of using virtual health technology, Zoom, when these communities suffer from a lack of communication capacity.

The same is true about employment opportunities. If we don't have employment opportunities in these communities, how do we expect there to be a long-term sustained solution to food insecurity? There are so many things that I think, if we don't address these very large and expensive infrastructure issues, I fear that many of our other public health interventions are not going to be a sustainable, but also not going to be as effective as we would hope them to be.

PIH: Thank you for bringing that up. On the sustainability piece, how do you think COPE’s years of working with the Navajo Nation has helped lay the groundwork for the COVID response?

Well, I think that they were able to contribute in a really important role, ranging from being able to help with coordination of testing to contact tracing. I think there's a really valuable role for these kinds of community and clinical partnerships.

PIH: Looking ahead, what are your goals as you continue your day-to-day work in the fight against COVID, and as you strategize to prevent another surge of cases?

One of the things we're actively working on in the Boston area is we have a more robust tracking system available to identify when hotspots may be occurring. We are clearly, in the Boston area, seeing a hotspot occurring in Lynn, Massachusetts. Right now our efforts are engaged in trying to prevent recurrence, trying prevent a second surge.

We have targeted outreach programs to all of our communities that represented hotspots during the first surge in March, where we really are encouraging the basics. Wear a mask, wash your hands, keep socially distanced as much as possible. And getting that message out in targeted media outlets—social media and radio and other places which have deeper penetration into these communities. We're also having community-based spokespeople create communication messages for us, video communications and otherwise, and really stressing these messages. Please wear mask, please wash your hands, please socially distance. This is the way we will keep the infection down.

When Carmela Sánchez gave birth to her son, Miguel Gómez, it was not apparent that he was deaf. It was only after he turned one year old that Sánchez and her husband, who live in the coffee-growing Sierra Madre region of Chiapas, Mexico, realized that Miguel did not respond when he was talked to and had no reaction to the noises around him. He had also started falling behind other children his age in saying his first words.

Worried and unsure what was happening, the Sánchez family took Miguel to a doctor, where they learned that their little boy could not hear the world around him.

At first, they did not know how to react; they weren’t expecting to face a challenge like this, and had no idea how to overcome it in their small, rural community of Laguna del Cofre. But they deeply loved Miguel, and were determined to fight so that he could enjoy a better quality of life.

Their search for quality care took many years, and eventually led them to Compañeros En Salud (CES), as Partners In Health is known in Mexico.

CES began collaborating with Mexico’s Ministry of Health in 2011 to support care at 10 clinics in remote areas, serving more than 140 communities in rural Chiapas—including Laguna del Cofre. Primary care often is provided by first-year physicians carrying out their social service year, known as pasantes, whom CES recruits by partnering with medical schools in Mexico.

Pasantes perform a variety of tasks, from well-baby visits and regular check-ups to home visits and emergency care. Yet some patients arrive with health challenges that require specialized attention, which only can be accessed hours away in more urban hospitals.

Recognizing this gap in care, CES created a referral program to serve as a link between local health centers and government hospitals. The Right to Health Care program is dedicated to helping patients navigate the health care system and find all available resources, while addressing the barriers—such as arranging and paying for transportation and lodging—that patients face when trying to access care and alleviate their suffering.

The Sánchez family were among those needing such support, and they were not alone. Deaf people in Mexico face several structural barriers that affect their access to health care, education and other social services; these difficulties are often worsened in low-resource, marginalized areas with little access to quality health care.

Miguel, who is now 9, is one of thousands of Mexican children who are hard of hearing. Mexico’s deaf community includes 2.4 million people—84,957 are children under the age of 14, according to a national survey conducted in 2014.

After learning of their son’s condition, the Sánchez family spent the next several years searching for ways to support Miguel with hearing aids to help him hear and communicate better. But the process was long and difficult. They delivered various documents to a larger hospital but, in the end, an appointment was not made. If they wanted to get hearing aids, they learned, they would have to travel up to six hours to Tuxtla Gutiérrez, the capital of Chiapas—a process that would involve spending precious money on buses, taxis, lodging and food and leaving behind their jobs and kids for a couple of days. Despite these barriers, the Sánchez family held on to hope for a solution.

Then, they found CES.

When they took Miguel to the clinic in Laguna del Cofre, where CES began providing care in 2019, Dr. Magaly Montaño referred him to a clinic in Tuxtla. That sparked a renewed push for medical care. Miguel and his father traveled more than two hours to Jaltenango, where CES is headquartered, and spent the night for free at the house provided for patients. The next day, they woke up early to travel to Tuxtla, accompanied by Uver López, a CES driver, and Dr. Lorena Ponce de León, who leads CES’s referral program. There, at the clinic, Miguel for the first time in his life had molds taken of his inner ear. A few weeks later, he went home with hearing aids and a new sense of freedom.

“When Miguel put on the hearing aid for the first time he was absolutely surprised,” says Sánchez. “He kept clapping because he liked the sounds he could hear now. He’s more aware of his surroundings, he smiles a lot, and all of this helps him hang out with other kids his age.

“Thanks to Compañeros En Salud for supporting us, accompanying us at all moments,” she says. “The whole process was very quick, and in the past we never thought we would be able to get this kind of help because of how expensive it is. Thank you for staying with us.”

Despite Kazakhstan’s nationwide lockdown that began in March to contain COVID-19, Partners In Health clinicians have continued to examine and provide treatment—in person and online—for tuberculosis patients enrolled in a groundbreaking clinical trial.

Clinicians have had to communicate regularly with police to cross checkpoints and have used their own vehicles as testing sites, checking patients’ vision, hearing, and hearts for treatment-related side effects from the seat of a car.

Kazakhstan is one of seven countries participating in the clinical trial for the endTB partnership, a multi-year, international effort to fight the world’s deadliest infectious disease. It’s the biggest TB trial in the world, led by PIH and conducted in partnership with Médecins sans Frontières, Interactive Research & Development, and financial partner Unitaid. The endTB partnership also is seeing strong results from an observational study, in addition to the clinical trial. The effort’s overarching goal is to find better, shorter regimens for hard-to-treat, multidrug-resistant TB (MDR-TB), using the first new TB medications in nearly 50 years—bedaquiline and delamanid.

A post-Soviet country of more than 18 million located in Central Asia, Kazakhstan is one of the world’s top five countries for both new and previously diagnosed cases of MDR-TB, according to the World Health Organization.  It is also among the countries in the region hardest hit by COVID-19, with more than 110,000 confirmed cases and 1,300 deaths as of mid-August. Health officials fear that actual case and fatality numbers could be much higher than confirmed data.

“Given the situation, the Kazakhstan endTB team faced serious challenges to continue providing treatment to TB patients,” said Nataliya Morozova, program associate for PIH in Kazakhstan. “The team has urgently developed a set of measures to support patients in the settings of strict quarantine.”

A Bold Study

Standard, traditional tuberculosis treatments can last up to two years and include painful daily injections of drugs that can have multiple negative side effects, including temporary psychosis and hearing loss. The endTB trial tests five regimens and aims to show that bedaquiline and delamanid can offer patients a shorter course of treatment, with fewer side effects.

PIH and Kazakhstan’s National TB Program are collaborating to run the endTB trial with MDR-TB patients in the capital, Almaty. In Kazakhstan, TB patients normally are hospitalized for at least a few months at the beginning of care, with the goal of both containing the disease and properly administering treatment.

A total of 118 patients have participated in the trial in Kazakhstan, more than a fourth of the 463 patients in the endTB trial worldwide. Seventy of the Kazakhstan patients were continuing to receive treatment or follow-up as of mid-August. Some of the remaining 48 had already completed all procedures, while others had to withdraw from the study for various reasons.

COVID-19 Lockdown

From the beginning of the outbreak, Kazakh officials instituted severe measures to limit the spread of COVID-19. Since March 20, police set up roadblocks around Almaty. For more than two months the city was under lockdown, with many of its 2 million residents quarantined at home.

At the same time, a decision was made to empty TB wards and transform them into COVID-19 wards instead.

Raushanah Kuanysheva, a 23-year-old MDR-TB patient, was among those sent home. A self-employed marketing manager, she was diagnosed in January after suffering from severe pain in her upper back. An X-ray revealed an abnormality in her lungs. She was diagnosed with tuberculosis after a CT scan and sent to a hospital, where she was to undergo six months of treatment. However, Kuanysheva’s stay was cut short after just three months when the ward was transformed to care for coronavirus patients.

Initially, she received standard TB treatment. She said one of the drugs she was given was “really, really awful. It has negative effects on your mind.” At times, Kuanysheva said, she didn’t know who or where she was.

After two weeks, Dr. Amanjan Abubakirov, a TB specialist who works with PIH, offered her the opportunity to participate in the endTB clinical trial. She jumped at the chance, unafraid of the possible risks.

Her new regimen involves taking six medicines over nine months. She says none of them has caused serious side effects. When she was still at the hospital, specialists monitored her health, conducting weekly checks on her heart, vision, and hearing.

Video Treatment Support

The PIH team—including 10 trial coordinators and about 25 contracted hospital investigators, along with nurses and other support staff—used video treatment support (VTS) prior to the coronavirus pandemic. But now, it’s become an indispensable tool.

Kanat Khazhidinov, PIH research manager in Kazakhstan, said the team quickly switched all of the TB patients in the study from weekly hospital visits to receiving treatment via VTS. 

The reasons were twofold: first, to minimize the risk of COVID-19 transmission between doctors and patients, and second, to accommodate patients who couldn’t leave their home or neighborhood due to the citywide lockdown. Virtual treatment has the added benefit for patients of avoiding stigma associated with a TB diagnosis.

“It was interesting that many patients didn’t want me or other physicians to visit them at home,” Abubakirov said. “Sometimes they are hesitant because their neighbors and relatives might spot the doctors.”

Still, Kuanysheva said maintaining her schedule of being constantly tested has been “really difficult, because of COVID.”

Every day, she receives a virtual visit from nurse Duysebayeva Nurgul, via WhatsApp. Over video, the nurse asks about her condition and watches as Kuanysheva takes all 12 of her pills, which can take some time as they are hard for her to swallow.

Kuanysheva also needs to have her sputum checked, so a nurse comes to her home monthly to retrieve a sample. She has her bloodwork done at a nearby lab.

Over time, her nurse and PIH team members have become trusted friends.

“I really appreciate them,” Kuanysheva said. “I’m really grateful for their support, not only for my TB situation.”

Checkpoint Medical Exams

While VTS covered a good portion of care, endTB trial patients still needed their medicines, and medical checks had to be performed to monitor possible side effects throughout the study.

Dr. Merey Otepbergenova, co-investigator of the endTB study in Kazakhstan, was one of several team members who traveled with her own vehicle, along with various examination tools and machines, to meet patients wherever possible.

In some cases, she made home visits, while other exams were performed at lockdown checkpoints. That meant an electrocardiogram and audiometry exam sometimes were conducted in the backseat of the doctor’s car, or a vision test was performed on the spot. When necessary, drugs were delivered directly to patients’ homes.  

Due to his team’s determination, Khazhidinov said, “80 percent of all the activities within the endTB trial were accomplished during the lockdown.” 

Abubakirov said he’s seen a big change in the effectiveness of care over his career as a TB doctor.

“In 2010, when I started, the situation was not favorable,” he said. “There were no effective TB drugs.”

New drugs started to arrive in 2016 and initially offered an effectiveness rate of about 40 percent.

Now, 75 percent of patients have favorable outcomes, Abubakirov said.

Dual Pandemics

The endTB trial is continuing, all while clinicians face the very real risk of contracting COVID-19. At the end of May, the Kazakhstan government loosened lockdown restrictions, only to see COVID-19 cases spike. New lockdowns followed.

Even that gap was perilous, however.  In June, 11 of 15 core PIH staff members developed clinical symptoms of COVID-19. Abubakirov was among those who fell ill.

He was diagnosed with pneumonia, most probably due to COVID-19, although he was not tested. Twelve days later, he had recovered and was doing well. While some team members continued to work remotely, others took sick leave. After two weeks, no one from the team developed severe symptoms, and all have since recovered.

Abubakirov and his colleagues are just a few of the frontline, essential workers battling TB around the world. Now, in a cruel twist faced by health workers everywhere, they’re battling COVID-19, as well.

PIH honors the life and legacy of Mitchell Adams—trustee, advocate, and friend—who passed away on July 18, 2020.

A PIHer for more than a decade, Mitchell forged his PIH legacy through gifts, advocacy, and community building, first as a donor in 2008 and then through his ongoing commitment as a trustee from 2014-2020. His generosity supported our work in Haiti, Rwanda, and globally, helping to improve health outcomes in some of the world’s most vulnerable communities. A tree will be planted in his memory at University Hospital in Mirebalais, Haiti, next to a tree planted in honor of his husband, Kevin.

Mitchell’s years-long support for PIH reflects his lifelong advocacy for health care as a human right and solidarity with marginalized groups at home and abroad. He spent his life fighting for a more just and equitable world, notably standing with the LGBTQ+ community and people recovering from alcoholism.

Through the years, Mitchell supported PIH because he felt that it put his gifts into action in sustainable, impactful ways. After making a legacy gift in 2017, he shared: “Partners In Health basically helps more people for the given amount of resources you can imagine. In other words, it has a model that is extremely efficient. In supporting PIH, I can do more good for more people than in any other way I can imagine.”

He was deeply moved by PIH Co-founder Tom White, who inspired him to establish a legacy with PIH. Years ago, Mitchell shared in an email: “I'm personally honored to be associated with Tom White. Do you know his story? He's the fellow who got the whole thing started (in terms of financial support). Over two decades he gave PIH his entire fortune - and his attitude was that PIH was doing him a favor! I believe in angels, and Tom White was surely one of them.”

Mitchell’s support for PIH extended beyond financial generosity. He was committed to building community and sharing our work with his networks, often hosting fundraisers and events. Additionally, he led trips to our care delivery sites in Haiti and Rwanda, where he visited programs and patients at PIH-supported hospitals and clinics and met with several staff members. At the time, he described meeting with 35 members of an HIV cooperative in Rwinkwavu, Rwanda, as a particularly moving experience.

As his obituary notes, Mitchell died in Boston. He was 75 years old.

Before his passing, he requested that donations in his memory be made to PIH.

PIH remembers Mitchell for his lifelong commitment to standing in solidarity with marginalized groups and proving that injustice has a cure. As we celebrate his legacy—marked by generosity of spirit and commitment to helping the most vulnerable—we draw inspiration from one of his favorite sayings: “Where there is life, there is hope.”

A new study in seven countries supported by Partners In Health is using routine health data to look for abnormal spikes in ailments that could be related to COVID-19, such as respiratory infections or pneumonia, and assess whether people are changing how they use health services amid the global pandemic.

A lack of reliable data can be an enormous roadblock for understanding the burden of disease and changes in the use of health services during a public health crisis, severely affecting countries’ ability to plan effective responses.

COVID-19 also threatens to undermine care and outcomes in important health areas such as maternal health, family planning, childhood vaccinations, HIV, TB, and malaria, along with treatment of non-communicable diseases such as cancer. That threat is particularly severe in low- and middle-income countries, where limited resources may be diverted from those areas to battle COVID-19.

Additionally, fear of contracting the disease can prevent people from seeking care at health facilities, creating further risks of untreated health problems.

Clinical and research leaders from PIH teams in multiple countries are undertaking the new study to examine and address these gaps, in collaborative with Dr. Michael Law of the University of British Columbia and Dr. Bethany Hedt-Gauthier of Harvard University.

The Canadian Institutes for Health Research (CIHR) are providing technical support and funding. The institutes also are supporting postdoctoral researcher Dr. Isabel Fulcher, who has been leading the development of data and analytic methods for the project for several months.

By working with routine health data that is already collected, Drs. Law and Hedt-Gauthier hope to overcome COVID-19 testing restraints and provide a much-needed source of data on COVID-19 in low- and middle-income countries.  

PIH Canada recently spoke with Dr. Law about the study.

What are the study’s objectives?

The study has two key objectives. The first is to perform syndromic surveillance to detect early signs of a COVID-19 outbreak, and the second is to investigate potential declines in health service use to design and target interventions. Each of these objectives will be carried out in the following seven countries: Haiti, Lesotho, Liberia, Malawi, Mexico, Rwanda, and Sierra Leone.

Why were these seven countries chosen?

Actually, the seven sites were already working together and had identified these two topics as a priority. The CIHR funding call provided an opportunity for us to rally resources to respond to these identified needs.

Because each of these countries are PIH sites, the other important aspect here is that it allows the research project to rapidly scale since we already have the existing relationships and infrastructure within the country to do that. Our research team has really benefitted from the leadership of Jean Claude Mugunga, a deputy chief medical officer at Partners In Health, and Harvard Professor Megan Murray, who is also a PIH Research Director, who have been coordinating cross-site research for COVID-19-related work more broadly.

Excitingly, this is the most countries that have participated in a single PIH research project at the same time to date.

What exactly is syndromic surveillance? Is it a replacement for testing?

Syndromic surveillance is essentially a way to use the data that we have. We know these routine data are being collected, we know they are being assembled. And so, the hope is that those will be useful for being a ‘canary in a coal mine’ in helping highlight when testing might be necessary.

Syndromic surveillance is especially important in low- and middle-income countries, where testing is both limited and expensive. And while not a replacement for testing, it serves as more of a complementary procedure in which you can glean information on where potential hotspots of COVID-19 may be occurring to target your testing, and subsequently focus health care efforts. For example, if you see a spike in a region with people showing up with respiratory issues, then you might think that would be an area you would like to focus on more closely.

Why look at other non-COVID-19 health outcomes?

With the rise of COVID-19 cases, it is likely that people will be more reticent to seek out health care services at a facility where they fear COVID-19 may be spreading. This study is particularly focused on comparing the number of individuals receiving care for things like maternal health, family planning services, childhood vaccinations, and malaria treatment to expected numbers pre-pandemic. If it turns out there is a decline in the use of these services, there can be a lot of downstream impacts. After all, these are services that are really important to protecting and producing population health in these settings.

The benefit of this data-forward approach is that you can go full circle with it. In other words, you can see where problems are coming up and target a policy towards those problems. Then, the real advantage of using routine data is that you can turn around and evaluate the impact of those policies that you have put in place.  

There is evidence to show that this approach works. We did some work in the past with the Ebola virus outbreak in the Democratic Republic of the Congo and found that when we instituted a free care policy after the virus outbreak, visits to health facilities actually increased. So, there are policy measures you can take to try and ensure that people don’t stop seeking out health care that we would otherwise want them to continue on with.

What will this study ultimately accomplish?

The fundamental goal of this research project is to support the national COVID-19 responses in these seven countries. The study will provide ways of using data to identify hotspots and deal with some of the secondary consequences of COVID-19.

But there is also the hope to take it one step further by using this study to help demonstrate the value of health data as countries continue to invest in data collection and use. What is going to happen in the coming months with regard to COVID-19 in low- and middle-income countries will largely depend on the policy responses, which in turn are heavily reliant on the data.

As a result, it is critical that we recognize the importance of data and policy working hand-in-hand to tackle the COVID-19 pandemic and bring it under control.