Dr. Cyprien Shyirambere is the oncology program director for Inshuti Mu Buzima, as Partners In Health is known in Rwanda. He leads the bustling, vital Cancer Center of Excellence at PIH-supported Butaro District Hospital in the country's mountainous north. Many patients, family members, and caregivers travel to Butaro from across Rwanda or from surrounding countries such as Burundi and the Democratic Republic of Congo, where high-quality cancer care is scarce or nonexistent, to receive lifesaving treatment at the hospital. In recognition of World Cancer Day on Feb. 4, Dr. Shyirambere talked about what's new in Butaro, and how global action is needed to reduce vast disparities in cancer care around the world.       

Q: Butaro District Hospital recently opened its Cancer Support Center, providing a place to stay during extended treatment for patients who live far away and their families. How is the Support Center working out so far? How is it affecting cancer care at Butaro District Hospital?

The 68-bed Butaro Oncology Support Center is open six to seven days a week, and accommodates cancer patients who come to Butaro as ambulatory chemotherapy patients, and outpatients. The average stay is two nights. Patients receive free meals, laundry, and nursing care, as well as counselling services by a qualified clinical psychologist, to help them cope with the disease. Since opening last August, the center has seen about 5,500 patient visits. With a nice view of the mountains in Burera District, it offers a dignifying environment and brings hope to our patients’ faces.

This center has improved the way we provide care to our patients, since it has decongested oncology wards and decreased burdens for patients, many of whom used to pass nights in the cold outside the hospital because they had nowhere to stay. 

Q: Rwanda Military Hospital in Kigali now offers radiotherapy, which previously could not be accessed anywhere in Rwanda. Has that made a difference in treatment and referrals at Butaro District Hospital? What does it mean for cancer care in all of Rwanda?

The radiotherapy center at Rwanda Military Hospital has two state-of-the-art linear accelerator machines, which is a huge step towards cancer control in the country and the entire East African region. More than 50 percent of cancer patients need radiation therapy at some point of their treatment, either for curative intentions or as part of palliative care, to control symptoms and improve quality of life.

No country can achieve access to cancer care without planning for access to radiotherapy. More Rwandans and patients from neighboring countries now can access radiotherapy services, which previously was impossible for the majority of them.

Q: Has the hospital begun interacting with UGHE students? What has been happening, and are there plans for an expanded relationship in the future?

So far, the interactions between UGHE students, Inshuti Mu Buzima—as PIH is known in Rwanda—and Butaro District Hospital have been focused at the community level, to give students a sense of the social and economic determinants of health, and how community health workers are involved in the health care system.

There is a plan to expand the hospital to meet accreditation standards to become a teaching hospital for UGHE. In 2021, if all goes well, UGHE medical students will start doing clinical rotations in the hospital, and we hope our physicians will be involved in teaching those students.

Q: What’s new at the Butaro Cancer Center of Excellence? What challenges and successes have you seen lately?

New at the Butaro Cancer Center of Excellence:

• Digitalization of data from our women’s cancer early detection program, in Open MRS (Open Medical Records System, an electronic, open-source medical record platform)
• Pilot project to implement a patient navigator program, to reduce delays in care and abandonment of treatment, initially focusing on patients with Wilms’ tumor (a rare kidney cancer that primarily affects children)
• Cultivating a culture of quality improvement, using quality improvement champions
• Continuous medical education program for oncology clinicians, in collaboration with the Dana-Farber Cancer Institute’s Center for Global Cancer Medicine

Challenges:

• Limited access to modern imaging technology, such as CT scans; limitations with pediatric oncology surgery and intensive care
• Survival rates are still low, compared to high-income countries, and some drugs needed to improve that rate are still unaffordable
• Limited space to accommodate growing numbers of cancer patients

Q: What else would you like to talk about on World Cancer Day, that I haven’t asked about?

On this World Cancer Day 2020, I stand with thousands of cancer patients around the world and their families. I salute efforts to address this growing burden and I urge the global community to reduce the disparities in cancer care, in order to achieve universal health coverage.

There are nearly 1 million new cancer cases and more than 500,000 cancer-related deaths in Africa per year, and these totals are projected to double by 2040. Training the next generation of health leaders to counter this rise is of critical importance. Increasingly, we see a need for cancer education that explores both the prevention measures and social determinants of this highly treatable, but highly prevalent, disease. In recognition of World Cancer Day, we spoke to the University of Global Health Equity's founding Dean, Prof. Abebe Bekele, to spotlight his holistic approach to cancer education.

Q. This is the first academic year for students in UGHE’s new medical program. Those students arrived on campus last summer and will study for more than six years. They’ll have significant interaction with Butaro District Hospital, the Partners In Health-supported facility across the valley. What have the medical students seen of the hospital so far, and particularly its Cancer Center of Excellence?

UGHE’s MBBS program has an integrated curriculum. Students don’t spend the first two years just in classroom or the lab—they get exposure to clinics, health centers and health posts, right from the start. We call this progressive clinical immersion. Already, our students have visited the hospital twice, met the medical doctors, visited the health centers and spent time in the community. In January, they will start their basic sciences training, which consists of all the basic sciences in an integrated manner with clinical care. Students will spend time in the hospital, with patients and learning vital communication skills, alongside cancer diagnosis and treatment.

Q: How will students’ involvement with the hospital grow in years to come, through UGHE’s focus on progressive immersion within the curriculum?

Progressive clinical immersion is vital as it serves to blend and balance basic medical and clinical sciences. The first two years are focused mainly on basic medical sciences. That focus decreases as they progress, in a way that’s directly proportional to an increased focus on clinical sciences, with year three as the intersection. Why do we do this? It’s tied to the competencies: What kind of doctors are we trying to train, and what do we need them to do after graduation? These students will go on to diagnose and treat patients, conduct and understand research, serve as health system leaders, advocates of equity, and scholars. So we need to reverse-engineer the curriculum; defining the competencies first, then designing the curriculum, in a way that’s tailored to equip the students with the competencies.

Q. How does the integration of humanities in the curriculum contribute to students’ holistic approach to health delivery?

Humanities directly ties to clinical care within the cancer center. Our students learn about African history, the social determinants of health, political economy, gender and justice, and examples that relate to health, such as the identification of lymphoma in Uganda, Ebola, and the health impacts of the rubber industry in the Democratic Republic of the Congo. These examples directly tie to cancer care, looking first at the reasons behind the resurgence of cancer in Africa as a starting point.

Q: What makes the study of cancer, and cancer care, different from other medical areas of focus?

Data shows that cancer is on the rise in Africa. We need to prepare our doctors to first appropriately diagnose the diseases, then promptly refer these cases to proper therapy, and later, as they mature in their careers, consider specializing in cancer care to cater to these growing numbers. We should be looking at prevention as the starting point. Breast and cervical cancer are the two most common cancers affecting our population. Cervical cancer is preventable with appropriate vaccination, and both are treatable if diagnosed early.

Q: What are some examples of how UGHE students will study cancer, in the classroom or outside of it?

When our students enter their clinical years, they’ll spend significant time in the cancer ward: learning and contributing to quality improvement, data collection and research. In terms of research, our MGHD students complete research papers about cancer in the cancer hospital. This emphasis on research also is strongly supported by our faculty; the basic sciences team is developing a proposal in breast and colon cancer, something we hope will help students become more engaged in the subject.

Q: The WHO reports that cancer cases numbers could double by 2040 without strong counter-measures. How can UGHE play a role in addressing, and preparing for, Africa’s growing cancer crisis?

The most common cancers in Africa—breast and cervical—are preventable, or, if not, early diagnosis gives us a greater success in treating them. All of us have a role to play here: as physicians, nurses, public health experts, advocates, governments, policy makers and others. If we collaborate and contribute to prevention of those cancers, we can rapidly reduce the number of cases we see. Advocacy is important. UGHE trains its students to become experts in the diagnosis of cancers, as well as advocates and drivers of social mobilization and policy support for the government.

We also teach our students about equity in everything we do; it is the centerpiece of academics at UGHE. Women have better health-seeking behavior but they face enormous barriers to accessing care. They are restricted by finances, transport, access to hospitals, cultural taboos, responsibilities at home, gender-based biases and other factors.

Things are stuck at the moment, but not because of lack of awareness—we already know about and understand the mounting incidence of cancer in the continent. It is about who is going to take the bold step to address it.

We have not yet declared cancers as an emerging public health problem in the region. Now is the time to focus on cancer, now is the time to take action.

Partners In Health strives to address these inequalities by working with midwives—often expectant mothers’ most trusted companions—to expand access to women’s health services in the countries where we work.

Below, meet some of PIH's amazing midwives, who we will honor and celebrate throughout 2020, which the World Health Organization named the Year of the Nurse and Midwife.

Isata Dumbuya, Sierra Leone

When a young pregnant woman was rushed into the maternity ward at PIH-supported Koidu Government Hospital (KGH) in Kono, Sierra Leone, Isata Dumbuya, head of reproductive, maternal, neonatal, and child health, recognized the look of anguish on her team members’ faces. The woman was in critical condition, suffering from pre-eclampsia. Had she visited the hospital earlier in her pregnancy, for prenatal care, she likely would have been bound for a safe delivery. But with just days until labor, her long untreated condition threatened her and her baby’s lives.

Such a dire case is all too common at KGH. 

Isata often compares her experiences as a nurse-midwife in the United Kingdom versus Sierra Leone, where she was born and where she began working in June 2018. In 19 years delivering babies in the U.K., Isata witnessed one woman go into pre-eclampsia shock. At KGH, this is a pregnancy complication that she and her team combat weekly — often when it’s already too late.

Over the past year, Isata has discussed at length with her fellow clinicians why so many pregnant women seek care too late. “In many instances, patients seek help from local community healers before coming to the hospital, simply due to lack of transport or understanding what care is available,” she explained.

Determined to further understand and transform this reality, Isata formed a community outreach team of six clinicians from KGH and nearby PIH-supported Wellbody Clinic. The team travels to all of the 14 chiefdoms in Kono District to make known the critical care and services at KGH and Wellbody.

Their efforts have already begun to pay off. Since the outreach team began its work, staff have been admitting patients from parts of Kono they've never seen represented at either facility. And for Isata and the maternity ward, the number of lifesaving C-sections performed at KGH continues to steadily increase.

Go on the road with Isata

Margarita Perez Jimenez, Mexico

At the age of 14, Margarita Perez Jimenez began working as a traditional midwife in Chiapas, Mexico.

Decades have since passed, and Margarita says she has delivered more than 5,000 babies, most of them within a mud brick, zinc-roofed shack behind her home in the rural town of Francisco Madero. 

Margarita was the first traditional midwife to deliver her patient at Casa Materna, a maternal home supported by Compañeros En Salud, as Partners In Health is known in Mexico. It was a major win—proving that local expertise can partner with modern medicine to bring quality maternal health care to women living in rural Chiapas.

Since the facility opened in May 2017, more than 360 women have given birth at the hands of doctors and OB/GYN nurses who staff the clinic 12 hours a day, seven days a week. On average, 280 women arrive each month for urgent care and exams, after being referred from the neighboring health centers in Jaltenango and surrounding communities.

Since the facility’s early days, PIH staff have seen an increase in the number of women choosing to come to the Casa for prenatal services and, when the time comes, to deliver. The trend is reassuring, especially in Chiapas, a state where the rate of maternal mortality is among the highest in Mexico—49 per 100,000 women.

Read about Margarita’s bond with her patients

Habibatu Alu, Liberia

Habibatu Alu, a 42-year-old certified midwife, has been working at Pleebo Health Center in southeastern Liberia since 2011. On a typical day, Habibatu arrives to work by motorcycle taxi and enters the clinic through triage. Because of the deadly Ebola outbreak that began in 2014, triage centers have been installed at health facilities throughout the country to identify suspected cases of diseases with epidemic potential. 

Once cleared, she starts the day by counting her stocks of emergency obstetric medications and sterile delivery supplies. As one of only a few midwives usually on duty, she has to be prepared for whomever walks through the door. On average, Habibatu sees 50 pregnant patients and attends to at least two deliveries per day.

For patients with complicated pregnancies, Habibatu will recommend consultation with a PIH obstetrician at the high-risk pregnancy clinic. Offered once a week at Pleebo Health Center, the high-risk clinic brings specialized maternity care to patients in their home communities.

While Liberia has the seventh highest maternal mortality rate in the world, midwives like Habibatu are working to change that trend so that women can give birth safely and return home with healthy newborns.

Spend the day with Habibatu

Boyama Gladys Katingor, Sierra Leone

Walking around the PIH-supported Wellbody Clinic in the muggy heat of eastern Sierra Leone, Boyama Gladys Katingor attracts a lot of attention. People rush up to the 52-year-old head midwife from every direction: uniformed midwives, women with newborn babies strapped to their backs, heavily pregnant women. She speaks to everyone in a gentle, encouraging tone and goes out of her way to offer advice wherever possible. 

Known as Gladys to friends and colleagues, she joined PIH in 2014 and has since been a positive role model for  female empowerment at Wellbody Clinic. Gladys strives to standardize a modern approach to women’s health care. And in doing so, she tackles a number of universally debated and politically charged issues—including teenage pregnancy, abortion, and female genital mutilation—by listening, loving, and, when necessary, lecturing.

Sierra Leone had the seventh highest rate of teenage pregnancy in the world, with 38 percent of women delivering their first baby before the age of 18. At Wellbody, expectant mothers under the age of 18 are invited to stay at a birth waiting home for the month preceding their due date. During their stay, they receive free prenatal care and meals, and enjoy a supportive environment.

Postnatal classes are also available at Wellbody following a birth, and Gladys makes sure new mothers are supported in a number of ways, including through family planning services.

Learn more about Gladys’s advocacy

When Dr. Tebo Buduo, a young Liberian physician from Monrovia, heard he’d be doing his medical internship in remote southeastern Liberia, he felt some apprehension. Maryland County is some 250 miles from the Liberian capital—a journey that can easily take two days in the rainy season, when dense, orange mud clogs the rural roads. 

But when Buduo arrived at J.J. Dossen Hospital, he was pleasantly surprised. Partners In Health, which has been supporting the government-run referral and teaching hospital since 2015 after arriving to respond to the Ebola epidemic, had recently completed a renovation of the site, equipping it with diagnostics and specialist services and giving it a fresh coat of paint. 

Buduo, who spent three months interning at the hospital, described his time there as “wonderful.” “I experienced a lot at J.J. Dossen that I would not have experienced in an urban area like Monrovia,” he said. “It surprised me that although it’s in a rural area, there’s nothing that you want in terms of facilities or management of patients that is lacking. It’s really helping to shape our specialty program and to enhance our health care delivery.”

Growing rural medical expertise

J.J. Dossen’s medical education program has been up and running since 2016. Its cornerstone is the residency program in family medicine, which is led by PIH-er Dr. Rebecca Cook, director of medical education and interim director of clinical services. When Cook arrived in Maryland in 2016, there were no specialist doctors assigned to J.J. Dossen; like most of the county hospitals outside of Monrovia, it was staffed by a small number of general practitioners who also juggled leadership and administrative responsibilities.

In partnership with the Ministry of Health, Cook and her team set about improving that.

“We saw early on that training doctors outside of Monrovia would ensure that physicians are getting experience [in rural areas] to hopefully help improve their ability to practice outside of Monrovia, as well as their desire and retention,” she said.

J.J. Dossen is the only rural rotation site for family medicine training in Liberia. Harper is now in its third year of hosting family medicine residents, with 11 residents expected to rotate at J.J. Dossen this year. The first class is set to graduate in 2020. Meanwhile over the past 12 months, J.J. Dossen has been growing as a training hospital for physicians at various stages, including now hosting intern doctors and general practitioners for their emergency obstetric and surgical care rotations.

"The clinical training they're getting here is excellent, both in terms of supervision and teaching by the consultants that are here."

Cook said it’s common for residents and interns to experience some apprehension “about being very far from their home and in an unknown place that they see as quite rural. But overall the reports and reviews of the experience have been very positive.” She added that from a learning perspective, “the clinical training they're getting here is excellent, both in terms of the supervision and teaching by the consultants that are here.”

On-site experts, world-class mentoring

Long-term specialists in pediatrics, internal medicine, surgery, and obstetrics and gynecology are based on-site in Harper serving with PIH, with additional subspecialists visiting, allowing interns and residents to benefit from world-class medical knowledge gained all over the world. At the same time, the physicians-in-training are gaining a broader view of the Liberian health system and of the barriers to accessing health services in the remote southeast.

Because J.J. Dossen is the southeast’s only regional referral hospital, it serves a diverse range of patients, who present with everything from skin complaints, diabetes, and hypertension to complicated cases of malaria, TB, and HIV. And unlike at other county hospitals, there is a greater number of diagnostic tools and therapeutics available, which as Cook says, helps the physicians in training “do more as doctors to take care of patients.”

Empowering nurse leaders

Nurses and midwives are also benefiting from the medical education on hand at the hospital, in partnership with nearby Tubman University, which since 2015 has been the main training site in southeastern Liberia for registered nurses and midwives.

In 2016, J.J. Dossen became the first Liberian hospital to offer a clinical mentorship program for nurses. Every ward now has a clinical mentor and a preceptor—an experienced practitioner who mentors new staff—who both work alongside the government nurses, finding gaps that need to be addressed together.

“In the pediatric ward, the clinical mentor found gaps in administration, and the nurses came back with ideas and projects,” said Viola Karanja, PIH Liberia’s deputy executive director. “In the medical surgical ward, they found gaps in the documentation of vital signs. They also started a project on bed sores, and we found there was a remarkable improvement in the reduction of bed sores.”

Because not every hospital in Liberia is as well-equipped as J.J. Dossen, PIH is teaching both innovation and improvisation. 

“We’re fortunate in the OB/GYN ward to have things like phototherapy for cases of jaundice in newborns,” said Karanja. “But in case our nurses later work at a facility without that, we also show them the natural way: simply putting the baby close to the window, where there’s sunlight.”

When Karanja first began finding innovative solutions to care, bed occupancy was high and staff motivation was low. Both have since been transformed. 

“Once we started having clinical mentors in the wards, the nurses could actually see training outcomes,” Karanja added. “They started coming up with new ideas, because they were so motivated.”

There are performance incentives too for those excited to advance their clinical nursing career. Last year two Liberian nurses had the opportunity to spend a month in Rwanda for PIH cross-site training in neonatal care, returning home with innovative new ideas to implement. 

Opening doors to state exams

That isn’t the only kind of travel that PIH has been supporting. Historically the Liberia state board exam in nursing has only been held in Monrovia, presenting a tough barrier to overcome for aspiring nurses from the southeast who often lack the funds and resources to travel. And so for the last few years, PIH has been supporting Tubman University nursing students by paying for their travel and lodging while they sit the exam in the capital. Since 2014, 140 nurses have graduated from Tubman University, including 44 graduating with a Bachelor of Science in Nursing.

“It has been a big relief for these students that PIH has been able to organize their transport to Monrovia, because it ensures they don't miss the exam,” said Daniel Maweu, PIH nurse educator and midwife coordinator.

“In the rural areas, you see the gravity of the health care needs of the people.”

Last year, for the first time in Liberia’s history, the nursing exam was decentralized and students prepared to sit it in Harper, saving the time, costs, and stress of travelling to Monrovia.

Tubman University nurses aren’t the only ones excited by the opportunity to stay in the southeast.

For Buduo, his internship at J.J. Dossen has sparked what may be a lifelong passion for practicing medicine in underserved parts of Liberia. “In the rural areas, you see the gravity of the health care needs of the people,” he said. “That in itself is a push factor for any physician who wants to serve the underprivileged, and not just be an office doctor.”

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Minutes after the earthquake hit on January 12, 2010, Loune Viaud began weaving her way through rubble-strewn streets to the General Hospital in Port-au-Prince, Haiti. As the executive director of Zanmi Lasante—as Partners In Health is known in Haiti, Loune knew the injured would soon begin arriving at the city’s largest public hospital and wanted to help in any way she could.

The building had suffered damage, but was still standing. She searched for the executive director, who was assessing the situation and triaging personnel to where they were most needed.

“How can I help?” Loune asked.

“’Go find the kids,’” she remembered him saying. “’Go to the pediatric ward and find what happened to the kids.’”

Loune knew exactly what he was talking about. She wove a well-worn path through the hospital, straight to the Salle des Abandons, or the room for abandoned children. She found 38 children—many of whom had disabilities—safe in the room, but hungry and extremely scared.

There wasn’t any hesitation in Loune’s mind. When the hospital executive director sent her to take care of the kids, she took it one step further—one giant step further. Over the course of months and years, she became the legal guardian to all the children and, with the help of Operation Blessing International, found a property on the outskirts of Port-au-Prince where they could create a new home. Zanmi Beni, or “Blessed Friends” in Haitian Creole, was formed.

Currently, 64 children live at Zanmi Beni, all of whom lost their parents or guardians in the January earthquake, or became orphaned, displaced, or abandoned in the years since. They range in age from 7 to 26 years old. Partially to help remember all of their birthdays, Loune chose one day on which they would all celebrate turning a year older—her birthday, on March 17.

Stepping through the gated entrance to Zanmi Beni, visitors are greeted by a friendly herd of dogs. A playground, soccer field, and picnic tables cluster outside the children’s on-site school, which is attended by roughly half of the children. The other half attend schools in neighboring communities, depending on their grade level.

Two dormitories, Kay Rose and Kay Sammy, sit in the back corner of the compound, not far from St. Rose of Lima Chapel.

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A bakery, barber shop, and restaurant that meet the needs of the children, as well as provide them space for hands-on job training as they get older. Altogether, 150 people work at the children’s home, including nurses, therapists, cooks, drivers, teachers, and maintenance staff.

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There are future soccer stars, photographers, and teachers among Zanmi Beni children. At least, those are some of their emerging talents.

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Loune said she talks to them often about what they’d like to be as adults.

Some of the children live with severe disabilities, and so Loune has organized for them to receive a series of visitors throughout the week, including regular sessions with physical, occupational, and speech therapists. They learn arts and crafts and receive visits from local musicians and authors. Some, like 14-year-old Nephtalie, make t-shirts, bracelets, and other jewelry to sell to Zanmi Beni visitors.

“We're trying to accompany them as much as we can,” Loune says, “and making sure they know that they're loved.”

Lessons from an innovative Ebola screening and isolation unit for pregnant women, created five years ago in West Africa, could inform maternity care and save lives during the current outbreak in the Democratic Republic of Congo (DRC), a new study shows. 

A Partners In Health team opened the groundbreaking isolation unit in November 2014 at Princess Christian Maternity Hospital in Freetown, Sierra Leone, in collaboration with the country’s Ministry of Health and Sanitation. The need for the unit was dire: Pregnancy-related complications frequently can mirror Ebola symptoms, creating huge challenges for maternal care in what was already one of the most dangerous countries in the world to be pregnant.

In Sierra Leone, one in 17 women dies because of complications from pregnancy or childbirth. Sierra Leone sees more than 1,300 maternal deaths for every 100,000 live births and has fewer than 10 nurses or midwives for every 10,000 people—compared to the more than 85 nurses or midwives available for every 10,000 people in the United States.

Those conditions were exacerbated by the deadliest Ebola epidemic to date, which would claim more than 11,000 lives across several countries—including nearly 4,000 in Sierra Leone—before ending in 2016.

“The symptoms of pregnancy look so similar to Ebola,” says Ahmidu Barrie, operations director for PIH in Sierra Leone and former director of the Wellbody Alliance, with which PIH partnered during the 2014-16 epidemic. “One of PIH’s first interventions at Princess Christian Maternity Hospital was training staff on infectious prevention control measures and how to spot Ebola symptoms in patients.”

Working to improve maternal care, reduce pregnant women’s risks of Ebola infection and death, and create better, safer conditions for pregnant women in Ebola screening units were vital parts of PIH’s response.

PIH midwife Diana Garde, clinical lead for the isolation unit, and Drs. Rebecca Kahn, Annelies Mesmen, Alimamy Philip Koroma, and Regan Marsh, now director of clinical systems for PIH, published lessons they learned from that response in July’s Journal of Midwifery & Women's Health. Their paper, “Care of Pregnant Women: Experience from a Maternity-Specific Ebola Isolation Unit in Sierra Leone," includes recommendations that the team says could be invaluable during current and future Ebola outbreaks.

“We recommend implementation of basic emergency obstetric and neonatal care interventions in isolation facilities…while ensuring the highest attention to infection, prevention, and control, and health care worker safety,” the paper states. “Supervised birth reduces maternal mortality through the ability of the attendant to manage hemorrhage, eclampsia, infection, and other pregnancy complications. Providing emergency obstetric and neonatal care adapted to the isolation context was possible and likely lifesaving.”

Lifesaving lessons

Specifically, Garde hopes their research will help medical teams fighting the ongoing Ebola epidemic in the DRC, where more than 2,200 people have died across three provinces since the summer of 2018.

“We want to encourage those (treating pregnant women) in the DRC to offer a higher level of obstetric care while still addressing the spread of infection, and improving data collection, on-site, timely access to laboratory facilities, and other elements of care,” she says.

The urgency to reduce Sierra Leone’s maternal mortality rate became even more drastic in early 2014, when Ebola spread across the Guinea border and many development agencies delivering care fled the country.

Garde, though, was arriving at that time. She began her work with PIH on a six-week stint at Princess Christian Maternity Hospital, and quickly became part of the Ebola response. While she also worked at a maternity unit in a remote, impoverished region of Sierra Leone called Kono District, she soon was fully assigned to Princess Christian and Freetown because of continuing Ebola cases.

“We created isolation and management plans for maternity at the hospital,” Garde says. “As caregivers, women were disproportionately affected by the epidemic.”

Conditions were challenging to begin with. Before Ebola struck, many women in Sierra Leone were delivering at home, because they couldn’t pay for care or didn’t fully trust a medical system that was gutted by a lack of resources, staffing, and even electricity at hospitals and clinics, following the country’s civil war. Home deliveries accounted for more than 50 percent of childbirths in Sierra Leone before Ebola, and the percentage worsened during the epidemic.

Travel restrictions further hurt women’s ability to reach hospitals, and risks didn’t end when they arrived. Before PIH helped Princess Christian improve its Ebola screening and isolation, expectant mothers unknowingly infected with the virus could be placed in the maternity ward among healthy women.

At that time, there wasn’t a system in place to screen mothers, so Garde and other health workers at Princess Christian began refining staffing and treatment models, clinics, and even other community centers, to help those facilities safely and accurately screen pregnant women for the virus.

In November 2014, the PIH team implemented what, to their knowledge, was the world's first maternity-specific screening and isolation system.

Better maternal care

Garde’s six-week stint turned into 18 months, as the team established a novel model of screening, isolation, and care for maternity patients that effectively reduced women’s risk of infection and mortality during the outbreak, and was developed in collaboration with other international groups and experts.

The maternity unit’s 11 beds were rarely empty during that time. Many women brought to the clinic by family members were treated for preeclampsia, a serious pregnancy complication in which high blood pressure leads to seizures.

“We’d deliver and look after the baby, not knowing if the mother was going to make it,” Garde says. “But with great effort and teamwork, it was incredible to look into the unit, two days after delivery, and see the mom sitting up in bed eating.”

For nearly two years, working with hospital leadership and Sierra Leone’s Ministry of Health and Sanitation, PIH supported Princess Christian Maternity Hospital in strengthening the health care system to improve safety and health outcomes, addressing the unique needs of pregnant women during the epidemic. They worked tirelessly, adapted screening guidelines to include maternal health care issues, built a new screening area, lowered turnaround times for lab results, and improved the isolation unit to enhance safety and care delivery.

Additionally, they trained and hired additional staff for infection prevention and control, so the hospital could continue to provide care for pregnant women during outbreaks. Training in emergency obstetrics also was a focus, as many of the women who arrived at the hospital already were in serious conditions.

PIH teams also performed general maternity and psychosocial care, not only to help run the isolation unit, but also to establish a higher long-term standard of health care in Sierra Leone.

“When the outbreak was declared over we started to work on preparedness planning, so the hospital would be ready for future outbreaks of infectious disease,” Garde says.

Lasting model

Barrie said that work has continued.

“The model of care PIH implemented at Princess Christian was important for teaching clinical staff the skills needed to protect women during that time. It also went a long way in starting to build trust with women that a clinical facility is somewhere they can receive proper care,” he says. “The infection prevention control techniques PIH established are still in motion at Princess Christian’s delivery center. Those learns are still benefitting patients today. The government staff in Sierra Leone rotate around different hospitals as part of their job, so the learns at Princess Christian are also being shaped at other facilities around the country.” 

By 2016, when the outbreak began to subside, one of every 10 Ebola survivors in the Sierra Leone had been a PIH patient. Today, PIH continues work to lower Sierra Leone’s maternal mortality rate, with ongoing projects and improvements in collaboration with the Ministry of Health and Sanitation.

“If a patient needs an emergency delivery, we can put them on an ambulance, which wasn’t previously available, and they are treated by an obstetrics specialist,” says Marta Lado, an infectious disease specialist and chief medical officer for Partners In Health in Sierra Leone. “We have services mothers need for all types of deliveries.”

This time two years ago, Margaret had never heard of choriocarcinoma—cancer of the cervix and uterus. So when clinicians at Koidu Government Hospital (KGH), the Partners In Health-supported facility in Kono, Sierra Leone, diagnosed her with it in July 2018, she remembers feeling a wave of fearful confusion.

“I had no idea what was happening,” Margaret said. “None of my family or friends has had this sickness before. My mum thought I was going to die when they explained to her that it was cancer. When people in Sierra Leone have cancer, they rarely survive.”

Indeed, Margaret’s health was dire when she was readmitted at KGH in July 2018, five months after initially being treated at the hospital for a molar pregnancy (commonly a precursor to choriocarcinoma). Experiencing a fever and intense bleeding to the point of unconsciousness, Margaret was unable to walk, stand, or eat, and relied on the hospital’s blood bank and emergency blood donations from family members and KGH staff to stay alive.

“She bled two or three times a day. We needed to constantly replace her blood,” KGH midwife C.J. said. “Even maternal staff on the ward thought she might not make it.”

Clinicians had quickly discovered the cause of Margaret’s condition—a carcinoma, or cancerous growth, located in her cervix. After getting her bleeding under control, the KGH team turned to the larger problem: How could they treat this case, in a country where oncology care is nearly nonexistent?

“Very challenging” was how Dr. Marta Lado, chief medical officer for PIH-Sierra Leone, diplomatically described the current state of cancer care in Sierra Leone, where even basic health infrastructure is limited, at best. In partnership with the Ministry of Health, PIH is adding high-quality cancer care to its work strengthening Sierra Leone’s health care system, and is beginning to tackle the many challenges the country faces when it comes to oncology.

First of all, the diagnostic process is long and expensive, as samples and lab tests need to be sent to external private laboratories for analysis. If the result is cancer, a limited number of oncology drugs are available; Sierra Leone has no established national chemotherapy program. What’s more, most patients arrive at health facilities when their cancer is already advanced to a stage where palliative care is the only viable option, having held off going to see a doctor for fear of the cost of care and lack of access to nearby clinics or hospitals.

Another concern is that nurses and pharmacists don’t have formal training opportunities in cancer care, so many lack expertise in how to manipulate and administer oncology drugs. The country also has limited lab capabilities to properly diagnose cancer, and social support programs—which would help patients meet such needs as food, transportation, and housing—are rarely part of care.

All of these programs and resources are currently being planned for at KGH, which each month sees one or two patients arriving with any type of cancer—usually advanced stage lymphoma, leukemia, or, as in Margaret’s case, choriocarcinoma.

“At KGH, when we find a case that is an early stage and can benefit from treatment, we have been able to refer patients to PIH in Rwanda, or buy some chemo and administer it locally with the collaboration of a clinic in Freetown that has some trained and skilled staff,” Lado explained. “But honestly, these are very exceptional cases. We strongly believe that as we grow in our clinical care, we will start identifying more cancer cases in early stages; therefore, we need to start organizing the necessary care for them at KGH.”

Margaret was one of these exceptional cases—and one who helped set in motion the expansion of cancer care at KGH.

PIH-Sierra Leone’s supply chain team managed to secure a shipment of Methotrexate, the drug that could cure Margaret, from India. She began inpatient chemotherapy in August 2018, and by December was discharged, needing to come back to the hospital every three to four weeks for her next round of treatment.

“Margaret looks great now and is a joy to have around the ward,” said Isata Dumbuya, KGH’s maternity manager, last summer. “She likes making everyone laugh and is always trying to help with things.”

After a year of care, in August 2019, Margaret completed her full course of treatment, with the next step involving quarterly blood tests to monitor her health. Now, she is poised to become the first woman to survive chroriocarcinoma at KGH.

She won’t be the last, however. Because her case made Methotrexate available, two other women with choriocarcinoma are currently receiving treatment.

More patients will follow, Lado said. “At KGH we are working really hard to increase the standard of care for our patients, including setting up a basic protocol for chemotherapy. We have already started with choriocarcinoma, and care for Kaposi Sarcoma and some types of lymphomas in children will be developed this year.”

The aim too is to expand this care beyond KGH. “The government of Sierra Leone is extremely supportive with our programs and excited about all of our initiatives in Kono. Together, we are setting examples and role modelling, to give hope for a better health care system in the entire country,” Lado said.

At the center of this slow and steady progress at KGH and throughout Sierra Leone is Margaret. “She really has carved a path for others needing this care,” Dumbuya said.

Margaret herself may someday be providing it, as her experience as a patient has informed her future career goals. Determined to become a nurse, Margaret has returned to school with support from PIH, and on any given day can often be found in the KGH maternity ward offering moral support to patients.

“The doctors and nurses were encouraging, and my mum sees me now and she has good faith,” she said. “I want to get a job so I can be working and supporting my parents—I want to be a nurse. I like it at the ward; I want to be part of the KGH midwife team.”

University Hospital in Mirebalais, Haiti, received accreditation from an international oversight group this week, affirming that the hospital meets the highest global standards as a teaching institution—and causing Dr. Paul Farmer to reach for a seat. 

“There’s a Haitian expression—news that demands a chair,” said Farmer, Partners In Health co-founder and chief strategist. “Usually it’s bad news, but this is truly exceptional. I have no way to express my gratitude and admiration to the Zanmi Lasante team. They have been tireless.”

PIH was founded in Haiti more than 30 years ago and is known in Haiti as Zanmi Lasante. The team opened University Hospital in Mirebalais in 2013, in collaboration with Haiti’s Ministry of Health. The 300-bed teaching hospital is home to residency programs in internal and family medicine, pediatrics, surgery, obstetrics and gynecology, neurology, nurse anesthetists, and emergency medicine. 

ACGME-I, the international arm of the U.S.-based Accreditation Council for Graduate Medical Education, notified PIH of the institution’s accreditation this week, after a multi-year process and extensive analysis. University Hospital joins internationally accredited facilities in just seven other countries and is the first such facility in the Western Hemisphere, and the first in a low-income country.

Dr. Sterman Toussaint, director of medical education at University Hospital for Zanmi Lasante, emphasized that distinction.

“This is a big achievement,” he said. “Most of the time, institutions in high- and middle-income countries get access to accreditation—not institutions in low-income countries like Haiti. This is a reflection of the commitment of PIH and Zanmi Lasante to education.”

Toussaint noted that the accreditation application was due in September, during the height of recent political unrest in Haiti that essentially shut down the country.

“Despite all of that, we have been able to meet the standards,” he said. “PIH is committed to meeting the standards that everyone is meeting around the world.”

Dr. Edward Hundert, dean for medical education at Harvard Medical School and an advisor to PIH, praised the milestone.

“This achievement, of the internationally recognized highest standard for the educational programs at University Hospital, represents a truly wonderful validation of the years of hard work to build these programs, and of the outstanding quality of training that they represent,” he said. “This is exciting news not just for the hospital and the people who made it happen, but ultimately for all of the patients who will be cared for by the clinicians who train in these now ACGME-I accredited programs.”

Since the start of its medical education programs, Zanmi Lasante has graduated 123 residents, 98 percent of whom have remained to work in Haiti, including 58 percent at facilities supported by Zanmi Lasante. Another 116 residents are currently enrolled.

University Hospital's recognition this week is known as institutional accreditation. That process assessed the hospital's educational structure and setting, including everything from its educational mission to support for residents, committee oversight of educational programs, communication channels, patient-centered approach, and more. With that accreditation now in hand, the hospital team plans to apply in coming months for programmatic accreditation, which will more specifically assess medical education curriculum, faculty, and programs.   

Dr. Mary Clisbee, administrator for graduate medical education at University Hospital, said the accreditation overall could bring many benefits, including a greater ability to attract and retain physicians from Haiti and abroad, who are seeking residencies at an accredited hospital.

“Now we have hard evidence that our programs here meet the highest educational standards—what we hope is that this will help in retaining physicians that, in the past, we’ve lost to other countries,” she said. Additionally, physicians from “other countries will be able to come here and do rotations in our hospital, because those rotations will meet those standards. There are mutually beneficial results of those exchanges.”

ACGME-I provides accreditation services to graduate medical education programs and institutions outside the U.S., to improve health care in the countries it serves. Within the U.S., ACGME is the accrediting body for the vast majority of teaching hospitals.

“No credible American medical school or teaching hospital functions without it,” Farmer said. “A lot of people didn’t believe that (a facility in) Haiti could do this.”

The accreditation comes during an emotional time in Haiti, which just marked the 10^th year since the devastating earthquake of Jan. 12, 2010. University Hospital was built as a response to the earthquake and has since transformed health care for more than 1 million people across Haiti’s Central Plateau.

Farmer has been back and forth between Boston and Haiti over the past two weeks, speaking at commemoration ceremonies and sharing close, personal reflections with the Zanmi Lasante team.

“This is the best possible time for them to get that (accreditation) news,” he said.

Nearly seven years have passed since University Hospital in Mirebalais opened its doors and began transforming health care for more than one million people across Haiti's Central Plateau. Since March 2013, thousands of patients have had access to specialized care provided by clinicians working with Zanmi Lasante, as Partners In Health is known locally.

University Hospital has also been home to a growing medical education program, which has graduated 123 residents from a variety of specialties, including emergency medicine, surgery, and pediatrics, to add to the growing health care workforce in Haiti.

For a deeper dive into University Hospital's many accomplishments, check out the below image, a bird’s eye view of the campus. Hover over various sections to learn more about how hospital staff save lives every day by providing high-quality care to all patients, regardless of their income.

A Safe Haven for Mothers and Babies

When University Hospital opened in 2013, staff frequently saw full-term pregnant women sleeping overnight on cement sidewalks waiting for labor to begin. Many of them lived far from care and wanted to be near the hospital as their due date approached. Mothers of babies in the neonatal intensive care unit also slept outside to be available for feedings. These everyday scenes were a testament to the mothers’ determination to receive high-quality care for themselves and their newborns. They also were the inspiration for Kay Manmito, the maternal waiting home PIH built on the grounds of University Hospital.

Kay Manmito, or “Mother’s Home” in Haitian Creole, hosts women with complicated pregnancies and mothers of premature and NICU infants, guaranteeing them a facility-based birth and providing them with free prenatal care, meals, psychosocial support, and health education. In 2019, Kay Manmito housed 378 women so that they could receive the lifesaving, dignified care they needed, from blood pressure monitoring to C-sections. These patients were among the 15 women, on average, who delivered each day in the neighboring hospital’s maternity ward. For expectant mothers like Natacha Jean Paul, whose risky pregnancy brought her to the facility, “the care found here is priceless.”

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Training Haiti’s Next Generation of Clinicians

Brain drain has long stymied Haiti’s health care system. Doctors and nurses have historically had few options for specialized training within the country, and 80 percent of those who do train in Haiti leave within five years of graduation to practice abroad. The few clinicians with specialized training who remain in Haiti typically work in the capital of Port-au-Prince, far from where most patients—particularly the rural poor—can access care.

Medical education is integral to University Hospital, which was built as a teaching facility where Haitian clinicians could train in advanced specialties. Since opening, the hospital has begun offering residency programs in pediatrics, surgery, obstetrics and gynecology, neurology, nurse anesthesiology, and family, internal, and emergency medicine. To date, 123 clinicians have graduated from these programs, including the family medicine residency at PIH-supported St. Nicholas Hospital in St. Marc. Nearly 98 percent have chosen to work in Haiti and 60 percent with PIH-supported facilities, strengthening local health systems and caring for the most vulnerable patients.

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Cancer Care for All

Cancer affects people around the world proportionately, yet access to treatment is disproportionate, as lifesaving chemotherapy and surgeries are often unavailable or inaccessible in poor countries. University Hospital’s oncology department is changing this reality. There, patients from across Haiti receive the diagnoses, specialized care, and psychosocial support they need to survive.

Last year, University Hospital provided cancer treatment to 652 patients, the majority of them women with breast cancer. Cita Cherie* is one such patient: She has been receiving palliative chemotherapy for an advanced stage of breast cancer since the hospital opened. “If it were not for the Mirebalais hospital, I would not be alive today,” Cherie says. “I get all my medication for free, and when I come to the hospital, the doctors take really good care of me. They welcome me and they really value me.”

*Name has been changed at patient’s request.

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A Lifesaving Laboratory

The Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory, which PIH opened in 2016 across from University Hospital, has transformed health care for more than 1 million people. The 15,800-square-foot facility contains a clinical lab, a pathology lab, and Biosafety Level 2 and 3 laboratories, allowing staff to quickly and confidently diagnose and monitor infectious diseases and noncommunicable diseases like cancer. Highly trained technicians use advanced tools to improve the quality and timeliness of diagnostic services, meaning more patients receive better care in less time.

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Rehab for the Body, Mind, and Spirit

The Center of Excellence in Rehab and Education is the first public facility of its kind in Haiti. Here, patients from all walks of life come for outpatient physical therapy sessions, and a select few remain for extended stays to recover from trauma. They are stroke survivors and amputees, accident victims and people living with various forms of disability. They come for physical transformation, and often leave with a mental and emotional lift as well.

Staff and patients interact in one of the most pleasant spaces on the University Hospital campus. The L-shaped facility fills with natural light and bright tile mosaics decorate the walls, some with Haitian proverbs worked into the design. One, appropriately, says: “Piti piti zwazo fè nich li,” or “Little by little the bird builds its nest.”

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A Hub of Activity

University Hospital’s emergency department buzzes with activity. The suite of rooms rarely has an opening in its 16 beds, and two rows of chairs regularly fill with awaiting patients. Renovations are currently underway to expand the space to 36 beds and add on bathroom and shower facilities for patients on longer stays.

There are the typical emergencies, from broken bones and lacerations to heart attacks and motorcycle accidents. But there are just as many patients who come following acute episodes spurred from chronic illnesses, such as diabetes and heart failure.

The emergency department is often the first stop for University Hospital patients, who come from across the country at all times of day. They are greeted by seasoned clinicians and medical residents on rotation through the ward. So far, 16 emergency medicine residents have graduated from the program since its launch in 2013.

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A Cut Above the Rest

University Hospital is home to six state-of-the-art operating rooms, tucked away in the heart of the facility. In 2018 alone, surgeons performed 1,666 lifesaving cesarean sections and more than 600 other women's health-related procedures, such as hysterectomies.

The operating theater hosts routine surgeries, such as appendectomies and the removal of tumors. It has also hosted teams of international surgeons who, in collaboration with PIH clinicians, have conducted cleft palate repairs and—most impressive of all—the separation of conjoined twins.

So far, 19 surgical residents have entered University Hospital’s medical education program, six of whom have graduated so far.

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Always a Full House

In the pre-dawn hours, dozens of patients begin arriving at University Hospital’s main entrance to await their turn for high-quality care, at little or no cost. Last year, clinicians conducted nearly 182,290 outpatient visits and admitted close to 4,320 patients, many of whom had traveled hours to be seen by the facility’s top-notch doctors and nurses.

Once patients have registered and had their vitals taken, they sit in one of several waiting rooms for their name to be called. They come for consultations with maternal and mental health, dental services and radiology, oncology and chronic diseases. Those who are admitted may end up in a number of departments, such as labor and delivery, pediatrics, or isolation—should they be diagnosed with an infectious disease, such as multidrug-resistant tuberculosis.

Regardless of why they come, they will receive care within specialties that would otherwise be out of reach for the rural poor across Haiti.

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In the earthquake’s aftermath, the need to rebuild the medical education system was abundantly clear. In partnership with Haiti’s Ministry of Health, Zanmi Lasante—as Partners In Health is known in Haiti—opened University Hospital in Mirebalais, a 300-bed teaching hospital home to specialized care and medical residency programs. Here, Haitian doctors, nurses, and other health professionals provide high-quality care to those most in need and train the next generation of care providers.

In a country, where only one-third of physicians has the opportunity to do a residency program enabling them to train in a medical specialty, Zanmi Lasante is one of the major partners of the public sector in medical education and clinical care provision. It currently runs eight residency programs in the critical areas of internal and family medicine, pediatrics, surgery, obstetrics and gynecology, neurology, nurse anesthetists, and emergency medicine. 

Since the start of these programs, Zanmi Lasante has graduated 123 residents, 98 percent of whom have remained to work in Haiti, and 58 percent of them within  Zanmi Lasante-supported facilities. Another 116 residents are currently enrolled. Together, these highly trained professionals are bolstering Haiti’s health system, one new graduate at a time. 

Here are some of their stories: 

Dr. Philippe Dimitri Henrys grew up in Hinche, north of Mirebalais. He was in medical school in Port-au-Prince—sitting in class at the Université Notre Dame d’Haïti, where his father was a professor—when the earthquake struck.

He said that experience--helping the injured in neighborhoods near the school and witnessing firsthand the critical shortage or absence of emergency care in Haiti--played a huge role in his decision to become an emergency physician.

Henrys completed the three-year emergency medicine residency at University Hospital, and for the past five months has worked at PIH-supported St. Therese Hospital in Hinche. He is also the first president of the newly formed Haiti Society of Emergency Medicine and Disaster Medicine.

Henrys said he’s often reminded of the impact of Haiti’s growing emergency care network when he’s out and about in Hinche, at the market or on his way to work, and former patients approach to thank him for the care they received.

“They remind me they've been to the ER, and they really like the way I took care of them. And they appreciate it,” Henrys said. “And this is the kind of thing that really gives you a sense of purpose. To know what you're doing is useful, to know it helps people, to know it improves their daily life.”

Dr. Ketly Altenor grew up in the western coastal city of St. Marc, Haiti, and lost her father at 12 years old. Her mother supported the family as a street vendor. Despite her family’s poverty, Altenor excelled in school and earned a competitive spot at the state medical school. She was accepted into the first pediatrics residency at University Hospital after graduation.

“After my training I intend to return to work in my hometown, where there aren’t enough pediatricians,” Altenor said upon the start of her residency. “I will try to extend pediatric care to remote areas of the Artibonite region. I want to work in social medicine and really help people.”

Dr. Jean Joel Saint Hubert, of Aquin in southern Haiti, knew from the time he was 16 he wanted to be a doctor. 

“My aunt was a midwife and was always delivering babies,” he said. “There was a time when she was by herself...and she called me to help with a birth. There were two people in labor, and she told me to stay in the room, watch the patient, and call her when I saw the baby’s head. I saw the head and called her, but she couldn’t come because she was with the other patient. 

“So I put on gloves and held the baby’s head as the baby came out. The only thing I couldn’t do was cut the cord. Ever since then, everyone—even my friends—have called me ti doktè, which is Kreyòl for “little doctor.” 

Hubert decided to apply to the University Hospital medical residency program after attending an orientation about Zanmi Lasante. He liked how physicians talked about caring for patients and giving them attention. He has since taken that philosophy to heart.

“I’m not just a doctor,” he said. “I connect with my patients.”

Above: Nurse Nataly Cueva screens a student’s health at an elementary school in Carabayllo, Peru.

The team in Liberia parades through the streets of Harper in celebration of the fifth anniversary of PIH’s work in the country. In five years, we’ve transitioned from helping end the Ebola epidemic to strengthening Liberia’s overall health system, in partnership with the Ministry of Health.

Makatiso Seeiso holds the youngest of her six children, 2-year-old Banele, at PIH-supported Nkau Health Center in Mohale’s Hoek District, Lesotho. Banele receives care at the health center, where Seeiso has been bringing him since he was born.

Sophie Prowd was the first patient in PIH Liberia’s mental health program. After 15 years living on the street, Sophie began medication to treat her schizophrenia and is now thriving. She is pictured here in the window of her adoptive family’s restaurant, which she helps manage.

Dusk settles over Chiapas, Mexico.

Loune Viaud, executive director of Zanmi Lasante, as PIH is known in Haiti, briefed the United Nations Security Council on the challenges facing women and girls in Haiti. Her remarks on women’s unequal access to care, sexual and gender-based violence, and women’s political participation drew on PIH’s decades of work providing essential women’s health care.

Olivier Habimanaand (right) and Esperance Benemariya, oncology nurse educators at PIH-supported Butaro District Hospital in Rwanda, meet with Keza Solange, who is being treated for leukemia, and her mother in the pediatric ward.

William Owen, a driver and mechanic for PIH in Malawi, checks on the health of one of his team’s SUVs. Given the extreme remoteness of where PIH delivers health care, vehicles and their drivers prove essential to our work in Neno, Malawi — and all around the world.

A newborn rests and receives care at PIH-supported University Hospital in Mirebalais, Haiti, where there are pediatric and neonatal intensive care units.

Cylian Kargbo pays a visit to PIH-supported Lakka Hospital in Freetown, Sierra Leone, the country’s only facility offering treatment for multidrug-resistant tuberculosis (MDR-TB). Cylian received MDR-TB treatment at Lakka, made available through PIH and the Sierra Leonean government’s partnership, and survived the deadly disease. She is now a healthy 13-year-old, who dreams of being a lawyer.

At the United Nations General Assembly, PIH protested for “care not coverage.” In the face of proposals for a dollars-driven vision of universal health coverage, we led a demonstration to advocate for truly transformational universal health care that meets the health needs of all people, no matter where they live, what they make, or how complex the care they require.

A mural in Carabayllo, Peru, spreads the word of PIH’s work to end the country’s epidemic of tuberculosis and multidrug-resistant tuberculosis: “Health is the future for all. Stop tuberculosis.”

Co-founder Dr. Paul Farmer mentors clinicians and medical students on a visit to PIH-supported Koidu Government Hospital in Kono, Sierra Leone.

Rorisang Lerotholi, nurse-in-charge at PIH-supported Nkau Health Center in Mohale’s Hoek District, Lesotho, makes a home visit to 19-year-old Moselantja Ntaote and her 3-month-old son, Atlehang.

Drs. Jesica Anahí Ramírez Guzmán and Luis Javier Pola Sería celebrate after helping perform a C-section to deliver twin girls at the hospital in Jaltenango, in the southern state of Chiapas, Mexico. Thanks to PIH’s support, the hospital’s surgical capacity grew dramatically this year.

The class of 2019 at PIH-supported University of Global Health Equity in Rwanda celebrates earning a Master of Science in Global Health Delivery.

Nurse Esther Mahotiere makes a home visit to 2-year-old Senia Nard, a malnutrition patient in Mirebalais, Haiti.

Laboratory technicians and leaders from PIH-supported labs around the world gather for the third-annual global lab workshop at PIH’s Boston office.

At PIH-supported Lisungwi Community Hospital in Neno, Malawi, Clinical Officer Medson Boti sits with 7-year-old Kevini Jamu, who receives free, specialized care and medicines for sickle cell disease.

The biggest news for Partners In Health supporters in 2019 is clear: The appointment of our new CEO, Dr. Sheila Davis, and a feature about her incredible dedication to PIH over 10 years with the organization, topped the list of the most-read stories on our website this year. Davis took the CEO helm in June and already has begun realizing her inspiring vision, bringing leaders of all our teams together to foster collaboration with a new Leadership Council and ethic of “OnePIH.”

That shared mission is evident in all of the stories that caught readers' attention this year. From improving food access in Navajo Nation and welcoming the first class of medical students—two-thirds of which are women—at the University of Global Health Equity in Rwanda, to an Ebola survivor who’s thriving in Sierra Leone and quadruplets born at University Hospital in Mirebalais, Haiti, 2019 was a year to remember in all of the places where PIH works.  

 10. The Social Worker Extraordinaire Helping Breast Cancer Patients

Oldine Deshommes never has an empty office. The social worker is a go-to resource for every cancer patient passing through the double doors of the Roselene Jean Bosquet Center at University Hospital in Mirebalais, Haiti.

Deshommes has worked with Zanmi Lasante, as Partners In Health is known in Haiti, for nearly 10 years, starting shortly after the devastating Jan. 12, 2010, earthquake by providing psychosocial support to survivors living in temporary shelters in the capital, Port-au-Prince. Read more. 

9. Innovation: Contraception Program Empowers Women in Haiti

A recent PIH study at University Hospital in Mirebalais found that increasing contraceptive education for nurses and providing new mothers with more family planning access and options led to, “a great improvement in the percentage of women who had delivered in the maternity ward accepting a long-acting contraception method,” such as the Jadelle implant, which can be left in  a patient’s upper arm for five years. Read more. 

8. Celebrating Six Years of Accomplishments at University Hospital in Haiti

Six years have passed since University Hospital in Mirebalais opened its doors and began transforming health care across Haiti's Central Plateau. Since March 2013, thousands of patients have had access to specialized care provided by clinicians working with Zanmi Lasante, as Partners In Health is known locally. Read more and check out our interactive map of the hospital campus. 

7a. UGHE Welcomes Inaugural, Majority-Female Medical Class

The University of Global Health Equity, in the rural Butaro community in the mountains of northern Rwanda, made gender equity a priority in admissions, as part of efforts to increase the number of female doctors in Rwanda and beyond. The Class of 2025 is comprised of 20 women and 10 men, all from Rwanda—and all with personal experiences of inadequate health services that have inspired them to work toward positive change in their home country. Read more. 

7. 'We Get to Set the Tone': UGHE's First On-Campus Students Reflect on Landmark Year

The 24 students in the 2018-19, one-year Master of Science in Global Health Delivery program at the University of Global Health Equity, were the first class to live and study full-time on UGHE’s campus, formally inaugurated last January in northern Rwanda, about 80 miles north of Kigali. The class included students from 11 different countries. Read more. 

6. Ebola Survivor Fights Odds and Expands Her Family

Mariama Kamara felt suddenly unwell upon coming home to her daughter and grandson one evening in August 2016. After walking the familiar dusty road home from the diamond mine where the 43-year-old worked in Sierra Leone’s Kono District, she sat down in the kitchen with a worsening headache and nausea. The terrifying realization came to her as she listened to her family’s playful evening chatter—her symptoms pointed to Ebola. Read more. 

5. Need to Know: MUAC and Malnutrition

Spend a day at any Partners In Health site and there’s a good chance you’ll hear a phrase you’re unfamiliar with. Perhaps it’s a clunky acronym or polysyllabic drug name. But don’t worry: Keeping up with the ever-evolving world of global health is hard, even for insiders. In Need to Know, we cut through the complexity and deliver the most pertinent and interesting information on a single subject. Today, we fill you in on mid-upper arm circumference. Read more. 

4. Heart Patient, Advocate, and Soon-to-be-MD

Erneste Simpunga was diagnosed with rheumatic heart disease at age 16, in his home country of Rwanda. After a lengthy journey to surgery, he had two heart valves replaced in July 2008, at Brigham & Women’s Hospital in Boston. The experience inspired him to become a doctor, and on November 8, 2019, his 30^th birthday, he graduated from the University of Rwanda’s School of Medicine and Pharmacy. Read his personal account of his life story. 

3. Quadruplets Born at University Hospital Amidst Haiti Unrest

Madeleine and her husband, Stevenson (names changed for privacy), knew their family life was about to drastically change. They had seven children at home in Port-au-Prince, Haiti, and found out through an ultrasound that they were expecting triplets. But on a Saturday in late September, Madeleine was among thousands of Haitians across the country caught in life-threatening situations, as Haiti continued to be mired in protests that closed health facilities amid roadblocks, demonstrations and more. 

Yet Zanmi Lasante, as Partners In Health is known locally, has kept open all its clinics and hospitals at 12 sites across the lower Artibonite and Central Plateau, including University Hospital in Mirebalais. So when Madeleine and Stevenson, a 48 year-old shoe shiner, knew they needed to get to a hospital—and fast—a family member began asking around to see if University Hospital was still open. It was.

They just had to make it there. Read more.  

2. Innovative Solution to Food Deserts on Navajo Nation

On Navajo Nation, grocery stores are few and far between. Most people shop at gas stations and trading posts, where healthy foods are scarce. To widen access to fruits and vegetables—and improve overall health—Partners In Health (PIH) and its sister organization on Navajo Nation, Community Outreach and Patient Empowerment, launched an initiative to encourage shops to stock and sell produce and traditional Diné foods. Read more.

1a. Meet New CEO Dr. Sheila Davis: "Firefighter," HIV Advocate, and Nurse Poet

Dr. Sheila Davis knows about her reputation as a firefighter at Partners In Health. She led the organization’s Ebola response in West Africa from 2014 to 2016, then helped transition the teams to rebuilding the health systems in Liberia and Sierra Leone. She was the first one called to help the Haiti team when Hurricane Matthew wreaked havoc in Haiti in October 2016, and when flooding wiped away entire neighborhoods in Lima in the spring of 2017.

Each time, Davis was the steady hand that guided PIH through the literal, or figurative, storm. So it was no surprise that she emerged at the top of a global search for PIH’s next CEO, following the retirement of Dr. Gary Gottlieb at the end of June. Read her thoughts on her work as an HIV advocate, the positive response she’s received from nurses on her appointment as CEO, and her vision for PIH’s future.

1. Dr. Sheila Davis Named New CEO of Partners In Health

On June 5, Partners In Health named Dr. Sheila Davis as its new Chief Executive Officer. Formerly the Chief of Clinical Operations and Chief Nursing Officer, Dr. Davis succeeds Dr. Gary Gottlieb, who in the spring of 2018 informed the board of his intention to step down.  

“Thanks to her vast experience, strategic acumen, unwavering solidarity, and passionate commitment to our mission, Sheila is a brilliant choice to help the organization meet more of the needs of those we serve,” Dr. Gottlieb said. Read more. 

The past decade has seen a global watershed for the prevention of mother-to-child transmission of HIV. New international guidelines, stronger treatment regimens for pregnant women with HIV, and increasing adoption of lifelong HIV treatment for mothers all have combined to significantly lower HIV-related risks for women and children.

A study that Partners In Health supported in Rwanda has played a role in that global effort, providing strong data for use by countries around the world and continuing to have lifesaving impacts today.

The improvements in treatment and outcomes have been dramatic.

UNAIDS estimates, for example, that programs known as prevention of mother-to-child transmission, or PMTCT, prevented about 1.4 million potential HIV infections in children between 2010-18. Additionally, 80 percent of pregnant women with HIV worldwide were receiving antiretroviral therapy by 2017, up from about 50 percent in 2010.

But while clinicians and policymakers long have been guided by principles that increasing HIV treatment for pregnant women would reduce HIV transmission to their children, there was little hard data to support those principles, aside from controlled experiments.

That lack of implementation data created barriers for governments and organizations seeking to implement stronger policies and create large-scale improvements for the treatment of pregnant women with HIV.

PIH, known in Rwanda as Inshuti Mu Buzima, helped set the stage for those improvements with a study that examined the effectiveness of improved HIV treatment regimens for pregnant women. The study used routinely reported data from health facilities across the country, during a period from 2009-12.

Results were clear: The adoption of increased treatment “contributed to an immediate decrease in the rate of HIV transmission from mother to child,” and suggested “other countries may benefit from adopting” new guidelines, the study states.

In 2018, the PLOS ONE research journal published the study, titled: “The impact of ‘Option B’ on HIV transmission from mother to child in Rwanda: An interrupted time series analysis.” The study’s authors included Monique Abimpaye, formerly in the HIV division for the Rwanda Biomedical Center, and Catherine Kirk, director of maternal and child health for PIH in Rwanda.

Understanding the study’s impacts requires a quick look back at 2010, when Rwanda’s government implemented a WHO policy known as Option B. The policy essentially dictates pregnant women with HIV be given treatment known as “triple therapy,” which combines HIV drugs to boost effectiveness.

Prior to that implementation, many pregnant women in Rwanda and elsewhere were treated with a single-therapy regimen. Reasons included concerns about the availability and affordability of HIV medicines; thresholds of illness that women had to meet in order to access those medicines; and other factors. 

Those practices changed when Rwanda became one of the first countries in sub-Saharan Africa to implement Option B broadly at its health facilities.

“This was a big shift, to say that we have to prioritize the best available option,” Kirk said. “And clinical trials backed that up.”

The study also assessed Option B+, an additional WHO measure that stipulates women continue triple therapy for life, not just the period surrounding pregnancy and breastfeeding.

“We were curious about whether this triple therapy would reduce HIV transmission from mother to child,” Kirk said. “There had been clinical trials, but in real-world implementation, would we see that same impact?”

The answer was a strong affirmative. Across the country, Kirk said, Option B saw a high impact in reducing HIV transmission from mother to child.

The study also opened new doors for data collection and analysis in Rwanda. Abimpaye, in her role with the Rwanda Biomedical Center, knew that examining the impacts of Option B could enable the center to use data from Rwanda’s own health facilities, rather than data from outside the country.

“Part of the whole goal was to strengthen the HIV/AIDS Division (at the Biomedical Center) and the ability to use their own data for their own learning,” Kirk said.

The study’s impacts spread beyond Rwanda, as well, by adding to a growing body of clinical trials that have influenced international guidelines for treating pregnant women with HIV.

 From 2013 to 2015, WHO guidelines increasingly affirmed the importance of immediate and lifelong antiretroviral therapy for pregnant women with HIV, citing clinical trials in its recommendations. 

By 2017, when authors of the Rwanda study submitted their work to PLOS ONE, many of the 23 countries that UNAIDS had deemed a priority for preventing mother-to-child transmission of HIV were moving to implement WHO guidelines—and now had more concrete data to support those efforts. 

“These results suggest that the adoption of Option B/B+ contributed to a national decline in HIV transmission to children at six weeks following birth in Rwanda,” the study states. “These findings provide population-level evidence that support WHO recommendations for wide-scale adoption and implementation of Option B+ in sub-Saharan Africa.”

Dr. Linda Rimpel said two of the most important questions about lifesaving care—where are you when you have an emergency, and what can be done for you—are, all too often, much too closely connected.  

“Emergencies happen everywhere in the world, but they are not treated equally,” Rimpel, chief of emergency medicine at the Partners In Health-supported University Hospital in Mirebalais, Haiti, said this month.

In low- and middle-income countries such as Haiti, Rimpel said, there frequently is not enough health infrastructure or trained clinicians to provide high-quality emergency medicine and care. The emergency medicine shortfall in impoverished countries around the world creates a staggering, deadly gap: 54 percent of the entire, worldwide burden of disease could be treated with emergency care, potentially saving more than 24 million lives annually.

“There is a tremendous unmet need,” said Dr. Shada Rouhani, Partners In Health senior adviser for clinical operations. “Globally, emergency care capacity is very limited.”

Zanmi Lasante, as Partners In Health is known in Haiti, is doing pioneering work to bridge that gap in the Caribbean nation. Rimpel’s comments came at PIH’s offices in Boston, where she and other emergency physicians gathered for a weeklong training on how to teach and implement the World Health Organization’s Basic Emergency Care course. The goal is for participants to return home and train other physicians and nurses across Haiti in vital emergency care procedures, essentials, and techniques.

Haiti’s devastating 2010 earthquake, which killed nearly 300,000 people and injured hundreds of thousands more, made the need for emergency care in Haiti starkly clear. Zanmi Lasante opened University Hospital—a 300-bed teaching hospital known locally as Hôpital Universitaire de Mirebalais—in 2013, in partnership with Haiti’s Ministry of Health. One of the hospital’s primary goals was to strengthen emergency care in the country. When the hospital opened, there were no emergency doctors in the country, so most patients with emergency conditions were treated by providers who didn’t have emergency care expertise, often contributing to unnecessary deaths or disabilities.

To address this, PIH began the nation’s first emergency medicine residency in 2014.

In the five years since, 18 fully qualified emergency physicians have graduated from University Hospital, and now work at several hospitals around the country. Yet, Rimpel knows that to truly have an impact on emergency care in Haiti, training programs must expand beyond University Hospital. 

Across Haiti, PIH supports 15 health facilities—seven hospitals and eight health centers—while also providing emergency medicine training at facilities outside its network.

The need for good emergency care is driven by much more than trauma. In Haiti, nearly 80 percent of emergency patients are not suffering from traumatic injuries. Heart failure, hypertension, pneumonia, tuberculosis, cancer, and other ailments also can bring people to emergency departments.

At University Hospital, that means serving a population of more than 3 million people from the surrounding region, and beyond. Emergency patients needing specialized care often get referred to University Hospital from other health facilities across Haiti, and from the capital of Port-au-Prince, which itself has a metropolitan area of an additional 2.6 million.

One result of the large population and low number of hospitals is that emergency patients often first go to smaller, local facilities, where they should get the essential medications and procedures needed to stabilize them. However, most physicians and nurses in Haiti, particularly in such frontline facilities, have not had formal emergency care training. That means critically ill patients don’t always get the immediate stabilization they need to survive, let alone reach specialized care at University Hospital.

This is the need that Dr. Rimpel and her team are working to address. She and her colleagues will implement the WHO’s Basic Emergency Care course with front-line providers across the country, training them in the key skills they need to care for emergency patients.

It’s one part of a much larger solution. While the WHO course is only a week long, teaching it across Haiti will spread vital lessons and techniques that can immediately improve emergency care and save lives, with relatively low expenses or resources, while long-term training programs, like University Hospital’s emergency medicine residency, continue.

Implementing the WHO course also will help build emergency medicine advocacy and awareness in Haiti. That momentum already is growing: Rimpel said there’s a new Haiti Society of Emergency Medicine and Disaster Medicine—and its first president is an emergency doctor who trained at University Hospital.

Dr. Philippe Dimitri Henrys grew up in Hinche in central Haiti, north of Mirebalais. He was in medical school in Port-au-Prince—sitting in class at the Université Notre Dame d’Haïti, where his father was a professor—when the earthquake struck.

He said that experience, helping people outside the building, and witnessing firsthand the critical shortage or absence of emergency care in Haiti, played a huge role in his work to become an emergency physician.

Henrys completed the three-year emergency medicine residency at University Hospital, and for the past five months has worked at PIH-supported St. Therese Hospital in Hinche.

Henrys said he’s often reminded of the impacts of Haiti’s growing emergency care network when he’s out and about in Hinche, at the market or on his way to work, and former patients approach to thank him for the care they received.

“They remind me they've been to the ER and they really like the way I took care of them and they appreciate it,” Henrys said. “And this is the kind of thing that really gives you a sense of purpose. To know what you're doing is useful, to know it helps people, to know it improves their daily life.”

Habibatu arrives at work by motorbike, the most common form of transportation in this part of Liberia. The ride from her house takes about 15 minutes over bumpy, dirt roads.

Like all visitors to the health center, Habibatu first passes through triage. Because of the deadly Ebola outbreak that began in 2014, triage centers have been installed at health facilities throughout the country to identify suspected cases of diseases with epidemic potential.

Her temperature today is 98.2 degrees. With no fever and no infectious symptoms, Habibatu is cleared for work. She takes all triage requirements, such as hand washing, very seriously. She remembers what it was like to work at Pleebo during the time of Ebola.

She starts the day by counting her stocks of emergency obstetric medications and sterile delivery supplies. As one of two midwives on duty today, she has to be prepared for whomever walks through the door.

Prenatal clinic is held Mondays, Wednesdays, and Fridays from 8 a.m. to 7 p.m. On average, Habibatu sees 50 pregnant patients and attends to at least two deliveries per day.

Habibatu’s first patient of the day is Betty, a first-time mother who is 30 weeks pregnant.

Betty has always been small, and with a height of 4'2”, her short stature may contribute to complications during childbirth. Here, Habibatu measures Betty’s fundal height, or the size and growth of her uterus, to track fetal development.

Measuring the fetal heart rate. At 148 beats per minute, everything is right on target.

Given Betty’s height, Habibatu recommends consultation with a PIH obstetrician at the high-risk pregnancy clinic. Offered once a week at Pleebo Health Center, the high-risk clinic brings specialized maternity care to patients in their home communities.

During a gap between patient visits, Habibatu prepares for her next appointment. She also takes this time to eat. Today’s lunch is shortbread and milk, a common Liberian meal.

After lunch, Habibatu performs an ultrasound on a patient complaining of stomach pains.

Turns out, those stomach pains were more than just cramps — her patient is in labor. Here, Habibatu prepares for delivery with the assistance of her co-midwife, Sophie Chea. It’s a boy!

On April 10, 2019, her patient, Katrin*, safely gave birth to an 8.6-pound baby boy. Here, Habibatu shows Augustine Saylee, a student nurse midwife, the importance of immediate skin-to-skin contact between baby and mom. *Name changed for privacy

Sophie applies antibiotic ointment for Katrin’s son to prevent common newborn eye infections.

After delivery, Habibatu and Augustine escort Katrin to the three-bed post-partum ward inside Pleebo Health Center. Habibatu is eagerly awaiting the opening of a new 19-bed maternity unit at Pleebo later this year.

Sophie is another of Pleebo’s most seasoned midwives. Last year, she, Habibatu, and four other midwives helped 866 women undergo safe and healthy deliveries. Today, Sophie will monitor Katrin’s vital signs, assess for excessive bleeding, counsel Katrin on post-partum family planning options, and schedule her for a post-partum check-up.

Katrin’s son will receive Vitamin K, umbilical cord care, and his first doses of BCG and polio vaccines as part of the comprehensive routine newborn care offered at Pleebo.

While Liberia has the 7th highest maternal mortality rate in the world, we are proud to say Katrin will not be part of this statistic. There was not a single maternal death at Pleebo Health Center in 2018.

Habibatu admires the construction of the new Pleebo maternity ward, where she and fellow midwives will be able to help more women give birth safely and return home with healthy newborns.

Help a poor woman stay in school, a recent study found, and her children are more likely to survive.

Help a mother earn a couple extra dollars, and her kids will get a better education.

Give a woman a loan and, more than a man, she tends to repay it.

Help her secure rights to her land, and domestic harmony increases. 

Conversely, let a mother suffer depression and family members are liable to go hungry.

Let a mother die soon after giving birth and her child is probably going to pass away within a month.

Empowering marginalized women is of course a fundamentally good thing to do. Gender equity gives women the rights they deserve. At least since 1990, when Amartya Sen published his landmark essay “Missing Women,” about how discrimination leads to tens of millions of premature deaths, aid and development organizations have pushed to ensure that women get a fair shake.

What has become especially clear in the last decade or so is that helping marginalized women leads to disproportionately good things. Women, more than men, tend to pay forward investments in their well-being—a truth variously dubbed “the double X solution,” or “the girl effect,” or a “double dividend.”

“More and more, the most influential scholars of development and public health—including Sen and (Larry) Summers, Joseph Stiglitz, Jeffrey Sachs, and Dr. Paul Farmer—are calling for much greater attention to women in development,” wrote Nicholas Kristof and Sheryl WuDunn in their 2010 bestseller Half the Sky. Now everywhere, from universities to Goldman Sachs and tiny charities to the United Nations, women’s development is seen as a centerpiece, if not the key, to society’s development.

The movement isn't without drawbacks. It has popularized at least one boosterish, sourceless "ghost statistic," as The New Yorker noted earlier this year, and encouraged some organizations to throw a few bucks in the laps of superwomen, sit back, and wait for them to solve the problems of the world. 

Partners In Health, with its social justice roots, takes a more active approach.

“We’re probably one of the largest employers of women in a lot of the places we work,” says PIH CEO Dr. Sheila Davis.

From the hilly slums of Lima, Peru, to the wooded townships of Siberia, Russia, PIH employs thousands of women, in positions ranging from community health workers to nurses and doctors. The women help heal the sick, but they also do more. Local staff in Chiapas, Mexico, for example, showed a whole town that a woman’s work is not just in the home, paving the way for other women to get jobs.

PIH clinicians consult, diagnose, and treat a lot of women, as well.

“Maternal health is a major focus in many of our sites,” says Davis.

In all 11 countries that PIH supports, local staff help women get prenatal check-ups and medication to prevent mother-to-child transmission of HIV, if needed. In Lesotho, Sierra Leone, and elsewhere, PIH has built waiting homes near health clinics, so pregnant women who live far away can rest easy before going into labor. When it comes to delivery, women have access to trained midwives and, if complications arise, they are referred to a nearby facility for life-saving procedures such as cesarean sections. Afterward, women are able to return home to care for their families.

Many other programs address important issues. PIH cares for women with mental health and other non-communicable diseases, and helps women plan whether and when they have children. In Haiti and Rwanda, PIH offers oncology care for women with breast cancer, including mastectomies and chemotherapy treatment. Midwives like Gladys not only deliver babies, they defend women and girls against systemic cruelty and violence, and PIH leaders take these issues all the way to the UN Security Council. 

Everywhere they work, PIH staff are committed to keeping women healthy—in part because strong women tend to make everyone stronger; in part because equity demands it. 

This story was originally published in November 2016. It has been updated with new information and context. 

In Haiti, one in five children is malnourished and faces physical and cognitive stunting. Severe malnutrition is a life-threatening condition and, when not addressed aggressively, is a leading cause of death for children under 5 in Haiti, and all around the world.

To tackle this problem, staff across 12 hospitals and clinics working with Zanmi Lasante, as Partners In Health is known in Haiti,  distribute a fortified, peanut-based food supplement called Nourimanba to families of children diagnosed with malnutrition. By eating several servings of protein- and vitamin-rich Nourimanba each day in addition to their meals, children quickly gain weight and grow inches within weeks of starting treatment. Last year alone, 8,500 children were treated for malnutrition at PIH-supported facilities.

Nourimanba is produced in a state-of-the-art PIH facility that employs more than 50 people in rural Haiti to turn the crops of local peanut farmers into 120 metric tons per year of the lifesaving supplement, which staff refer to as medicine. In this way, Nourimanba not only helps malnourished children recover, but it also stimulates the local economy by producing local jobs and larger markets for peanut farmers, thereby tackling the root cause of malnutrition: poverty.

When a young pregnant woman was rushed into the maternity ward at PIH-supported Koidu Government Hospital (KGH) in Kono, Sierra Leone, Isata Dumbuya, head of reproductive, maternal, neonatal, and child health, recognized the look of anguish on her team’s faces. The woman was in critical condition, suffering from pre-eclampsia. Had she visited the hospital earlier in her pregnancy, for prenatal care, she likely would have been bound for a safe delivery. But with just days until labor, her long untreated condition threatened her and her baby’s lives.

Such a dire case is all too common at KGH. Dumbuya often compares her experiences as a nurse-midwife in the United Kingdom versus Sierra Leone, where she was born and where she began working in June 2018. In 19 years delivering babies in the U.K., Dumbuya witnessed one woman go into pre-eclampsia shock. At KGH, this is a pregnancy complication that she and her team combat weekly — often when it’s already too late.

“It’s horrible to watch when you know you can’t do anything else for a patient,” Dumbuya said. “Young girls in particular tend to have eclampsia fits, and sadly these are the most likely to deliver babies at home. A girl recently had a stroke due to an eclampsia fit and now is frozen down her left side.”

Over the past year, Dumbuya has discussed at length with her fellow clinicians why so many pregnant women seek care too late. “In many instances, patients seek help from local community healers before coming to the hospital, simply due to lack of transport or understanding what care is available,” she explained.

These discussions revealed that seeking care too late wasn’t just a maternal health issue; it was a recurring theme across all patients. Hospital data backs up Dumbuya and her colleagues’ experiences: KGH’s emergency ward, for example, has admitted more than 650 patients since opening in May, highlighting the urgency of the medical conditions that many patients are arriving with.

Determined to further understand and transform this reality, Dumbuya formed a community outreach team of six clinicians from KGH and nearby PIH-supported Wellbody Clinic. The team would travel to all of the 14 chiefdoms in Kono District to make known the critical care and services at KGH and Wellbody, and to empower community members to help one another make safer health care choices. Dumbuya emphasized communication with not only families and local clinicians, but in particular chiefs and other community leaders.

“We needed to go out there and have a dialogue with people who have sway in the community,” Dumbuya said. “To explain: this is what happens to patients, this is why, and this is how you can help us save more lives. We wanted to give leaders a sense of responsibility and ability to help. They have a crucial role to play in helping their population make the healthiest choices possible.”

This approach has already begun to pay off. Since the outreach team began their visits to chiefdoms throughout Kono, spreading information and partnering with key local leaders, staff have been admitting patients from parts of Kono they’ve never seen represented at either facility. And for Dumbuya and her team, the number of lifesaving C-sections performed at KGH continues to steadily increase.

Below, join Dumbuya and the team on one of their outreach visits, and see what a day in the life promoting health equity looks like.

Leaving early on a cloudy Wednesday morning, the team bundled into PIH vans, ready for the three-hour journey from KGH to Kainkordu, Soa Chiefdom. The further out of Koidu — Kono’s capital, where KGH is located — they drove, the more difficult the roads became to navigate. The vehicles struggled through the muddy sludge typical of a road in rural Sierra Leone during rainy season, and one became wedged in a ditch. Dumbuya sighed and envisioned how pregnant women must feel being jostled on treacherous roads in an ambulance or on the back of a motorbike, uncertain of the care available at the end of their journey.

Upon arriving in Kainkordu, the team gathered in the community’s central building, regularly used for events, to discuss their presentation and prepare to welcome 30 guests from across Soa Chiefdom. The list of attendees ranged from paramount village chiefs, to police officers, to clinicians from local village clinics.

Dumbuya kicked off the team’s presentation, providing a broad overview of why early patient referrals are crucial; what happens when symptoms go unchecked and undiagnosed; and why prescribed medicines are so important, as opposed to traditional medicines that can cause irreparable damage to the body. She concluded by talking about the importance of blood donations, relieving attendees’ concerns by stating boldly that she regularly gives blood and is “still standing.”

Boyama Gladys Katingor, head midwife at Wellbody Clinic, next gave a rousing speech about the sense of empowerment that the clinic’s birth waiting home provides women. She emphasized the risk that women face when travelling along bad roads while in labor and described the nurturing care available at the birth waiting home.

Sister Jenneh Dakowah, midwife at Wellbody Clinic, then outlined the importance of pre- and postnatal care. And echoing Katingor, she emphasized the importance of partner involvement during a woman’s pregnancy and the crucial role men should play throughout. Dakowah also discussed other services available at Wellbody, from nutrition support and blood pressure monitoring, to malaria, worms prevention, and childhood immunizations.

Extending beyond maternal health care, Doris Miatta Komba, a nurse at KGH, spoke about the twice weekly noncommunicable diseases (NCDs) clinic available at the hospital, which has treated more than 2,500 patients with hypertension, diabetes, hepatitis, and other NCDs since opening in late 2018.

Closing the presentation, Mary Cabo and Hawa Musa, both mental health community health workers based out of KGH, dismantled myths and stigma surrounding mental illness. They explained that mental health is just like physical health and that effective care is possible for mental health conditions. They also encouraged the group to support members of their community in seeking care.

After listening closely to each presentation, attendees had the floor for questions and comments.

The maternal health care information prompted a resounding agreement from the group: Pregnant women should be referred to KGH and Wellbody if the local clinics are not able to provide effective medicine and trained clinical care.

Many in attendance were impressed to hear that extreme sickness wasn’t a prerequisite for a visit to a health facility ;  they could go to a facility for a checkup before their health became critical. They were also relieved to hear that those struggling with mental health conditions could become well again . Some even mentioned people they knew who might benefit from treatment.

In response to the poor road conditions that make it difficult for ambulances to get to patients, the group debated cracking up rocks to cover some of the worst potholes along the road, as a temporary measure to help patients’ passage to KGH and Wellbody.

As questions were asked and answered, and conversation continued, food was provided for anyone who wanted to join the event. This drew a slightly younger crowd.

At the end of the day, the outreach team said their goodbyes and thanked everyone for their time. They clambered back into the vans for the journey back to Koidu and for a reflection on the visit.

Dumbuya noted a trend: There hadn’t yet been an outreach visit where attendees didn’t ask for PIH’s help building better local clinics closer to the villages. In the face of continuing need, however, the team chatted excitedly about the engagement they received from community leadership.

“The community leaders have a crucial role to play in helping their population make the healthiest choices possible,” Dumbuya said. “My only regret is we couldn’t do this work sooner, and we can’t do more because of the roads.”

In August 2018, 17-year-old Isata Biango welcomed her triplets, Sarah, Caleb, and Isaiah Biango , into the world at PIH-supported Wellbody Clinic in Kono, Sierra Leone. The birth was a joy and relief not just for Biango , but also for the midwife and traditional birth attendant who assisted her. The staff met the potential risks of the birth—Biango 's young age, her first pregnancy, and delivering multiples—with consistent, high-quality maternal care, including prenatal care at Wellbody's birth waiting home. Biango stayed at the birth waiting home for the month leading up to her due date, receiving consistent care, monitoring, and meals, and ensuring that she would be at the facility when time to deliver.

As a result, the new mother and her three babies left Wellbody safe and healthy, a testament to PIH and the Sierra Leonean government’s joint investments in and improvements to health care in the world’s most dangerous place to be pregnant. A woman in Sierra Leone’s lifetime risk of dying in pregnancy or childbirth is 1 in 17—compared to 1 in 3,800 for women in the United States.

Eight months later, as the family made routine visits to Wellbody for the triplets’ checkups, clinicians diagnosed them with moderate acute malnutrition (MAM)—a condition that, if left untreated, could stunt Sarah, Caleb, and Isaiah’s growth and lifelong health.

Wellbody staff immediately enrolled the triplets in the clinic’s MAM program, which PIH had newly established to reach more children with the food and nutrition support necessary to prevent their malnutrition from becoming severe.

Biango took her children to nutrition sessions at Wellbody, where nurse and nutritionist Mariama Mansaray led her and other caregivers in preparing monthly rations of food combined with Bennimix, a locally available, highly nutritious supplement. Within six weeks of their fortified diet, the triplets gained an average of 15 percent in weight, and each grew nearly two inches.

Now healthy 16-month-olds on the move, Sarah, Caleb, and Isaiah continue receiving care at Wellbody. Biango takes them for regular checkups, during which clinicians monitor their growth and provide them Vitamin A and other supplements that protect their good health. Such care is allowing the triplets to continue growing stronger—and is a marker of their country’s health system following suit.

In the nearly 33 years since co-founding Partners In Health, Dr. Paul Farmer has gone from a medical student working in a one-room clinic in rural Haiti to a renowned infectious disease doctor, professor of medicine, and leader of one of the world’s most influential humanitarian organizations. Through all of this growth, for both him and PIH, he’s never stopped seeing patients: spending time by their bedsides, advising on their treatments, and doing whatever it takes to make them well again.

During visits to PIH-supported hospitals in 11 countries around the world, Farmer conducts rounds to help care for the sickest patients and mentor local clinicians and medical students. Below, accompany him on rounds at Koidu Government Hospital in the eastern Kono District of Sierra Leone, and see and listen to how he and the PIH team are delivering unprecedented, lifesaving health care.

A hospital reborn

PIH-supported Koidu Government Hospital (KGH) is Kono’s main facility providing secondary health care — from C-sections and other essential surgeries to treatment for complex illnesses and conditions, such as tuberculosis (TB) and heart failure. When the PIH team arrived at the height of the Ebola epidemic, in the fall of 2014, the hospital had been shuttered by Ebola, and several nursing assistants had just died of the disease.

Since PIH began improving the hospital’s clinical care and increasing community outreach, more people than ever before have visited the facility, which is a significant accomplishment given the extreme poverty and historical mistrust of the health care system among Kono’s 500,000 people. Last year, the hospital admitted nearly 3,000 inpatients and provided more than 4,700 outpatient visits.

Farmer was led through the hospital to consult on the staff’s toughest cases by Dr. Marta Patiño Rodríguez, KGH’s medical supervisor and a fellow infectious disease doctor.

Lifesaving triage

Their first stop was KGH’s newly opened adult emergency ward, where 67-year-old Isatu* had arrived in respiratory distress and soon fell unconscious. The emergency team had administered oxygen, placed her on a heart rate monitor, and obtained her history: she lives with congestive heart failure and ran out of the two-week supply of medication she had received at the hospital three weeks ago.

Alongside Rodríguez and Dr. Chiyembekezo Kachimanga, KGH’s head of noncommunicable disease care and a PIH veteran from Malawi, Farmer coached four young doctors and the ward’s two nurses through a physical exam of Isatu, and congratulated the staff on the care they had already delivered. “This is the first patient I’ve seen with the new triage system, and they just saved her life,” he marveled.

A quick physical revealed some swelling in Isatu’s legs and an enlarged spleen, likely the result of repeated bouts of malaria. But more importantly, it exposed the cracks persisting in the Sierra Leonean health care system — in this case, inadequate attention to community-based care and resupply of her medications.

“This is not your fault,” Dr. Farmer said to the team about the patient’s condition. “It’s a structural problem.” What was most needed was stronger follow-up at home to ensure Isatu could more easily refill her prescriptions, despite obstacles like poverty, distance, and a lack of transportation to the facility.

A mysterious TB case

A visit to 22-year-old Foday* in the male inpatient ward was next. Farmer took notes as Rodríguez summarized the case: based on a physical exam and ultrasounds, Foday presented a loss of appetite, inflammation around the lungs and in the knees, and abdominal pain and distension. Clinicians had tested him for TB using a GeneXpert machine — the most advanced diagnostic tool possible for such a case — but examination of sputum from his lungs had come back negative.

Still, TB was Farmer’s suspicion, though he listed a number of infections, malignancies, and inflammatory diseases that could also account for Foday’s signs and symptoms. He encouraged the staff to check Foday’s white blood cell count and run a few more lab tests before starting him on any intensive treatments.

“Where are our Rwandan ultrasound superstars?” he asked with a smile. One of his former students from Rwanda stepped forward with the requisite equipment. “This guy is the best,” he said of Dr. Nyimanzi Valens.

“The main problem in patients like this is delay in TB treatment, but I’m not positive he has TB,” he added to the others rounding with him. “We’ll get his social history, review his labs, and put it all together.”

Farmer headed to the laboratory, where he, Rodríguez, Lab Manager Musa Bangura, and KGH’s team of lab technicians examine blood, urine, stool, sputum, and pleural fluid samples from Foday.

Most samples tested normally, but the pleural fluid did not. Looking through a microscope, each clinician saw that the fluid surrounding Foday’s lungs had an elevated white blood cell count, signaling infection. Foday’s chest x-ray did not show the disease within the lungs. But extrapulmonary TB, or TB located outside of the lungs — difficult to diagnose even using GeneXpert — was their agreed upon diagnosis. The team could start Foday on TB medication.

“Missing atypical TB presentations constitutes a big crisis in this hospital and this country,” Farmer remarked. “Over-treating this disease is not going to be your problem for a while.”

Food as medicine

Indeed, another TB case was brought to Farmer back in the male inpatient ward. Moussa*, 50, was in critical condition: he was living with AIDS, TB, and chronic dysentery; had recently had a fever, diarrhea, and loss of appetite; and was suffering from the most severe wasting syndrome in the entire hospital. Though Rodríguez had started Moussa on antiretroviral therapy and TB medications weeks ago, his health had not begun to improve — a concerning sign.

“We should have some response,” Farmer said. That treatment wasn’t working could indicate several possibilities: that the patient was suffering from an additional “opportunistic infection,” wasn’t really taking his medications, or had some other serious health condition, like a malignancy.

Turning to the team of KGH’s current and future doctors, Farmer reminded them: “Common things are common. As a clinician, you look at the X-rays and lab data, look at the chart, and ask, ‘What could he have that’s so overwhelming?’”

The group’s next move would be to re-examine Moussa’s X-rays. But in the meantime, Farmer emphasized the importance of stimulating his appetite, as quickly as possible.

“What is the food you would most like to eat right now?” he asked Moussa, before turning back to the team of doctors and the ward’s nurses. “I would like rice, beans, or soup,” Moussa replied softly.

“Whenever a patient is wasting away in front of you, and he’s on therapy, he’s in a dangerous situation,” Farmer cautioned. Normally clinicians would insert a feeding tube, but Moussa was still able to eat on his own. Given that, Farmer said, “we do everything except break Sierra Leonean law” to make Moussa feel better.

Farmer asked staff to speak with the patient in Krio, the lingua franca, to determine what his favorite food might be, then go and find it for him as quickly as possible to begin to restore his appetite.

In the radiography department, the team pulled up Moussa’s X-rays, which Farmer said was “classic miliary film,” showing scattered opacities in each lung. “It’s still too classic a presentation of TB to change the treatment,” he said. It was possible that the medication just needed more time to take effect.

Common things are common. And in this case, starvation — an age-old barrier to health — was keeping Moussa’s condition from improving. Food would prove as important as any medication. Farmer advised to prioritize feeding, medicine checks, and an additional antibiotic. After three weeks, if Moussa did not begin to feel better, the team could consider a new diagnosis or treatment.

Farmer said Moussa reminded him of patients he used to see in Malawi, Rwanda, and Haiti, countries where PIH has provided support for twice as long as it has in Sierra Leone, where it began collaborating with the government in 2014 to battle the Ebola epidemic. “We don’t see that much anymore in those countries,” he said, “because of antiretrovirals, food support, and community health workers.”

Lessons from Haiti

Farmer’s last stop of the day was the women’s inpatient ward, where 47-year-old Marie* had been admitted three days earlier after experiencing a sudden onset of pain, weakness, and then paralysis in her legs. The doctor tapped Marie’s knees; there was no response. She was able to squeeze his hand, but said the numbness was climbing.

“Anybody who could walk a few days ago and now can’t, that’s pretty scary,” Farmer said. But it also felt familiar to him. A few years ago in Haiti, during an outbreak of the Zika virus, he saw many patients who experienced this same loss of sensation and sudden paralysis, characteristic of Guillain-Barré syndrome.

The team would have to rule out a tumor, and monitor the paralysis to ensure it wouldn’t reach Marie’s diaphragm, which would prevent her from breathing by herself and require a breathing machine — technology the hospital did not yet have. Confident that it was indeed Guillain-Barré, from which patients can recover, Farmer was mostly concerned about keeping Marie’s spirits up.

“I would spend a lot of time reassuring her,” Farmer said. “I know I would be terrified. What we have to do is make her feel assured that she’s going to make it.”

*Name has been changed for privacy.

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Following rigorous debates at September's United Nations General Assembly in New York City, and marking Universal Health Coverage Day on Dec. 12, Dr. Joia Mukherjee, PIH's chief medical officer, and Hani Termanini, PIH partnership strategy officer, describe the critical question facing all of us amid the ongoing fight for true universal health care.

Seventy-four years ago, at the end of World War II, the United Nations was born to foster international collaboration and prevent the recurrence of fascism epitomized by the Nazi government. The Peoples of the United Nations, represented by their leaders, drafted a document that sought a collective fight against the destructive forces of extreme nationalism, and warned against a “separate peace”—which could reflect a nationalist mentality of every country fending only for itself. The charter of the United Nations encouraged mutual interdependence and embodied an unwavering determination “to reaffirm faith in fundamental human rights, in the dignity and worth of the human person, in the equal rights of men and women and of nations large and small.”

At the end of September, the member states of the United Nations met at the UN General Assembly. Members held a summit on climate change and a high-level meeting on universal health coverage, addressing two of the most pressing issues of our time. These issues are fundamentally interrelated: Caring for our planet and for each other must be the task of our globalized world, the UN meetings suggested, particularly as we all work to ensure a better future for the next generation.

Yet, the 74^th session of the UN General Assembly was divided by two fairly dichotomous views, of both climate action and health care. One view promoted profit over regulation; nationalism over global collaboration; and a lack of recognition of basic human rights, including women’s sexual and reproductive rights, over the broad inclusion of all in the fruits of science. It is alarming in the 21st century to hear world leaders—such as the presidents of the United States and Brazil—promote, from the platform of the UN, the very policies and ideas the UN was created to combat. 

But this debate is not new.

At the 1978 Alma Ata conference, the international community pledged health for all by the year 2000.  Yet, these pledges were not backed up by political will or financing mechanisms. The promise of achieving universal health coverage was hamstrung by nihilism—and the result has been selective primary health care, with poor countries administering just small packages of what’s considered feasible. 

To fulfill the promise of health for all, international solidarity is an imperative."

We now are hearing this mindset again: Rather than fighting for universal health coverage that embodies the progressive realization of the right to health, world leaders are talking about “sets” of “essential” health interventions that impoverished countries can afford with their domestic resources. 

Accepting the narrow scope of health that is possible with domestic resources of impoverished countries obscures the cause of massive global inequality. That inequality is the result of historical and contemporary forces, from colonialism to neoliberal capitalism. The political rhetoric of U.S. President Donald Trump, Brazil President Jair Bolsonaro, and others, is only a visible fraction of a much deeper and more pernicious system. Nationalism—backed up by racism, xenophobia, and militarism, and the neoliberal capitalism that it champions—ensures that impoverished people and impoverished countries will remain poor and sick and that our earth’s ecosystem will continue to hurtle toward catastrophe.

Belief in such a system is openly expressed not only by right wing leaders but also by some academics, such as those who advocate for the teaching of medicine as an exclusively technical discipline, one devoid of understanding of social context or social justice as determinants of well-being. These nihilistic views serve a political ideology rooted in the defense of the unjust status quo, and are in direct conflict with those calling for a just and equitable society. A fight in which health professionals, closer than anyone to suffering, can turn the tide.

At Partners In Health, informed by decades of working hand-in-hand with communities and governments in some of the world’s most impoverished places to ensure that everyone has the right to quality health care, we have learned several critical lessons.

Care for people means care for Earth."

First, every person is a person—or “tout moun se moun”, as the saying goes in Haitian Kreyol. Health is a human right, and in today’s globalized world we all need to organize and engage in direct actions to denounce the forces of ill health and pronounce a stronger sense of global responsibility for respecting, protecting, and fulfilling the right to health.

Second, to fulfill the promise of health for all, international solidarity is an imperative. The limited health budgets of impoverished countries have external causes—from un-taxed resource extraction to neoliberal constraints on lending. We need to remind ourselves that today, and for centuries, Western countries have enriched themselves by extracting human and material resources from the very countries some now claim are “aid dependent.” Development aid given by rich countries to impoverished ones pales in comparison to the large and often illicit outflows of cash out of the global South.

Third, care for people means care for Earth. Walking in solidarity with people and governments on their journey toward health and well-being is intimately linked to achieving environmental justice. Rationalizing public spending, to invest in peace rather than war and to restore the dignity of our planet and its inhabitants, will reap dividends that could be channeled toward further investments in the economic and social advancement of all peoples.

The 74th UNGA meeting in September posed a historical question that requires a loud and clear answer: Do we want an interdependent, caring world, or one based on nationalism, extreme shortsightedness, and greed? We, the Peoples, have a choice to make and a decision to act upon.

Dr. Joia Mukherjee, MD, MPH: Chief Medical Officer at Partners In Health and Associate Professor in the Department of Global Health and Social Medicine at Harvard Medical School

Hani Termanini, MBA, MPA: Partnership Strategy Officer at Partners In Health

Spend a day at the Partners In Health-supported J.J. Dossen Hospital in Harper, Liberia—or in the homes and communities the hospital serves—and you’ll find mothers and babies enrolled in a vital program called kangaroo mother care (KMC).

Mothers like 22-year-old Cecile Johnson, and babies like her 10-week-old daughter, Sheba Nyemade. Sheba is Cecile’s fourth child. Her first three were born full-term, and now are 2, 3, and 5 years old. But with Sheba, Cecile needed an emergency cesarean section when she was just 28 weeks pregnant. She received the lifesaving care she needed, and baby Sheba was born Aug. 4 at J.J. Dossen, weighing 1.4 kg (2.2 pounds).

PIH’s care for the family has continued in the months since.

While kangaroo mother care has a light-hearted name, it’s a well-known approach that clinicians around the world use to decrease deaths of premature newborns, especially in countries where incubators and reliable electricity are hard to come by. Those conditions apply in Liberia, which has one of the world’s highest infant mortality rates: 62 deaths per 1,000 live births. That’s a stark comparison with rates in wealthier countries, such as the U.S., which sees about 4 newborn deaths per 1,000 live births.

KMC is an intervention following childbirth, in which health workers place a newborn on the mother’s chest for skin-to-skin contact. The direct contact promotes temperature regulation, early breastfeeding and mother-infant bonding. Clinicians recommend constant skin-to-skin contact for all infants born at a low weight. Premature births, like Sheba’s, are the cause of low birth weight about 15 percent of the time. In low-resource countries like Liberia, KMC also is recommended due to the unavailability of medical equipment, inadequate staffing of trained health workers, and unreliable utilities.

PIH Liberia provides KMC at J.J. Dossen Hospital and in the Maryland County communities it serves, with nurses providing care and follow-up directly in new mothers’ homes. Infants at the hospital are eligible for KMC if they have a birth weight of less than 1.8 kilograms (about 4 pounds).

Cecile began doing KMC while still at the hospital, after delivering Sheba. But with three other small children at home, when Sheba was discharged at a healthier weight, it was a better fit for Cecile to transition into PIH’s community KMC program.

She was able to do so with the help of community health worker Evelyn Toee. Evelyn has been with PIH since 2015, and was part of the first class of CHWs who PIH trained in Maryland County. She visits Cecile every Tuesday, to check on her, Sheba, and Cecile’s three other children. During each visit, Evelyn notes Sheba’s weight, makes sure Cecile has enough baby formula, and checks in with Cecile about how Sheba is doing, to see if additional support is needed. The results are evident: Sheba has been gaining weight and is continuing to receive care, such as immunizations, at J.J. Dossen.

PIH health workers began providing community-based KMC in August 2018 and have enrolled 56 babies since, all born with low weights. While four of those newborns failed to recover and two were lost to follow-up—meaning, clinicians lost contact with the family—42 of the newborns enrolled in KMC from the surrounding community graduated. Graduation from KMC means babies reached at least 3.5 kilograms (almost 8 pounds) in weight and received vaccinations at 10 weeks old. For a recent graduation, many families involved in community care gathered at the hospital to celebrate.

Here, learn more about KMC at J.J. Dossen Hospital and beyond, with responses compiled by PIH experts including Viola Karanja, deputy executive director for PIH in Liberia.

Why is kangaroo mother care (KMC) important?

Kangaroo care is a proven, important strategy to promote optimum growth and development for premature infants. The direct contact prompts the infant’s body to release hormones, specifically oxytocin, that relieve stress and stabilize body temperature, breathing rate, and heart rate. Providing kangaroo care in communities and homes also can shorten hospital stays for new mothers and babies.

How do you practice kangaroo care?

Nurses encourage mothers to start KMC very soon after birth, when a newborn meets the low-weight criteria. The infant is placed between the mother’s breasts, wearing only diapers, socks and a head cap. The baby’s head is turned to one side and slightly elevated, hips flexed and abducted—meaning, with legs spread—and arms well flexed. The baby lies stomach-down, its abdomen resting just above the mother’s stomach.

The baby is then wrapped in a warm, locally made KMC binder or blanket, around the mother. The mother then covers the baby with an extra blanket, and is able to move around or sleep as she chooses. The mother should carry her baby for as long as the baby can tolerate, removing the baby preferably only during diaper changes. The minimum duration is 60 minutes per session, during the first 12 weeks of life.

Estimating child mortality levels and trends is difficult. When do you know that kangaroo care is effective?

We know KMC is effective by setting criteria and monitoring outcomes.

As an example, we’ve enrolled 56 babies from J.J. Dossen, with low birth weights, into community-based KMC. The smallest baby in the program was enrolled at the hospital at 890 grams (less than 2 pounds), and discharged into community KMC at 1.2 kilograms (about 2.6 pounds). After four months in the community program, the baby graduated at 3.5 kilograms (almost 8 pounds).

A dedicated team of community health workers, nurses and a pediatrician monitored all 56 families, mostly through home visits. The team visited most families once a week after they left the hospital, weighing the baby each time and checking for warning signs of jaundice, poor feeding, cord infections, or sepsis. The team also provided ongoing mentorship in KMC and breastfeeding, along with social support such as new bed nets, mattresses, and blankets.

What happens as a result of effective kangaroo care?

Effective KMC strengthens bonds between the mother and her baby, improves the baby’s regulation of body temperature, and promotes weight gain. The baby’s risk of infection also decreases, and the baby becomes healthy, strong, and ready to be discharged home.

What is PIH doing to encourage KMC? How else does PIH support these families?

PIH Liberia has provided thorough, ongoing training for 10 nursing aides in the pediatric and obstetric wards at J.J. Dossen. The aides are the hospital’s KMC champions, and able to describe and explain KMC, help mothers begin KMC with their new babies, educate and counsel new mothers of preterm or low-weight babies, enroll newborns into KMC, mentor mothers on how to perform KMC independently, and teach mothers about healthy breastfeeding.

PIH Liberia also provides social support to mothers and families, including baby formula for mothers with low milk supplies, or for caregivers of premature babies whose mothers died in childbirth. Staff members also ensure that mothers are educated on family planning options, and able to make the best choices for themselves. PIH Liberia also encourages and supports teenage mothers who are interested in going back to school.

For Partners In Health staff, commitment to social justice isn’t just a job—it’s a passion. Ask any PIHer what they’re reading, listening to, or watching in their free time, and chances are they’ll make at least one recommendation related to the fight for basic human rights for all.

Below are some of these recommendations—the books, podcasts, and films that staff around the world say motivate and enlighten them most. Heading into the season of giving, and of holiday travel, we hope this list provides you company, insight, and inspiration.

The Divide: A Brief Guide to Global Inequality and its Solutions

Written by Jason Hickel

Jason Hickel’s The Divide: A Brief Guide to Global Inequality and its Solutions is the most readable, and indeed, eloquent analysis of the rise of global inequality, a damning critique of ill-thought foreign aid, and a stirring call to action. Every PIHer would be well advised to read it, and more than once.

- Dr. Paul Farmer, co-founder and chief strategist

And the Band Played On: Politics, People, and the AIDS Epidemic

Written by Randy Shilts

San Francisco journalist Randy Shilts wrote And the Band Played On in 1987 in the middle of the HIV epidemic in the United States. It outlines the political landscape at the time and provides historical insight into a very complex time in the U.S.  I lived through this time as a new HIV nurse and read this book right after it came out. Shilts gave me insight into what was happening behind the scenes and validated so much of what I was feeling. I recently re-read it, and it brought me back to that tumultuous time.

- Dr. Sheila Davis, chief executive officer

La Casa de los Espiritus (The House of the Spirits)

Written by Isabel Allende

I love reading novels, especially when they are historical. Isabel Allende, one of my favorite authors, always manages to make me binge read. Her first novel narrates the postcolonial story of Chile, with a mix of brave women, love, revolution, social class, and politics.

- Dr. Valeria Macias, executive director of Compañeros en Salud (PIH in Mexico)

"For Sama"

Directed by Waad al-Kateab and Edward Watts

"Injustice anywhere is a threat to justice everywhere." - Martin Luther King, Jr.

In "For Sama," al-Kateab records her life in Aleppo, Syria, documenting some of her major life milestones while her home city crumbles. The film is put together as a love letter from al-Kateab to her daughter, Sama.

"For Sama" is a re-humanizing love story that calls out on us to move away from our comfortable sidelines, join the struggle, and fight. Truly fight.

Whether in Aleppo, Syria or in El Paso, Texas, injustice has the same bitter taste. And whether it is for Sama al-Kateab, now 4, or for Jakelin Caal Maquin, always 7, it's about time for each of us and all of us in what King calls the "inescapable network of mutuality" to work alone and work together to make sure that justice is served.

- Hani Termanini, associate partnership strategy officer

Custer Died for Your Sins: An Indian Manifesto

Written by Vine Deloria, Jr.

The late Vine Deloria was able to walk in both worlds successfully, using his humor throughout his advocacy for American Indian rights and social justice. He was eloquently able to inform readers about still pertinent indigenous issues through his writing. While this book was published back in 1969, it is a must read or re-read for those wanting to understand indigenous issues and viewpoints.

- Nitumigaabow Champagne, executive director of COPE (PIH on Navajo Nation)
 

Democracy Now!

Hosted and produced by Amy Goodman

I listen to the Democracy Now! podcast every day. Amy Goodman is a fantastic reporter, with a great team providing the most progressive voice on Haiti, climate change, and global affairs.

- Dr. Joia Mukherjee, chief medical officer

American Street

Written by Ibi Zaboi

American Street is a beautiful novel by emerging Haitian-American author Ibi Zaboi, written from the perspective of a young Haitian girl, Fabiola Toussaint. Toussaint ends up immigrating by herself to live with her aunt and cousins in Detroit after her mother is detained at customs in New Jersey. It’s an intense plot with stark prose and some magical realism sprinkled in, and tackles some tough topics – culture shock, racism, substance abuse, gang violence, class oppression, and police brutality.

Fabiola’s voice never wavers in its truth, clarity, bravery, and humor. She and the book definitely inspired me to continue to seek out authors with backgrounds unlike my own, or who represent communities that don’t often have the chance to be heard.

- Maia Olsen, NCD Synergies program manager

We Should All Be Feminists

Written by Chimamanda Ngozi Adichie

My recommended reading is We Should All Be Feminists. The title says it all!

- Vicky Reed, director of nursing for PIH in Sierra Leone

Silvester Dambe said that when he first began visiting Keredonia Wilfred, she was so weak that she declined medicine for her HIV, thinking her recent diagnosis meant she had no chance of living.

The senior community health worker gradually convinced her to stay on antiretroviral therapy, though, telling her that it was not the end of her life, and that he would keep visiting her to provide access to medicine and care through his role with Partners In Health in southern Malawi. Dambe reassured Wilfred that if she kept up with treatment, she would have an excellent chance of staying healthy, for a long time to come.

That was 12 years ago.

He’s still visiting Wilfred today, at her family’s home high in the mountains surrounding Dambe Health Center in Malawi’s Neno District. During his visits, he now gets to watch Wilfred, 55, play with her three grandchildren. She has maintained her antiretroviral therapy and managed her HIV, which is no longer the specter it once was for her.

Lately, as Dambe strides up the steep hills in Ndoma Village toward Wilfred’s home, his focus has been helping the family through a different health concern. Malnutrition is a serious threat now and in coming months for the 140,000 people whom PIH serves across Neno, where a food crisis looms as many continue to suffer from harvests lost during Cyclone Idai last March.

The cyclone pummeled southeastern Africa, killing an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affecting 1 million; and destroying vital crops at the end of the rainy season, leaving farmers no opportunity to replant. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 across 15 of the country’s southern districts, including Neno.  

The Malawi government recently estimated that 1.1 million people would not be able to meet their food requirements through March 2020, when new harvests finally should ease the burden.  

Dambe is one of 96 community health workers (CHWs) on the front lines of the fight against malnutrition in the most mountainous, isolated part of Neno, with which he shares a name.

The 56-year-old has lived in the Dambe area all his life. He’s been a CHW since 2007, when PIH, known locally as Abwenzi Pa Za Umoyo, began partnering with the Malawi government and working in Neno.  

In addition to supervisory roles as a senior CHW, Dambe regularly visits 15 homes, including Wilfred’s. As he arrived at her home for a scheduled visit one afternoon in October, she was seated outside with her daughters, 19-year-old Sofia Gerald and 20-year-old Lusca Gerald. In Sofia's lap was her 2-year-old son, Samuel Peter Gerald.

Dambe keeps a close eye on Samuel Peter during his visits, making sure the toddler is staying healthy in the critical early years of childhood development. After chatting with the family and going through basic health checkups, Dambe uses an adjustable armband to measure Samuel Peter’s mid-upper-arm circumference, or MUAC, a standard gauge for malnutrition. Anything less than 12.5 centimeters (about 5 inches) appears in a red zone on the armband, signaling high risk.

Samuel Peter’s upper arm measures 15 centimeters (about 6 inches) on this day, though, appearing in the green zone on the armband and indicating adequate health. It’s positive news for the family, which has faced challenges growing food since Wilfred’s husband passed away about three years ago.

But if problems arise, additional health services are not far away. Their home is atop a ridge, and Dambe Health Center is visible atop another ridge, across a valley. It’s about a 40-minute walk or a 10-minute drive away. The health center serves more than 11,400 people across 18 villages in the region, and offers malnutrition clinics every Thursday.

James Lipenga, CHW site supervisor for the Dambe region, said only eight children younger than 5 were enrolled in the malnutrition clinic as of early October—a significant drop from previous years, and a testament to the dedicated work of CHWs like Silvester Dambe.

PIH in Malawi has adopted a household model for CHWs, meaning every household has a CHW assigned to it, who visits regularly and provides access to care. Lipenga said that in the Dambe region, malnutrition care includes screenings and checkups, such as the MUAC measurement. CHWs' work is designed around early detection, referral, and treatment, to prevent severe malnutrition and provide families with access to services such as clinical needs and social support programs.

When malnutrition cases arise, CHWs help families and young children access the clinic and other services at the health center. For severe cases, PIH staff at the health center refer and transport families to the PIH-supported Neno District Hospital, about a two-hour drive down steep, rugged dirt roads to central Neno.

Across Neno District, PIH's malnutrition program provides monitoring and lifesaving treatment for more than 2,400 children under 5 per year, as of 2017 data. 

It’s a ground-up, home-by-home system built on the foundation of CHWs, who provide vital, lifesaving care for their neighbors, in the communities where they live.

For Silvester Dambe, that used to mean a lot of walking. Before Dambe Health Center was built in 2016 and more CHWs joined the ranks, he served families in the large catchment area for Nsambe Health Center, as well as Dambe, requiring three-to-four-hour walks each way to reach homes. He covered that territory for nine years, including frequent visits to Wilfred, to enable her to maintain her HIV treatment and raise a family that continues to be healthy.

“That was how we developed a good relationship,” Dambe said, recalling long conversations about health, resources, and positivity.

The conversation on this particular day was warm, with the familiarity born of long friendships. As Dambe prepared to leave, with other visits on his schedule, their goodbyes were brief—he and Wilfred both knew Dambe would see her and her family again soon.

The hardest part about growing rice in a lush river valley in southeastern Rwanda, a dedicated group of farmers says, is “keeping the beds”—in other words, frequently yelling and waving to scare away flocks of hungry birds that descend on the paddies.

Farmers’ piercing calls create a steady background noise along this rural stretch of the Kadiridimba River, where rice paddies form a checkerboard across the flooded lowlands and—scavenging birds or not—an innovative agriculture program is changing the lives of 18 families with children affected by malnutrition.

The Kadiridimba is a major source of water for Kayonza District, and a major thoroughfare for agriculture in Rwinkwavu, a region in Kayonza where Partners In Health supports Rwinkwavu Hospital, strengthens the health system and provides health services in numerous communities. Last year, staff with PIH’s livelihood program successfully worked with the local government to dedicate one hectare of river-fed land—about 2 ½ acres—for a rice farming program. Parents of malnourished or diabetic children now work the one-hectare paddy and use the harvests for food, income and, potentially, growth of a small business.

Partners In Health has worked in Rwanda since 2005, and is known locally as Inshuti Mu Buzima. Kayonza is one of three districts in which PIH works, and across all of them, livelihood programs—formally called the Program on Social and Economic Rights, or POSER—are a key part of caring for people’s entire health needs, beyond clinical care.

Malnutrition care

Christian Mazimpaka, PIH’s clinical director for Kayonza District, said many people who receive health care and screenings from PIH are then connected with POSER programs because of malnutrition.

“At the hospital they get food, but when they go home, it is a problem,” he said. “These programs are to make sure after they are discharged, they can get food, and they are not coming back to the hospital.”

Clement Cyiza, a POSER program assistant, said PIH supports 800 households in Rwinkwavu with programs including agriculture training, direct food assistance, livestock, and more. Cyiza said those 800 households include more than 50 local community groups, in which neighboring families take on collaborative projects.   

Such as growing rice to produce additional food for their children.

Clementine Nyirashyirambere was one of five parents who sat on a thick bed of straw in their shared paddy on a sunny afternoon earlier this year, and talked about the program. She is a mother of six children, including two enrolled in PIH’s malnutrition program. She said PIH has provided health checkups and care for her family, direct food support along with the rice farming effort, additional training on how to grow better vegetables at home, and transportation for her children to visit Rwinkwavu Hospital.

And with harvests under their belts, she and her co-workers already were talking about expanding their sales. 

Food security

The parents’ success has come with a lot of dedication. They work in the rice paddy from 7 to 11 a.m. every weekday, learning daily lessons in the labor-intensive process. Beds of rice have to be moved as they grow, transplanted from one soggy patch to another over about three months, until they mature. Beds of rice that are ready for harvest are taller than waist-high. Empty beds that recently have been harvested are covered by thick layers of straw, heavy enough to sit on and walk across, until the next planting.

Florenti Rukiriza, a PIH agriculture facilitator and a father of four himself, has been guiding the new farmers along the way.

Rukiriza, 52, said he’s been farming rice “since before the genocide.” That’s a common marker of time in Rwanda, where the 1994 genocide against the Tutsis led to the deaths of 1 million people—nearly 20 percent of the country’s population at the time—and displaced millions more. 

Community empowerment and building health from the ground up, through programs such as communal rice farming, are a crucial part of Rwanda’s national revival in the 25 years since.

Rukiriza said before the program began, they surveyed community members to assess needs for seeds, land, and supplies—such as an irrigation pump for the Kadiridimba, which is heavily farmed and flows sluggishly through the valley.

After the first planting in August 2018, the group now is about to reap its fifth harvest, in late November. Members collected more than 2,100 kilograms of rice across four harvests. Each harvest bore about five sacks, each weighing 100 kilograms. Cyiza said each sack sold for about 30,000 Rwandan francs, or more than $32.

Altogether, that amounts to about 630,000 Rwandan francs, or $675. Divided among the 18 families in the program, that means each family gained 35,000 francs, about $38, over the year. In rural areas such as Rwinkwavu, that's more than enough to feed a family of five for a month.

Mazimpaka, the clinical director for Kayonza District, said those gains are translating directly to greater food security for people in PIH’s malnutrition programs across Rwanda. The rice farming program is part of a larger effort called All Mothers and Children Count, which includes a variety of maternal and child health initiatives, POSER programs, and more.

Child health

“When we started this project, we did a survey,” said Mazimpaka, who also is project manager for All Mothers and Children Count. “All the beneficiaries reported they only had food security for five months out of the year.”

That 2016 survey spanned 2,400 households, across the three districts—Kayonza and Kirehe in the southeast, Burera in the north—in which PIH works in Rwanda.

Since that time, Mazimpaka said, average food security for families surveyed has grown to eight months out of the year, rather than five.

That’s only a start, of course. But for parents including Cristine Mukabarisa, who has children in the Rwinkwavu malnutrition program and has been growing rice alongside Nyirashyirambere and others, the impacts have been very real.

She gave a simple description of how her children have been doing since the group began harvesting.

“Abana baraho,” she said in Kinyarwanda, as Cyiza translated. “(My) children are so good.”

In part as a response to this growing pressure on our systems and staff, PIH is crowdfunding the cost of six major equipment replacements or upgrades at PIH’s University Hospital in Mirebalais, Haiti (HUM). Dr. Christophe Millien, chair of the Obstetrics and Gynecology department at HUM sat down to explain the urgent need for equipment in his department.

While Dr. Millien focuses on the lifesaving power of ultrasound machines, PIH is crowdfunding the cost of six other major purchases, including: an electrosurgical machine, another anesthesia machine, patient monitors, replacement probes for the ultrasounds, and patient-return electrodes for electrosurgical machines.

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Watch Dr. Millien below as he walks us through the situation at hand:

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Most mornings on his way to work in Harper, Liberia, Dr. Jacquelin Pierre says he is met with a beautiful sight. As he climbs the hill above the ocean, sunlight glinting off the waves, a group of runners wearing brightly colored workout gear greets him. 

“Hey Doc,” they yell out, smiling and catching their breath. “We’re doing physical exercise,” they say. Sometimes they call out numbers. “95!” they call out. Or, “100!,” high fiving him as they run on.

Pierre is PIH’s noncommunicable diseases (NCD) program lead in Liberia, and among the runners are some of his diabetic patients. The numbers they yell out are their latest blood sugar readings, and they bring him joy. 

When Pierre arrived in Liberia’s Maryland County 15 months ago, many of the patients he saw at J.J. Dossen Hospital and Pleebo Health Center presented with both hypertension and sky-high blood sugar. Most didn't know what was wrong. Some even had blood sugar readings of more than 500—a life-threatening level that is considered a medical emergency. 

Complications from uncontrolled diabetes can quickly lead to heart disease, nerve damage, skin conditions, and damage to sight and hearing, particularly in Liberia, where awareness of diabetes is limited. “Sometimes you cannot imagine how a patient can live with such high blood sugar for a long time,” said Pierre.

Breaking down barriers to access

Liberia still lacks exact data on the prevalence of diabetes, but the rate has more than doubled across sub-Saharan Africa since 1980, triggered by sedentary lifestyle changes like greater access to cars and fast food. And diabetes care across the continent can be expensive. In parts of West Africa without access to free health care; the bill for glucose strips, a month’s supply of insulin, and a blood sugar monitor can easily total $300—a significant barrier to access for the vast majority of Liberians, 84 percent of whom lives below the poverty line of $1.25 per day. 

PIH has been partnering with Liberia’s Ministry of Health since 2014 to overhaul access to diabetes care and improve patient outcomes. The PIH approach hinges on a combination of building capacity at health facilities in conjunction with health education, access to medication, lifestyle changes, and support groups. Diagnosis and treatment is free of charge at Ministry of Health sites supported by PIH, such as at J.J. Dossen Hospital and Pleebo Health Center in Harper, where Pierre sees patients. As of late September, he said, there were already 1,166 patients enrolled in the NCD program.

“We all know that if we want to do something sustainable, the first thing to do is build capacity. We’re training young doctors and nurses in NCDs,” said Pierre, who previously rolled out PIH’s NCD program in Haiti in partnership with the ministry of health that saw an overall drop in mortality from complications from 27 percent to 6 percent. “That’s the same thing that my team and I at PIH, together with the ministry of health, are doing in Liberia.”

A patient leader for diabetes

The PIH team includes not only clinicians but patient leaders. Among them is Alexander Quaye, an associate professor of economics at Harper’s Tubman University, who was diagnosed with type 2 diabetes a year ago. Through a combination of diet, exercise, and medication, Quaye has seen his blood sugar level drop fivefold, from 541 to 111.

His story began in November 2018, when he was escorting another sick colleague to the hospital. But when he arrived, Dr. George Methodius, Maryland’s chief medical officer, took one look at Quaye and insisted he have his blood sugar level tested. He hadn’t been experiencing any symptoms, although with hindsight he remembers feeling tired.

“The nurse who did my sugar test was afraid. It was 541. The hospital gave me a bed and four IV lines,” said Quaye, who was more shocked than anyone. He had simply been expecting to drop off his colleague and head back to work.

At the NCD clinic the next morning, Pierre and the clinical team met with Quaye to discuss some ways he could adapt his diet to improve his health, integrating more fruits and vegetables into his daily meals. It seemed like Pierre was suggesting the impossible. Southeastern Liberia may be home to fertile land watered by the long rainy season, but few fruits or vegetables are farmed or readily available there.

“But doctor,” said Quaye, “how can I do that? Here in Harper we have nothing. It’s only rice every day. It seems like for me, diabetes is a very difficult disease to deal with, and I’m going to die.”

Together they came up with a plan to improve his diet. “It’s possible for you to get better, and we’ll take care of your disease together—not only us as health care providers, but with you,” Pierre assured him.

First up was breakfast. They replaced visits to cookshops—the popular roadside coffee shops that serve fried eggs and hot sugary donuts—with oatmeal and fresh milk. They added avocados, known in Liberia as butter pears, along with other fresh fruits and vegetables, such as seasonal mangos and juicy oranges. They adapted recipes to include less sugar, salt, and palm oil, and they replaced rice with the Ghanaian staple kenkey, which is pounded from maize and is widely available in the southeast. 

Now, Quaye hasn’t eaten rice for a year—an astonishing feat in a region where most people rely on rice and sauce several times a day. He regularly goes for long walks in the mornings, even in the rainy season, and encourages others in his community to get their blood sugar level tested, including his mother, who was also subsequently diagnosed with diabetes and learned to adapt the meals she cooks at home. He takes Metformin, a common medication for type 2 diabetes, twice daily, and he watches his blood sugar level like a hawk. 

“It is incredible how he has made himself healthy with what is available to eat in Harper,” said Pierre, who also oversees regular cooking workshops and patient support groups for patients diagnosed with diabetes in Harper. There, patients can also trade tips with others suffering from the same condition. 

“We’re doing integrative social medicine based on patient education,” Pierre said. “We do home visits to get an idea about patients’ economic status, how they live, and we take the time to educate them about how to use the minimum they have to adjust their diet to the disease they suffer from. That’s what we did for Alexander, it’s what we’re doing for all NCD patients, and it works.”

Opening health workers' eyes

The approach is impacting not only patients but also health workers, many of whom had had little access to information about diabetes until recently. 

Cyrus Randolph, a physician’s assistant, has been working with PIH and the ministry of health on the NCD program for the past two years. After overseeing the training of nurses and physician’s assistants at Pleebo Health Center, also in Maryland, he has seen a drop in the number of patients suffering from complications. 

Recently, he was thanked by the parents of one young patient who had no idea their daughter was sick. They didn’t realize that the reason she wasn’t doing well at school wasn’t an academic one. As it turned out, she had been going into diabetic ketoacidosis—a serious condition that requires immediate supportive care, including fluids and insulin. 

Since she was diagnosed with type 1 diabetes, she is suddenly excelling at school. “Her blood sugar is well controlled and she’s passing her exams,” Randolph said. “It’s wonderful to be able to help more patients like her.”

“Until recently, some health workers in Liberia had no idea about diabetes,” he said. “Now we have established protocols and are building a system for providing them support and hope.”

Sofiya Simoni said it took a lot of legwork to figure out why her son Kerefasi was suffering from fevers, stomachaches, and vomiting.  

Now 14 and in sixth grade, Kerefasi Wiliyamu began feeling those symptoms several years ago. He and his mother live in Masinde Village in southern Malawi, near the commercial city of Blantyre. The closest health center to their home is a facility named Mdeka, but when Simoni took Kerefasi there for tests, clinicians found no disease. Neither did staff at a private clinic they tried next.  

But when they visited Partners In Health-supported Zalewa Health Center—where tests again showed no malaria, no HIV—they were referred to Lisungwi Community Hospital, also PIH-supported. Simoni and her son had finally found a place that could answer their questions: PIH’s Advanced NCD Clinic.

The clinic is held weekly at the hospital and provides specialized, personal care for children and adults with advanced cases of non-communicable diseases, or NCDs, ranging from type 1 diabetes, sickle cell, heart problems and kidney failure to severe asthma, epilepsy, and more.  

For Kerefasi, the condition that had been keeping him out of school and significantly affecting his health was one that, in countries like the United States, would be much easier to diagnose: type 1 diabetes. But in Malawi’s rural, remote Neno District, accessing proper treatment and medicine for an NCD like type 1 diabetes can be challenging—which makes the specialized care that Kerefasi is now receiving all the more remarkable.  

PIH, known in Malawi as Abwenzi Pa Za Umoyo, started the Advanced NCD Clinic at Lisungwi in November 2018. PIH also offers the clinic weekly at Neno District Hospital and monthly at Matope Health Center, to reach as many as possible of the 140,000 people PIH serves across Neno’s rugged mountains and lowlands.  

Clinical officer Kenwood Kumwenda said more than 100 families are now enrolled at Lisungwi’s Advanced NCD Clinic, which sees about 20 families per week.  

“It was established because, initially, we only had IC3, which is Integrated Chronic Care Clinic, where we see NCD plus HIV (clients) together,” Kumwenda said. “But it was noted that there are some clients who are very sick, and they need advanced care. Because in IC3, for example, we can't do ultrasounds or other advanced things like electrocardiograms,” or closely monitor and adjust insulin for children with type 1 diabetes.   

On a hot, dry Thursday in October, Kerefasi and his mother made their third visit to the Advanced NCD Clinic. They first received a general checkup and consultation, as Kumwenda and clinical officer Medson Boti checked his vital signs and chatted with Kerefasi about how he had been feeling lately.  

Kerefasi and his mother said he was feeling good, much better than he’d been for some time, but a problem remained. Despite the insulin he’d been receiving at the clinic, his blood sugar levels weren’t dropping.  

Kumwenda later said that was because Kerefasi wasn’t getting as many meals as he needed, and skipping his insulin because of weakness he would feel after taking the medicine on an empty stomach.  

Food insecurity is all too common in Neno District, and the community around Lisungwi.  

“This is a rural community, and most of the people, they are poor, and they cannot afford the diabetic diet we advise, meaning three regular meals a day," Kumwenda said. “Most of them, they maybe afford one, and eat one meal per day, or two. So with diabetes, on insulin, that's a very big challenge. So they may end up opting not to give the insulin. Instead, they say, ‘I will give it when I have food.’” 

Taking insulin without eating can lead to dangerously low drops in blood sugar for people with diabetes. That compounds existing problems of malnutrition that, for many people in Malawi, will be especially dire in the months ahead.   

Last March, Cyclone Idai struck southeastern Africa and massively exacerbated an already heavy rainy season. The cyclone killed an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affected 1 million; and forced hundreds of thousands from their homes. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 others across 15 of the country’s southern districts, including Neno.  

Relief efforts have been ongoing, but the needs remain great. The Malawi government’s annual food security report, released in September, estimated that 1.1 million people across the country will not be able to meet their food requirements from October through March 2020, when new harvests finally will ease the burdens.  

Kumwenda said Kerefasi and his family could be a candidate for additional food support from PIH, through its Program on Social and Economic Rights, or POSER. The Advanced NCD Clinic provides POSER support to many of its patients, usually through cash for transportation costs, furthering PIH’s belief that social assistance is a critical part of medical care.    

“In this area, people have difficulties in accessing the health center, in terms of transport,” Kumwenda said. “Because they have to travel on foot. There's no—most of them, they don't have a means of transport. They don't have bikes or they don't have anything. So, they have to travel by foot.”  

Kumwenda said some patients travel more than 60 miles, each way, to reach the clinic.  

Simoni said she and Kerefasi had left their home at 6 a.m. that day, to reach the clinic by about 8 a.m. They took a bus part of the way, she said, and happened to catch a passing hospital vehicle that gave them a lift. Had they not caught that vehicle, they would have continued on the transportation regularly paid for by PIH.  

The ride was welcome on a hot day. October heat can be brutal in Neno, particularly in the lowland Lisungwi community, which doesn’t have the cooler mountain air found in the district’s higher elevations. On this Thursday, temperatures at Lisungwi topped 38 degrees Celsius, or about 100 degrees Fahrenheit.  

Despite all of those challenges—heat, distance, food insecurity, and failed diagnoses at several facilities—Kerefasi, finally, is feeling better. He said his favorite subject in school is English, and he likes to read, especially poetry. Simoni said they’d return to the clinic the following week, to keep more frequent checkups to monitor Kerefasi’s blood sugar.  

Kumwenda said that kind of improvement is his favorite thing about the Advanced NCD Clinic.  

“You know, in Malawi, when you talk of type 1 diabetes, everyone will say: ‘Who is going to manage this?’” Kumwenda said. “Even heart failures. Even chronic kidney disease—they are difficult to manage here.”  

Kumwenda said those difficulties gave him doubts, when he joined the clinic in September 2018, about whether they would be able to find success. He took the position not knowing whether they would actually be able to help the advanced NCD patients they were hoping to treat.  

Kumwenda, Boti, and all of PIH’s team in Malawi are steadily putting those doubts to rest.  

“What I most like most (is that) most of the patients, now, since we started, we are helping them,” Kumwenda said. “They are stable. They are going home, they are happy. They come here (and say), ‘I am fine now, I am able to walk.’ So I think this is very interesting to me.” 

In Sierra Leone, where extreme poverty means nearly half of families don’t have enough food on a daily basis, children are particularly vulnerable to malnutrition. The consequences of this lack of nutrition are staggering, and long-term. Nearly 40 percent of kids in Sierra Leone have suffered stunting, or impaired growth that can permanently damage cognition and overall health, limiting their potential and that of the country.

Partners In Health has been combating this injustice since 2014, when our partnership with the Sierra Leonean government began. In Kono District, clinicians at PIH-supported Wellbody Clinic have been treating young children for severe acute malnutrition (SAM) and have established a social support program that provides food assistance to families.

But this work to prevent the lifelong harms of malnutrition wasn’t reaching everyone truly in need. Some children were not fairing as badly, but still fell under the category of moderate acute malnutrition (MAM). They did not qualify for the SAM program, nor did clinicians want to see their conditions worsen.

In response to this critical gap, PIH established the MAM program this year. By providing treatment and nutrition support to more malnourished children and their families, clinicians are stopping this life-altering, potentially deadly condition in its tracks earlier, and saving and improving more lives throughout Kono.

Take a look at this photo essay to see how the new program works:

Each month at Wellbody Clinic, around 50 mothers and caregivers gather to prepare and share large quantities of highly nutritious food for their children diagnosed with moderate acute malnutrition. The clinic’s nutritionist guides the group, and all of the ingredients and tools are supplied by PIH.

The women work together to debone dried fish and measure out rice, which they will then cook over a fire.

They combine the fish and rice with Bennimix, a locally available food supplement. The three ingredients are ground together to create a large quantity of highly nutritious food. Each family takes home a share.

While the women cook, their children play together in the shade.

Families walk away from each cooking session with not only a month’s worth of therapeutic food for their infants, but also a greater sense of community.

In between the monthly cooking sessions, children receive regular checkups at the clinic, during which they are weighed in a bucket scale and measured to ensure that their healthy growth is on track.

They also receive regular home visits from PIH’s community health staff, such as John Suluku, an acute needs program officer and leader of the MAM program.

Lansana Sidibay, 18 months, steadily gained weight and grew after his mother, Fatmata Mansaray, enrolled him in the MAM program at Wellbody Clinic. Fatmata still makes Bennimix for Lansana, who is now a healthy and spunky toddler, and has taught family and neighborhood friends how to make the nutritional supplement for their children.

Loko Kallon, 13 months, also graduated from the program. After Loko lost her appetite and was running a fever, her mother, Finda Kallon (above right), took her to Wellbody and discovered she was suffering from malnutrition. Meals fortified with Bennimix, provided through PIH, allowed Loko to get to a healthy weight and regain her energy.

On Navajo Nation, grocery stores are few and far between. Most people shop at gas stations and trading posts, where healthy foods are scarce. To widen access to fruits and vegetables—and improve overall health—Partners In Health (PIH) and its sister organization on Navajo Nation, Community Outreach and Patient Empowerment, launched an initiative to encourage shops to stock and sell produce and traditional Diné foods.

Through the Healthy Navajo Stores Initiative, PIH is supporting shop owners with the technical assistance they need to source and stock healthy foods, plus supplying them with tools, from refrigerators to marketing materials, to promote their new inventory. As of this year, PIH has partnered with 31 convenience stores and trading posts to help them provide healthier options, as well as cooking demos to build community and customer engagement.

The initiative goes hand-in-hand with the Fruits and Vegetables Prescription program, through which more than half of health facilities serving Navajo Nation have provided families vouchers to buy produce and healthy Diné items. Together, the programs are helping both small businesses and families, and closing the loop on PIH's work to revitalize the food system on Navajo Nation.

Spend a day at any Partners In Health site and there’s a good chance you’ll hear a phrase you’re unfamiliar with. Perhaps it’s a clunky acronym or polysyllabic drug name. But don’t worry: Keeping up with the ever-evolving world of global health is hard, even for insiders. In Need to Know, we cut through the complexity and deliver the most pertinent and interesting information on a single subject. Today, we fill you in on mid-upper arm circumference.

What is it?

Mid-upper arm circumference, often shortened to MUAC, is a measurement that allows health workers to quickly determine if a patient is acutely malnourished. PIH, as well as many other organizations, measures the circumference of a patient’s arm at the midpoint between his or her shoulder and elbow.

Why is it important?

The burden of malnutrition is staggering. According to a series of articles in The Lancet, more than 3 million child deaths every year are associated with malnutrition. Put another way, nearly half of all children who die each year do so because they don’t have access to enough of the right food. Our health workers in Haiti, Malawi, Lesotho, and Rwanda, among other locations, encounter malnourished patients every day. MUAC provides a fast and effective screening method.

How do you make the measurement?

There are specific paper MUAC bands that are color-coded. If the girth of the patient's arm falls within the green part of the band, it indicates that the patient is not malnourished. A measurement that falls within the yellow part of the band indicates that the patient may be at risk of malnutrition. Lastly, the red portion of the band indicates that the patient is severely malnourished and at risk of death. Some bands include a fourth color, orange, which indicates the patient is moderately malnourished.

What happens after the measurement is taken?

Well, that depends on the measurement. Generally, if a child is malnourished, we provide treatment with ready-to-use therapeutic food, commonly known as RUTF. These foods are high in fat and protein and fortified with the vitamins and minerals necessary to treat severe acute malnutrition. A few weeks of treatment with RUTF can bring about significant improvements. PIH will often take steps to improve the long-term food security of patients’ families. This might include enrolling people in job training, delivering food assistance, or providing materials for farming.

Malnutrition is a complex problem. Is a paper arm band all you’re using in the fight against it?

Absolutely not. MUAC is an immensely helpful tool but it’s not foolproof. For instance, a simple arm measurement doesn’t tell us whether a patient has kwashiorkor, or protein malnutrition. Furthermore, the accuracy of MUAC diminishes as the child ages. That’s why we’re constantly devising and implementing new ways to alleviate the root causes of malnutrition and catch malnourished children earlier.

In Malawi, for instance, we conduct regular community malnutrition screenings to identify young patients who haven't been able to travel to clinics, which are sometimes hours away by foot from their family home. Meanwhile, in Haiti, we opened a facility in 2013 that has dramatically scaled up the production of Nourimanba, a ready-to-use therapeutic food made from locally grown peanuts. PIH produced 165,000 pounds of the nutritional supplement last year alone. MUAC is merely one part of a comprehensive strategy that helps us make proper diagnoses and act accordingly.

For more than 50 years, Community Health Representatives (CHRs) have formed the backbone of the Navajo Nation’s health system. 

Trained as nursing assistants, the corps of roughly 80 CHRs consult patients in their homes throughout the vast, largely rural Navajo Nation – some 27,000 square miles spanning portions of New Mexico, Utah, and Arizona. CHRs conduct health screenings and home safety assessments, help people access medical resources, conduct well baby checks with Public Health Nurses (PHNs), and work directly with patients to manage chronic conditions. 

In addition to the often long distances between patients and clinicians, CHRs are able to bridge linguistic and cultural divides—between the English and Diné (Navajo) languages, between science and spiritual beliefs, and between western and traditional medicine. 

In 2009, the Navajo Nation invited individuals affiliated with Brigham & Women’s Hospital and Partners In Health (PIH) to help better integrate CHRs into the health system through the Community Outreach and Patient Empowerment program, or COPE. Incorporating as a Native non-profit organization in 2014, COPE has worked with CHRs and the clinical facilities serving the Nation to better coordinate care, conduct training sessions, and develop a standardized suite of health promotion materials for use by CHRs during home visits with high-risk individuals. 

In 2014 and 2015, COPE staff surveyed CHRs about their perceptions of and experience with the intervention, and their findings, published in the journal BMC Public Health, point to a positive impact on clinic-community linkages. 

“We knew that CHRs themselves are in the best position to guide the program,” says Hannah Sehn, who has worked with CHRs as part of the COPE work over the past nine years and a co-author on the paper. “So rather than say, here are all the things that are wrong, we listened to them—we tried to see things from their perspective. And it’s really by implementing the suggestions they gave us that we’ve been able to strengthen their role.”

Information as power

One suggestion was to improve communication between CHRs and clinic staff, including by expanding access to patient data. Before COPE began working with the CHR program, CHRs weren’t able to access a patient’s electronic health record (EHR), which had limited their ability to document patient encounters. After COPE facilitated access to EHRs for several groups of CHRs, those groups reported better communication with clinicians and felt recognized by clinicians as part of their patients’ care team. 

COPE also sought to strengthen CHR-clinician relationships by organizing monthly training sessions led by clinicians. “For example, if the training was foot care, we’d have the podiatrist from the health facility lead the training,” says Olivia Muskett, a co-author on the paper who was a CHR before joining COPE staff as the Training & Outreach Specialist. “The CHRs can learn from the podiatrist’s expertise, while the podiatrist gets a better idea of the challenges in the community, the things CHRs are seeing day-to-day.”

Other efforts to strengthen community-clinic linkages include establishing consistent referral processes, enabling clinicians to refer patients to CHRs, and the coordination of case management meetings, where CHRs and other members of the care team, such as PHNs, come together to discuss mutual patients. COPE also supports joint home visits, giving CHRs an opportunity to build collaboration with clinicians, something they say enhanced their ability to address key health challenges, including type 2 diabetes.   

Rising concern about diabetes

Over the past several decades, diabetes has significantly increased among American Indians, and its rising prevalence owes in large part to low consumption of fresh fruits and vegetables and increased consumption of highly processed foods. It’s estimated that 1 in 3 individuals on Navajo Nation are now diabetic or pre-diabetic, and with more and more cases in their communities, CHRs have made the management of diabetes a focus of their work.    

Prior to partnering with COPE, CHRs say, they made their own training materials. But given their limited contact with clinicians, they couldn’t be sure that the messages they were sharing in their communities were consistent with the guidance patients were getting in health facilities.  

“CHRs told us they wanted health promotion materials that were Navajo specific,” adds Muskett, “particularly for individuals with uncontrolled diabetes.”

With that feedback, she says, COPE developed a flexible curriculum of modules for addressing diabetes that can be provided to CHRs in either printed format as flipcharts or on pre-configured tablets. Each module used a “motivational interviewing” approach, encouraging CHRs to explore how a patient feels about a given topic rather than offering unsolicited advice. 

As one CHR told a focus group, the motivational interviewing “taught us how to communicate with our patients, how to talk to them, to not just give [them] yes and no questions.” That led, in turn, to increased trust between patients and CHRs, some of whom reported spending home visits “just listening to patients express their emotions.” 

And that’s characteristic of the approach COPE takes to strengthening the role of CHRs, says Sehn. “We see that the answers lie within the community itself,” she says. “From its inception, this has been a community-driven process, and I think that’s why it worked so well.” 

“We are the ones who have to believe change is possible and work with patients to make healthy change a reality,” wrote members of the Gallup and Shiprock Navajo Nation CHR program in a 2011 article for the Journal of Ambulatory Care Management. With the new tools provided by the COPE program “and our many years of experience guiding us,” they added, “we know if we are persistent and believe it, we make a difference.”

Five years ago this fall, the governments of Liberia and Sierra Leone invited Partners In Health to help respond to the world’s worst Ebola epidemic. Although the organization had never responded to this type of public health emergency, PIH leaders knew they would join the fight and not only deal with the outbreak, but also stay for the long term to help rebuild the nations’ weak health systems. The goal was to better guarantee West Africans’ right to health, both immediately and into the future.

The primary reason Ebola ravaged West Africa and not Spain or the United States—where cases were found, but did not spread—is that Liberia and Sierra Leone lacked strong health systems. In Sierra Leone, for example, 7 million people are served by only 150 doctors. Compare this to the 7 million people in Massachusetts, who are served by more than 20,000 doctors. It then becomes easier to understand—but much harder to accept—why Ebola sickened 28,600 people and killed more than 11,000 people across West Africa.

When PIH arrived in Liberia and Sierra Leone in October 2014, clinicians and staff rapidly cared for the sick, accompanied survivors, and helped transform the health system so that—should Ebola return—the deadly virus would never again take such a heavy human toll. And while not perfect, PIH’s response was guided by the firm belief that everyone deserves the best care possible. 

Here are some of the ways in which PIH and local partners innovated to provide care in the midst of the epidemic:

1. First, care not containment

The Problem: Sierra Leone and Liberia did not have readily available infrastructure to house and care for a vast number of patients sick with Ebola, especially in remote, rural areas. Patients were often quarantined in locations where little to no care was provided. Meanwhile, other NGOs’ first order of operation was to build Ebola treatment units, while patients and the community effectively went without care.

The Solution: PIH collaborated with the Sierra Leonean government to work out of the Maforki Ebola Treatment Unit in the northern Port Loko District. The facility, which was originally built as a technical school for former child soldiers following the civil war, was always packed with patients and served as the only treatment unit in the district. The team worked to improve safety standards, operations, infrastructure, and WiFi access, all while clinicians cared for patients. 

And in Liberia, PIH helped the national government design and run Ebola treatment units to the south of the capital, in Grand Gedeh and Maryland counties, and helped respond to a cluster of Ebola cases in River Cess County. Smaller Ebola community care centers were established in Grand Gedeh, Maryland, and Grand Kru Counties to isolate and begin treating patients suspected of Ebola while they awaited lab results.

2. Rapid-response Ebola treatment

The Problem: Before PIH’s arrival in Sierra Leone, patients suspected of contracting Ebola were only admitted to treatment units during daylight hours. They also did not receive care until a lab test confirmed they were positive for Ebola, which often took multiple days—if such testing was available at all.

The Solution: The Maforki Ebola Treatment Unit was the first in the country to remain open 24/7 to receive new patients. There, PIH quickly adopted aggressive treatment protocols for patients suspected of contracting Ebola, including IV fluid resuscitation, antibiotics, anti-malarial medication, and more. 

3. Installing lab and ultrasound equipment

The Problem: Testing outside of the capital of Freetown was extremely rare during the epidemic. Clinicians often relied on physical symptoms to arrive at a diagnosis, yet nausea, vomiting, and fever are common manifestations for multiple diseases, not just Ebola.

The Solution: PIH installed lab testing and ultrasound equipment at the Maforki Ebola Treatment Unit and at Princess Christian Maternity Hospital in Freetown within months of arriving in Sierra Leone. This allowed clinicians to properly diagnose Ebola and rapidly treat patients, or triage them out of the Ebola ward.

4. Separate Ebola screening for pregnant patients

The Problem: At Princess Christian Maternity Hospital, all patients used to be screened in the same location. Because women in labor often display the same symptoms as patients sick with Ebola, they were mistakenly assumed positive and isolated together. This made it easier for the deadly infectious disease to spread. Meanwhile, clinicians hesitated to provide care to women in labor, as contact with body fluids increased their chances of contracting Ebola.

The Solution: PIH opened the first Ebola screening unit at the hospital to safely isolate women suspected of Ebola. If patients tested positive, clinicians treated them separately and provided them with the maternal care they also needed, including helping with obstructed labor, managing eclampsia, and treating infections—all common causes of maternal death. 

5. Continuous care at district hospitals and clinics

The Problem: During the time of Ebola, local clinicians were overwhelmed responding to the outbreak and were not available to help people who needed more routine health care. 

The Solution: While PIH clinicians cared for Ebola patients in Sierra Leone, other team members worked at Koidu Government Hospital and Wellbody Clinic in the east and Port Loko Government Hospital in the north to provide routine care to patients, including pregnant women, children with malaria, adults with TB or HIV, patients dealing with complications from high blood pressure and diabetes, and more. 

In Liberia, PIH kept hospitals and health centers open and running, including Martha Tubman Memorial Hospital in Grand Gedeh County and J.J. Dossen Hospital and Pleebo Health Center in Maryland County. Meanwhile, community health workers in both counties worked to identify patients with a variety of diseases, such as tuberculosis, leprosy, and HIV, and connect them with care. 

6. Employment of Ebola survivors

The Problem: Stigma toward Ebola survivors was high. Many returned home to discover that their family members had died, all their possessions had been destroyed, and they no longer had jobs. 

The Solution: In Port Loko, PIH employed more than 700 survivors to educate community members about Ebola and help screen for new cases. Others chose to be care providers in the Maforki Ebola Treatment Unit, ensuring patients had food, water, and other basic needs. PIH also helped create the Sierra Leone Association for Ebola Survivors, which continues to provide a supportive community and services, such as literacy classes, to survivors. Other organizations are now replicating these practices in the Democratic Republic of Congo, where the most recent Ebola outbreak is more than one year old.

7. “The 5 S’s”

The Problem: Responding to Ebola as a medical emergency was first and foremost in people’s minds throughout the West Africa outbreak. However, once survivors emerged from treatment units, they were stigmatized and suffering from the personal loss of loved ones, all their possessions, and any means of employment. National health systems also were left weaker, as many local clinicians had contracted Ebola and died responding to the emergency.

The Solution: PIH approached the situation holistically, as in every country where it works. Clinicians provided quality care to Ebola patients, but also advocated for survivors so that they could access lodging, food, clothing, and gainful employment. They also provided survivors follow-up care when Ebola-related symptoms, such as vision problems from uveitis, emerged in the weeks following their cure. 

Meanwhile, PIH leaders partnered with the national government to ensure the right staff, stuff, space, systems, and social support—the 5 S’s—were in place to help rebuild the health systems in each country.

Madeleine* and her husband, Stevenson, knew their family life was about to drastically change. They had seven children at home in Port-au-Prince, Haiti, and found out through an ultrasound that they were expecting triplets. 

Like any woman in late pregnancy, Madeleine was feeling off balance, as her abdomen swelled and her center of balance shifted. On a Saturday in late September, the 33-year-old mother fell to the floor while trying to get into bed. Soon she began feeling pains and noticed fluid discharge, interpreting them as the signs of early labor. With growing concern, she called her physician, who informed her that no one was at the clinic to help. Demonstrations and barricades had blocked all traffic.

Madeleine was one among thousands of Haitians across the country caught in life-threatening situations, as Haiti continues to be mired in more than one month of protests that have resulted in some 200 people injured and 20 killed. Roadblocks and demonstrations have cut off transportation in and around the capital, as well as across the country, as inflation spikes and Haitians struggle to access gas, food, and clean water. Banks, schools, businesses, and many health care facilities have been closed for weeks.

They are doing whatever it takes to take care of patients."

Yet Zanmi Lasante, as Partners In Health is known locally, has kept open all its clinics and hospitals at 12 sites across the lower Artibonite and Central Plateau, including University Hospital in Mirebalais. Staff are working long hours, and scrambling to secure fuel for generators. Some have traveled hours by foot and motorcycle, dodging stones and tear gas, as they pass barricades to arrive for shifts. They are doing whatever it takes to take care of patients.

Fear gives way to relief

So when Madeleine and Stevenson, a 48 year-old shoe shiner, knew they needed to get to a hospital—and fast—a family member began asking around to see if University Hospital was still open. It was. The three hired a taxi the following day and sped toward Mirebalais, typically a 45-minute drive north of Port-au-Prince. 

Not long into the trip, they hit their first roadblock. Their driver, a consummate negotiator, explained the couple’s situation to the demonstrators. A moment of fear gave way to relief. Not only did the demonstrators let them pass, they helped the car clear roadblocks and showed them the fastest back roads to the hospital. Two hours after leaving home, but much faster than they’d expected, they arrived at University Hospital.

Nursing staff swung into action. Madeleine was suffering from pre-eclampsia, they realized, and needed immediate attention. While they worked to get her blood pressure under control, they prepared her for labor so that, late Sunday evening, she safely delivered two babies before midnight. Two more babies followed in the wee hours of Monday morning.

And that’s when Madeline and Stevenson discovered they had quadruplets, not triplets. 

Two girls arrived at 2.5 and 3.4 pounds, and two boys at 3.6 and 4 pounds. Because the newborns were underweight and had arrived more than two months early, they were placed in incubators to maintain their body temperature and receive constant monitoring in the NICU. While waiting to be transferred, Stevenson provided one of the babies kangaroo care, which allows infants skin-to-skin contact with their caregivers to help maintain body heat and stimulate feeding.

Meanwhile, Madeleine was in critical condition herself. She had lost a good amount of blood and required a transfusion. Hearing that the unrest had calmed, hospital leadership sent an ambulance to the Red Cross in Port-au-Prince that Tuesday to gather lifesaving units of O+ blood. The driver arrived back, safe and sound, and staff immediately provided the new mom with a transfusion.

The family remains in good hands at University Hospital, where they are cared for by a rotating crew of Haitian clinicians who arrive for shifts after overcoming their own obstacles each day. PIH staff form the backbone of a hospital that is trusted and always open, with lights on to receive more patients, like Madeleine and her family, every day.

*Names have been changed for privacy.

PIH CEO Dr. Sheila Davis spoke recently with leaders at Zanmi Lasante, as PIH is known in Haiti, and provides the latest information about the past six weeks of unrest across the country.

I’m reaching out to share with you an update on the ongoing crisis in Haiti, and what PIH is doing to make sure health care continues to reach every patient in need.

The protest movement that began last summer has escalated to massive demonstrations over the last six weeks. Throughout the country, hundreds of thousands have taken to the streets to protest the devaluation of local currency, high inflation (20 percent), and the alleged misuse of billions of dollars meant for social programs and infrastructure investments.

Protesters are demanding that President Jovenel Moïse step down and for a transitional government to assume power until new elections are held. President Moïse has so far refused to do so, further inflaming the protest.

Unofficial estimates say over 200 people have been injured and 20+ killed. It is impossible to predict when demonstrations will end, but movement leaders are vowing to maintain an “unlimited mobilization.”

Zanmi Lasante has kept the doors open and the lights on in every single facility."

The team at Zanmi Lasante is displaying extraordinary courage and shown incredible dedication amidst the strife, even over concerns for their personal safety. With gas stations running dry, grocery shelves emptied, banks closed, and health facilities shuttered throughout the country, Zanmi Lasante has kept the doors open and the lights on in every single facility.

As other hospitals shut down, more people are traveling to our facilities to seek urgent care. The hospital we support in St. Marc delivered 720 babies last month -- a 144 percent increase over the same period last year. While we’re proud to stand as a safety net for the entire Haitian health system, we know that many more mothers are unable to find a safe place to give birth as this crisis escalates.

Staff are scrambling to secure fuel for generators, dodging stones and tear gas—all to care for each other and our patients, many of whom struggle to meet their most basic needs on a good day. If PIH was founded on the idea of providing care that prioritizes the needs of the poor, then our colleagues are exemplifying the best of PIH. But they are in urgent need of fuel, food for patients and themselves, and basic supplies.

I will share updates as the situation progresses. Meanwhile, please keep Haiti and Zanmi Lasante in your thoughts and, if you can, consider making a donation to help us stay open.

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It has been five years since I went to Liberia and Sierra Leone to launch Partners In Health’s Ebola response. The memories from that first trip are very vivid. I remember sitting on empty planes arriving to airports, where most people were trying to leave the countries. I remember repeated temperature screenings in and out of every place we went, including along the roadways when we would need to get out of our car and line up to get our temperature checked before piling back in. I still have a pair of pants from those days with bleach stains up and down the legs, as we had to step in pans of bleach every time we went in buildings. And then there was the endless handwashing.   

It was a challenging time organizationally, as this was the first time we were entering two new countries to respond to a disaster of epic proportions. PIH responds to crises—acute and chronic—in every place we work: the tragic Haiti earthquake almost 10 years ago, hurricanes, floods, fires, cholera outbreaks, and the omnipresent crisis of devastating poverty. The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering. But the logistical challenges of setting up operations in two new countries simultaneously was another story. 

The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering."

I remember every PIH country site offering to send staff and provide operational support, although all sites run with not enough of their own staff on a daily basis. It was never a question that we should go and that everyone would pick up the slack, as many staff were needed immediately to provide logistics, operational, and on-the-ground support. The sense of solidarity that staff throughout all PIH sites showed to people they have never met, in places they have never been—that’s what was and remains the most compelling part of the PIH community. 

In Liberia, we were asked by the Ministry of Health to work in four of the southernmost counties, where there was limited access to any care, and the distances between sites on very difficult roads proved nearly impossible. We set up Ebola screening units and began working immediately to strengthen and rebuild the shattered health system. We remain in Maryland County today, home to J.J. Dossen Hospital and Pleebo Health Center. These facilities have transformed from empty, broken buildings with few—if any—staff, to bustling places full of clinicians, staff, and patients. They are also home to lifesaving surgeries and innovative community programs addressing mental illness and maternal and child health. Together with the government, we revitalized the entire country’s multidrug-resistant tuberculosis program, and patients now have access to care in a safe, dignified facility with expert clinicians. 

In Sierra Leone, we had planned to work in Kono District, where our sister organization Wellbody Alliance had been for a number of years. Instead, we were asked to go to Port Loko, the hotspot of the epidemic. True to our mission of partnering with the public sector, we joined the Ministry of Health in providing care at the Maforki Ebola Treatment Unit. We saved thousands of lives through the care delivered by PIH in partnership with the government in very difficult circumstances in the ETU, in community care clinics, and at Princess Christian Maternity Hospital—the high-risk hospital in Freetown, where women were dying in the parking lot. During our efforts, we hired more than 900 Ebola survivors to become part of our staff as community health and outreach workers and in all other aspects of our work. 

We have remained in Sierra Leone, and now the once empty Koidu General Hospital is thriving and serving more than 500,000 people in Kono District. We are focusing on reducing maternal mortality by building a comprehensive maternal center of excellence, and have transformed the mental health hospital in Freetown. Just as in Liberia, we’ve brought our expertise from other PIH sites to tackle MDR-TB and provided the first comprehensive care for patients ever available in Sierra Leone. 

When I visit West Africa now in my current position as CEO, I will see the amazing influences of Haiti, Rwanda, Malawi, and all PIH sites. If Ebola were to strike again in the places we work, I know that the outcome would be very different because of our past five years of experience in Liberia and Sierra Leone. We responded to a disaster, and we stayed. Our mission of responding to human suffering and providing quality health care for all is what connects us throughout the world, and what will sustain us moving forward.

All over the world, millions of girls are denied basic human rights, such as access to health care and education. Since 2012, October 11 has marked the annual International Day of the Girl, a celebration that advocates for girls’ empowerment and human rights.

This year, at Partners In Health, we are celebrating girls who have broken down barriers, defied stereotypes, and beaten the odds to work toward their dreams.

Promoting gender equity is a central mission at the University of Global Health Equity, a PIH initiative in the rural, northern Rwanda community of Butaro. When admitting its first class of medical students, the university prioritized the education of young women, who have been historically underrepresented in higher education and medicine in Rwanda.

The inaugural class includes 30 students, two-thirds of them women. Every one of them has a strong belief in health equity and providing for the poor. Today, we share the stories of three of these young women, each of whom had experiences as young girls that have inspired them to pursue careers in global health. 

For this International Day of the Girl, we celebrate their achievements, and their journeys toward becoming the next generation of women leaders in global health.

‘We are still so grateful’

Alima Uwimana, 20, could hardly believe where she was when she stepped foot on campus in Butaro, alongside 29 strangers who would be her classmates and community for the next six and a half years. For her entire life, until that moment, her new reality had never seemed like a possibility.

Uwimana grew up in a rural village in western Rwanda, near borders with the Democratic Republic of Congo and Burundi. Her family often struggled with money, and never thought they’d be able to send her to university. 

But Uwimana, the youngest of 10 children, now could be the first to graduate from college. Of her six sisters, she is the only one to make it to high school, where she excelled in the sciences and worked hard to maintain good marks.

She now is attending UGHE on a full scholarship, thanks to the generosity of UGHE donors and a partnership with Rwanda’s Ministry of Health.

“We were all laughing and smiling so much,” Uwimana said, recalling the moment she and her family learned she would join UGHE’s inaugural medical class. “We were so thankful. My family had no idea it was possible for me to get a full scholarship. We are still so grateful.” 

Uwimana is an aunt, with 28 nieces and nephews, and she wants to help each of them believe in themselves and pursue their passions, as she did.

“I want to show them that even though they may not have a lot of money, if they have commitment and patience and if they study hard, they can achieve their dreams,” she said.

Uwimana knew her dream at a young age. She remembers watching television as a girl and listening to Rwanda’s newest minister of health at the time, Dr. Agnes Binagwaho—now UGHE’s vice chancellor—outline her vision for the country’s health system. Binagwaho called for quality health care for all and an agenda that focused on the poor and vulnerable. 

I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

Uwimana thought about her own family, who had faced so many challenges with the health system due to financial difficulties, and how Binagwaho’s vision could affect them. 

One of Uwimana’s brothers lost his abilities to speak and hear, due to ailments that could have been cured had their family had the money for the specialist he needed. Her nieces and nephews, the very ones she hopes to inspire with her career, have often suffered from malnutrition, and her siblings have gone into debt to get them treatment. 

Listening to Binagwaho, Uwimana began to understand not only her feelings while watching her family’s struggles, but also how she could help. She could become a doctor who cared for those in need, regardless of their economic status. She thought that maybe she could even be Rwanda’s minister of health and, like Binagwaho, change the system so families like hers could get the health services they needed. 

“I was inspired by the way she put the health of the citizens first, and she is the one who first saw that everyone deserves health regardless of financial capacity,” Uwimana said. “I was inspired by her and thought, one day, maybe I could be like her.” 

Now, as a first-year medical student at the university led by Binagwaho, Uwimana can’t help but smile when asked how she feels about studying under the woman who inspired her, years ago, to pursue this path. 

“I’m so happy and excited. I feel blessed being here,” she said, glancing toward the entrance to Binagwaho’s office. “I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

‘A smile is enough’

Marie Immaculee Dusingize, a 19-year-old from Rwanda’s Southern Province, knows the inside of a hospital far too well for someone her age. 

When she was 10, she started complaining of debilitating stomachaches. She couldn’t keep food down and had to resort to an extremely strict diet to minimize her pain. Dusingize spent many days and nights in different hospitals and health centers seeking treatment, but to no avail. To this day, she still experiences aches and pains and maintains the same rigid diet.

Her time in the hospital, while challenging, opened Dusingize’s eyes to the problems people face seeking health treatment. Her experiences left her dissatisfied with the quality of available health care, but it was the inequities she saw in the experiences of other patients that truly had an impact on her.

“I remember someone rich came in with just the flu and got treated right away, while someone with a serious kidney condition had no money for the exam and was turned away,” she said . “How can poor people die in front of the door of the hospital just because they don’t have money to pay?”

When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of."

Dusingize has always looked out for others in need. Early in high school, she noticed how many graduating students would throw away most of their things at the end of the year. She thought about her neighbors—who couldn’t afford basic needs like shoes, clothing, and school supplies—and realized she could do something. So she stood next to the trash can, and when students came to throw their things away, she would ask them to give them to her instead.

“My friend saw me by the trash can and asked what I was doing, and when I explained it to her, she helped me announce it to the school. We decided to make it permanent,” she said. And that was the origin of her nonprofit, Charity Foundation. “Every time we throw away things we no longer need, those things may be useful to those who can’t afford them.” 

Dusingize attributes this selflessness to her mother, who showed her the power of a helping hand. Her mother has been by her side throughout her years of illness. While her mother has no formal medical training, Dusingize says she has been a healer in her own way. 

“What I learned from her is that we should give what we have. It’s not necessary that we say that, because I am not a medical doctor, I can’t help,” Dusingize said. “A smile is enough. She could always smile at me and say words that would make me forget that I was even sick, so I really regard her as a medical doctor.” 

The values that Dusingize draws from her mother have guided her to where she is today. 

“When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of,” she said. “I feel like the world will be mine to change.”

‘We share the same vision’

Eden Gatesi didn’t get to spend much time with her mother when she was growing up. Her mother was a nurse, and would leave early in the morning to take care of patients, then return home late at night. The precious time they spent together, however, had a big impact on Gatesi.

“What impressed me most was even the little time she could spend at home, we would get visitors coming over to thank her for saving the lives of their beloved ones,” Gatesi recalled. ”That showed me that dedicating my life to being a health professional would help me to have an impact on my community and save their lives as my mom does.”

Although Gatesi knew she wanted to follow her mother’s footsteps, she felt pressured by societal and cultural norms. Many people in her life didn’t understand how she could spend so many years at school, and felt she should instead focus on raising a family. She didn’t know a single female cardiologist, the profession she knew she wanted to pursue. Gatesi, herself, began to experience doubts about whether she should follow her dreams.  

All that changed in 2016, when Gatesi was invited to attend a prestigious camp called Women in Science, organized by the UN-backed nonprofit GirlUp. The camp was an opportunity for girls from across the globe interested in science and technology to come together for two weeks of leadership development training. 

“It was a great honor for me,” Gatesi said. “It was my first time ever leaving the country, because the camp took place in Malawi, but it was a very good experience for me to meet girls from all over the world. We don’t share the same culture, but we share the same vision and same ambition.”

Being around these like-minded girls, who all had dreams of having an impact on the world through science, removed any doubt from Gatesi’s mind about becoming a cardiologist.

..the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”

Gatesi returned home with a renewed belief in herself. But she knew there were many other girls who hadn’t had an opportunity like hers, and might still be experiencing the same doubts that she had. She joined a group called Dear Doctor, which brings together students who have an interest in careers in medicine, as a way to give back to girls like herself. 

“I came back to school wishing to help other girls who think that they can’t (be a doctor),” she said. “Joining the Dear Doctor club helped me to show them that they really can.”

As part of the club, Gatesi helped organize events where girls discussed challenges females face in the medical field, and invited doctors to speak about their careers. She also facilitated visits to nearby hospitals to meet with patients, and coordinated student internships with local health centers. 

Now, as a member of UGHE’s majority-female, inaugural medical class, Gatesi brings the lessons she learned growing up to a university that prides itself on its commitment to equity. Here, she has found another community of people who share her vision, and said she feels optimistic about this new generation of leaders.  

“Starting my journey at UGHE, where we are 20 girls and 10 boys, it has shown me that the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”

Cylian B. Kargbo is planning for her future. “My birthday is coming up!” the 12-going-on-13-year-old from Calaba Town, Sierra Leone, proudly announced, looking ahead a few weeks when she would celebrate with, first and foremost, “pizza!” Further down the line, Cylian has even bigger dreams: “I want to be a lawyer—study abroad, then come back to Sierra Leone to help the people in my country.”

Warm, thoughtful, and fiercely intelligent, Cylian has a bright future ahead, from her next month to her next 10 years. But it wasn’t always guaranteed. Plans for law school or even a birthday party began slipping away when, last July, she experienced her first symptom of multidrug-resistant tuberculosis (MDR-TB).

“Side pain,” Cylian remembered simply, citing the reason her family first took her to Ola During Children’s Hospital the capital city of Freetown. There, she was diagnosed with and treated for malaria, but her pain persisted. By October, said her father, Manso Kargbo, it got so severe that Cylian was unable to sleep.

Another trip to the hospital resulted in a diagnosis of tuberculosis (TB). But even TB drugs did nothing to improve Cylian’s health, which was deteriorating faster and faster. By the third week spent in her local emergency room, Cylian was in and out of consciousness, on oxygen, and unable to digest food. The Kargbo family’s friends and neighbors suspected witchcraft, and suggested that Cylian be seen by a traditional healer.

Doctors and nurses had another theory: MDR-TB, the drug-resistant strain of the world’s leading infectious disease killer.

An Escalating Illness, and a Lifesaving Partnership

Though TB was eradicated long ago in most wealthy parts of the world, poverty and a lack of strong health systems have allowed it to plague Sierra Leone, where, according to the World Health Organization, roughly 300 cases of TB are found per 100,000 people. For comparison, high-income countries find less than 10 new cases of TB per 100,000 people—around the rate at which MDR-TB cases present in Sierra Leone. The specialized drug regimens and care required to cure patients with MDR-TB were never available in the country, leaving countless people to die and the deadly airborne disease to proliferate.

This unjust reality faced a turning point in April 2017, when Sierra Leone’s National Leprosy and Tuberculosis Program, led by Dr. Lynda Foray, and Partners In Health (PIH) jointly established the country’s first and only MDR-TB treatment program, located at Lakka Hospital in Freetown. The National Tuberculosis Program brought in the critical equipment to diagnose MDR-TB, the lifesaving drugs to treat it, and the hundreds of team members to deliver the care. Despite this commitment, a gap remained—which PIH swiftly filled.

PIH infused Lakka with the other resources necessary to cure MDR-TB: a robust supply chain to ensure the availability of critical equipment and drugs for managing TB complications; the addition of clinical mentors with expertise in the disease; and continual building renovations to make receiving and delivering care more comfortable and dignified.

Together, Sierra Leone’s Ministry of Health and Sanitation (MOHS) and PIH also ensure 24-hour electricity and running water at the facility, in addition to providing support packages to outpatients who couldn’t otherwise afford food or transportation to the hospital for check-ups.

So far, clinicians at Lakka have treated more than 322 MDR-TB patients, and have seen a cure rate of 74 percent—among the best success rates globally, even with only a handful of doctors working specifically on TB within the country.

Saving Cylian, Through Food, Medicine, and Care

Support from the government and PIH arrived at Lakka not a moment too soon, and neither did Cylian. “When they referred me to Lakka, I was unable to walk, I was unable to eat for myself,” she said. Nor was she able to stand or sit on her own. “Her condition was so critical,” Kargbo said. “There was no flesh; only bones. You could count her ribs.”

Dr. Rashidatu Fouad Kamara, MOHS lead clinician at Lakka; Dr. Mariama Mahmoud, the facility’s now medical superintendent; and TB doctor Dr. Michael Mazzi reassured Kargbo that his daughter would get better, and immediately began her on treatment. This consisted not only of medication, but also food, which her body desperately needed to tolerate harsh MDR-TB drugs and grow stronger. PIH and the National TB Program began a special meal program, with foods rich in protein and fat, and asked Cylian what she liked to eat. Fried rice, her favorite, became a regular menu item, and was arguably as essential as drugs.

“With that special food, it was like magic,” Kargbo said. “Cylian’s health was changed within two months. She started to walk. Dr. Kamara and Dr. Mazzi exercised with her every day.” This success inspired hospital staff to introduce enriched meals to other TB patients in similar situations; today, they equally benefit from an enhanced diet.

Kargbo stayed with his daughter for more than one month as she recovered, then sent one of Cylian’s cousins to stay and keep her company. But even in the family’s absence, he knew Cylian was in good hands. “I’m so grateful,” he said. “It was not only the nutrition and feeding they provided to Cylian, but they also provided psychosocial counselling. I think of that—to have people get close to Cylian, to embrace her.”

With this comprehensive health care, Cylian’s health only continued to improve. After five months at Lakka, she was healthy enough to be discharged and continue treatment at home. And soon later, she was declared free of MDR-TB.

“Imagine—when Cylian was first taken to the hospital, she cannot walk, she cannot breathe properly without oxygen. Now, she can breathe for herself. She can walk. She can eat. She’s gained weight,” Kargbo said. “With timely intervention, Cylian recovered within a short time. I can embrace my child in her healthy condition.”

A TB Advocate is Born

Cylian isn’t the only one looking forward to the days ahead; her father is, too. “I hope for Cylian to achieve all her dreams,” he said. “Whatever she wants to be, that will be determined by Cylian. And I will give her the support to reach those heights. If you have a dream, you must have somebody to help you reach it.”

Last March, hinting at what type of attorney she might someday become, Cylian urged her government and PIH to continue fighting to eradicate TB and MDR-TB in Sierra Leone and around the world. Paying a visit on World TB Day to the facility that helped save her life, she shared her story in front of patients, staff, and Dr. Alpha Wurie, Sierra Leone’s Honourable Minister of Health and Sanitation. Her speech ended in an appeal for more support for Lakka, and for others to seek treatment there.

“We beg other patients who have TB, do not sit in your house,” she said. “Let them come and see the doctor and they will give them the right medicine.”

Community health workers are the bridge connecting their neighbors, friends, and family to local clinics across the 10 communities in which Partners In Health works in rural Chiapas, Mexico.

In July, Compañeros En Salud—as PIH is known in Mexico—launched a new initiative that trained five workers in the provision of mental health care, with the hopes of soon growing their number to 10.

This innovative program directly addresses a mental health care gap in Mexico. There are an estimated 210 psychologists and four psychiatrists in the entire state of Chiapas, home to 5 million people. Broken down by population, that means there are roughly four psychologists for every 100,000 people, compared to 12 psychologists for every 100,000 people in the rest of Mexico. About 1.4 million people in Chiapas suffer from depression and other mental illnesses.

There are simply not enough properly trained clinicians available to address the burden of mental illness in Chiapas.

That’s why PIH’s community mental health workers in Monterrey, Honduras, Laguna del Cofre, Salvador Urbina, and Capitán are key to reaching the most vulnerable patients battling depression and anxiety. After patients have been diagnosed by a PIH-supported clinician in these rural communities, they are connected with a community mental health worker, who visits their home regularly to provide counseling and support.

In honor of World Mental Health Day, each community mental health worker below shares why she is committed to providing care to her neighbors, friends, and family.

Zoemia Salas Morales

“My work consists of making home visits to patients who have been diagnosed with depression and anxiety, giving them short therapy sessions so they can understand their feelings better and get tools to overcome these conditions.

Sometimes it’s hard to be a community mental health worker. After doing my work, I have to get back home, cook for my family, take care of my husband and children, do the laundry, and clean the house. Even then, some people in the community judge me because they think I should be staying at home, that I’m not doing enough for my family. But they don’t understand I’m doing this because I want to help people, even if it means walking long distances to get to my patient’s houses.

There are some patients who refuse to get treatment because they’re ashamed of themselves. They fear people around them will find out they’re suffering from a mental illness, but that’s just a stigma we’re trying to overcome. I like to keep learning about mental health, because it’s so much different from physical pain. Sometimes people don’t realize that what’s being hurt is their feelings, and how important it is. I’m here to help them have a safe space to talk about it.”

Roselia Díaz

“I want to help people suffering from mental illnesses, because in the past I’ve suffered from them too. I can understand how my patients are feeling, and I want them to know that if I’ve been able to overcome these problems, anyone can.

It has been hard for me because I’m a very shy and anxious person. But while I help others, I know I’m helping myself too, conquering my own fears, and turning them into self-confidence.”

Juana Roblero

“The community mental health workers’ program immediately called my attention, because I knew my mom had suffered from depression and I didn’t know how to help her. I thought that if I became one of them, not only would I be able to help out my mom, but the rest of the people in the community, too.

Sometimes we don’t have any idea of what others are going through. And sometimes even these people can’t exactly explain how they’re feeling. That’s when I come in, helping them out with these problems, giving them hope.”

Carolina Guzmán

“As a community mental health worker, I feel like there are a lot of things depending on me and my perseverance. It is important not to give up on others. Because after all, I’m doing this to help them, and helping is never a burden. When it comes straight from your heart, it will never feel like it’s hard, or impossible.

I know I still have a lot to learn, but I’m positive that every single day I’m becoming a better person.”

Nelcy Roblero

“People know me because I’m a hard-working woman, and my passion is to help other women, men, and children. I’m very happy to be a community mental health worker, because now people don’t have to travel long distances to the closest towns in order to get this kind of attention.

I like it when patients come to me and tell me how much I’ve helped them. I enjoy watching them flourish, because more than a worker, I would like for them to see me as a trusted friend, lending a hand to them, showing them that they’re not alone. Beyond the poverty and marginalization, there are so many capable, strong, and loving people around here.”