Viola Wleh thought she had a common cold, but her diagnosis was more serious: multidrug-resistant tuberculosis (MDR-TB). 

The infectious disease can be deadly—especially the drug-resistant type—so patients should receive care immediately. Unfortunately, there was no treatment for MDR-TB available at the county public hospital, and Viola’s cough persisted. In an effort to take matters into her own hands, Viola purchased painkillers and cough medication in the hopes that this would improve her condition. 

The cost of these drugs far outweighed her low monthly income of $4,000-5,000 LRD ($25-30 USD). Typically, she used that money to support her eight children; however, her health was in jeopardy. Her situation was gradually becoming a death sentence, she says. 

“I was going to die,” Viola thought.

A few weeks later, a home visit by a Partners In Health (PIH) Liberia community health worker gave Viola hope. She learned about the importance of early treatment and was referred to PIH-supported J.J. Dossen Hospital, the first and only decentralized tuberculosis ward in the country, where she could receive free care. The 15-bed unit opened its doors to patients in 2017.

Viola left her mother’s house, a 3-bedroom dirt home with a zinc roof and no ceiling, where she was living with her children, and headed to the hospital. She traveled 133 kilometers (82.6 miles) via motorbike—the main means of transportation in rural Liberia—from her home in Sinoe County to Maryland County. 

On June 14, 2022, Viola was admitted to the MDR-TB ward at J.J.Dossen Hospital.

Road to Recovery 

Upon her arrival, the 49-year-old mother was given TB medication—at no cost to her, this time. She also received support beyond medical care, including food, housing, and transportation. Guided by social medicine principles, PIH believes it’s important to treat the whole person, not just their disease.

As the days and weeks passed by, Viola became more hopeful. 

“I’m so happy to be alive again,” she says.

After an extensive and consistent nine-month treatment regimen at J.J. Dossen, Viola regained the weight she lost and began to feel healthier. She became well enough to be transferred from the hospital to a PIH-provided home in New Kru Town, a suburb of Harper, Liberia, where she lived for about six months. On March 6, she was reunited with her family in Sinoe County. 

Viola is one of hundreds of patients with tuberculosis who receive PIH support each year. Many low-income countries are burdened by tuberculosis and Liberia is in the top 30 countries worldwide with the highest TB burden. In 2021, Liberia reported 7,446 tuberculosis cases with a treatment success rate of 77%, according to the World Health Organization. 

For the last three decades, PIH has treated patients like Viola and has shown that recovery is possible with the proper treatment plan, social support, and community-based care.

As a record-breaking storm winds down after battering Malawi and neighboring nations, Partners In Health’s emergency response team is tending to patients with medical assistance and other emergency support.

Cyclone Freddy hit Southern Malawi on March 13, after making landfall in Mozambique.  Now, the storm, reported to be the longest-lasting tropical cyclone ever recorded in the southern hemisphere, has left more than 679 people dead in Malawi, with 2,178 injured, according to a March 16 report from the country's Department of Disaster Management Affairs. More than 537 people are missing, the report states, and 659,278 people have been displaced. 

Death Toll Rising

The casualty toll is expected to rise, officials said, as a result of widespread flooding, mudslides, and collapsed buildings. Compounding the devastation, Malawi is grappling with a cholera outbreak that has already killed more than 1,500 people.  

At Abwenzi Pa Za Umoyo (APZU), as Partners in Health is known in Malawi, teams based in Neno District, where storm damage is currently minimal, have been asked by the Ministry of Health to support the emergency response in harder hit areas to the south. That support will initially be directed at the city of Blantyre, the second largest in the country, which to date has the highest number of casualties, and is within 10 districts that have been officially declared disaster zones, according to reports. 

Extending Support to Hard-Hit Regions

APZU is coordinating with Neno District Local Council and the District Health Office to support ongoing assessments and follow-ups where there is a need for support. 

Through the Emergency Operations Center, a unit created to facilitate humanitarian coordination between government, NGOs, and development partners, APZU’s support is being extended to other affected areas beyond Neno District.

The cyclone has compromised infrastructure throughout Malawi, making some roads unnavigable and causing blackouts. APZU is anticipating how this will affect supply chains and is preparing accordingly to ensure patient care remains constant. 

While all of the 14 health centers in Neno remain open, three of them—Matope, Nsambe and Dambe— are largely inaccessible except to foot traffic due to poor road conditions, officials said.  All other facilities remain accessible.

A Potential Cholera Surge

Beyond the potential for more storm-related deaths and damage, officials are worried that Freddy will exacerbate what has been deemed the country’s deadliest cholera outbreak on record, which began in March 2022. To date, the recent outbreak has killed more than 1,500 people in Malawi. APZU team leaders said they are preparing for another surge of the water-borne bacterial disease. Flooding and damaged infrastructure, specifically water and sanitation systems, can contaminate water sources and spread cholera, they added.

To date, over 50,000 cholera cases have been reported in Malawi. While instances of cholera in Neno District have been low compared to the rest of the country, the APZU team is poised to respond to an increase in disease.

Cholera is a deadly disease that can cause severe diarrhea and vomiting. Children, the elderly and patients struggling with other illnesses are often most affected, and can quickly become dehydrated, go into shock, and die within 24 hours if they are not treated. The disease can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between two hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae.   

This summer, a massive cholera vaccination campaign reached a total of 87,352 individuals, or 59% of the district’s target population, who were given both doses of the vaccine, meaning they are fully vaccinated. More than 86% of the population received at least one dose of the oral cholera vaccine during the campaign.

That effort is one possible reason that cholera cases in Neno District were relatively low compared to other regions in Malawi, APZU leaders said.

In the rural community of Rwinkwavu, in eastern Rwanda, Jean Claude “Gatoto” Rutayisire spends his days managing care for patients living with non-communicable diseases—making sure they have a community health worker assigned to their case and access to free medical care and resources offered by Partners In Health. Gatoto can relate to them in ways few others on staff can: he was once a patient.

Gatoto is one of several health workers with PIH who once were patients themselves, enabling them to relate to patients on a deep level and showing how access to health care can transform lives.

For more than 30 years, PIH has provided world-class medical care, strengthened health systems, and advocated for global health equity in impoverished communities worldwide, guided by the belief that health care is a human right. PIH currently works in 11 countries, where we partner with governments to make free, accessible health care a reality.

Many PIH patients have gone on to become health workers themselves, including doctors, nurses, midwives, therapists, and community health workers. Their stories are a testament to the transformational impact of health care that is free and accessible.

Below are three of their stories:

Jean Claude “Gatoto” Rutayisire

Gatoto, 45, remembers a time when no HIV treatment was available in Rwinkwavu, and people were dying at home, alone. It was a terrifying reality. Gatoto, who lives with HIV, began to wonder how many people in his community were also suffering in silence. In the early 2000s, he started a support group for people living with HIV. The group met regularly to offer a supportive space, accompany patients to the hospital, and bury those who died.

When PIH began its work in Rwanda in 2005 and free HIV treatment became available, Gatoto and the support group were instrumental in helping PIH connect with the community and build its HIV/AIDS program—an experience that since inspired him to become a health worker.

Now, Gatoto is a community health worker supervisor, mentoring a group of over 1,000 community health workers in eastern Rwanda and ensuring that patients have access to the care and support that he once had to survive without.

“My experience as a patient helps me connect on a personal level…I understand them in a way someone who didn’t go through the same experience wouldn’t,” he says. “Every patient deserves to be heard.”

Hawa Koroma

As a facility-based peer counselor with PIH Sierra Leone, Hawa Koroma meets with patients and offers care, support, and resources as they navigate their diagnoses—and, for many, their darkest moments.

It was support that, years ago, she needed herself.

Koroma had been sick and living on the streets of Freetown when Partners In Health workers found her and connected her with HIV and tuberculosis screenings, free of charge. She tested positive for both—a diagnosis that put her on the path to medication, care, and recovery and instilled in her the desire to support others.

She first signed up to volunteer with PIH, then joined as staff. Now, Koroma, 39, is a peer counselor at Wellbody Clinic, drawing on her own experiences to support patients and offering reassurance that healing—and hope—is possible.

“PIH has changed my life and my story,” she says.

Rebeca Velasco

Day to day, Rebeca Velasco felt healthy. But when she went in for a check-up at her local clinic in Plan de Libertad, a rural community in Chiapas, Mexico, she received unexpected news: She had a heart murmur, along with other complications. After a series of tests, doctors concluded she would need open heart surgery, or her heart could stop at any minute.

The news terrified Velasco. But fortunately, she was not alone. PIH, known locally as Compañeros En Salud, was there to support her, from testing to surgery to recovery. All expenses were paid through its Right to Health Care program—essential for Velasco, whose family is low-income.

The experience opened Velasco’s eyes and inspired her to work in health care. She is now a community health worker supervisor, using her experience as a patient to guide her work. There’s another inspiration driving her, too. Years earlier, her grandfather passed away due to complications from diabetes, a condition he had lived with for decades.

“When he died, it was very difficult for me, because I felt we could have done more for him. That maybe with the right care, we could have saved him,” she says. “It inspired me to be able to accompany patients in their illnesses, to teach them to take care of themselves, to remind them about their medications…to be a bridge for them, so they are not alone.”

Farmers and families aren’t the only ones keeping an eye on chickens. Global health experts, too, are closely watching the bird.

That’s because of a variant of avian flu, also known as “bird flu” or H5N1, that has spread farther than ever before in recent years. While there is little threat to humans right now, it’s a trend that has global health experts alarmed: if the virus ever mutated to cause human-to-human transmission, it could become the next pandemic.

Avian flu isn’t the only virus raising concerns.

In early February, an outbreak of Marburg virus in Equatorial Guinea prompted a global emergency response. The hemorrhagic fever, which closely resembles Ebola, had never been detected in the country before.

Avian flu and Marburg virus are vastly different diseases. But they have one thing in common: they’re both appearing in locations and populations where they haven’t typically appeared before. And that has global health experts like Dr. Marta Lado, Partners In Health’s cross-site senior health and policy advisor, worried.

“We need to have a clear surveillance system…because viruses can change, can mutate, and if this mutates it can definitely produce big outbreaks,” she says. “These kinds of viruses normally, in humans, produce a lot of mortality. Like people really die.”

PIH has responded to infectious disease outbreaks for more than 30 years, from tuberculosis to Ebola to COVID-19. While avian flu and Marburg virus aren’t currently affecting the 11 countries where we work, PIH experts—along with the global health community—are closely monitoring them as we continue to advocate for pandemic preparedness and stronger health systems worldwide.

Marburg Virus

Historically, outbreaks of Marburg virus have not been large. But the mortality rate is alarming: up to 88%.

First detected in Germany and Serbia in 1967, Marburg has since largely appeared in a handful of African countries, where outbreaks have historically been harder to contain due to a lack of health infrastructure and resources. The current outbreak in Equatorial Guinea began in early February; nine deaths, with one linked to Marburg, have been reported so far.

Much is still unknown about Marburg, but it closely resembles Ebola, spreading through bodily fluids such as blood, vomit, and saliva and living on surfaces for one hour, which puts health workers at highest risk. Symptoms include fever, diarrhea, and vomiting. Ultimately, like Ebola, the virus leads to multi-organ failure.

No vaccines or antiviral treatments have been approved for use, though clinical trials are being designed. The global community mobilized quickly, says Lado, launching rapid emergency response efforts and dispatching health experts and supplies to Equatorial Guinea.

“I think the global community right now is more alert and responds quicker,” she says. “I think COVID has taught us a lot of lessons.”

The global response has been much faster than the early days of Ebola, she adds.

In those days, she recalls, global health experts in high-income countries were saying nothing could be done for Ebola patients and only prevention was possible—despite the fact that when Americans and Europeans became infected with Ebola, they were evacuated to countries with highly-resourced health facilities where their lives were saved, thanks to stronger health systems that lowered the virus’ mortality rate to less than 30%.

The apathy of Western leaders during Ebola was a status quo that PIH refused to accept. Lado and others argued that saving lives was, indeed, possible with the right early detection measures in place and the highest standards of care, including IV fluids, antibiotics, and oxygen.

“I’ve participated in all the outbreaks of Ebola since 2014 until now and these principles are now respected,” she says. “They are the basis of any response to an outbreak of Ebola and Marburg. So I think PIH and other partners made a very strong advocacy at that time.”

Now, Lado is taking her expertise to the World Health Organization, advising on case management for Marburg and drawing from her years of experience responding to Ebola.

What’s especially concerning to her about Marburg is how it has changed over time: the virus is now affecting countries, including Equatorial Guinea, that have never had an outbreak, originating in bats. While not likely to trigger a pandemic, such outbreaks could be devastating for low-income countries with weak health systems—a threat that makes global solidarity, including vaccine equity, crucial in the fight against Marburg.

“The risk of this expanding to other countries is not like COVID or the flu, but the problem is that it happens in places where normally they have weak health care systems,” she says. “It would be complicated in Europe, but in countries where it happens, it’s even worse.”

Bird Flu

Dead minks in Spain. Dead sea lions in Peru. Dead seals in the United States.

All of these animals were killed by avian flu, a virus that has historically affected birds, but in recent years has spread to other mammals. These outbreaks have global health experts worried that the virus could one day mutate to transmit among humans—a change that could trigger a global pandemic.

“If we start seeing clusters of human cases of these avian flus, then that would mean the virus has mutated enough to pass the barrier between animals and humans and that would be definitely worrisome,” says Lado. “That is exactly what happened with COVID.”

Symptoms of avian flu include a fever and coughing, resembling those of other flus. The virus is airborne, enabling it to become a pandemic if it ever transmitted human-to-human.

Humans have caught variants of the flu through contact with infected birds. An 11-year-old girl in Cambodia died of avian flu after coming into contact with poultry. (Her father in the same household was infected, but had no symptoms and survived.)

The mortality rate from avian flu, in humans, is 53%—COVID-19, by contrast, is 1% and the seasonal flu is 0.1%.

Still, says Lado, the general public should not panic. No sustained human-to-human transmission has been reported, and the risk to the public is low. There have been nine cases reported in humans worldwide since early 2022, the start of the current outbreak. But the scientific community is—and should be—worried.

“If this ends up having some mutation and producing more disease in humans, we want to be detecting it as soon as it happens,” she says.

The global health community has already begun pandemic preparedness measures, setting up surveillance groups to identify cases. The U.S., which has a stockpile of avian flu vaccines, is considering mass vaccination of poultry and has reportedly sent viral samples to drug-makers.

A recent report by PIH’s Garrett Wilkinson, government relations and policy officer, and James Krellenstein of the consulting firm Global Health Strategies found that the U.S. could need at least 650 million doses of the H5N1 vaccine for use in humans. It’s unclear how that number could be produced with current manufacturing capacity.

Worldwide, the picture is even more bleak.

As with Marburg virus, Lado is concerned about low-income countries that don’t have strong health systems and infrastructure in place, including the testing and lab capacity to even detect the virus. More outbreaks mean more opportunities for the virus to mutate.

“If some small aspects change, like some mutations happen, this could become the next pandemic,” she says.

Leoncio Carrión was struggling to breathe.

The 78-year-old was battling pulmonary fibrosis, his breaths becoming shorter by the day, and had arrived at the hospital gasping for air.

Had he come just weeks earlier, he may not have survived. But the Rosa Sanchez de Santillan Hospital in Ascope, a town in Trujillo, Peru, had just acquired a lifesaving resource: medical oxygen.

Several tons of it, to be exact, supplied by an oxygen plant newly repaired by engineers with Socios En Salud, as Partners In Health is known in Peru.

Oxygen is essential for patients with a host of respiratory illnesses, including tuberculosis, lung disease, pneumonia, and severe COVID-19. But in many low- and middle-income countries, medical oxygen is in extremely short supply. Even before the pandemic, 9 in 10 hospitals in low- and middle-income countries lacked access to oxygen therapy. And as many as 800,000 children died due to lack of oxygen.

The oxygen shortage only worsened during the spread of COVID-19—a reality that staff at the Ascope hospital saw every day.

“We did not have a separate area, health personnel, [or] medical supplies to care for COVID-19 patients,” says Ana, a nurse at the hospital. “We witnessed the loss of many people’s lives who did not have the chance to receive oxygen.”

Supplying Oxygen, Saving Lives

That’s an issue BRING O2 is trying to address.

BRING O2 is PIH’s initiative  to accelerate access to safe, reliable, and high-quality medical oxygen in five countries: Malawi, Rwanda, Peru, Lesotho, and Madagascar. The initiative, which is funded by Unitaid and completed in partnership with Build Health International and Pivot Madagascar, has facilitated over a dozen oxygen plant repairs, along with training for staff. Through the initiative, Socios En Salud has repaired 20 oxygen plants across Peru and trained staff on how to operate and maintain the equipment.

“Having medical oxygen available 24 hours a day means having the possibility of saving [many] lives,” says Dr. Luis Cáceres, a doctor at Rosa Sanchez. “We all deserve to receive the best health care and delivery, [provided] with quality and equal opportunity.”

Oxygen plants are crucial to delivering that care. Housed in standard-size shipping containers, oxygen plants can run 24/7 and produce thousands of liters of oxygen per day—enough to support patients in the hospital and to refill oxygen tanks for those at home, as well as for health centers and emergency response teams.

Before Socios En Salud’s repair work began, the oxygen plant at the hospital was rundown, leaving Ascope, a town of more than 6,800 in northern Peru, with virtually no access to medical oxygen.

“It is vital to plan for, implement, and follow up on the maintenance of this equipment,” says Jean Franco Bravo, an engineer with Socios En Salud and coordinator of the BRING O2 project.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the decades since, Socios En Salud has expanded its programs to provide medical care and social support for thousands of patients from Lima to Trujillo to Arequipa. That work is part of Partners In Health’s larger mission to strengthen health systems and achieve universal health care in the countries where it works, in partnership with local and national governments.

As Peru has responded to devastating surges of COVID-19 and other respiratory diseases, including tuberculosis, accelerating access to medical oxygen has been crucial to strengthening health systems and care.

Helping Patients Breathe

In November, Socios En Salud’s team of clinicians and engineers arrived in Ascope and carried out an assessment. The oxygen plant had dangerously high voltages and lacked safety features such as fire alarm systems and generators, among others. Hospital staff also weren’t trained on how to operate or maintain the plant.

Over two months of repair work followed, along with training for hospital staff. The Socios En Salud team also performed a simulation of a COVID-19 surge and how it would impact oxygen supply, identifying gaps in care delivery where every second, every breath, counts.

Now, thanks to that work, the hospital has a fully operational oxygen plant—a victory not only for patients in its oxygen therapy beds, but also for those at home and for the 15 health centers and various medic teams who rely on it to refill oxygen tanks.

The relief couldn’t come soon enough. The plant has provided oxygen therapy for more than 200 patients in Ascope and surrounding areas.

Carrión is one of those patients. His family goes to the hospital every week to refill his oxygen tank. Health workers also visit him at home to help him take his medication—part of the accompaniment that is key to Partners In Health’s work worldwide.

That care has sustained Carrión, in more ways than one.

“I feel calmer and safer,” he says. “Thank God, now the Rosa Sanchez de Santillan Hospital has an oxygen plant that allows me to continue living.”

After the devastating 2010 earthquake struck Haiti, health systems were fragile. Hospitals were destroyed. Clinicians lost their lives. And resources were limited.

Then, more than ever, spaces and systems needed to be revitalized to address the immediate and long-term health needs of Haitians. That’s when Hôpital Universitaire de Mirebalais and graduate medical education became a top priority for Zanmi Lasante, as Partners In Health (PIH) is known locally, and the Haitian Ministry of Health. On March 14, 2013, the hospital opened its doors to patients, providing services to more than 185,000 people in the region.

Since then, the hospital and its staff have achieved a long-list of accomplishments, contributing to a much-needed sustainable health system for local communities.

“Public-private partnerships lead to big change in low- and middle-income countries, such as Haiti,” says Dr. Sterman Toussaint, former director of graduate medical education at Hôpital Universitaire de Mirebalais. “This partnership model after the earthquake, in just a decade, has brought so much in terms of access to quality and diversity in health care and medical education.” 

A research paper, published in Academic Medicine and co-authored by Toussaint, who is currently PIH Liberia's director of clinical services and director of medical education, highlights those achievements, challenges, and lessons learned while bolstering graduate medical education and transforming the health system in Haiti after the 2010 earthquake.

Internationally Recognized, Haitian-Led Institution

The vision for Hôpital Universitaire de Mirebalais was always to meet international standards. And in 2020, it officially did when it became the first such facility in the Caribbean, and the first in a low-income country to receive institutional accreditation from an international oversight group. This prestigious milestone indicates that the hospital meets the highest standards for graduate medical education in the world.

“The accreditation highlights a decade of commitment from the leadership team in Haiti to making sure that the standards were put forward and upheld. Those standards are the north star in a lot of ways for the level of quality and commitment the institution strives for,” says Co-author Dr. Michelle Morse, assistant professor at Harvard Medical School and former deputy chief medical officer at PIH, and now chief medical officer for the New York City Health Department.

Like the students, those leading the residency program are all Haitian.

“The program was built by Haitians, led by Haitians, and graduates Haitians,” says Morse.

This significant achievement and model has helped carry Haiti beyond acute relief and toward a more reliable health system. Since 2012, the medical education program has trained 194 clinicians across 11 specialties and subspecialties, including surgery, pediatrics, and emergency medicine. Most graduates (77%) have stayed to work at clinics and hospitals in rural Haiti. And 75% of training programs are now led by alumni, according to Dr. Ornella Sainterant, Zanmi Lasante's director of medical education.

Additionally, all graduates have completed a required social medicine seminar and been evaluated monthly during their mandatory clinical rotation, as social medicine is considered one of the seven core competencies in resident training at HUM. This is a big deal, says Morse, who notes such a requirement doesn’t yet exist in many countries, including the United States. Social medicine brings a social science lens to training to help clinicians understand the full picture of disease, beyond medical symptoms. This includes factors such as education, economic status, nutrition, and structural forces driving poor health. Social medicine training is especially important for those caring for marginalized populations, the authors note in their paper. 

"Our hope for quality health care for all can only be realized through quality training of the future generaion of empathetic, committed, and highly qualified health care professionals," Sainterant says. "Over the past 10 years, we have proven that investing in high-quality of medical education following the ideology of social justice and equity in health care is successful."

Looking Ahead 

As the graduate medical education program continues to expand, leaders are working to strengthen the program through various strategies. Building on the institution’s accreditation, one of the next steps is to earn accreditation for individual specialties, explains Co-author Dr. Mary Clisbee, director of research and administrator for graduate medical education at Hôpital Universitaire de Mirebalais.

Another goal is to maintain retention of graduates in Haiti, especially in the public sector. Though there is a critical need for doctors, nurses, and midwives in Haiti, there are sometimes not enough available roles in the public sector, which drives clinicians to seek work outside of the country or in the private or nongovernmental sectors. Creating additional positions, based on projected population needs, will help create a sustainable work force and health care access for Haitians.

“We remain inspired and feel assured that the sustained commitment and solidarity demonstrated by all stakeholders will continue to flourish and transform health care in Haiti,” the authors wrote in their published paper.

On a sunny Wednesday morning, women of varying ages wait outside of a room tucked in a corner of Butaro Health Center.

Each woman is here for a breast cancer or cervical cancer screening.

Inside the room—dedicated for screening for women’s cancers—is a nurse named Raissa Umutesi, who has worked at the health center for 15 years.

One by one, Umutesi meets with the women and performs breast exams to check for abnormalities or lumps, along with pap smears to examine the cervix. Luckily, none of the patients today have symptoms of breast or cervical cancer—two of the cancers that most often affect women. After each screening, she records the patient information using a tablet.

Just a few years ago, she would have been writing those notes by hand.

Early Detection

Breast and cervical cancer are among the most common forms of cancer affecting women worldwide, making screening and early detection—including for women who appear healthy—critical.  

"Breast and cervical cancer can be cured when detected early," says Umutesi.

Across Rwanda, women can access free cancer screenings from Partners In Health, known locally as Inshuti Mu Buzima, in partnership with other NGOs and the Ministry of Health. These screenings are offered as part of Inshuti Mu Buzima’s Women’s Cancer Early Detection program, a Partners In Health initiative that connects thousands of women with lifesaving treatment. The program typically involves training community health workers and nurses to provide education, screening services, and referral pathways for patients who need further care.

Since the program expanded across five districts in Rwanda in 2018, there has been a significant increase in the number of women seeking cancer screenings. The influx of patients has, however, challenged record-keeping systems—historically, a logbook with hand-written notes about a patient’s personal information, test history and results, and next course of treatment.

For nurses like Umutesi, managing piles of logbooks was overwhelming. But what concerned her most was the risk of losing data and how that would affect a patient’s treatment.

“We receive around 100 women per month,” says Umutesi. “There was a big risk of losing patients’ information. The logbook can easily be lost and extracting information from multiple logbooks is hard.”

In cases where a patient had to be referred to another hospital, their history would often be lost, or key information would be lost in translation, which would hinder the patient’s treatment.

Now, Umutesi and other clinical staff have access to new technology that aims to fix this issue: mUzima.

A New Tool

mUzima is an app allowing health workers to collect and manage patient data on tablets. The app, which can be used offline, securely stores data and is synchronized with a national server on Open Medical Record System (OpenMRS), allowing different hospitals and health centers to access the same data. This ensures that patients with abnormal initial tests can be linked to timely diagnosis and care.

OpenMRS, co-founded by PIH, is tailored for use in developing countries. Today, organizations and governments in 64 countries use this program.

The mUzima app has another important feature: tracking a patient’s appointment history. For instance, if a nurse at a health center schedules an appointment with a specialist at a referral hospital, they will know if the patient attended their appointment, allowing them to follow up.

“Sometimes a patient faces a problem that prevents them from attending their appointment,” says Umutesi. “We get a notification and call them or contact a community health worker near them to know how we can help.”

Since its launch in 2020, the mUzima app has spread to 16 districts across the country. Partners In Health, in collaboration with the Rwanda Biomedical Center, Clinton Health Access Initiative, and Brigham and Women’s Hospital, has trained over 694 clinicians at 273 health centers and 22 hospitals, enabling the tablet-based tool to be routinely used in the cancer early detection program. And Partners In Health has donated 77 tablets to be used by health care providers at PIH-supported districts.

The impact of mUzima has been remarkable. From July 2020 to December 2022, 167,715 women accessed screening for cervical cancer and 89,449 were screened for breast cancer, according to OpenMRS data.

As Partners In Health continues to accompany Rwanda on the journey to enhance data-driven decision-making to improve health services and outcomes, mUzima is an important tool for managing patient data—and saving lives.

“mUzima application has revolutionized how we keep and manage data about patients,” says Umutesi. “It will benefit the patients a lot.”

Partners In Health continues to work with the Ministry of Health and other partners to expand use of this important application to all health centers in the country.

Ana Cecilia Ortega, a psychologist with Compañeros En Salud, as Partners In Health is known in Mexico, helps patients access care and support through the mental health program. Below, she shares a typical afternoon at a women's circle in Matazano, Chiapas, where community members gather to "socialize, share insights, relax, and cultivate a sense of community and belonging." 

It is 5 a.m. and Bernarda Roblero starts her day grinding corn to make tortillas for her three children's breakfast. The electric corn mills sound in unison—evidence that women wake up first in Matazano.

Matazano is a rural community in the highlands of Chiapas, Mexico, surrounded by mountains and trees. Walking down its dirt streets, you can hear the voices of young men sitting on their motorcycles, listening to loud music; they are outside the Ejidal house, where most of the men meet to make community decisions. On the next street corner, a group of men chat on the sidewalk, drinking beer and aguardiente. A few feet ahead, a bouncing basketball echoes across the court as some young men laugh loudly.

A few teenage girls watch the basketball game from the bleachers, and there are mothers walking around the court with their children, but most of the women are at home, doing housework and caregiving—making it difficult for them to connect with women outside of the family.

But there is a group of women in Matazano who are changing this dynamic and are connecting with other women in the public space.  

In a classroom at the local elementary school, more than 15 women arrive punctually to a group known as “the women's circle.” This time, they have to rearrange the space because the room where they usually meet is busy. However, they seem to adapt quickly; the younger ones help the older ones by pulling the desks into a circle so they can all look at each other. In the center is Bernarda, who works as a community mental health worker with Compañeros En Salud, as Partners in Health is known in Mexico.

Compañeros En Salud has worked in Chiapas, Mexico since 2011, providing health care and social support to thousands of patients in the rural, mountainous Sierra Madre region. Community health workers have been integral to that work, accompanying patients to medical appointments, helping them access medications, and checking in with them at home.

Since 2019, Compañeros en Salud has trained nine community health workers known as cuidadoras (Spanish for “caregivers”) in mental health interventions. The cuidadoras support patients as they navigate common mental health conditions, such as depression and anxiety, and help prevent these conditions in general by offering the women a source of community and support.

The women’s circle, which began last year, is crucial to that work, especially as women in Chiapas are disproportionately affected by mental health conditions due to poverty, gender inequity, and gender-based violence. 

Compañeros En Salud organized its first women’s circle in 2022 to provide a safe space for women to connect with each other. The women’s circles are facilitated by the cuidadoras, and all women interested in the community are invited to participate every two weeks. The circles offer a space for the women to socialize, share insights, relax, and cultivate a sense of community and belonging.

At the women’s circle in Matazano, the activity of the day is embroidery. Everyone receives a set of materials: colored yarn, cotton fabric, and wooden hoops. Bernarda begins the session by inviting the women to give a round of applause and then reminds them of the importance of respecting confidentiality in the group to ensure it is a safe space.

As the women start embroidering they begin to talk about how they have been doing. Bernarda asks questions to prompt conversation, such as “What is the most beautiful gift you have been given?” Some of the women remember gifts from loved ones who passed away. Others remember other types of loss, such as when a family member had to leave to work in the United States. Some participants share memories of gifts that remind them of when they felt loved by their spouses or children. During the sharing, some women smile wistfully; others let the tears flow.

After the women share their personal stories, Bernarda serves small cups of rice pudding. As everyone eats and mingles, she asks, "What things that we talked about today made you reflect or connect with your own story?" This question encourages the women to learn from each other. Many are surprised by the things they learn in the circle.

"We see each other on the street, but we don't know what's going on in each other's lives," says one participant.

Another one adds, “I now know that I am not the only one going through this.”

Most importantly, the circle offers a space in the community where women’s voices matter. Or, as a participant put it: "For me, the women's circle means friendship, unity, and trust."

When health worker Alicia Cortez set out to evaluate community needs in New Bedford, Mass., she was resolute that her own community should be heard. 

So, Cortez, working with a team of 11 other community health workers, known as the promotoras victoriosas, showed up at the fisheries and markets, shopping areas and public spaces where she knew people of Guatemalan descent gathered. This new effort, backed with training by the New Bedford Health Department and the U.S. division of Partners In Health, worked.

“We know where people walk around and at what times, so we would just stop them and ask them,” said Cortez, who was born in Guatemala and has lived in the U.S. since she was 8 years old. “We’d tell them we want to know how they feel about the health department, and ask if they know all the services available. … We said if they’d answer a few questions, it would open up doors to their health.” 

Barriers to Care

And open up they did. People cited an array of barriers to getting quality health care: inadequate transportation; no time off from work to see a doctor; a dearth of dental care; a lack of understanding from health officials when they had trouble understanding English-only materials; no insurance; fear of deportation; and cultural stigma surrounding illness. 

In the end, the PIH-trained promotoras, working with SouthCoast Health and the local health department, gathered over 800 of the more than 1,200 surveys collected from people detailing their health needs, challenges, and concerns about the system. Two years earlier, a different health assessment team, that didn’t lean on the expertise of the promotoras, collected only 430 surveys.  

Two-thirds of the recent survey respondents were Hispanic, women, and living with a median household income below $25,000. By comparison, in 2019, the vast majority of respondents were white, female, and highly educated. 

Marlene Cerritos-Rivas, PIH’s health equity program manager in New Bedford, said it was meaningful that the latest survey included communities that were previously overlooked. “To have their voices included, that was very important, “ she said.

“For the health department, but also for the community to know that the government wanted their input, wanted to know about the barriers. It was a very empowering experience.” 

The new data, which will be analyzed, verified, and ultimately used to inform future regional public health planning strategies, offers a deeper understanding of the demographic evolution of New Bedford.  

A City of Immigrants

Located in southeastern Massachusetts, New Bedford is home to about 105,000 residents, including approximately 5,000-10,000 undocumented immigrants. Like many other cities with comparable demographics, New Bedford has been hit hard by health crises, including the COVID-19 pandemic, the opioid epidemic, and homelessness, among others. As a result, according to the health department, New Bedford’s Hispanic population and other marginalized groups suffer from disproportionately poor health outcomes. 

To begin to address this, the health department hired three full-time outreach workers who provide services to community members in English, Spanish, Portuguese, and Cape Verdean Creole. And, in collaboration with PIH-US, the department provided training and employment to the promotoras in order to reach out to communities that had never before been asked for their opinion. This practice of hiring local community health workers to strengthen and broaden care is modeled off of PIH's work globally, where CHWs are a central component of every health care team.

The PIH-New Bedford partnership started in late 2020, as PIH began responding to requests for technical support from regions across the United States slammed by COVID-19. In early 2021, PIH-US recruited, hired, and trained a five-person team embedded in the New Bedford Health Department. The team’s full-time epidemiologist, contact tracer, community liaison, health equity specialist, and senior team leader began supporting all aspects of the city’s COVID response, but are now pivoting to support the development of a stronger, more equitable regional health system. 

“Our emergency response work in New Bedford has evolved into a longer term commitment to improving health equity,” said Katie Bollbach, executive director of PIH-US. “As we now work to address the underlying systemic issues that drove deeply inequitable COVID-19 outcomes, we’re deepening our partnerships in the city to ensure local expertise and experience are driving identification of new solutions to these long-standing challenges.”

A significant element of this strengthening involves gathering more input from people who are most affected by various health care policies and structures.  

Gaining Trust

So, Cerritos-Rivas said, in the summer of 2022, the promotora training began. “They practiced with friends and family and then began reaching out to the broader community, going to public areas, festivals, church, and then to the streets, to places with heavy foot traffic by the Hispanic community.” The promotoras, she said, reflect that community: they are predominantly from Central America, notably Guatemala and El Salvador. Four of the health workers speak K’iche, a language indigenous to Guatemala. “We’d had a hard time reaching out to the K’iche community,” she said. “There was a lack of trust.” 

Luisa Carina Raymundo, another promotora from Guatemala, said community members were motivated to speak to people familiar with their struggles and lived experience. “They do this because they believe that together we will be able to make changes and because they are tired of living in an oppressive system.” 

Raymundo, who was raised by a single mother, and has lived in New Bedford for the past four years, said there is significant fear in these immigrant communities. “One of the things that worries me is knowing that there are families that experience domestic violence and knowing that there are many children who are growing up in an unsafe family environment,” she said. “Many people are scared because they do not feel safe on the streets, and others cannot feel safe at home because of alcohol abuse or other problems.” 

Overall, the promotoras said, their goal is essentially to help people use the health care system to improve their daily lives. 

All of the information from the surveys will inform a comprehensive health disparities data analysis, documenting the impact of race and ethnicity on health outcomes in New Bedford.  

Based on this information, officials said, new recommendations on health policy and programming will emerge, “providing a blueprint to reduce, and ultimately eliminate, racially- and ethnically-driven health inequities.” 

The vision, added Alicia Cortez, is “to send a powerful message…this job, the work is very powerful and we can save lives.” 

As Partners In Health marks one year since the passing of Dr. Paul Farmer, we remember our beloved co-founder’s life and legacy—a force that planted the seeds of our community decades ago and continues to grow and guide us today.

From treating our first patients in Haiti in the 1980s, to urging global leaders to act in solidarity with the poor, to accompanying doctors on rounds, Paul put his values into practice every day. Those values—including a preferential option for the poor—inspired generations of doctors, nurses, patients, students, and more, creating a global community united by the belief that health care is a human right.

Paul held many titles and received numerous accolades throughout his life. But he accompanied patients and presidents alike, remembering faces, names, and details few others would. No one was a stranger to Paul—or, at least, no one was a stranger for long.

Paul may have left us in 2022, but his legacy lives on in every person, policy, and program he touched. His teachings—captured in books, speeches, and interviews—offer a reminder of our past and a roadmap for our future. Paul left an indelible mark not only on global health, but on our hearts and the hearts of everyone he healed and held, comforted and challenged, taught and tended to.

Below are excerpts from reflections written last year by those who knew Paul:

A Practice of Accompaniment 

Sheila Davis, Partners In Health CEO: 

“What inspired me most about Paul was his practice of accompaniment. He had a unique ability to meet people exactly where they were – no matter where that was – and sit beside them, with them, accompanying them. From community health workers, who are our true heroes and teachers as Paul would always say, to patients to colleagues – Paul would show up, listen, and make the person in front of him feel special.”

Bill Clinton, 42nd president of the United States, wrote a tribute to Paul. The following is an excerpt from TIME:

“But his voice still rings in our ears. All our lives are passing, but the purpose of living endures: to lift others and empower them to live and work just as he did—with love, gratitude, and joy.”

Claudine Humure, among Paul’s first patients in Rwanda in the early 2000s, who later worked at PIH’s University of Global Health Equity in Butaro:

“I was grateful to have been blessed to know him. He was truly a blessing. He first became my doctor, then he became my friend, then he became my colleague, and then he became a father. Our relationship was profound, and it is truly the definition of what he always taught his staff: accompaniment. The power of walking with those you serve and those you serve with. We walked the walk together.”

A Visionary with Moral Clarity

Matthew Bonds, associate professor of global health and social medicine at Harvard Medical School and cofounder of PIVOT:

"Paul’s genius was that he not only saw how each part of the system was connected—from frontline care providers to global funders to drivers, scientists, cleaners, and everyone in between—he knew how to fortify and grow those connections around a common moral clarity on behalf of patients everywhere."

Joseph Rhatigan, Jr., associate professor of medicine and global health and social medicine, and associate chief of the Division of Global Health Equity at Harvard Medical School:

“Hope, for Paul, was a moral decision.  He often told me that it was irresponsible for us, the privileged, to give into the temptations of cynicism and despair because there was so much we needed to do to address the situation of those suffering from poverty and disease.”

Regan Marsh, senior strategic advisor at Brigham and Women's Hospital and former director of clinical systems at PIH:

“He was ambitious about what must—and can—be done. He refused to be constrained by people’s lack of imagination. In making everyone a bit nervous with his vision, we achieved things that we were told weren’t possible. He told all of us to do what was needed, and that we would sort out the details later.”

Gregg Gonsalves, co-director of the Global Health Justice Partnership and an associate professor of epidemiology at the Yale School of Public Health, wrote a tribute to Paul published in The Nation. The following is an excerpt:

 “Gone now, I hope, is the idea of Paul as the good doctor, who is—was—there to make us feel like he was one of the better angels of our nature, a humanitarian who tended to the poor and sick, without making any claims on us.”

Jacklin Saint Fleur, chief of operations at PIH’s Hôpital Universitaire de Mirebalais in Haiti:

“Paul was a great father taking care of his family, a passionate physician who treated his patients with compassion, respect, and dignity, a great professor who helped his students mastermind the most complex concepts, and a loving friend with a great soul. A global health visionary  who dedicated his life to improving human health and advocating for health equity and social justice worldwide.”

Alicia Ely Yamin, PIH's senior advisor on human rights, wrote a reflection about Paul, published in English and Spanish on OpenGlobalRights. The following is an excerpt: 

“Paul had an extraordinary impact on everyone he touched in every corner of the globe, whether through his healing hands, his mentorship and friendship, or his inspirational writing. He literally connected the world through his work and his life, and continually showed us our common destiny and shared humanity. At a time when the world seems so broken, it could not be more urgent to carry forward Paul’s vision for human rights.”
 

Mark Brender, national director of PIH Canada, wrote a reflection about Paul Farmer, published on PIH Canada's website: 

“The tributes from philanthropists and colleagues and those who considered him a mentor all speak to a once-in-a-generation life cut far too short, a momentous global loss. But I don’t worry for PIH’s future without him. . .The movement will continue to grow and blossom, building on successes to show the world what is possible. That was always Paul’s plan.”

An Advocate for Patient-Centered Care

Tracy Kidder, bestselling author of Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, wrote a tribute to Paul in The New York Times. The following is an excerpt:

"Paul’s basic belief was that all human beings deserve equal respect and care, especially when they are sick. His dream, he once told me, was to start a movement that would refuse to accept, and would strive to repair, the grotesque health inequities among and within the countries of the world. When I first met him — in Haiti, in 1994 — he had already created a growing health care system in a desperately impoverished area. I thought he’d done a lot already. Now, looking back, I realize that he was just getting started."

Dan Palazuelos, PIH’s director of community health systems and assistant professor at Harvard Medical School:

"I lost my captain, my mentor, my trickster uncle, my great friend. I didn't think there would be much utility in grieving publicly, but I'm looking up from my grief to remember that what Paul wanted was incredible in its simplicity. His message was radical but straightforward: national borders, price points, patents, policy — everything is mutable if we focus first on how we treat one another.”

Cate Oswald, PIH’s chief policy and partnership officer:

“When I was going through the act of completing this work over the past many years I had not realized—until stepping into my current role dedicated to advancing our policy and advocacy efforts—that each and every action I was taking—that Paul had demonstrated to me first hand—was in and of itself advocacy. Patient advocacy. Leading with the patient at the center.”

Aaron Berkowitz, neurology advisor for PIH:

“His writings, the organization he built, and the community of practice he created will continue to inspire generations to serve those less fortunate than them, fight for health equity, and do what is good and just. But for those of us who had the chance to meet him even briefly, he will also inspire us to do as he did: lock eyes with everyone we meet, slow down the handshake, truly see the person in front of us, listen to them, and thank them for the work they do.”

Joia Mukherjee, PIH's chief medical officer:

“Everyone who knew Paul, knew how he lived in this space between sorrow and joy. For when we truly feel the pain of others—in our chest, in our bones—it is because we love; because our connection is rooted in the undeniable humanity of one another.”

Andy Wilson, PIH's chief development officer, wrote a reflection about Paul, published in Interfaith America. The following is an excerpt:

“Paul’s last text to me from Rwanda was a reminder of why we had to save this patient: “This is such a big part of our mission. You know, an antidote to despair.”

Alex Coutinho, former executive director of Inshuti Mu Buzima, as PIH is known in Rwanda:

“Paul died like he lived his life, at the frontline serving patients and always teaching and mentoring. The greatest lesson you could learn was to observe Paul’s interaction with the sick and poor and hungry. The love, compassion, care and reassurance he gave his patients was like a spiritual experience reminding us of how our patients and their many needs should always come first.”

A Revolutionary Caregiver

Jim Ansara, co-founder and executive director of Build Health International, wrote a tribute to Paul for WBUR's Cognoscenti. The following is an excerpt:

"Dr. Paul Farmer’s unreasonable vision about what was possible, and what could be accomplished has led to great advancements in the global health community, time and time again. From proving against conventional wisdom, and the scientific community, that multidrug-resistant tuberculosis could be treated successfully through a low-cost community health model, a program in Haiti to treat HIV/AIDS patients, building a hospital, cancer center, and then medical school in rural Rwanda, to leading PIH into an emergency Ebola response and then permanent programs in West Africa."

Gunisha Kaur, assistant professor of medicine at Weill Cornell Medicine and medical director at the Weill Cornell Center for Human Rights, wrote a tribute to Paul in TIME. The following is an excerpt:

"With his radical approach and generosity of spirit, he trailblazed a pathway for global health to be a social justice movement. Through his own work, and through the continued work of his students, he improved the life and wellbeing of countless patients across the world.”

Ashish K. Jha, physician and dean of Brown University's School of Public Health, wrote a tribute to Paul in The Atlantic. The following is an excerpt:

"He was unconstrained by small thinking. He rejected the artificial limitations we put on caring for the world’s poor—limits we would never put on ourselves or our families. He refused to accept the soft bigotry of low expectations. When HIV was devastating Haiti, the standard response in public health was to write off people, saying HIV therapies were too expensive and difficult to deliver to the world’s poor. So Paul set out to prove everyone wrong. He set up clinics and hospitals with a simple goal: deliver the same quality care that he provided when he was caring for patients in Harvard’s teaching hospitals. It wasn’t an easy task, but it worked. Tens of thousands of people received the latest HIV care. So many lives were saved."

Arachu Castro, a public health professor at Tulane University and former PIH volunteer and Harvard Medical School faculty:

"Paul was inspired by many but followed no one’s path. He treasured his family, friends, students, and, above all, his patients. Despite his premature death, Paul did manage to change the world, and his vast legacy will live on through generations."

John Green, bestselling author and longtime supporter of PIH:

"I don’t really believe in heroizing individuals, but Paul was, for me and for many, a hero. As a medical anthropologist and physician, he was deeply committed to the belief that all human lives had dignity and that every person deserves access to high-quality health care. He lived this belief for his entire career."

Michael Murphy, founding principal and executive director of MASS Design Group, wrote about Paul. The following is an excerpt from MASS Design’s newsletter:

“But the other lesson of why we were there—to ‘beautify’ the grounds of a rural clinic—is equally important. We have to remember that the person we lost on February 21st was not only a father figure and leader, a humanitarian, and a voice for change. Paul Farmer was also one of the greatest designers of our built world, one of the greatest systems thinkers to have ever lived. He was the kind of architect I aspire to be.”

Michelle Williams, dean of the faculty at Harvard T.H. Chan School of Public Health, wrote about Paul in The Boston Globe. The following is an excerpt:

"Paul Farmer never accepted the status quo. … Inequality is status quo. Racism is status quo. The notion that the poor will live in misery and die from diseases that are eminently treatable — that’s status quo too. And Paul would have none of it."

Hugo Flores, former executive director of Compañeros En Salud, as PIH is known in Mexico:

“Those of us who had the opportunity to know him saw that he never rested. He was always traveling, carrying the message, inspiring, seeking funds, envisioning what was impossible for many to achieve, a 3rd level hospital in the middle of Haiti, a world class university in Rwanda. I never saw him refuse his attention to anyone who wanted to talk to him, even if it was 2 o'clock in the morning. He always saw patients wherever he went.”

An Inspiring Teacher

Bill Gates, co-founder of Microsoft and co-chair of the Bill & Melinda Gates Foundation, wrote a tribute to Paul in The Atlantic. The following is an excerpt:

"There will never be another Paul Farmer. I will miss him deeply. I am comforted by the knowledge that his influence will be felt for decades to come. His work will continue through Partners in Health, and it will be carried on by the many people he trained and inspired."

Steve Reifenberg, a teaching professor at the Keough School of Global Affairs at the University of Notre Dame and a member of PIH’s Board of Trustees:

"His work in global health was transformative. He gave many of us working in the field a new vocabulary that overcomes ‘failures of imagination’ by seeing what is possible if we work together in partnership. His life and work embraced proximity to the poor and pragmatic solidarity. ‘It isn’t just signing a petition or voicing one’s displeasure or anxiety,’ he’d say, ‘but actually doing something with solidarity.’”

Katie Kralievits, Paul’s chief of staff:

“Paul taught us many things, but understanding what it takes to be a caring and loyal friend will be one of the most important lessons for me. In these last few weeks, while Paul was in Butaro, doing what he loved so deeply, he didn’t give me much to worry about. I could tell it in his voice during our daily calls. “Free for a quick hi?” we’d ask each other before dialing. (Paul wasn’t a fan of “cold calls.”) He was so at peace in Butaro, and so in his element. He was surrounded by cohorts of loving students, patients who needed his attention and care, and dozens if not hundreds of redwoods and rose bushes. The time he spent there was a gift he wholeheartedly deserved.”

Sriram Shamasunder, physician, associate professor of medicine at the University of California San Francisco, and co-founder and faculty director of the HEAL Initiative—wrote a tribute to Paul. The following is an excerpt from NPR's Goats And Soda:

"When I finished my residency, like so many physicians in my generation, I attempted to follow his example. I wanted to work in Haiti, where he started his organization Partners in Health in 1987. On a brief phone call, he instead enrolled me to work over the next year in rural Burundi, a place with even fewer physicians. Like so many before me, so early in my career, he made me feel as if I were making the only career decision that made sense—choosing what he called 'pragmatic solidarity' alongside the poor."

Vikram Patel, the Pershing Square Professor of Global Health in the Blavatnik Institute's Department of Global Health and Social Medicine at Harvard Medical School, wrote a tribute to Paul. The following is an excerpt from the Indian Journal of Medical Ethics:

“It was watching and learning, how you had transformed global health from a highly academic subject, typically taught in wealthy countries about the less fortunate peoples of the world, by scholars whose lives are disconnected from those peoples, into a subject suffused with rights, equity, dignity, inclusion, compassion, and most of all, outrage… .”

Junaid Nabi, a physician and senior researcher in health care strategy, wrote a tribute to Paul in STAT. The following is an excerpt:

"Farmer taught an entire generation of physicians to reimagine the practice of medicine and work toward treating the systems that surround patients, and not just the diseases they had."

Cameron Nutt, infectious disease fellow at Massachusetts General Hospital and Brigham and Women's Hospital and Paul's former research assistant, wrote a tribute to his mentor. The following is an excerpt:

“Those who stuck around, though, often learned remarkable things. More than simple facts about verdure, his lessons included metaphors for our own lives and shared work. Paul’s beloved giant sequoia, for instance, slowly grows its seeds in clusters of resin-covered cones high above the forest floor and holds fast to them for years. Through a property called serotiny, the tree releases these seeds, suddenly and all at once, only after exposure to fire.”

In November, the American Public Health Association (APHA)––the largest member-based public health organization in the United States––passed the policy statement A Strategy to Address Racism and Violence as Public Health Priorities: Community Health Workers Advancing Equity & Violence Prevention, acknowledging community health workers as a critical tool for addressing violence prevention and improving health equity. This comes on the heels of the APHA’s 2020 declaration that racism is a public health crisis.  

Public health advocates have long understood the link between structural violence in the United States and broader public health drivers like access to food, shelter, or employment. Beyond naming racism and violence as detrimental to public health, the new policy statement, written and prepared by the Community Health Worker section of APHA and endorsed by many organizations––including PIH-US––recognizes community health workers as a part of the solution to addressing these problems.  

Below, we summarize this statement and explain why it is important and what happens next.   

What does this new policy propose? 

The new APHA policy statement lays out a pathway to address violence and racism through a public health lens by partnering with community health workers. Community health workers, also known as promotoras de salud, as well as other members of the community-based workforce are frontline public health workers who are trusted members of and/or have a close understanding of the community that they serve. The authors of the policy statement recognize these community experts as integral to helping break through barriers left by systemic racism and structural violence in the United States.   

What gaps do the authors of the policy statement hope to address? 

The APHA’s new policy identifies gaps in past public health policies that have failed to address structural violence and have contributed to inequities in our public health and health care systems, including:  

• Partnerships that have prioritized (through funding, coordinated messaging, and staffing) large health care institutions over community-based organizations and trusted messengers in the community.  

• An over-emphasis on medical care, rather than addressing social drivers of health rooted in structural racism and structural violence.  

• Inequities in access to health care and financial resources.  

• Inequitable research practices that perpetuate racial biases through the research conducted, authors of that research, and, ultimately, programs funded and implemented. 

The new policy statement recognizes that although community health workers are equipped to respond to the social determinants of health, bring cost-savings to the health care system, and intervene both on structural racism and violence, as a workforce they face many barriers to success, including:  

• Lack of recognition or support from public health, health care, and other sectors addressing social determinants of health.  

• Lack of consistent, sustainable funding for community health worker programs and activities. 

• Chronically low salaries and inequitable pay.  

• Over-medicalized community health worker training, rather than training that emphasizes community knowledge. 

Why did PIH-US endorse this policy? 

The new policy statement from APHA acknowledges structural violence and identifies community health workers as a core part of the work to combat structural violence and deliver on health equity. Since 2020, PIH-US has applied lessons from our global work to lift up this critical workforce throughout the COVID-19 response and beyond.  

The statement directly supports the efforts PIH-US has been engaged in to expand the community health workforce across the country. Now, we plan to leverage the recommendations within the policy and to continue to advocate for sustainable investments in community health workers.  

In addition, some of PIH-US’s experts contributed to the author’s work. 

Why is the APHA’s passage of this policy significant?  

Though statements like this don’t change governmental policy, they do offer recommendations for policymakers, public health departments, and other actors. As one of the most influential organizations in public health in the United States, the APHA’s stance matters: when the organization takes a decisive policy position, it broadens the opportunity for research, advocacy, and more on the topic. This statement, voted on through the APHA’s democratic processes, added a new perspective to the conversation about community health workers, focusing on this workforce as a way to address structural racism, community violence, and health inequity in the United States.  

Now that this policy has been adopted by the APHA, what impact can it have on health?  

Now that this statement has been recognized by the APHA, it is on the shoulders of public health practitioners at the community, state, and federal level to put this plan into action.  

The APHA policy recommends that Congress pass legislation to support community-based organizations to hire community health workers and strengthen efforts to address racism and violence in communities across the country. APHA also recommends that state legislators follow suit. It calls for community health worker associations to implement trainings on violence prevention and structural racism, for philanthropic entities to help fund those trainings, and for higher education institutions to integrate into curriculums the importance of community health workers in addressing structural racism and violence prevention. 

PIH-US urges recipients of CDC funding for public health infrastructure to consider the importance of investing in community health workers, via partnership with community-based organizations, for long-term health equity.  

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Authors, contributors, and endorsers of A Strategy to Address Racism and Violence as Public Health Priorities: Community Health Workers Advancing Equity & Violence Prevention:

• Authors: Rumana Shams Rabbani, CHW-VPP, MHA, PhD Student, RWJF HPRS; Abdul Hafeedh bin Abdullah, CHW-VPP; Dannie Ritchie, MPH, MD; Cynthia Williams, PhD; Keila Marlin, MPH; Noelle Wiggins (Advisor), EdD, MSPH
• Contributors:  Angie Kuzma, MPH, CHW; Evan Richardson, RN, MSN, CNM; Dina Ferrenti, RN, PhD; Charlie Bruner, PhD; Honey Estrada, MPH, CHW; Marcia Morales Villavicencio, CHW, MPH;  Jamie Santana, CHW; Maria Lemus, Promotora; Ashley Rodriguez, CHW; Justin Mendoza, MPH; Devin Worster, MD, MPH; Ali Bloomgarden, MA; Brenda Galloway, CHW-VPP; Vance Williams, CHW-VPP, Keshana Owens-Cody, HRM; Dwight Myrick, CHW-VPP; Juliette Jenkins, PhD, MSN; Teresa Campos-Dominguez, CHW; Jennifer Norville, BS; Mae-Gilene Begay, MSW, CHR; Maria Velasco, MA, CHW
• Governing Councilors: Mae-Gilene Begay, CHR; Maria Hererra, Promotora
• Special Acknowledgements: Betsy Rodriguez, RN, BSN, MSN, DCES and Refilwe Moeti, MA; Center for Disease Control & Prevention
• APHA Endorsements: Maternal Child Health Section, Public Health Social Work Section, Oral Health Section, Family Violence Prevention Caucus, Women’s Caucus, Men’s Caucus, Law Section
• External Endorsements (prior to policy being passed): Community Healing through Activism + Strategic Mobilization, NC Area Health Education Center, NC CHW Association, Partners In Health, Common Indicators Project, The University of Wisconsin Population Health Institute

For years, the Pleebo Health Center laboratory consisted of a single room. In that room, limited medical testing occurred for more than 50,000 Liberians. Although the laboratory was functional, it faced many obstacles. 

For example, specimens couldn’t be processed there. Instead, they were taken to Partners In Health (PIH)-supported J.J. Dossen Memorial Hospital in Harper—about 16 miles away. There were often delays, which meant the samples had to be recollected. And, clinicians were unable to test patients on-site for tuberculosis or HIV (both common in the region). The necessary machines weren’t available. The lack of space and limited diagnostic equipment were major challenges for both clinicians and patients.

In 2022, significant improvements were made: more space and stuff were added—two of the five S’s essential to strengthen health systems. Now four rooms, the laboratory is also equipped to test blood, urine, and hemoglobin A; and diagnose tuberculosis and HIV—which wasn’t possible before the expansion. 

Often overlooked, labs are critical for diagnosing a patient’s condition, explains Isaac David, Jr., officer in charge at Pleebo Health Center. 

“The lab is now closer to those who cannot afford to travel to far places to do their tests. The tests are also free…and treatment is provided 24/7,” says David, Jr.

Laboratories run tests related to disease prevention, diagnosis, and treatment. With the expanded space, the center is able to hire enough laboratory personnel to quickly assess and identify potential health problems. Notably, the lab can now test viral loads—the amount of virus detected in patients with HIV. The optimized space is also newly equipped with machines such as the GeneXpert machine, which is used to diagnose and monitor the treatment of tuberculosis; and a complete blood count machine to measure red blood cells, white blood cells, and platelets. 

With these improvements, staff are encouraging community members to use the free health services. 

“Our goal is to give preferential diagnostics to marginalized [people]. Pleebo Health Center has a high patient load, which means they are not getting the ideal patient care. For us, we are improving diagnostics. It means the patient gets the right treatment and care because of the right diagnostics,” says Arnold Ayebare, PIH Liberia’s laboratory manager, who oversaw the expansion project.

Dr. Shada Rouhani thinks about emergencies often: How to prevent them, manage them, and better equip doctors and hospitals to handle them. 

As Partners In Health’s director of emergency care, Rouhani has, for many years, been deeply involved in developing innovative ways to deliver high-quality emergency care within resource-limited settings. 

From 2013-2018, she was the co-director of the department of emergency medicine at Hôpital Universitaire de Mirebalais [HUM] in Haiti, a national teaching hospital run by Zanmi Lasante, PIH’s sister organization. There, Rouhani helped establish the first emergency medicine residency program in Haiti, at HUM, and continues to research the burden, epidemiology, and costs of emergency care globally. Since 2018, she’s helped PIH sites around the world strengthen their emergency care programs. 

Rouhani recently returned to Boston from Sierra Leone, where PIH is rolling out an emergency medicine certificate for local health workers. We spoke to her about the importance of emergency medicine and how it’s evolving around the world. 

Why Does Emergency Care Matter? 

Emergencies happen everywhere and they happen to all of us. But where you are in the world when an emergency happens disproportionately determines your outcome.  No matter if we are talking about trauma, or acute exacerbations of a non-communicable disease like asthma or heart problems–when it comes to emergencies, the outcomes for patients in middle- and low-income countries are worse.  

How Much Worse? 

Much worse.

The overall burden of emergency disease is estimated to be four-to-five times higher in low-income countries compared to high-income countries. But the availability and quality of emergency care is very limited. One study found that the death rate in emergency departments in low-income countries was 45 times higher than in the U.S.

Over half of the entire, worldwide burden of disease could be treated with emergency care. That translates into over 28 million deaths annually from emergency medical disease. 

There is a tremendous unmet need.   

What tends to contribute to this higher mortality in countries with fewer resources? 

Simply put, people don’t have access to high-quality emergency care, or any emergency care at all. Despite the higher burden of emergency disease, emergency medicine is much less developed in lower income countries.  

It starts with the spaces: many hospitals don’t have emergency rooms at all, or people may have to travel great distances to reach care.  

Even where there is an emergency room, it often lacks the key components needed to deliver care. There are typically fewer staff, who are usually not trained to deliver emergency care. Facilities lack supplies—and we’re not talking about fancy machines here. Facilities don’t have the basics, like IV fluids, antibiotics, and oxygen. In many ERs, when these supplies are not available and you come in for a crisis, the doctor has to hand you a prescription to go buy IV fluids, antibiotics or basic supplies like gloves so the doctor can examine you. Even if a family member has money to go and buy those supplies for you, by the time they come back it may be too late. The supplies need to be in the emergency department so they can be used immediately when needed. And they can’t be dependent on someone’s ability to pay.  

Finally, emergency care systems are often less developed. Simple procedures that help you quickly assess and diagnose a patient can make the difference between starting a treatment right away or not. And though it sounds cliché, in emergencies, minutes matter. So those systems, those delays, can be the difference between life and death.  

How does this two-tier system play out? 

Take the example of triage. In the U.S., when you’re in the ER, when you get seen is based on how sick you are. This makes sure the sickest people get immediate treatment. That’s a system we take for granted. In most low-income countries that doesn’t happen. You come and you wait in line. People die waiting in line. You need a triage system and the relative cost of that is minimal.

Is emergency care all about trauma?  

Trauma is one part of emergency care, but only a small part. In Haiti, for instance, only 20% of emergency patients are suffering from traumatic injuries. Most often it’s heart failure, hypertension, pneumonia, tuberculosis, cancer, and other issues that bring people to the ER. Often, it’s exacerbations of chronic conditions.  

Think of asthma. Asthma can often be controlled with medications you take at home, but if you have a severe asthma attack, that’s an emergency and you need emergency treatment. During acute exacerbations like this, patients need emergency care to stay alive, and whether that’s available heavily influences your mortality.  

How does the ER fit into the overall health system? 

We generally think of emergency care for accidents, heart attacks, and acute health events. But its role is so much bigger. The ER is a plug-in to the health system. In many parts of the world, people are unable to seek routine preventative care. It costs money to get to a hospital and it means time away from work. So, they just go in when something’s wrong, and that generally means when something is acute, so they end up in the ER. The ER fixes the acute problem, but it can also help people to plug into more routine care to reduce future crises. We diagnose many chronic conditions like diabetes, heart disease, high blood pressure, and TB/HIV for the first time in the ER. Strong emergency care can educate these patients and connect them to long-term preventive care, which can transform and improve their lives. 

In addition, the ER department touches every part of the hospital—the lab, radiology, in-patient, and other systems. Strengthening emergency care works to strengthen reciprocal operations and tends to elevate the rest of the hospital. 

You oversaw the development of an improved ER system in Haiti after the 2010 earthquake. Talk about the before and after there. 

Haiti is a great example of what is possible–so much has improved in terms of capacity there. When the devastating 2010 earthquake happened, there were no Haitian emergency physicians in the country. Hundreds of thousands of people died, and who knows how many of those people might have been saved if immediate high-quality emergency care was available.  

The ER residency began at HUM in 2014 and has been graduating Haitian emergency physicians since 2017. It is fully self-sustaining and entirely Haitian-run since 2018. The HUM graduates now work throughout the country, strengthening care in many emergency departments.  

As many people know, Haiti unfortunately was struck by another earthquake [in 2021]. But the difference in access to emergency care in 2021 compared to 2010 was like night and day. Haitian emergency physicians—all of whom graduated from HUM since 2017— were involved in the response in so many ways, from working at a major referral hospital near the earthquake to receiving patients at other hospitals around the country to accompanying them in the air ambulance in between.

And they provided high-quality, top-notch emergency care in every one of those roles.   

For people in the U.S. and other wealthy countries, what do we need to understand about ER care in lower- and middle-income countries?   

First, you need to understand that the space and the staffing are very different, which translates into different care. When people in the U.S. think about emergency rooms, they think of arriving first in an area where cases are triaged to determine who needs to be treated first, then eventually going to a private treatment room to be seen by a provider. In the US, the vast majority of emergency patients are seen by emergency physicians, with specialized training in the diagnosis and management of emergent conditions.  

Compare that to many low-income countries. In many hospitals, the emergency room is just that: a room, usually a small room with three or four beds crammed in; there may be a nurse assigned there, but the doctor or provider is probably responsible for other parts of the hospital and occasionally stops in the ER. They probably don’t have any specific emergency training. This leads to people being misdiagnosed, because people come in with symptoms rather than a label saying what their problem is. For instance, if someone comes to the hospital because they can’t breathe it could be pneumonia, heart failure or even a car accident leading to a collapsed lung. You need someone trained to discern between these because the treatment for each one is incredibly different. You also need someone trained to start treatments right away before all the test results come back— in the ER you need to be diagnosing while you are intervening.  

Is there anything currently underway to improve ER care at PIH sites? 

Lots. The emergency medicine residency continues to train new providers at HUM in Haiti, and we have a new emergency ultrasound fellowship there that is training Haitian emergency physicians in advanced diagnostic skills. PIH-Sierra Leone just launched a certificate in emergency care—a 12-week course focusing on the most essential emergency care. It’s training the frontline ER providers at Koidu Government Hospital as well as students who will go on to practice in different locations. The team there also just finished a national survey of emergency care capacity around the country that will help guide future national planning. And those are just some of the activities–our teams in Liberia and Mexico also have ongoing trainings as well.  

All of that,  is only the tip of the iceberg of what is needed. Within the next five years, we hope to find the resources to expand trainings and systems even further and make PIH facilities national training hubs for emergency care.  

At Partners In Health, 88% of doctors, nurses, and other clinicians are from the countries where we work. In Haiti, our staff is 99% local.

Local staff are essential to what we do and the care we deliver at PIH: They speak patients’ language. They understand patients’ cultures. Often, they grew up in patients’ communities themselves, making them familiar faces and more readily trusted.

A deep understanding of language and culture is crucial to delivering health care that is respectful and effective. For example, handing out flyers with health information is ineffective if not written in a language patients can understand or if they are illiterate. Even opening a hospital or clinic is insufficient in communities where distrust of health care runs deep, due to histories of violence and discrimination at medical facilities.

Hiring locally is also important from an economic perspective, providing job opportunities in communities that have little to no formal economy. Income generation helps lift families out of poverty, enabling them to buy food and other necessities, pay for school fees, and improve their quality of life.

From Haiti to Peru to Rwanda, local staff are the lifeblood of PIH and enable us to provide care that is culturally relevant and effective.

Here are three ways we hire locally:

1. Clinical staff

In the 11 countries where we work, the vast majority of our doctors, nurses, psychiatrists, and other clinical staff are hired locally, enabling them to deliver care in patients’ languages and with deep cultural understanding. Our clinical teams partner directly with ministries of health, supporting governments as they work toward universal health care coverage. Our teams also meet regularly with local leaders and community organizations to understand communities’ needs.

Drawing on their shared cultural identities and our ethos of accompaniment, our clinicians build trust with patients and communities, leading to culturally relevant models for care delivery. In Mexico, Haiti, Liberia, and Sierra Leone, our clinical staff includes traditional midwives, whose healing and birthing practices have shaped maternal care there for centuries. In Chiapas, Mexico, our traditional midwives assist with facility-based births and help patients feel more comfortable giving birth in Sierra Madre communities scarred by histories of patient abuse and forced sterilization at hospitals.

2. Community health workers

At PIH, we don’t just care for patients in clinics and hospitals—we knock on their doors. This outreach is carried out by our 10,000 community health workers. Known in Mexico as acompañantes, in Peru as agentes comunitarios, and in Haiti as accompagnateurs, these workers are hired directly from the communities where we work and trained to provide basic health services, such as delivering medication, accompanying patients to appointments, or visiting patients at home to check on their mental and emotional health.

Community health workers have been central to our work since it began in Haiti in the 1980s. They are trusted neighbors, enabling them to build relationships with patients in ways no other staff can. And they bring deep cultural and community expertise to their work, delivering care in ways that patients can most easily receive it.

3. Support staff

Health workers aren’t the only local staff who make our work possible. Drivers, cooks, janitors, and other support staff enable lifesaving care and resources to reach our patients, wherever they are—and these staff members, like community health workers, are 100% local.

PIH has always provided more than medical care. In all communities where we work, we offer food, housing, transportation, and other essentials, which we call social support, tackling the systemic barriers to health care. Our support staff make this work possible. From cooks serving culturally appropriate food in our hospital cafeterias to drivers accompanying patients during doctor’s visits in communities far from home, support staff work tirelessly to create an environment where patients feel safe, welcomed, and respected.

Content warning: This story relates to suicide.

As the clock struck midnight, Brenda Mijahuanca ate 12 grapes while sitting under the table, celebrating the new year and reflecting on her resolutions—a tradition in Spain and several Latin American countries.

She once didn’t know if she would make it this far.

2022 had been a year of struggle—as a transgender woman, as a sex worker, as a daughter disowned by family. And she was used to struggling alone. No one to call. No one to check on her. No one to care for her.

The struggles had compounded over the years, too. First, it was a nasty case of COVID-19. Then, debt and bouts of homelessness. Then, what felt like the unthinkable—an HIV diagnosis.

Month after month, Mijahuanca fell deeper into depression. Some days she didn’t want to take her pills, prescribed for HIV, tachycardia, and hypertension. Every day became a battle—and she felt like she was losing. The dark thoughts grew louder and all-consuming. She began to think about ending her life.

“At any moment, I could get very sad,” she recalls. “I felt like not existing and not living anymore.”

In August, she heard about a mobile health clinic run by Socios En Salud, as Partners In Health is known in Peru, where tuberculosis (TB) and HIV screenings were being offered free-of-charge. And these diseases weren’t the only ones addressed at the mobile clinic. There, Mijahuanca received a screening that revealed another health condition: depression.

A Silent Crisis

Depression affects 280 million people worldwide, including more than 1.7 million in Peru. It can cause a loss of interest in activities, poor concentration, feelings of low self-worth, hopelessness, and, in its most severe form, can lead to suicide. Although treatment exists for depression and other mental health conditions, 80% of Peruvians lack access to it.

Mental health conditions are especially prevalent among people who identify as transgender due to stigma, discrimination, and violence. On the streets of Lima, 86% of transgender women report having faced discrimination. And more than half have experienced domestic violence, according to a survey conducted by Socios En Salud and Féminas Peru in 2020.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant TB in Carabayllo. For decades, its mental health team has delivered care to patients—including transgender women—in Lima and beyond. Mental health care is integrated into care for maternal health, tuberculosis, chronic diseases, and more.

In 2021, the mental health team provided more than 146,000 screenings in Lima and Trujillo and more than 41,400 mental health consultations. The team also works closely with other programs at Socios En Salud, including JunTrans, formerly known as Féminas, which supports transgender women.

Mijahuanca was one of thousands of patients who accessed a mental health screening from Socios En Salud last year—opening the door for life-changing care.

A Care Plan

Just days later, Mijahuanca received a phone call from Socios En Salud Psychologist Dr. Maria Fernanda Amézquita Olivares, who wanted to learn more about her experience with depression as well as provide basic education about the condition.

Mijahuanca was anxious at first; but as Olivares continued speaking, she felt more at ease.

“Maria gave me a lot of confidence every minute that passed,” Mijahuanca recalls, “because she provided me a lot of security and support and I felt that she really wanted me to keep going.”

They set up a time for a weekly therapy session. Each session would be an hour; the therapy would last two months.

Socios En Salud also helped Mijahuanca access other forms of support, including a support group for transgender women, home visits by a community health worker, and essential resources such as food, which is one of several ways in which PIH provides social support.

Over the weeks, Mijahuanca’s progress was notable.

“The first time I talked to Brenda, she was showing signs of depression and a deep sadness,” says Olivares. “But in the last session, she was totally different—a more recovered personality, more animated, with a more hopeful vision… I feel very proud of Brenda.”

Mijahuanca feels proud of herself, too. The depression is still there, but it is more manageable. And things are looking up.

She finished paying off her debts. She has her own apartment, where she lives with her dog and cat. For emotional support, she leans on friends and her partner. And she turned 35 this year—a birthday that is beating the odds. Across Latin America, most transgender women don’t live past their 35th birthday.

As for new year’s resolutions, Mijahuanca has a few dreams she’s working towards, including one day opening her own bar.

“There were days where I only thought about no longer existing, I had no energy, and I didn’t feel like myself,” she says. “Now, I see myself. I am a girl who wants to get ahead by herself. I am an encouraging person. I like to motivate the people that I appreciate and love. I like to set goals and projects for my life.”

Accessing mental health care was critical to turning things around.

“I no longer lack energy, feel crestfallen, and I am no longer thinking about negative things,” she says. “If anyone is going through the same thing or something similar, without a doubt, I would tell them to seek help.”

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

In November, when Dr. Marie Djenane José arrived for her first day on the job as director of the pathology lab at Hôpital Universitaire de Mirebalais (HUM), she was surprised to find a fairly well-equipped laboratory that met international standards.

The problem wasn’t the equipment, she said, but the lack of sufficient training for the technicians operating that equipment. This training gap, and other issues, led to a backlog of more than 500 specimens awaiting macroscopy, the slicing and processing of tissue samples so they can be examined on a slide for cancer or other diseases.  The backlog was exacerbated by the resignation of a previous pathologist months earlier and a chaotic system for identifying tissue samples awaiting analysis.

José sprung to action.

Her first move was to triage the specimens, prioritizing which, among the oncology, gynecology, and surgery cases, were possible cancers or other diseases requiring immediate attention. 

Then, she developed a plan to improve the technicians’ training so they could take on some of the critical work of the pathology lab, including a more in-depth study of human anatomy, tissue analysis, and the art of slicing and dicing, called “grossing.”

A Dearth of Pathologists

Her vision, José said, is to lay the groundwork for a residency program in pathology at HUM. With about six pathologists in all of Haiti, a country of 13 million people, “the country needs it,” she said. Indeed, delays in cancer diagnoses can mean the difference between lifesaving treatment or death, if tumors grow or cancer spreads while patients await medical interventions.  

A future pathology residency would add to a number of residency programs at HUM, the teaching hospital run by Zanmi Lasante, Partners In Health’s sister organization in Haiti, including in emergency medicine, surgery, internal and family medicine and obstetrics and gynecology.

Prior to José’s arrival, HUM was relying on a patchwork system of pathology that, as one doctor put it, “wasn’t perfect or permanent…but a mini-miracle in the context of everything happening in Haiti,” including escalating chaos, violence, kidnappings, and a lack of resources from fuel to electricity that impacted all departments.  

HUM’s pathology lab, which opened in 2016 within the Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory, helped accelerate cancer diagnoses by allowing many tissue samples to be analyzed locally, rather than mailed to hospitals in Boston, where volunteer pathologists reviewed and diagnosed the biopsied samples.  

A Telepathology Fix

Expectations among doctors and technicians rose when a tissue scanning machine was donated and delivered in 2019 to the pathology lab by the American Society for Clinical Pathology, arranged by its former chief medical officer, Dr. Dan Milner, who, with others, had consulted on the original pathology lab design. Milner said the scanner couldn’t be installed until 2021, when a visitor was able to travel to Haiti to support the process.

The problem, yet again, was training: no one knew how to operate the machine.

Frustrated that patients were waiting far too long for diagnoses, Rebecca Henderson, a University of Florida medical student, anthropologist, and long-time volunteer at HUM, taught herself how to operate the scanner and then trained several HUM staff in the basics. Henderson relied on 24/7 technical support from the scanner’s manufacturer when it broke or bewildered staff, she said. That support allowed the establishment of a rudimentary, but functional, telepathology system, anchored by the Haitian team.

"The technicians took on the challenge of mastering a difficult new piece of technology, made more difficult by Haiti's fragile electric grid and difficult internet infrastructure,” Henderson said.

HUM technicians started preparing and scanning tissue sample so that pathologists at Brigham and Women’s Hospital in Boston, which has a long-standing collaboration with PIH as part of the Global Health Delivery Partnership, could read and analyze them. Last year, for instance, more than 1,000 tissue samples were viewed by the Boston pathologists, said Dr. Jane E. Brock, chief of breast pathology division at Brigham and Women’s, who leads the team assisting HUM. Nearly half the tissue samples were cancerous, Brock said, most of them breast cancer, or cervical cancer, which are by far the most prevalent cancers for women in Haiti, according to the WHO’s International Agency for Research on Cancer.

The current system still involves mailing certain tissue samples to Boston. That’s because breast cancer requires more complex evaluation, what’s known as immunohistochemistry, a special process of staining that shows whether the cancer cells have certain hormone receptors, which can be crucial in determining a treatment plan. That means every breast tissue sample must be shipped to Boston for analysis in order to determine what treatment options to pursue. This can take several weeks for a complete diagnosis.

Still, Brock said, telepathology means that what used to take months, now takes weeks.

“Without the Boston pathologists,” said José, “I believe the [HUM] lab would have been totally dysfunctional.” Ultimately, with their additional training, HUM technicians will be handling the tissue samples while José and future Haitian residents will be able to analyze more routine cases, and only the very complex cases will need the Boston pathologists.

Top-Notch Training

José has seen up close the difference that top-notch training can make. She completed her medical studies at the Université Notre Dame d'Haïti  and pursued a residency program in pathological anatomy at the Hospital of the State University of Haiti, which, she said, “has serious problems of equipment, infrastructure, supply.”

Subsequently, José won scholarships in Martinique and Lille, France, at university hospitals equipped with state-of-the-art laboratories with immunohistochemistry and genetics.

“I was able to see the world of difference between these laboratories and those we had at the time in terms of infrastructure,” she said. “The HUM laboratory has at least a standard basis but requires more equipment and trained personnel. I dream that Haiti can have a pathology laboratory worthy of the name to conduct cancer research with a Haitian tumor bank.”

This dream aligns with PIH’s mission to offer “a preferential option for the poor.” But sometimes it takes time to get there. For people with cancer in Haiti, for example, there is no radiation treatment, and some of the newest, most effective chemotherapy drugs are financially out of reach. Still, cancer care at HUM has radically improved over the years, said Dr. Joarly Lormil, HUM’s chief of oncology, who recalls when he was a resident, and whole specimens, indeed every specimen, had to be sent by mail to Boston. “But hopefully,” he said, “with this new team and the current momentum, things will improve considerably.”

One thing that has already improved is the training and communications. Chantale Bellevue and Myrlene Mompremier worked for HUM in various capacities before entering the field of pathology; Taina Saint Jean, a medical assistant, is also studying to become a pathology technician.

In November 2022, Bellevue traveled to Boston for additional training, working with pathologists, including two who spoke Haitian Kreyol, to learn the latest techniques. This training, Bellevue said, “taught me how to do my job better…[and] bring those skills back and make our lab stronger.”

More training came by way of physicians at the University of Pennsylvania’s Perelman School of Medicine, who developed simple visual guides for macroscopy for the HUM technicians.

Still, said Marcellus: “Our training isn’t finished. It’s always continuing…and with telepathology, the patients can get their results so much more quickly.”

Faster Diagnoses

More support is needed. Lormil said in addition to faster turnaround time for specimens in oncology, a systematic method of entering pathology reports onto the digital electronic medical record is critical. And, he said, he’s eager to start using available technology, such as a GeneXpert platform cartridge that can perform all of the immunohistochemistry tests needed for a personalized breast cancer diagnosis on site.

Arranging for the distribution of these cartridges to HUM is underway.

“I'm really excited about the momentum we have in pathology,” Lormil said.  “And I hope that we will push it further. There are fewer and fewer pathologists in Port-au-Prince, and access for patients is increasingly difficult. It imposes on us, I believe, a moral duty to provide these services, with the highest possible standard.”

The following photos and story are by Thomas Patterson, PIH photo editor.

"The government needs the helicopter," Partners In Health (PIH) Lesotho Communications Officer Mpho Marole said, "so we're driving there instead."

For cross-country journeys, sometimes there's a spare seat or two on a government helicopter heading over the Maloti Mountains to the remote villages of eastern Lesotho, but during the week in August when I was there, it was being used for training.

More often, PIH drivers take clinicians and other staff members on this trek. So, dark-and-early one morning, Marole, PIH Lesotho Chief Medical Officer Dr. Afom Andom, PIH Lesotho Director of Policy and Partnerships Danielle Sharp, Videographer Caitlin Kleiboer, Driver Matlosa Phakisi, and I piled into a PIH truck and headed east out of the capital, Maseru, up into the mountains on one of the country's few paved highways. 

Lesotho is a small, landlocked country surrounded by South Africa, with a population of about 2.2 million. Our destination, PIH-supported Lebakeng Health Center, is only 130 or so miles away as the crow flies. But due to winding, washed out, boulder-strewn mountain roads, and the unpredictable nature of waiting for a hand-rowed ferry across the Senqu River, we expected the journey to take four or five hours. Lebakeng Health Center is one of seven small but vital sites offering comprehensive health care in a joint program with Lesotho's Ministry of Health called the Rural Health Initiative. 

Our first pit stop was at a lodge in Semonkong, in the center of the country, high in the mountains. Semonkong means "site of smoke" in Sesotho, the local language, deriving its name from the mist of the famous Maletsunyane Falls nearby. Unfortunately, viewing the waterfall itself requires a half-hour hike from the lodge, and we were in such a hurry to cross the country with enough light left in the day that we had no time for tourism. As Lesotho is in the Southern Hemisphere, August days are rather short.

After an hours-long final stretch over rock-strewn, deeply rutted roads, we reached the Senqu River. On the shore we met Mahase, a PIH employee, who helped us into his boat and rowed us to the other side, as he did all travelers who sought health care at Lebakeng Health Center.

​​​​​​From there, a steep hike up out of the canyon and onto a narrow ridge where the health center and adjoining airstrip lay.

All told, our journey from Maseru to Lebakeng Health Center took more than seven-and-a-half hours. Whereas we had (mostly) motorized transportation to take us to Lebakeng, many of the patients we met there were mothers who had also spent hours traveling that morning, but on their own two feet, babies on backs, to get pediatric checkups for their children.

Other people had traveled a long way to access health care at Lebakeng as well, for a variety of needs. In an area of rural Lesotho that truly feels like a medical desert, Lebakeng Health Center provides an oasis, a small community of accompaniment, with services from obstetrics to radiology, all in one place.

After a long afternoon meeting with patients and the clinicians serving them, we hiked down the hill, rowed back over the river and drove to the border town of Qacha's Nek to spend the night. The next day we drove a few hours to Nkau Health Center, another clinic in the Rural Health Initiative.

Day after day Johnson Doe and Saturday Wesseh prayed for a cure. They hoped to ease the pain of their chronic conditions and live healthy lives outside of the hospital. Their friendship grew stronger as the days and weeks passed. 

There was a natural connection between them, given their many similarities. They are both in their 50s, fathers, with the same diagnosis: a dangerous infection. Upon being discharged from Partners In Health (PIH)-supported J.J. Dossen Memorial Hospital, they got to know each other on a more personal level. 

“[We] do almost everything together,” says Wesseh, who considers Doe to be his brother. From playing games and running errands to checking-in and giving advice, they’re inseparable.

Wesseh and Doe are roommates living in rural southeast Liberia. After they showed consistent signs of improvement, they were transferred from the hospital to temporary PIH-supported housing. Wesseh moved in first, then to his surprise, Doe joined about a year later.

“When I saw him I was happy for him to come and join me,” says Wesseh.

Healing Together 

Doe and Wesseh understand each other. They both went through the challenges of buruli ulcer, a tissue-destroying infection that affects various body parts. For Doe, his foot and for Wesseh, his leg. Similar to a third-degree burn, buruli ulcer eats through skin, nerves, and blood vessels, making its way to bone. For many people, movement is restricted and only regained through physical therapy. Doe requires a wheelchair because of the condition. It is unknown how the disease spreads and there is no prevention, according to the World Health Organization, but there are treatment options. 

Both of their illnesses were originally attributed to witchcraft—a common belief among families in this region. In fact, Doe himself believed the sharp pains in his right foot were the result of witchcraft hunting by members of his community. And Wesseh’s wife and neighbors believed his unbearable pain and discomfort were due to witchcraft. Afterall, the medicines from local clinics weren’t helping and bumps began to appear on Wesseh’s leg, so what else could it be, they thought. 

Eventually, both men were referred to J.J. Dossen Memorial Hospital. Doe was referred by his younger brother after he wasn’t satisfied with the care at another facility. And Wesseh was referred to the hospital during a local PIH community outreach event. They were given buruli ulcer diagnoses and received standard medical treatment, including antibiotics.  

Although they are now out of the hospital, they still receive care. A nurse visits the men daily to care for their wounds; and a community health worker visits regularly to provide social assistance, including food, supplements, and transportation money for family members to visit them, among other things. And together, the men provide each other with emotional, social, and practical support.

“Sometimes when he doesn’t have soap, I can go and buy it for him,” says Wesseh. “And each time he needs anything, I can help.”

Treating the Whole Patient

At PIH sites around the world, care is focused on treating the whole patient, not just their illness. Quality care includes the five S’s: staff, stuff, space, systems, and social support. The fifth is just as important as the first four.  

Although social support comes in many different forms, it generally involves basic necessities including food, transportation, and housing. Safe, PIH-supported housing is provided at no cost, which is essential considering the men are currently unable to work due to their conditions. Previously, Doe worked in a gold mine and Wesseh was a sheriff in the judiciary court. 

The men are eager to fully heal and reunite with family and friends. Until that day comes, they’re glad to have each other.

“What I will forever remember and be grateful about is the social assistance that PIH is giving us,” says Wesseh.

Itumeleng Nkhabu, a 48-year-old widow, contracted tuberculosis (TB) in 2003. Then again in 2011. That was not the last time she got sick. 

In 2018, she was diagnosed with multidrug-resistant tuberculosis (MDR-TB), a severe form of the respiratory disease.

She soon began standard TB treatment, which typically includes up to two years of daily injections with a long list of side effects including acute psychosis and permanent deafness. The treatment is costly and often ineffective.

But there was more effective treatment on the horizon.

A few days later Nkhabu was admitted to Partners In Health (PIH)-supported Botšabelo Hospital in Maseru, Lesotho—the country’s only hospital for people with MDR-TB. About three weeks later, she enrolled in the endTB study.

endTB: a novel approach

The goal of Expanding New Drug Market for Tuberculosis (endTB) is to improve treatment for patients with the deadly disease. UNITAID funds the collaborative effort, which is a partnership among PIH, Médecins Sans Frontières (Doctors Without Borders), and Interactive Research and Development. 

Nkhabu is one of 81 patients who enrolled in the endTB study in Lesotho since 2018. Hundreds of additional patients are enrolled in 17 countries, including Kazakhstan and Peru—where PIH works.  

While on the standard treatment plan, Nkhabu recalls taking 27 pills per day. In the endTB trial, she takes fewer pills with less side effects. She continued treatment for a year and 10 months. 

Medication wasn’t the only form of support Nkhabu received.

Providing support beyond medical care is a key component of PIH’s work. It’s called “social support” and includes essentials such as food, housing, and transportation.

Upon being discharged from the hospital, Nkhabu continued with monthly check-ups. PIH provided free transportation to and from the hospital because she was too sick to drive herself. In between check-ups, nurses regularly visited Nkahbu at her home and provided food to take with her medications. Nurses would call her too.

“When I would receive a call, it gave me hope to continue to push and work together with the hospital staff to get well,” says Nkhabu. “They believed that I could recover even when I had no hope.”

Nkhabu recovered and is now leading a happy, healthy life again. 

Ts’eliso Pakeng, a 36-year-old patient co-infected with HIV and TB, is another one of the many patients who received TB care and social support. For several years, Pakeng was in and out of various hospitals. In 2021 he was admitted to Botšabelo Hospital and finally began to show signs of improvement. 

He says the hospital staff and social support played a vital role in his speedy recovery.

“Although my family supports me with a lot of things, they would have struggled to feed me,” says Pakeng. “I am very grateful…for the food. I do not know what I would have done without [it].”

Pakeng, who is enrolled in the endTB study, no longer relies on medication and has recovered from TB.

Since the introduction of oral medicines—namely bedaquiline and delamanid—TB treatment has greatly improved for many patients. endTB is leading the way in finding new treatment regimens. As the effort expands access and exposes demand, more patients will hopefully find relief from the disease in the coming years. 

“When patients are valued, respected, and [heard], the results become outstanding,” says Dr. Kunda Kwabisha Mikanda, DR -TB senior medical officer and site principal clinical investigator, who oversees endTB work in Lesotho.

From Rwanda to Peru, Partners In Health provides more than medical care: We cook meals for our patients. We give them a place to stay. We pay for their bus fares.

In communities where we work, where many live on $1 per day, health care often ends up on the back burner as people put their money toward essentials like food and housing—a struggle tied to poverty and systemic injustice.

At PIH, we understand it takes more than medical care to make patients well. In all 11 countries where we work, we offer social support—basic resources like food, housing, and transportation that make it possible for patients to access and benefit from health care.

Here are five ways that PIH provides social support:

1. Food

Healthy food is essential to staying well, but difficult for many of our patients to access, as they often spend what little they have on medical costs. At hospitals and clinics where we work, PIH makes sure patients and their families have food to eat.

When patients come to PIH-supported hospitals such as Butaro District Hospital in Rwanda, they are served three free meals a day, cooked with fresh, locally-sourced ingredients. Our food support extends beyond the hospital and clinic. In Peru, we deliver boxes of food and support community soup kitchens that provide daily hot meals to residents in Carabayllo, where thousands of our patients live.

2. Housing

Without safe and stable housing, it is nearly impossible for patients to stay healthy, whether recovering from an injury or managing a chronic condition. Around the world, PIH helps patients access short- and long-term housing.

During medical procedures such as surgeries or childbirth, we ensure patients and their families have a place to stay, hosting them at our guest houses or maternal homes onsite or providing vouchers for nearby hotels. We also help patients access long-term housing. In Malawi, PIH has built 137 homes and renovated 268 more in rural Neno District, serving more than 2,000 people. In Peru, PIH opened the first-ever safe house for people living with schizophrenia—a home that has since served as a model for 50 more across the country.

3. Transportation

For patients living on $1 per day, a bus ticket to the closest hospital or clinic can be too costly, resulting in missed doctors’ appointments and unfilled prescriptions. And for those with severe injuries or illnesses, travel on crowded public transit isn’t realistic; but private transportation is out of reach financially.

PIH recognizes that transportation is critical to a patient’s care, from diagnosis to recovery. In all countries where we work, we provide stipends for transportation, paying for bus tickets and taxi fares to ensure patients can reach the hospital or clinic. In Mexico and Rwanda, we deliver this and other social support through the Right to Health Care program. In these and other countries, we operate fleets of our own cars, staffed by our experienced drivers, who transport patients to and from appointments.

4. Education

Education equips people with the tools to make informed decisions about their lives, including their health and well-being. But in the communities where PIH works, this basic human right is inaccessible for many students, whose families must choose between school fees and other expenses, or send sons, but not daughters, to school.

PIH is determined to challenge those realities. In Malawi and other countries, we pay for school fees, uniforms, notebooks, and other supplies—expenses that total about $2 per child but are unaffordable for many families. Since 2007, PIH has covered school fees and other supplies for more than 1,100 students in secondary school and more than 2,000 in primary school in Neno District, widening access to education that can change lives.

5. Employment

In communities where PIH works, people often rely on jobs that are low-paying, seasonal, or otherwise unpredictable. In Peru, for example, 68% of workers are part of the informal economy. Paid work is essential to staying well, and a medical issue can take a devastating toll on health and finances, as patients miss work and accrue costs, fueling a cycle of poverty and sickness.

PIH supports patients as they seek job opportunities. In Kazakhstan, we’ve helped patients in our tuberculosis program access employment, along with residency papers. In Peru, PIH has distributed small business loans and helped patients start economic cooperatives. Our patients have joined our ranks too, becoming doctors, nurses, drivers, and more—evidence that care can change lives and improve outcomes.

Partners In Health is excited to announce the establishment of the Paul Farmer Collaborative of the University of Global Health (UGHE) and Harvard Medical School. This initiative, made possible by a $50 million gift from Cummings Foundation, will expand and deepen a long-standing partnership between the two institutions. The ten-year grant will be divided equally between the two institutions to support joint activities.

Building on Paul Farmer’s legacy, the collaborative will catalyze the development of sustainable, equitable health systems that improve health care delivery to underserved populations, helping to strengthen and influence the medical training ecosystem in Rwanda and across Africa. The work of the collaborative will involve the exchange of students, postdoctoral trainees, and faculty between UGHE and HMS; support for research, education, and teaching; an annual global health conference focused on health equity, global health delivery, research, education, and social medicine; and clinical training opportunities for medical students and residents at both institutions.

The collaborative will complement efforts we have underway to establish the Paul E. Farmer Scholarship Fund for UGHE. Although this grant will not be a part of the scholarship fund, it will enhance opportunities for both faculty and students supported by the scholarship fund. The visibility from this collaborative – as well as early commitments to the scholarship fund – will help us build momentum as we continue to fundraise toward the scholarship fund’s goal over the next three years. So far, we have raised just over $70 million toward the $200 million goal.

In addition to the $50 million gift to launch the collaborative, Cummings Foundation has contributed $2 million to Partners In Health to construct a residential facility to house and support faculty visiting UGHE’s campus in rural Butaro, Rwanda.

An initiative of Partners In Health, UGHE launched in 2015 with catalytic support from Cummings Foundation, the Bill & Melinda Gates Foundation, and the Republic of Rwanda. Its academic programs include a bachelor’s level medical degree and Master of Science in Global Health Delivery. UGHE also offers executive education programs with a focus on strengthening health care delivery systems.

It has been nearly a year since Paul’s sudden and unexpected passing, which occurred in Rwanda while he was working and teaching at UGHE. Paul fundamentally believed that universities should be critical agents of social change and active drivers of solutions to society’s most urgent needs. This gift, and the establishment of the collaborative, is the embodiment of this belief and his values.

Read the full press release.

As Robert Capa’s famous photography maxim goes: “If your pictures aren’t good enough, you’re not close enough.” Each year, Partners In Health (PIH) photographers show patients and staff in moments of hardship and celebration. To do so, we have to get close: into the communities where the work happens and into the lives improved by access to care.

Getting close is a hallmark of PIH’s mission of solidarity and accompaniment. Most PIH staff come from the communities they serve, giving back to their friends, neighbors, and families. Here’s just one example: In August, I photographed Community Health Worker Annie Jere as she conducted a home visit near the hospital in a remote village in Neno District, Malawi. She visited Milica Steven and her three children, screening the family for health concerns as the Stevens’ chickens pecked grain off the dusty path. In the above photo, Jere does a MUAC test for malnutrition, measuring one child’s mid-upper arm circumference. After the visit we walked a few houses away back toward the hospital, then Jere stopped, greeting two young girls in colorful attire. They were her daughters. We were right outside their house.

Here are some of the other images that spoke to us this year.

— Thomas Patterson, PIH photo editor

Zack DeClerck, production manager at PIH: “Photographing Paul Farmer’s memorial service in Boston was incredibly emotional. Not only had we lost a dear friend, mentor, and visionary, but it was also the first time many of us at PIH had seen one another since the start of the COVID-19 pandemic. Watching colleagues, family, patients, and longtime PIH supporters embrace each other throughout the day was truly in the spirit of what Paul taught so many of us about accompaniment. I know I wasn’t alone in sharing the lump in my throat while Dr. Anthony Fauci struggled to finish his remarks about Paul’s impact on his life.” Photo by Zack DeClerck / PIH 

Mélissa Jeanty, multimedia specialist at Zanmi Lasante, PIH's sister organization in Haiti: “When I got to the town square in Mirebalais, many had already gathered for the march in honor of Paul Farmer. Everyone was quiet. Some people were waiting and others were distributing candles and armbands. The communications team consulted earlier in the week regarding what message to print on these armbands. The [Hôpital Universitaire de Mirebalais] staff eventually settled for “Polo, nanm ou ap toujou rete,” meaning “[Uncle] Paul, your soul will live on forever”.

These very words came alive throughout the march. Those in attendance, whether from the hospital or from the community, sang and walked in a way that expressed the deep loss and sadness they felt over Paul's passing, but also the deep love and respect they all held for him.

As I walked among them that day, I could hear the grief in their voices. I could truly feel the desire they all shared to honor Paul Farmer's work and legacy in Haiti.” Photo by Mélissa Jeanty / PIH

Paola Rodriguez, communications coordinator at Compañeros en Salud, as PIH is known in Mexico: “For me, taking pictures means connecting with whoever is on the other side of the lens. Whether it's a staff member, a patient, or even the mountains! It brings me a feeling of gratitude when people share their stories and immortalize a moment and their essence while wearing a big smile. Pictures are also the way we share our reality with the rest of the world.

I met Límbano before because he runs a laundromat where I used to wash my clothes, and I knew it closed for a couple of months because he was ill. I felt joy when he came back and learned that he was a patient at the respiratory disease center where Compañeros En Salud staff work, so we decided to interview him. Although I knew his name and had talked to him briefly before, interviewing him allowed us to connect on a deeper level. He opened up to me with his vulnerability, but also his strength and love, which is something I cherish so much.

At the end of the interview I asked to take his portrait outside of his house, and the dogs he feeds immediately came to him. I could tell they were happy to see him. I wanted to include the dogs in the picture because they were part of what he told me is important to him.” Photo by Paola Rodriguez / PIH.

Jason Amoo, former communications specialist at PIH Liberia: "Like every interaction with beneficiaries, capturing Saturday and Johnson was very inspiring. Their bond and joy were infectious and thankfully that came across in the pictures. Photographing them required little effort because they naturally had a good relationship and all I had to do was capture the essence of it.

For two strangers who have now become inseparable, it was beautiful to see how they cared for and supported each other to overcome challenges presented by their medical conditions. It also goes to prove that making health care available and accessible to all is a human right and the key to building resilient communities." 

Diego Diaz Catire, communications professional at Socios En Salud: "Being part of the photo team at Socios En Salud has very important value and meaning in my life. It is the opportunity to learn about the reality and stories of many people, Peruvian brothers and sisters, who despite the needs and difficulties of their environment, always convey a strong feeling of hope and strength to get ahead. It's with our committed team, which I am proud of, that we can generate positive changes, strengthen the health system, and provide dignified and quality care for thousands of lives." 

Health workers this week launched a new cholera vaccine campaign, hoping to slow, and ultimately end, the current outbreak that has quickly spread throughout Haiti.

The weeklong campaign is led by the national Ministry of Health and Population (MSPP) with support from a team at Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti. The effort has so far reached more than 4,900 residents of the Mirebalais region in central Haiti and is expected to ultimately deliver a single dose of the oral vaccine, Euvichol-plus, to all eligible residents, about 105,390 people, health officials said. So far, nearly half of the vaccines administered have been to people over 15 years old, with the rest given to younger children.

"The goal is to vaccinate the whole commune with one dose of [the cholera vaccine] in order to reduce and stop the Vibro cholerae," said Dr. Ralph Ternier, ZL's director of programs, using the bacteria's scientific name and noting that many of the workers involved in the current campaign were the same people that fought the outbreak in 2010.

"The community health workers were successfully deployed and after four days we expect to reach one-third of the population," Ternier said. "ZL will put all the efforts to reach the target by the deadline" of December 28.

At the same time, the ZL team continues to treat cholera patients—3,000 people so far— at several facilities while grappling with chaotic conditions, such as widespread kidnappings and shortages of fuel, around the country. At the Hôpital Universitaire de Mirebalais (HUM), 80 beds for cholera patients quickly filled up and cholera treatment units at six other sites, including St-Marc, Petite Riviere, Verrettes, Jean-Denis, Boucan Carre, and Lascahobas, were established to care for additional patients.

As of December 19, Haiti’s MSPP reported 17,629 suspected cases of cholera, 14,972 hospitalizations, and 316 deaths.  The majority of cases continues to be children under 5 years old, who are particularly at-risk due to widespread malnutrition, which leaves young immune systems more vulnerable to disease, physicians said.

Even as cholera surges around the world, the global vaccine stockpile has been depleted, according to the World Health Organization. That means the vaccine is currently being rationed; it is typically given in two doses, but since mid-October, health officials overseeing the global distribution of vaccines made the decision to recommend only one dose to stretch supply. One dose of the vaccine provides between six and 24 months of immunity, while the two-dose regimen delivered four weeks apart gives four years of protection. ZL-led cholera vaccination campaigns in recent years have included a two-dose regimen.

Cholera is caused by drinking water or eating food from sources that have been contaminated with the bacterium Vibrio cholerae. It is found and spread in places where people have inadequate or no access to sanitation and clean water.

People infected with cholera develop watery diarrhea, vomiting, and leg cramps. They can become dehydrated rapidly, go into shock, and may die within 24 hours if they do not receive care.

Cholera was not detected in Haiti until after the 2010 earthquake, when it was inadvertently introduced by United Nations security forces, sickening 820,000 people and causing nearly 9,800 deaths. After multiple, successful mass vaccination campaigns led by ZL and others, and a decision by the World Health Organization to create a cholera vaccine stockpile, cholera was declared eliminated from Haiti in February 2022.  In late September, a new outbreak began in Port-au-Prince, quickly spreading throughout the country.

Looking back, 2022 was a tumultuous year for Partners In Health, marked by tragedy and resilience. 

As we mourned the passing of Dr. Paul Farmer and celebrated his life, we found strength and inspiration in his legacy, reflected in the millions of lives he touched and PIH’s continued lifesaving work around the world. 

Our media coverage and events this year honored that legacy. From penning op-eds in national newspapers to proposing unprecedented global health policy, we continued to advocate for what Paul so eloquently called “a preferential option for the poor”—fighting for all patients, everywhere, to have access to the same treatment we would want for our loved ones. 

In case you missed it, here are some of our favorite moments from 2022: 

1. The Boston Globe: “The White Nationalist Threat to Antiracist Medicine in Boston”  

In January, PIH board member Dr. Michelle Morse and PIH staff Dr. Bram Wispelwey, two physicians within the Division of Global Health Equity at Boston’s Brigham and Women’s Hospital, were targeted by white nationalists for practicing antiracist medicine. PIH CEO Dr. Sheila Davis and Co-founders Dr. Paul Farmer and Ophelia Dahl wrote an op-ed in The Boston Globe to express solidarity with their colleagues.  

They also used that opportunity to reexamine how social pathologies such as racism, neocolonialism, and structural violence continue to affect the health of historically marginalized people, making PIH’s fight for global health equity and social justice even more critical. Read the full piece. 

2. The Atlantic: “There Will Never Be Another Paul Farmer”  

The sudden passing of Paul Farmer in February was a shock for all of us, including people from all walks of life around the world. Paul was so many things to different people—the good doctor, the Harvard professor, the scholar, the global health equity icon and visionary. But to everyone, he was an amazing human being driven by boundless compassion, advocating for a preferential option for the poor and the marginalized. He left us with a remarkable legacy filled with compassion, moral clarity, radical hope, and optimism. Paul will be forever missed. In Bill Gates’s words: “There will never be another Paul Farmer.” Read the full piece. 

3. Forbes: “Countering Failures Of Imagination: Lessons We Learnt From Paul Farmer”  

In this piece for Forbes, Dr. Madhukar Pai recounts lessons learned from Paul Farmer, including the lessons of health care as a human right, accompaniment, and equity as central to global health. Pai recounts Paul's teachings to resist “failures of imagination” and move toward radical futures in solidarity with the poor. Read the full piece. 

4. The Wall Street Journal: “Expanding Global Access to COVID-19 Vaccines” 

In March, The Wall Street Journal hosted Sheila Davis and Tulio de Oliveira, director of the Centre for Epidemic Response and Innovation at Stellenbosch University in South Africa, for a discussion about global vaccine distribution and what should be done to face the next pandemic. Watch the video.

5. International Women’s Day: #BreakTheBias 

For International Women’s Day, PIH hosted a panel composed of Dr. Joia Mukherjee, chief medical officer at PIH, Dr. Cindy Duke, founder and director of Nevada Fertility Institute, and Edward Wageni, global head of HeforShe. The conversation centered around the importance of dismantling sexism and gender discrimination in health care and defended gender equity as an integral part of global health equity. Winston Duke, actor, producer, philanthropist, and PIH’s first global ambassador, served as the moderator. Watch the event.

6. NEJM: “Misusing Public Health as a Pretext to End Asylum—Title 42” 

In March 2020, President Donald Trump’s administration invoked Title 42, an obscure public health law, to use the COVID-19 pandemic as a pretext to deny asylum seekers at the United States border their right to protection. President Joe Biden’s administration, unfortunately, extended the order despite its devastating impact on vulnerable migrants, including those fleeing violence in Haiti only to face more mistreatment at the U.S. border. 

PIH leaders, namely Joia Mukherjee and Loune Viaud, contributed to a piece in the New England Journal of Medicine denouncing this decision and showing that there was no evidence that singling out asylum seekers contributed to stopping the spread of COVID-19. Read the full piece. 

7. The New York Times: “This Psychiatric Hospital Used to Chain Patients. Now It Treats Them.” 

In April, The New York Times covered PIH’s work over four years to renovate Sierra Leone’s only psychiatric teaching hospital, which is the oldest in sub-Saharan Africa. Renovations included a laboratory, an occupational therapy center, a soccer field, and a playground for the children’s clinic. New medications stock previously empty pharmacy shelves. Medical students also now conduct rounds in the now vibrant hospital, which serves as evidence of what is possible in Sierra Leone and across the Global South. Read the full piece. 

8. The Washington Post: “Where Pregnancy is a Deadly Gamble”  

Sierra Leone is one of the most dangerous countries on Earth to give birth. Its pregnancy-related mortality rate is surpassed only by Chad and South Sudan. The Washington Post released a story in May about PIH’s successful efforts in helping tackle that issue at Koidu Government Hospital in Sierra Leone. Read the full story.  

9. Pandemic Burnout: Impact on Nursing & Midwifery  

Nurses account for 60% of the global health workforce, forming the backbone of the global health system. The same holds true at PIH, where 54% of clinical staff are nurses. They have been on the frontlines of the COVID-19 response for more than two years. But that work has often come at the expense of their own mental and physical health.

During Nurses Week in May, PIH partnered with act.tv to bring together an impressive panel of nurse influencers to talk about the urgency of the global nursing shortage and the widespread burnout caused by the pandemic. Watch the event. 

10. Devex: “The Legacy of Dr. Paul Farmer Takes Shape in Congress”

In September, a new coalition in the U.S. House of Representatives, led by Reps. Jan Schakowsky, Barbara Lee, and Raul Ruiz, announced the Paul Farmer Memorial Resolution—among the most ambitious health legislation ever introduced in Congress. The resolution, presented as a “21st century global solidarity strategy,” asks the U.S. government to increase its global health aid to $125 billion, focusing on helping low-income countries build national health systems and empowering local partners. Read about the resolution. 

11. PIH Announces Winston Duke As First Global Ambassador

In November, PIH announced Winston Duke as the organization’s first global ambassador. Alongside his acting career, Duke has been a longtime philanthropist, humanitarian, and gender equity activist. The Black Panther star will represent the organization and join PIH in the fight for global health equity. In the spring, Duke traveled to Rwanda and saw first-hand how Inshuti Mu Buzima, as PIH is known there, is fighting injustice by providing quality health care across the country. Learn more. 

12. U.S. News and World Report: “Opinion: Enlist Community Health Workers to Help Patients Beyond the Exam Room”  

In December, Sheila Davis penned an op-ed for U.S News and World Report on how to improve health equity in the United States. In the article, she emphasized how PIH’s model, which focuses on addressing the basic needs of patients beyond medical care—such as food, housing, and transportation—has helped “dismantle health inequities for nearly four decades, reaching 12 million people with primary and specialized care and support across 12 countries.” Read the full piece. 

The maternal mortality rate is alarming in Sierra Leone, where 1 in 20 women face a lifetime risk of dying in pregnancy or childbirth. The mortality rate of infants and children under 5 are also among the highest globally: 122 deaths per 1,000 live births.

Many of these deaths are completely preventable when the right care is available. No woman should die from obstructed labor or a postpartum hemorrhage, nor should a child from diarrhea, pneumonia, or malaria.

In response to this injustice, Sierra Leone’s Ministry of Health and Sanitation (MOHS) is collaborating with Partners In Health (PIH) in the delivery of a pivotal project, the Quality Essential Health Services and Systems Support Project (QEHSSSP), which aims to improve care available at community health centers in rural districts so that patients, regardless of where they go, will receive the services they need—and deserve.

A partnership between the Government of Sierra Leone and PIH and funded by the World Bank, QEHSSSP is modeled after improvements made over the past several years at PIH-supported Wellbody Clinic and other facilities in Kono District. Patients have noticed the difference in quality of care, and each facility is now bustling with activity.

PIH leaders see huge potential in multiplying that impact more broadly.

“We should all see [this project] as a catalyst in changing and strengthening the health care system in Sierra Leone,” says Dr. Bailor Barrie, executive director of PIH Sierra Leone.

Project Goals

In December 2021, the World Bank approved a significant grant to support QEHSSSP, which will have a deep impact on maternal and child health services for 2 million people in Sierra Leone, a country of more than 8 million. The project focuses on 14 health facilities in five districts—Kailahun in the East, Bonthe in the South, Western Rural in the West, and Falaba and Tonkolili in the North—where the government of Sierra Leone will build resilient, efficient, and equitable health systems, with support from PIH. More specifically, the project aims to increase facility-based deliveries, access to basic nutrition services, and the number of pregnant women who receive a community health worker visit.

“This project will help very seriously to reduce maternal deaths,” says Michael Hallie Kendor, chiefdom speaker of Kissi Tongi in Kailahun District.

Key to success will be ensuring that each facility is equipped with essential health systems inputs. At PIH, we think of these investments as the five S’s:

• Staff: well-trained, qualified employees—such as nurses, midwives, community health workers, lab technicians, and more—in sufficient quantity to respond to patients’ needs
• Stuff: medication, diagnostic tools, medical equipment, furniture, and other resources to deliver services
• Space: safe and dignified facilities with the capacity to serve the community’s needs
• Systems: leadership and governance, information, and financial management systems for timely decision-making
• Social Support: meeting patients’ needs beyond medical care, including nutrition and social support

Improving Systems, Facilities 

PIH has decades of experience in designing and delivering primary health care with government partners. In Sierra Leone, leaders see this as a hub-and-spoke model reflected in the work across Kono District, at one point a district with among the poorest health care options, having been at the center of the years-long civil war. There, PIH supports Koidu Government Hospital (KGH), which is the main district hospital for specialized care, where patients access everything from emergency services and surgeries to pediatric and chronic disease care.  

At nearby Wellbody Clinic, a model primary care facility, patients access a variety of essential health services, such as prenatal and family planning appointments, malaria consultations, and malnutrition care. Complex cases, such as C-sections, are referred to the “hub” of KGH. Wellbody also serves as its own hub to which community health workers refer and accompany their neighbors from surrounding communities, and smaller “spoke” facilities. This continuous web of care flows back and forth, between hub and spoke, as patients’ needs are assessed, triaged, and met from community, to clinic, to hospital. 

The model, introduced in 2014 when PIH began working in Sierra Leone, has proved to be successful. There is an increased flow of patients and from 2018-2021, there were about 55% more facility-based deliveries, 116% more lifesaving C-sections, and 44% more antenatal care visits across all PIH-supported facilities in the country. Most importantly, there has been a significant decline in maternal and infant mortality. 

This success was recognized by the Ministry of Health and Sanitation (MOHS), which is why a hub-and-spoke model was prioritized for a new World Bank project that will support the ministry in creating new hubs across five districts. As with Wellbody Clinic in Kono District, to support MOHS, PIH will work to build health systems within the Jojoima, Bandajuma, and Buedu facilities in Kailahun District. In the other four districts, PIH will serve as an advisor to the MOHS, in an effort to replicate the hub-and-spoke model across 11 of the districts’ rural health centers.

Overcoming Challenges

While each facility and location are unique, they uniformly need immediate infrastructure improvements. Nearly all of the 14 health facilities struggle with electricity, making it difficult to provide services at night or power lifesaving equipment. Some lack access to water, leaving them with sanitation systems that, among other things, make sterilizing instruments challenging. 

“We are not able to handle some emergencies right now. We lack the necessary infrastructure,” says Ibrahim Allieu, a community health officer at Bandajuma Community Health Center in Kailahun District. “The well-being of our people in the community has been seriously impacted by this.”

Facilities lack well-stocked pharmacies, which leads to an inadequate drug supply and sometimes forces patients to buy questionable medication from outside vendors—or go without. Well-trained and sufficient staff is also in short supply. All of these and many other challenges have made it nearly impossible to deliver high-quality health services across the facilities.

Marian Sanjah, a midwife, juggles this reality every day at Jojoima Community Health Center in Kailahun District. “Our labor room is out of space and we struggle to get water at the facility,” Sanjah says. “Even though we have a solar-powered generator, we struggle with electricity. We experience frequent power cuts.”

“We use our phone lights or rechargeable flashlights to deliver [babies] at night,” she adds. “We are constrained and find it difficult to do our work. Delivering shouldn’t be done in the dark.”

Early Signs of Progress

PIH Sierra Leone staff and government partners have assessed all public clinics across the five districts to determine short- and long-term needs. Soon, repairs and construction will begin, medications will arrive to fill bare pharmacy shelves, and staff will receive training on new diagnostic testing that will ultimately improve the quality and variety of care available to patients in rural communities. 

The work will be similar to what has already taken place at the health center in Gandorhun in Kono District. The remote facility shines with a fresh coat of blue and white paint. Water and electricity are now available 24 hours a day. And lab and pharmacy staff prepare their renovated and stocked spaces for what will inevitably be a steady flow of patients.

Several hours further along a rutted dirt road, a large, modern facility rises within a walled compound up the hill from the Jojoima Community Health Center. The facility, built by the MOHS with support from the World Bank, will serve as a referral center for the surrounding region and specialize in maternal and newborn care, but will also be home to pediatric care and other essential health services. 

Touring the grounds on a recent September afternoon, Barrie envisions a future maternal waiting home at the site of the current health center and points to where the pharmacy, laboratory, kitchen, and laundry facilities will be, ideally, with a March 2023 opening. PIH is helping partners develop operational plans for the impressive facility, learning from work done in Kono District.

Meanwhile, back at Bandajuma Community Health Center, Allieu surveys the humble facility where he and other clinicians do what they can to deliver care without access to running water, electricity, and sufficient stock of essential medications. He has seen the work MOHS and PIH Sierra Leone have done together in neighboring communities, and he has hope.

“I believe with this intervention, some of these challenges will be addressed,” says Barrie.

When a 26-year-old man arrived at the hospital dripping in blood and holding nearly all of his intestines, Dr. Sterman Toussaint was optimistic.

“I told him to calm down and that everything would be okay,” says Toussaint, a surgeon and the director of clinical services at Partners In Health (PIH) Liberia.

The man suffered a stab wound. He was anxious and fearful of death because he couldn’t afford care. Unbeknownst to him, he didn’t need to be concerned: surgery is free for patients at PIH-supported J.J. Dossen Memorial Hospital.

His procedure went well and six days later he was sent home.

“In this case, how could surgery be a luxury? He didn’t stab himself. He had the right to live and that’s what he’s continuing to do,” says Toussaint.

Essential Care

Surgery is a necessity, not a luxury. It’s an investment, not a cost. Yet it often gets overlooked in low- and middle-income countries. Surgery is the “neglected stepchild of global public health,” PIH co-founders Drs. Paul Farmer and Jim Yong Kim wrote in a published paper more than a decade ago. At the time, basic surgical care wasn’t available in southeast Liberia.

If a person suffered an accidental injury, such as a stab wound or broken bone, or a mother needed a C-section, they had to travel hundreds of miles to the nearest clinic with a surgeon. People would often die during the costly journey that took several days due to poor roads. Staff at PIH Liberia vividly remember those days.

Specifically, they recall a motorbike rider who arrived at the hospital with a protruding bone and obvious signs of infection. Without a surgical team in place there was not much the staff could do for him, so they referred him to a clinic about ten hours away. The van got stuck and the patient died before reaching the hospital.

“Today, the story is different,” says Dr. Gerard Ekwen, a general surgeon who has worked at PIH Liberia since 2018.

Since then, Ekwen and his colleagues have completed more than 2,000 lifesaving surgeries at J.J. Dossen Memorial Hospital. Without those services, many people would likely have died from preventable health issues.

Steady Progress

Surgical cases have been on the rise since 2018 when Ekwen, nurse anesthetists, and an obstetrician were hired. Between July 2021 and June 2022, the comprehensive team completed 608 general surgeries, 290 C-sections, and 28 gynecological surgeries.

The quality of care is improving too.

There has been a steady increase in the use of general anesthesia in major surgical cases and a decrease in less safe methods such as the use of laryngeal masks and endotracheal intubation, both of which are inserted down a patient’s windpipe. This is because of well-trained staff—one of the five key elements of strong health systems. Highly skilled nurse anesthetists at PIH-supported facilities have the necessary skills to intubate and administer general anesthesia drugs and safely manage patients during surgery.

“Surgery is an integral, non-negotiable component of primary care in the developing world,” says Dr. Maxo Luma, executive director of PIH Liberia. “When surgery is well integrated into primary care, we save lives.”

As the team continues to grow, they’re simultaneously training the next generation of health care providers who specialize in surgery. Every year, residents and interns from Monrovia, the country’s capital, shadow surgeons at J.J. Dossen Memorial Hospital. They learn basic surgical skills and how to diagnose and treat patients with a range of conditions. Such training is a priority for PIH Liberia and PIH at large to build resilient and sustainable health systems.

Additional training is offered through the Global Action to Improve Nurse Midwifery and Care (GAIN) program, a cross-site mentoring initiative designed to train and empower nurses and midwives in Malawi, Liberia, and Sierra Leone. Thirty fellows have graduated from the program since its inception in Liberia in November 2020. The latest cohort of 14 fellows started their training in October. The academic and on-the-job training provided by GAIN plays a key role in establishing career pathways for nurses.

“As Partners In Health, we are committed and we are here to stay,” says Dr. Sarah Anyango, an obstetrician and PIH Liberia’s deputy director of clinical services. “We are committed to making sure we are giving care that is equitable, accessible, and affordable to the people of Maryland County.”

In the rural community of Reforma, 100 teens gathered to take photos, make collages, and paint a mural. But the lesson was about more than art.

The activities were part of a three-day workshop on sexual and reproductive rights hosted by Partners In Health, known locally as Compañeros En Salud. The workshop, held in September, is one of many ways that Compañeros En Salud helps young people in Chiapas, Mexico learn about their health and rights.

Compañeros En Salud has worked in Mexico since 2011, where it has partnered with the Ministry of Health to strengthen the public health system and improve patients’ access to care. Compañeros En Salud supports a hospital in the city of Jaltenango and clinics in 10 rural communities, along with a workforce that includes doctors, nurses, midwives, and community health workers.

Sexual and reproductive health have been crucial to that work. In Chiapas, Mexico’s southernmost state, the population is young, with the median age 24 years old, and rates of teen pregnancy and sexually transmitted infections are high, due to poverty and systemic barriers. Many patients seeking this care from Compañeros En Salud are teens and young adults.

After meeting with local leaders in Reforma, one of the communities where it works, Compañeros En Salud identified the need for sexual and reproductive health education. That inspired the team to organize the workshop.

Designed for students ages 12 to 15, the workshop used art to explore sexual and reproductive health, with topics ranging from consent to community. Lessons were divided into three units: “Our Life Plan,” “Our Community,” and “Our Body.”

In "Our Life Plan," students envisioned their dreams and goals in life, while also learning about the importance of family planning and the consequences of an unplanned pregnancy. Those dreams ranged from owning a home and planting coffee to becoming a hairstylist in New York.

In "Our Community," students tried their hand at photography and theater. They took photos that represented what community meant to them and acted out scenes that explored concepts like bodily autonomy and contraceptives.

In "Our Body," the lesson focused on consent, helping students connect with their bodies and notice how and when they felt comfortable, uncomfortable, safe, or in danger. This unit included role-playing exercises to practice various situations in which they might feel pressured to say yes, but had the right to say no.

Students came away from the experience with a greater understanding of their rights and resources, as well as a deeper sense of community—captured by a vibrant mural in a local park that served as the workshop’s final project.

"This workshop was very useful for me,” says Uver, 13, a student from Reforma. “I can plan what I want in the future, thinking about the repercussions of each decision I make, and thus achieve my goals.”

Students weren’t the only ones taking notes.

“When we think of strategies to engage with rural communities, there must be a decolonization of knowledge,” says Marina Luria, content manager at Compañeros En Salud, who helped organize the workshop. “We don't have all the answers and we have a lot to learn from the communities where we work. This workshop was a learning space for us, too."

It started with thirst.

Then came cramps. Then, hallucinations. That’s when Meysi Mendoza knew something was wrong.

The 53-year-old resident of Carabayllo, a district in northern Lima, had been feeling fine until then, selling fish, plantains, and aguaje, a fruit found in Peru’s Amazon rainforests, at the market as usual. But the sudden wave of symptoms alarmed her.

Mendoza, who has four adult children but lives alone, decided to seek help. She’d seen a poster at the local bodega about a free health campaign organized by Socios En Salud, as Partners In Health is known in Peru. It was scheduled for June.

There, at the clinic, she received a spate of tests and some unsettling news: she had diabetes.

Diabetes is a chronic health condition that affects 537 million people worldwide. Of the people with diabetes, almost 80% live in low- and middle-income countries, due to poverty and systemic barriers that prevent patients from accessing testing, treatment, and care.

For nearly 30 years, Socios En Salud has partnered with the Ministry of Health and local communities in Carabayllo and beyond to strengthen the public health system, along with improving access to testing, treatment, and care, free of charge. Since 2009, that work has included the Casas de la Salud program, which helps patients access treatment for diabetes and other chronic diseases, such as hypertension.

Casas de la Salud has connected hundreds of patients with care.

From October 2021 to June 2022, Casas de la Salud conducted follow-ups with 573 patients through home visits and virtual check-ins and accompanied 103 patients to medical appointments, helping them stay on track with their treatment plans. Sixty percent of the patients were women with Type 2 diabetes.

Mendoza was one of those patients.

After accessing screening and a diagnosis through Socios En Salud, she was connected with the Casas de la Salud program—and care.

That care included check-ins with a community health worker, one of 262 community members hired and trained by Socios En Salud to deliver medicine to patients’ homes, check in with them, and help them schedule and attend their medical appointments.

It also included a consultation with a nutritionist, who helped Mendoza review and modify her diet. Diabetes ran in her family, and she was also overweight, unable to maintain a healthy diet due to her demanding job. With the support of a nutritionist, she made plans to cut down on fat, flour, and sugar as much as possible.

“At the beginning, it was very difficult to adapt these new changes in my diet, because I was very used to eating seasoned and sugary foods,” she says. “However, I knew it was for my own good, so I followed all the doctor’s instructions.”

Now, months later, Mendoza is on track with her treatment plan. She takes three pills per day and attends monthly appointments at Hospital de Apoyo in Carabayllo, where her vital signs, blood glucose, and hemoglobin are monitored.

The community health worker assigned to her case, Elizabeth Anchante, is there to support her every step of the way, along with Socios En Salud’s team.

“I feel very grateful for the support,” says Mendoza. “The attention Socios En Salud provides is frequent. I know I can go to them quickly if I have any questions.”

As the latest cholera outbreak in Haiti continues, its impact is clear: children under 5 have been most affected. 

As of December 6, the Haitian Ministry of Public Health and Population (MSPP) reported 13,586 suspected cases of cholera, 11,670 hospitalizations, and 285 fatalities. The unofficial toll is likely even higher.  

Early on, clinicians noted that children were hardest hit by the disease, which causes diarrhea and vomiting and, when severe, can lead to fatal dehydration within 24 hours.  

Widespread Malnutrition 

“We were asking ourselves this question: ‘Why are children the main victims of cholera?’” said Dr. Jean Joel Manasse, an internal medicine physician and head of the cholera treatment unit at Hôpital Universitaire de Mirebalais (HUM), which is supported by PIH’s sister organization in Haiti, Zanmi Lasante, and built in partnership with the MSPP. Now, even as the percentage of adults with cholera rises, children remain the majority of cases, about 65%, Manasse said.    

One reason is widespread malnutrition. “A significant proportion of children with cholera also have associated malnutrition,” which, Manasse explained, tends to leave young immune systems more vulnerable to disease. “Those [cholera patients] with longer hospital stays face a risk of complications such as acute lung edema, infection, limb edema,” and other problems associated with severe malnutrition, he added. 

Malnutrition is on the rise in Haiti. According to The New York Times, “the United Nations reported [in October] that for the first time ever, hunger, which has long haunted Haiti, had reached “catastrophic” levels in the Cité Soleil neighborhood” of Port-au-Prince, among the most impoverished areas of the capital city. That designation is the most extreme level of hunger, which has left thousands facing famine-like conditions, the  article stated, noting that some residents have resorted to drinking rainwater and making meals out of boiled leaves.  

At HUM, physicians are initiating malnutrition treatment right at the cholera treatment centers, Manasse said, and then ensuring that children are referred to pediatricians and enrolled in the hospital’s nutrition program. 

Dire Working Conditions 

Staff continue to treat patients despite a country plagued by gang-related violence, kidnappings, rampant inflation, and ongoing shortages of fuel and other necessities. 

At Zanmi Lasante, Executive Director Marc Julmisse said the teams at HUM and five other ZL-supported clinics continue to work around the clock to provide cholera care, despite daily challenges.  

“On September 12, our country came to a standstill,” said Julmisse, speaking about conditions in Haiti as part of a PIH global health webinar in November. “We had been dealing for years with kidnappings, gang violence, roadblocks, but this is unprecedented. We haven’t seen it before.”  

Julmisse talked about the risks staff face simply getting to and from work, and acquiring much-needed fuel which, at its worst, was being sold for $20 a gallon due to countrywide shortages. “We had to make some tough decisions just to keep the doors open,” she said.   

But the doors have remained open, she added, as cholera cases keep rising.  

The first official case was on October 2. Within two weeks that number jumped to 66 cases. Now, case reports from the Ministry of Public Health and Population tick upwards daily.  

At HUM, the 60 beds for cholera patients quickly filled up; there were 200 patients being treated as of December 7 with a a total of about 1,000 cholera patients have been cared for and treated at HUM, a state-of-the-art teaching hospital built following Haiti’s devastating 2010 earthquake.  

Julmisse said the ZL team is actively working on opening new cholera treatment sites around the region and collaborating with medical and health care organizations throughout Haiti to strategize on how best to treat patients and save lives. 

This cooperation, she said, is critical: “It’s like, ‘What do you have, what do we have, can we share?’” she said. “We have formed a community of proactive groups to better understand what’s going on, each advocating for each other.”   

For instance, she said, it became clear that the community of Lascahobas was facing an increase in cases, but many patients living in remote, rural locations could not make the trek to clinics for care. This information was relayed to community health workers, and plans are now underway to get teams to that area to help residents who are sick.  

Recently, Airlink, an organization that works with partners, including Zanmi Lasante, to deliver crucial supplies during humanitarian crises, has established an “airbridge” to get water, sanitation, and hygiene supplies to Haiti to mitigate the outbreak.  

“We are in a dire situation,” Julmisse said. “But we have an amazing team.” 

Dr. Christophe Millien, medical director at HUM, said several new general practitioners and a pediatrician have been hired to help manage the cases. But critical needs for additional cholera treatment centers remain, notably: tents, beds, oral rehydration salts, IV and hygiene supplies, and more.  

Importantly, PIH and ZL, alongside government partners, are anticipating oral cholera vaccine to arrive in Haiti on December 12, with a coordinated vaccination campaign launching two days later, officials said. 

Cholera’s History in Haiti 

Cholera had not been detected in Haiti until after the 2010 earthquake, when it was inadvertently introduced by United Nations security forces, sickening 820,000 people and causing almost 9,800 deaths. After multiple, successful mass vaccination campaigns led by PIH and others, and a decision by the World Health Organization to create a cholera vaccine stockpile, cholera was declared eliminated from Haiti in February 2022.  

However, according to a recent analysis in The New England Journal of Medicine, reemergence of the disease was caused, at least in part, “by a descendant of the [cholera] strain that caused the 2010 epidemic.” 

The authors of the NEJM piece, including those affiliated with PIH, suggest several explanations: that the original strain persisted undiagnosed in the population  and recurred “in the context of waning population immunity coupled with a crisis in lack of clean water and sanitation;” that the strain persisted in environmental reservoirs; or that the current strain could have been reintroduced in Haiti from a nearby country. 

In any case, the authors conclude: “These findings, along with the resurgence of cholera in several parts of the world despite available tools to fight it, suggest that cholera control and prevention efforts must be redoubled.” 

In February 2022, Partners In Health’s (PIH) Co-founder and Chief Strategist Dr. Paul Farmer unexpectedly passed away. PIHers and individuals around the world mourned his loss and reflected on his commitment to delivering justice through health care, a movement he and others started more than 30 years ago that continues to save millions of lives today. Unsurprisingly, many of our most-read stories and social posts discussed Paul’s legacy. 

PIH supporters were also curious to learn more about our health care facilities and how we respond to emergencies, including natural disasters and cholera outbreaks in Haiti and Malawi. That curiosity extended beyond clinical work and to our advocacy efforts. From gender equity to systemic change, supporters wanted to know how to advance health care as a human right.

Below are our most-read stories, social posts, and videos published in 2022.

Dr. Paul Farmer

1. Remembering Dr. Paul Farmer

Paul passed away from an acute cardiac event on February 21. He is survived by his wife, Didi Bertrand, and their three children. Read more.

2. Watch: Dr. Paul Farmer's Memorial Service

The two-hour memorial service took place at Trinity Church in Copley Square in Boston, Mass., where Paul began his medical school journey and co-founded PIH. More than 600 people gathered that day to mourn and thousands more joined virtually, from Rwanda to Peru. View more.

3. Watch: Dr. Paul Farmer Tribute Video

PIH shared a tribute video with archival photos and videos of Paul during the March 12 memorial service at Trinity Church in Boston. Watch the video.

4. Photo Essay: Dr. Paul Farmer's Journey with Partners In Health

A glimpse of Paul’s more than 30 years treating patients, educating clinicians, and changing global health policy. Read more.

5. 5 Quotes from Dr. Paul Farmer that Inspire Us

These five quotes are a sample of the wealth of knowledge and insights Paul shared with all of us, captured in books, speeches, and conversations throughout his life. Read more.

Global Work

6. With Instability in Haiti, Doors Remain Open at PIH Facilities

Not only is Zanmi Lasante (ZL), PIH’s sister organization in Haiti, providing essential services in the midst of a crisis, it also continues to strengthen health systems overall through its medical training programs. The internationally accredited Hôpital Universitaire de Mirebalais’s  residency programs in 11 specialties graduate more clinicians every year, the majority of whom remain in Haiti to work. Read more.

7. Watch: Cange Declaration (Bending The Arc Excerpt)

In this clip from the documentary Bending the Arc, PIH Co-founder Dr. Paul Farmer reacts to archival footage of Haitians living with HIV--among them his former patients--reading aloud the Cange Declaration, a manifesto they wrote imploring world leaders to provide equitable access to antiretroviral treatment. Watch the video.

8. A New Cholera Outbreak Emerges in Haiti

ZL has been distributing food and hygiene supplies to staff and trying to procure fuel to keep medical facilities running. The team is also working with international partners to rapidly distribute essential supplies to respond to cholera, which reemerged in Haiti in October. To date, not one ZL facility has closed or been forced to stop caring for patients throughout the region as the number of people affected continues to climb. Read more.

9. Cyclone Rips Through Malawi Inflicting Massive Damage on Clinics, Homes

Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi, reached at least 2,800 people affected by a powerful cyclone that swept through the country’s south in January and delivered emergency packages across Neno District, where APZU focuses its work. Read more.

10. Cholera Outbreak Spreads Through Southern Malawi

Following an outbreak of cholera in March, APZU continues to fill medical and other gaps, for instance, by helping to procure more treatment and test kits and mobilizing a cholera vaccination plan. This is not new for PIH: successful cholera vaccination campaigns were launched previously in Sierra Leone and Haiti. Read more.

11. Watch: Kayima Community Health Center

Take a look inside Kayima Community Health Center, a clinic serving one of the largest communities in rural Kono District, Sierra Leone. The center is among a handful of PIH-supported facilities in the eastern region that are undergoing renovation and quality improvement projects to boost patient care, especially for mothers and children. Watch the video.

12. The Promise of Butaro District Hospital: Key Facility Meets Growing Demand, Need for Expansion

PIH and the Rwandan government broke ground on the next phase of growth for PIH-supported Butaro District Hospital. The ambitious, multi-year construction project is set to expand the hospital, located in northern Burera District, from 150 to 240 beds and further establish it as a leading medical institution and teaching hospital in the region, linked to the neighboring University of Global Health Equity. The facility provides thousands of people access to primary care and specialized services, such as oncology. Watch the video.

United States

13. Repeal of Roe v. Wade

In June, the U.S. Supreme Court overturned Roe v. Wade. PIH stands firmly behind women’s autonomy as a core principle of health equity. Read more.

14. Watch: PIH Chief Medical Officer Delivers Commencement Speech

Dr. Joia Mukherjee delivered an inspiring commencement address at the University of Michigan Medical School. She talked to future doctors about her personal experiences, her hope for the future, and the work PIH has done. Watch the video.

Advocacy

15. International Day of the Girl

PIH is proud to join other organizations around the world to celebrate International Day of the Girl in October. This year's theme —"Our time is now—our rights, our future"—reminds us that gender equity is ongoing work. Read artist, producer, activist, and PIH supporter Rosario Dawson’s statement.

16. Tipping the Scales of Justice, Presented by PIH

Moderated by PIH Co-founder Ophelia Dahl, a panel of powerful activists discuss modern day activism, the role of social media, and the importance of going beyond social platforms to create systemic change. Watch the video.

In November, PIH-US was invited to represent the Chicagoland Vaccine Partnership at the White House’s Summit on COVID-19 Equity and What Works Showcase.  

The event, which convened over 30 community-based organizations and community, government, and philanthropic leaders from across the country, highlighted bright spots from hyper-local efforts to alleviate the disproportionate impact of the COVID-19 pandemic on hard-hit populations.  

As part of the Chicagoland Vaccine Partnership, a consortium of community, philanthropic, government, and health care organizations, PIH-US helped to direct more than $3 million in grants to 100+ community-based organizations to design their own COVID-19 outreach and vaccine access solutions. These grants were used to help increase access to vaccine education, decrease barriers to vaccination, increase vaccine uptake, and coordinate broader COVID-19 relief efforts. In addition to distributing small grants, the Chicagoland Vaccine Partnership implemented several strategies to support equitable vaccine efforts including: partnering with Malcolm X College and the Chicago Department of Public Health to offer a free online training to equip community members to speak to their neighbors about vaccination; creating a scheduling tool to support vaccination registration; establishing a virtual learning community that provided a space for community members to problem solve, share personal stories, and exchange the latest resources; and launching a Speakers Bureau that connected area doctors, nurses, and other providers with interested community groups to share accurate, accessible, up-to-date information about COVID-19 and vaccines. 

Community-led efforts like those highlighted at the White House Summit are critical for not just closing gaps in vaccine inequity, but addressing the long-standing health injustices that underpinned barriers to COVID-19 vaccination. 

Below, we share photos from the event.  

In early 2020, as millions worldwide were grappling with the onset of the pandemic, Cruz Antonio Sifuentes was weathering another storm: a diagnosis with HIV.

The 35-year-old resident of Los Olivos, an impoverished community in Lima, knew little about the disease. But he feared the worst.

“The first thing I thought was that I was going to die,” he says.

He had felt sick for weeks, waking up in the middle of the night with cold sweats and battling so much fatigue that he could only walk a few steps before needing rest.

Despite his worsening symptoms, he worried that he wouldn’t have the money to see a doctor. As the pandemic took hold and cities went into lockdown, he had lost his job as a security guard; it was unclear when his next paycheck would come. And there were only so many jobs he could do in Lima as a migrant from Venezuela.

As he got sicker and his money dwindled, he heard about a free mobile health clinic in his community, geared toward migrants. The clinic was run by Socios En Salud, as Partners In Health is known in Peru.

Sifuentes hadn’t heard of Socios En Salud, but knew he needed help and decided to go. There, at the mobile clinic, he was able to access HIV testing, free of charge.

The result was positive and Sifuentes, devastated.

“That day was horrible,” he recalls. “The truth is that I don’t even know how I had the strength to make it.”

Lifelines

HIV affects 38 million people worldwide. In Peru, 91,000 live with the disease, according to the Ministry of Health. Low- and middle-income countries are disproportionately affected by the virus due to longstanding injustices in global health, including lack of access to treatment.

Socios En Salud has worked in Peru since the 1990s to expand access to treatment and care, first with multidrug-resistant tuberculosis and then with HIV and a host of other health conditions. That work, carried out in partnership with the Ministry of Health and local communities, has saved thousands of lives. This year, Socios En Salud screened 1,500 people for HIV and connected 92% with antiretroviral therapy.

Through Socios En Salud’s support, Sifuentes was able to access free HIV treatment just days after his diagnosis, along with support from a community health worker—one of 262 locals hired and trained by Socios En Salud to help patients stay on track with their treatment and navigate the health system.

HIV treatment and care weren’t the only lifelines for Sifuentes: he was also able to access mental health care.

HIV is treatable, and access to antiretroviral therapies (ART) has dramatically improved over the decades, with 75% global ART coverage. But despite this progress, testing and treatment remains difficult to access in impoverished places and the disease is still widely stigmatized and misunderstood.

The AIDS epidemic, which began in the United States in the 1980s, was blamed on gay men, fueling violence and discrimination against the LGBTQ+ community and leading to widespread stigma around the disease, along with the enduring misconception that HIV leads to death.

Such stigma makes mental health support especially crucial for people living with HIV. As part of its work in HIV and other clinical areas, Socios En Salud provides mental health care to patients, free of charge.

'I see this as a rebirth’

At first, Sifuentes told no one about the diagnosis.

Through Socios En Salud’s mental health program, he was able to access therapy and a support group to process his complex feelings, eventually making the decision to share the news of his diagnosis with the people he trusted most—his best friend and his sister. The disclosure, while difficult, helped him feel less alone and opened up more sources of support in his life.

His physical health was showing signs of improvement, too.

As he took his medication at 10:30 each night, his energy began to return. Day by day, he felt stronger and more in control. His symptoms started to fade.

Now, two years later, Sifuentes says his life has completely changed.

“I no longer feel tired or run out of energy,” he says. “I can do all my activities all day and without feeling sad or depressed.”

He continues to take his medication. He is working again. And he is using his story and first-hand experience to help others, spreading the word about HIV care and countering stigma and misinformation. For those who are navigating the unknowns before and after an HIV diagnosis, he has a simple yet powerful message: healing is possible.

“I was afraid and scared of having the disease. At the same time, I felt relieved…that I was not alone,” he says. “Now, I see this as a rebirth.”

Cholera outbreaks in Haiti and around the world are worsening, triggered by droughts, floods, war, and political instability that have forced vulnerable people to live amidst unsanitary conditions. At Zanmi Lasante (ZL), PIH’s sister organization in Haiti, doctors and medical staff are currently caring for more than 300 cholera patients at six clinics and hospitals in central Haiti; but more than 800 total have already been treated at ZL’s teaching hospital, Hôpital Universitaire de Mirebalais.  

The Haitian Ministry of Public Health and Population reported 11,953 suspected cases of cholera, 10,247 hospitalizations, and 227 fatalities as of November 28.

Children under 5 have been most affected; one reason is that malnutrition, which afflicts about 1 in 5 children in Haiti, makes young immune systems more vulnerable to disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours.

Haitians never experienced cholera before 2010. That year, a new group of United Nations peacekeepers arrived in the country from Nepal, which had suffered a spike in cholera cases, and set up operations in a long-established base near Mirebalais with poor plumbing. Contaminated sewage leaked into the Artibonite River, a major water source for all Haitians, leading to a massive national cholera outbreak that lasted many years and killed more than 9,000.

PIH was among the first responders to that 2010 outbreak, ultimately treating more than 180,000 people in Haiti.  In 2012, PIH and its partners launched mass cholera vaccination campaigns in Haiti, reaching more than 45,000 people. That successful early effort led the World Health Organization to call for the establishment of a global stockpile of cholera vaccine. Additional mass vaccination campaigns, in 2016 and 2017, followed.

But the current surge in cholera globally has “so severely strained the supply of cholera vaccines that global health agencies are rationing doses,” according to The New York Times. 

We reached out to Garrett Wilkinson, PIH’s government relations and policy officer, who has been working on issues related to vaccine access for COVID, mpox (formerly monkeypox), cholera, and Ebola over the past few years, to better understand the status of the global cholera vaccine stockpile, why its supply is not meeting demand, who is most impacted, and what PIH is doing to make a difference.  

What is driving the current global shortage of cholera vaccines?

There’s limited funding to purchase cholera vaccines, and as a result there’s limited production. Most of the world's current cholera vaccine is manufactured by EuBiologics in South Korea. Around 15% of the world’s cholera vaccine is made by an Indian subsidiary of Sanofi (the company from which PIH directly purchased the original doses distributed in Haiti in 2012), but they’re leaving the market next year. EuBiologics is expanding manufacturing capacity and another manufacturer will be entering the market soon, but there will be a gap in availability of doses as these manufacturing shifts occur. 

Additionally, demand has grown with an increasing number of emergencies, such as the flooding crisis in Pakistan.  

Around 36 million doses are expected to be produced this year.

Wasn't the stockpile created to deal with such shortages? Why is it so depleted?

Like most global health programs, the size of the program is smaller than the burden of disease. We, as a global community, need to raise our aspirations, announce an intent to purchase millions more doses each year for the foreseeable future, and work with manufacturers to scale production to meet that demand. So, yes it’s about funding and supply and demand, but also a skewed global economy that doesn’t invest in preventing public health emergencies.

Who is most affected by the current vaccine shortage? Is the vaccine being rationed in countries experiencing cholera outbreaks?

Because cholera thrives in settings with limited clean water and sanitation infrastructure, those most impacted by the disease are the global poor and victims of natural disasters and war.

Right now, the cholera vaccine is being rationed to make up for supply constraints. It is usually given in a two-dose series, but as of mid-October, the International Coordinating Group (ICG), which was established in 1997 to coordinate the global distribution of vaccines to United Nations agencies including WHO, UNICEF, MSF, and the International Federation of Red Cross and Red Crescent Societies, have made the exceptional decision to recommend only administering one dose in order to stretch the limited supply.

One dose of the vaccine provides between six and 24 months of immunity, while the two-dose regimen delivered four weeks apart gives four years of protection. It’s urgently important that we scale production so we can maximize the benefit this vaccine can confer to people in need. 

What is PIH's involvement in this situation?

PIH has advocated for mass cholera vaccination campaigns for years, particularly in Haiti during times where other global health leaders disparaged cholera vaccination as not cost-effective. Because cholera can usually be treated with oral rehydration salts and antibiotics, some have argued that spending $1.50 per dose for millions of people is far more costly than merely treating the sick. This argument is misguided. First of all, people deserve not to be sickened with cholera in the first place. And secondly, vaccination can stop transmission and prevent an epidemic from spreading.

PIH is calling for increased cholera vaccine production. We’re speaking with our global partners about how we can raise sufficient funds to elicit increased production from existing or new manufacturers (this is sometimes called an Advance Market Commitment). The United States is a major investor in the United Nations system and ICG. U.S. global health funding is determined by Congress. Reaching out to your Congress member and raising this urgent concern to their attention can help.  

What is being done globally to fix this crisis?

Presently, this crisis is being addressed by dose rationing. This may be necessary to stretch limited supply in the short term, but it is an unacceptable strategy in the long term. While the primary cholera vaccine producer is increasing manufacturing, it’s not doing so by nearly enough. We need to see global partners step up with bold goals to administer millions more doses than we are now and to work with manufacturers to meet this demand.

The world has produced tens of billions of COVID-19 vaccine doses over the last two years. The technological challenge at hand with scaling cholera vaccine production is a mere fraction of what we just accomplished with COVID-19 vaccine production. We know it can be done. What is standing in our way is a lack of political will.

What about Haiti, specifically?

The Haitian Ministry of Public Health and Population and the prime minister have agreed to order cholera vaccine doses from the global stockpile. The total quantity of doses available and the arrival date in the country are still to be determined, but it could be in the next few weeks.

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Finding the best nonprofit to support requires some research. The organization’s mission should align with your personal values. It should tackle the complex issues you are passionate about. And it should have a proven record of impact.

So, how do you assess that?

Get to know them. Read what they write, listen to what they say, and—most importantly—watch what they do. Volunteer your time and attention to their work. Share what you have learned about them with others. And, when the time is right, support their work through donations.

At Partners In Health, we deeply value our supporters, especially those who attend our events, volunteer their time through grassroots advocacy, and donate to support the work we do all around the world.

Here are five reasons PIH has earned that support:

1. We Achieve Long-Term Impact

We measure our impacts over decades. PIH is not an emergency response organization, at least not in the traditional sense. Our global staff definitely respond to crises—both natural and manmade—but we do so while building stronger health systems for the long term.

We take this approach because those in need are our neighbors, friends, and family; 99% of PIH staff were born and raised in the country where they work.

We provide care and support for patients and their families. We learn from, mentor, train, and educate those working alongside us. We conduct research to discover best practices, then share those lessons learned with the larger world. And we use that evidence to influence national and global leaders, who can replicate and adapt our successful models of care in more countries around the world.

One key example of our unique model is our HIV work, which started in Haiti in the late 1990s and then spread around the world.

That is long-term, generational impact.

2. We Merge Social Justice with Medicine

PIH is a global health and social justice organization driven by a medical and moral mission to provide health care to those who need it most.

Our clinicians place patients at the center of all decision-making. Taking that perspective, we see that the right diagnosis and treatment plan is only part of a patient’s cure; we also need to address their social, emotional, and financial situation to effect lasting change.

When we look at this whole picture, we see the need to advocate for and with our patients, to fight injustice—in all its many forms—so that they will be able to enjoy their full right to health.

As our Co-founder Dr. Paul Farmer once said, and our supporters firmly believe: “The idea that some lives matter less is the root of all that is wrong with the world.” 

3. We Accompany Our Partners

PIH’s work is built on optimism, action, and accompaniment—doing whatever it takes, for as long as it takes, to ensure our patients’ right to health.

We accompany first and foremost our patients, whom we often refer to as “our bosses,” but we also accompany colleagues in ministries of health, public officials, partners, and our supporters as we learn from and with each other.

Only by keeping an open commitment to collaboration, we can aspire to solve problems caused by centuries of oppression and to find the hope needed to overcome seemingly insurmountable challenges.

Our community health workers embody accompaniment in every country where we work. They are recruited from their communities, trained and mentored, and serve as the living link between their neighbors, friends, and family and local health facilities. Their regular home visits forge a connection with patients and help guarantee successful outcomes.

4. We Disrupt the Status Quo

In the late 1990s, PIH leaders delivered a message that no one in the global health establishment wanted to hear: thousands of miles away, in Peru, people were dying of multidrug-resistant tuberculosis—a deadly infectious disease—and world leaders had turned their backs. With the right medication regimens and steady support from community health workers, our clinicians proved that patients could be cured at higher rates than previously thought possible.

It wasn’t the first time PIH had challenged the status quo. And it wouldn’t be the last.

Since 1987, PIH has been caring for some of the world’s most impoverished patients and speaking truth to power, because we firmly believe a better, more just world is possible. 

Our defiant optimism has changed global health policy and strengthened the movement for health equity worldwide.

5. Your Money Goes to Patients and Programs

We can proudly say 92% of the money PIH raises each year is funneled directly to support our global programs. Recognizing this effective use of funds, Charity Navigator awarded us its top four-star ranking as one of the nonprofits to which supporters can “give with confidence.”

Read our annual report to see what we accomplished, thanks to our supporters, last year.

Babies born prematurely or with complications in Kirehe, Rwanda now have a higher chance of survival.

Partners In Health recently opened a newly-renovated Neonatal Intensive Care Unit (NICU) at Kirehe District Hospital, in partnership with the Rwandan Ministry of Health. The NICU will provide lifesaving care for newborns in one of Rwanda’s busiest maternity wards.

“The newly renovated NICU will improve the quality of care, help staff to easily identify newborns who need immediate care, and will be a friendly, safe [environment] for the mothers, babies, and staff,” says Dr. Jean Claude Munyemana, the hospital’s director general.

Partners In Health, known locally as Inshuti Mu Buzima, has worked in Rwanda since 2005 and in Kirehe since 2006. Inshuti Mu Buzima partnered with the Ministry of Health to build the district hospital in 2007, as part of its mission to strengthen the public health system.

Kirehe is a district in Rwanda’s Eastern Province, known as the country’s breadbasket for its large-scale commercial agriculture. But with a population of nearly 450,000 served by one hospital, the demand for health care is high.

NICUs are crucial resources for newborn care, providing oxygen therapy and other lifesaving services for babies born prematurely or with complications. But mothers in Rwanda’s rural communities rarely have access to a high-quality NICU, even though the under-5 mortality rate is higher in the country’s rural areas compared to urban areas.

Newborn care at Kirehe District Hospital began with one incubator and four beds in 2009, using space in the pediatric ward. The hospital has had a NICU since 2015. The NICU cares for as many as 160 newborns each month and, along with the hospital, serves thousands of patients, including from Rwanda’s largest refugee camp, Mahama.

But before the renovations, that care came with many challenges. Bed occupancy was at 85-160%, even as demand grew year-over-year. Equipment was outdated. And there were only four wards, structured in a way that complicated care delivery and infection prevention and control.

The renovation comes as a massive step in the right direction.

Now, the NICU has five wards for at-risk infants and a total of 40 beds. The renovations also include a resting room for mothers whose babies are incubated, a “breastfeeding expression room” where mothers can breastfeed in privacy and receive training from Inshuti Mu Buzima’s “expert mothers,” and separate entrances for patients and hospital staff, expediting care and allowing an ambulance to access the unit quickly.

“As a clinician and also a mother, with the new space we have, I feel more comfortable staying in the NICU,” says Dr. Angelique Charlie Karambizi, a pediatrician with Inshuti Mu Buzima.

Even after the renovation, needs remain. The NICU needs more equipment, including five more incubators, an onsite biomedical engineer, and an upgraded laboratory.

But the newly-renovated NICU will provide lifesaving care for the youngest, most at-risk infants in Kirehe and beyond. It comes as the latest chapter in PIH’s ongoing work to dismantle longstanding injustices in global health—work that also includes Inshuti Mu Buzima’s cancer care program at Butaro District Hospital and an ongoing partnership with the University of Global Health Equity, founded by PIH in 2014 to train African doctors and nurses and shift the center of gravity in global health toward the Global South.

The NICU renovations also come as part of PIH’s decades-long partnerships with ministries of health in the countries where it works, strengthening public health systems to promote health care as a human right.

“We work towards a world where newborns and mothers not only survive, but thrive,” says Dr. Erick Baganizi, director of maternal, neonatal, child, and adolescent health at Inshuti Mu Buzima. “This will be a center of excellence for neonatal care.”

A pill could save the man’s life. But it wasn’t available in Liberia.

For months, he had suffered from an unknown disease, without access to a diagnosis or drugs. He had poured his life savings into a search for answers. But his money was running out. So was his time.

He was already skin and bones—a shell of who he once was. In a last-ditch effort, he went to Monrovia, the capital, where the country’s most advanced hospitals were located.

He brought a coffin.

It was a story that Dr. Maxo Luma and others at Partners In Health had seen too many times—patients becoming impoverished and eventually dying because they lacked access to lifesaving drugs.

Fortunately, Luma recalls, the man was able to access a diagnosis—extensively-drug resistant tuberculosis—and medication through Partners In Health.

But not all patients make it.

“Every year, millions of people die of HIV and TB,” says Luma, executive director of PIH in Liberia. “It is not really the diseases that kill them. It’s social injustice.”

Tuberculosis is 100% curable. HIV can be brought under control within six months with medication. Yet, millions of people die each year of these diseases and others, overwhelmingly in low-income countries, because they lack access to treatment and care.

That’s a reality that PIH is determined to change.

For more than 30 years, PIH has provided lifesaving drugs to millions of patients, free of charge, along with the care and essential resources they need to survive. That work is guided by a simple yet radical vision: health care is a human right.

Dying of Poverty

Years later, Dr. Carole Mitnick still remembers the lengths people would go to in order to get lifesaving drugs in Lima, Peru in the early 1990s, when treatment for multidrug-resistant tuberculosis wasn’t widely accessible.

Patients could get drugs for tuberculosis for free from the Ministry of Health; but if they needed treatment for MDR-TB, an especially deadly and drug-resistant variant of the disease, they would have to buy the medication themselves—nearly impossible for those living in Carabayllo and other communities in Lima, where the average income was as little as $1 a day.

“The stories were just heart-wrenching,” recalls Mitnick, who was doing her doctoral research with PIH in Lima at the time.

A man with MDR-TB would go to the markets in wealthy parts of town and rummage through trash in search of lemons to sell. A woman became a sex worker to afford her husband’s medication.

If patients and their families managed to buy the drugs, they would often ration supplies—cutting pills in half, taking pills every other day instead of daily, or taking them for a month and then stopping—lessening their effectiveness and putting patients at risk for even more resistant tuberculosis.

Thousands more couldn’t access the drugs at all.

By 1995, an outbreak had emerged in Carabayllo, where PIH Co-Founder Dr. Jim Kim had begun to work with Peruvian colleagues. But the growing number of deaths were ignored by the global health establishment at the time. Health leaders in the Global North argued that a disease like MDR-TB was too costly and complicated to treat in impoverished places like Carabayllo.

PIH set out to prove them wrong.

Working in partnership with Peruvian doctors and the Ministry of Health, PIH began treating patients in Carabayllo—against the advice of the global health establishment—providing drugs and care, free of charge.

Dr. Leonid Lecca, now executive director of Socios En Salud, as PIH is known in Peru, saw that work and its impact first-hand.

“I remember in the beginning, when Socios treated MDR-TB patients, we had many challenges,” he recalls. “Now, the situation is different…the MDR-TB program in Peru is due to Socios En Salud’s work.”

Thousands of lives were saved. And a growing body of evidence was created to show the world that MDR-TB was, in fact, treatable in the poorest places, contrary to what global health leaders had once claimed.

PIH’s efforts catalyzed change on a national and international level and bolstered a growing movement for global health equity. In Peru, the Ministry of Health launched a nationwide program to provide MDR-TB testing and treatment for free. And the World Health Organization updated its policies, expanding global access to lifesaving MDR-TB treatment.

“It was really transformative,” says Mitnick, who is now professor of global health and medicine at Harvard Medical School. “It was transformative for individual patients, and it was transformative for programs and clinicians.”

A Cure For Injustice

PIH’s work to make drugs free and accessible had begun years earlier, thousands of miles away in Cange, Haiti, in response to another disease.

PIH began its work in Haiti in 1983, when Co-Founders Dr. Paul Farmer and Ophelia Dahl opened a clinic in Cange, a rural village in the Central Plateau. As Farmer, Dahl, and their Haitian colleagues provided free health care to dozens of people once unserved, a deadly infectious disease was spreading worldwide.

The first case of AIDS was detected in 1981 in the United States. By 1986, more than 38,000 cases had been reported from 85 countries. AIDS is the latest and deadliest stage of infection with HIV, a virus that attacks the immune system.

“Back then, HIV was a death sentence,” says Maxo Luma, who saw friends fall ill with the disease in Haiti, where he was born and raised.

The first antiretroviral treatment for AIDS was approved in the U.S. in 1987. But the drug remained unavailable in most of the world. It was nowhere to be found in Haiti, where even the richest patients would have to fly to Miami and pay as much as $4000 per month to access it, Luma says.

At the time, global health leaders argued that treatment wasn’t a sustainable option in impoverished communities and advised prevention instead—an approach that would’ve left millions worldwide without care.

It was a status quo that PIH refused to accept.

Farmer and his colleagues—primarily Haitian doctors and nurses—decided to treat patients anyway. PIH staff bought drugs in bulk in the U.S. and took them to Haiti, sometimes in backpacks, where they were given to patients free of charge.

As its HIV work expanded, PIH joined a growing global health movement in demanding that the U.S. and other wealthy nations make HIV treatment accessible to all patients, worldwide. No patient, PIH argued, should have to die because they couldn’t afford drugs and care.

The work that began in Haiti soon spread beyond its borders.

More Than Medicine

As a young clinician in Rwinkwavu, Rwanda, Dr. Jean Claude Mugunga remembers the constant frustration of seeing pharmacy shelves empty and having to write prescriptions for patients that he couldn’t fill.

“For me, as a doctor, it was very frustrating,” he recalls. “It was so demotivating.”

No HIV drugs were available in Africa in the early 1990s, despite their availability in the U.S. and Europe. The first highly active antiretroviral combination therapy—a far more effective treatment—was approved in rich countries in the mid-1990s. But the drugs were unavailable in Africa. Only the wealthiest Rwandans could access them and, even then, would have to travel abroad and spend thousands of dollars.

Mugunga first learned of PIH as an intern at Rwinkwavu Hospital.

“I heard of PIH doctors from the U.S. coming to rural areas. They were bringing HIV drugs,” he says.

The news intrigued him.

Most international organizations in Rwanda at the time were working in major cities like Kigali, not in rural areas, he says. And doctors with PIH were providing more than medicine: they were asking if patients had food to eat.

“I was like, wow this is unheard of. No other place was doing that,” Mugunga says. “But PIH was making sure patients were coming and were not charged.”

Since its earliest years, PIH has provided not just medical care, but also essential resources like food, housing, and transportation. That work is guided by the belief that it’s not enough to hand a patient a drug or even provide a surgery—they need food, housing, transportation, and financial stability to stay on track with their recovery. In fact, those essentials, which PIH calls “social support,” often make or break whether a patient can access health care at all.

That approach has saved lives.

Mugunga, who joined PIH in 2013 and is now deputy chief medical officer, recalls seeing patients, on the brink of death, make full recoveries. Some would even join PIH, known in Rwanda as Inshuti Mu Buzima, to help their communities, becoming some of the country’s first community health workers.

The stories were a “miracle,” says Mugunga. And their impact was felt far beyond Rwinkwavu.

PIH’s HIV work helped inspire global policy change, including the creation of The Global Fund and PEPFAR—two crucial mechanisms that have enabled low-income countries to access treatment for HIV, malaria, and TB, saving millions of lives.

‘A Moral Imperative’

Even as colossal strides have been made in the fight against HIV, TB, and other infectious diseases such as hepatitis over the years, there is still much work to be done. Drugs and health care remain unaffordable for millions worldwide.

In recent years, the COVID-19 pandemic has brought new challenges to the movement for drug access, highlighting longstanding injustices in global health as wealthy nations hoarded the world’s supply of vaccines. The pandemic also deepened enduring challenges like the fight against TB.

But PIH remains committed to the work it began, decades ago. Making drugs free and accessible and saving lives, says Luma, is not a “favor.”

“It’s a moral imperative,” he says. “This is what everyone should get. We’re talking about health care. This is a basic human right.”

What struck Winston Duke the most while visiting Partners In Health in Rwanda was not the hospitals, or the medicine, or even the stories from patients and staff—it was the sense of community.

Duke, an actor and philanthropist known globally for his role in Black Panther and Black Panther: Wakanda Forever, joined PIH for a two-week trip to the East African nation in late May. PIH, known locally as Inshuti Mu Buzima, has worked in Rwanda since 2005, strengthening the health system and providing medical care and social support in partnership with the Ministry of Health.

During the trip, Duke met with patients and staff in Rwinkwavu, PIH’s first site in the country; accompanied community health workers on a house call; stayed overnight at the home of PIH Co-founder Dr. Paul Farmer, and visited PIH-supported Butaro District Hospital, currently under expansion, and the University of Global Health Equity.

It was an experience that left him feeling inspired and changed “fundamentally, forever.”

Below, Duke, who is PIH's first global ambassador, shares some key reflections from the trip and what draws him to PIH.

The conversation below has been edited and condensed.

Was there a moment that made you realize on a personal level that health care should be a human right?

During one of our first visits in Rwinkwavu, we met a woman whose life was changed—you know, a complete 180—where she was brought to PIH on the brink of death, after being found on the side of the road.

PIH helped her to combat HIV and live with the disease. They provided her a home. They then helped her to acquire land. She had children that she was separated from. She was from Tanzania, a country just right across the border, and they were able to help her get her kids from there and rebuild her entire life to the point where now she is a landowner and entrepreneur and her kids are in the best schools in Rwanda. It feels like a mountain of a story, but that is her human right. Her human right is to live. Her human right is to have access to health care—that is, not only pills and medication, but the holistic ability to live a fulfilled life.

And everyone is entitled to that—every single human being. That moment really showed me the impact of the work that PIH is doing and can do and will do in the future and that every person—no matter where they're from, no matter where they live, no matter what they were born into, no matter what circumstances have happened to them—deserves health care. That moment redefined health care for me, as something much larger.

You stayed at Paul Farmer's home for part of your stay in Rwanda. Tell us about that experience.

Yes, we stayed in Paul Farmer's home, the Friendship House. We walked in his footsteps, and that was an incredible experience to see how barebones the home was and to see that he really was just about the work. There was nothing glamorous.

The Friendship House is a space of deep intention, meaning, and impact, and it was really great to sleep in that home and see how he even had his family there and how he was part of the community—understanding how he walked the yard and picked out every tree that was planted there and why there was a meaning behind each and everything. It really conveyed to me that this man was very intentional while also being a great visionary.

We were thrilled when you expressed interest in our work in Rwanda and even more excited to welcome you here in person. What has it been like talking to doctors and patients and seeing the work up close?

It was really great to actually see the work firsthand—to see not only the patients but also the human beings dedicating their life to this kind of work, to changing the health systems and making them way more equitable and accessible for people all over the world.

And in a place like Rwanda—which is both a place of incredible beauty, personality, very individualistic heritage and nuanced history and also a place of great need—seeing these doctors show up every single day and give their lives, give their blood and sweat, was just something that was incredibly enriching to my life. I'm really going to take that message with me as I move forward, seeing the kids that they're working with and how they're changing the health care systems to combat all the -isms of the world, white supremacy, racism, implicit biases.

It was really incredible to see that. And it's changed me, fundamentally, forever.

Trips like this can bring about a lot of feelings and thoughts. If you were to try to condense how you're feeling now at the end of this trip into a word, what word would you choose and why?

Inspired. I'm inspired to carry forward the mission of Partners In Health. I'm inspired to change how we see health care and redefine a lot of the words that we use in our everyday life that have lost meaning and become a bit mundane. Health care is one of those words where we take it for granted, and we think that it just means a trip to the hospital, being able to see a doctor, having access to medication. But it's so much more. It's community. It's fulfillment of dreams. It's people being able to feel like they are recognized and empowered. It is so much more. It's family—it's creating family, it's redefining family, it's creating a global family. And I think that's what Partners In Health has inspired me to do—to really just reframe and redefine a lot of the words, and contexts that we use those words in, day to day.

To truly understand Dr. Benoucheca Pierre, it’s worth recounting her recent travels to Madagascar, where she lead physicians creating new national standards for delivering medical oxygen to patients.  

In July, Pierre, chief of the ICU at Hôpital Universitaire de Mirebalais, couldn’t fly out of Haiti, where she was born and lives, because all direct flights to Europe had been canceled in the wake of an escalating security crisis marked by nationwide violence and fuel shortages.   

So, she drove about six hours to the Dominican Republic, boarded a plane to Paris, waited 12 hours and then continued on to Mauritius. But because her COVID-19 test had expired prior to her final flight to Madagascar, Pierre was prohibited from boarding. And, without a local hotel reservation, she was detained in immigration. After several hours of fraught calls, Pierre was able to book a hotel and secure a flight that connected to Madagascar through Reunion Island, which sits in the Indian Ocean as a department, or region, of France. Holding a French visa, Pierre assumed there would be no problem traveling this route. However, officials told her that her French visa was unacceptable, and she would have to wait for a direct flight the next day. 

“So, 48 hours after she finally lands, she leads the workshop,” said Dr. Paul Sonenthal, an associate physician in the division of pulmonary and critical care medicine at Brigham and Women’s Hospital in Boston and director of inpatient medicine and critical care for Partners In Health. “There was never a moment where she said, ‘Maybe I shouldn’t do this.’"

He added: “I have the deepest respect and admiration for her commitment,” 

‘I Am a Doctor’ 

The daughter of an artist and salesman, Pierre grew up in Port-au-Prince where she attended high school and worked at her local church. “I wanted to be a doctor because I worked with the kids at church, and I was very interested in keeping them healthy,” she said. Following her medical studies at Notre Dame University, Pierre received a prestigious fellowship in France, training in anesthesiology and critical care. But rather than accept a lucrative position in Europe, Pierre returned home to Haiti, specifically to Hôpital Universitaire de Mirebalais, the teaching hospital run by Haiti’s Ministry of Health and Zanmi Lasante, as Partners In Health is known in Haiti.  There, she said, “I could continue my learning in intensive care.”  

Indeed, Pierre not only continued learning; she became the chief of the unit and, in the country’s public sector, the only ICU-trained doctor in Haiti. She remains one of only two intensivists in the country. “She has a singular and unique set of world class skills and expertise that she is sharing with the nation,” Sonenthal added.  

Even before the pandemic hit, he said, Pierre was busy directing the planning and establishment of the country’s first COVID-19 treatment unit at HUM. When ill patients began arriving with the virus, and other doctors feared coming into the clinic, Pierre did not hesitate and remained on call essentially 24/7, said her colleague, Dr. Christophe Millien, chief medical officer at HUM.

“She said, ‘I am a doctor. It is my responsibility to take care of patients,’” Millien said.  

Sharing Oxygen Expertise  

At that point, there was a dearth of knowledge or standards on effective oxygen administration in Haiti, Sonenthal said.  There were no protocols in place that detailed the correct amount of oxygen given in certain cases, or whether it was best to use a nasal cannula, face mask, or breathing tube, he said. That’s when Pierre took charge, recognizing an opportunity to build the hospital’s critical care capacity.  

“She essentially developed all the protocols for oxygen therapy for COVID-19 patients at HUM and then took that to the national level throughout Haiti,” he said, adding that in less than a year, Pierre’s physicians “were fully capable of independently managing patients on ventilators, adjusting settings and sedation to ensure the provision of lung protective ventilation.” Then, she expanded the curriculum nationwide, he said, training dozens more clinicians, while continuing to oversee care for patients at HUM. 

Now, Pierre is spreading her oxygen expertise into other regions as a senior expert advisor in Madagascar for BRING O2  a Partners In Health-led initiative to increase access to safe, reliable medical oxygen in five countries—Malawi, Rwanda, Peru, Lesotho, and Madagascar. The effort is funded by Unitaid, in partnership with Build Health International and PIVOT Health Madagascar. 

Pierre’s job is to support the medical professionals in Madagascar, where there had been no standard oxygen guidelines; to develop national oxygen protocols, and to advise professional training  

An Unsung Hero 

Pierre’s efforts have led her to be nominated for an “Unsung Hero” award from the organization Reaching the Last Mile. In his nomination, Sonenthal wrote: 

“She has remained committed to these activities despite the rising level of insecurity in Haiti. For extended periods, when the commute from home became too dangerous, Dr. Pierre has opted to live within HUM’s grounds so she could continue to serve her patients.”  

Millien noted Pierre’s ability to both teach and mentor other physicians while also delivering top-notch, compassionate care for patients and saving countless lives.   

Sonenthal recalls one of Pierre’s patients, a 20-year-old who’d had a severe asthma attack and needed to be placed on a ventilator. “The odds of him surviving in a U.S. ER were 50/50,” Sonenthal said. He and Pierre consulted back and forth for days and into the night as the patient’s condition fluctuated, from stable to being on the “brink of death,” with airways so narrow that too much outside oxygen pressure could blow out a lung and prove fatal.  

Due to Pierre’s “quick response and recognition” of the patient’s condition and her “subtle, elegant” shifts on the ventilator, he survived.  

Pierre said she often keeps in touch with her patients. She remembers a recent case, a man who had to be intubated: “I remember he told me, ‘Doctor you are going to make me sleep and not wake up, and I am the only one working in my family, I am the only provider,’” she said. “I told him we would give him the very best care. He was a very big challenge, intubated for two weeks. Then when he was discharged, we celebrated with the family.” 

Pierre continues to face dire conditions in Haiti, most recently an oxygen shortage with one of the main hospitals reporting limited supply and patients at risk. 

“All the main health structures of the country are on alert, such as the General Hospital, because they depend on external oxygen supplies, ” Pierre said. “At the University Hospital of Mirebalais, we have two oxygen generators on site that completely fill our need for oxygen for the good of our patients. The second one, not yet operational, was donated by the Ministry of Public Health in the midst of the fight against COVID-19....So in the last few weeks we have been more affected by the fuel shortage as we are struggling to provide continuous power to the hospital and our sites.” 

Her ability to persevere through such difficulties is unique, colleagues said. Pierre’s grueling trip to Madagascar is an “illustration of the complex barriers she faces,” according to Sonenthal. “It was not easy for her to get there, there were so many barriers, but she persisted, she never wavered. She is my greatest clinical hero.” 

The Sierra Leone Psychiatric Teaching Hospital (SLPTH) has received a formal 5-year accreditation  for the first-ever psychiatry residency program in the country. With this accreditation, Sierra Leone will be able to train its own psychiatrists for the first time, while strengthening the capacity of other health professionals in mental health care delivery.  

“It is a huge accomplishment for the nation and a testament to the hard work and resources that we have put into the development of mental health treatment in our country,” says Dr. Jusu Mattia, one of seven residents in the program. 

The Partners In Health (PIH)-supported facility was accredited by the West African College of Physicians, an association of medical specialists that promote professional training of physicians in West Africa to improve standards of practice and specialty training.  

In order to receive accreditation, hospitals must submit an application and coordinate a visit for an assessment of the facility.  Some of the factors assessed include: human resources capacity, including presence of a neurologist to train residents; infrastructure capacity, including a laboratory to run tests and monitor medications; quality of the drug rehab therapy program, as well as child and adolescent services; and the condition of triage and outpatient supplies and other essential equipment like ECT and EEG machines, among other criteria.  Once the assessment is complete, the findings are then shared with the board and applicants await a decision.  

While the process was extensive, the SLPTH accreditation team met the requirements and received full accreditation on the first attempt.  

Much-Needed Training, Support 

The accreditation is a huge accomplishment, not only for the hospital but also for the nation. There are currently only three psychiatrists in the country, which is home to more than eight million people. And for many years, there was one psychiatrist. Additionally, psychiatric training wasn’t available.   

“As a result, medical doctors like myself were required to receive psychiatric training in a foreign country. We will no longer need to [do that], which will increase the human resources in mental health care,” says Dr. Haja Abibatu Jalloh, a resident in the first cohort. “For me, it is like a dream come true!” 

This in-country training will increase the retention of doctors, while also attracting doctors from other countries to receive psychiatric training. 

With the partnership and continued support of PIH and Harvard Medical School, the program will expose doctors to evidence-based practices and serve as an opportunity for cross-site learning. By training with and learning from medical professionals with various backgrounds and knowledge, residents will be equipped to practice anywhere around the globe.  

The residency program will serve as a hub for building, expanding, and strengthening mental health care in the country. It will not only train specialists in psychiatry but will also build the capacity of other health care professionals in the delivery of mental health services as well as providing strategic leadership, planning, and administration at government and international levels. The specialists will provide leadership in a multi-disciplinary mental health team, at all levels of care, provide effective teaching to all categories of health workers and public groups, and be able to carry out relevant research in the field of global mental health and related disciplines.   

“I am so excited to be part of this amazing accomplishment that gives hope to people who for decades have been abandoned, isolated, chained, starved, and hugely stigmatized because of their mental health problems,” says Chenjezo G. Gonani, PIH’s mental health program manager. 

Previously known as Kissy Mental Hospital, SLPTH is the oldest psychiatric hospital in sub-Saharan Africa and the only dedicated psychiatric hospital in Sierra Leone. Once an under resourced facility, it has since transformed into a hospital capable of providing comprehensive clinical services and teaching the next generation of medical professionals. Through a partnership with PIH in 2018, the team progressed from an average of 40 to 75 monthly outpatient visits to 75 to 300 monthly  visits since the start of the program. The improved services have also resulted in an increased number of new patients coming from other districts, given that SLPTH now offers some of the best services in the country. Through infrastructure improvements for care delivery, renovations of patient wards and grounds, and improving monitoring of patients, the hospital has been able to expand clinical services for substance use, launch a child and adolescent mental health unit, and offer treatment for urgent mental health diagnosis. 

With the recently announced accreditation, SLPTH staff and residents hope the hospital and residency program will become an example of the quality of care that is possible in the country and region, while giving patients the mental health care they deserve.

Advocacy plays a vital role in building a larger community of globally minded citizens. At Partners In Health, it is our moral imperative to expose social injustice and to work toward correcting those systemic forces that create inequalities, no matter how impossible or challenging the task may appear to be. Optimism and action are part of our DNA, and why we have made a global impact.

Below are resources shared by Nick Seymour, PIH’s manager of grassroots strategy, to help you learn about and advocate for health care for all.

Take Action

1. Spread the word about global health equity.

Share a story over coffee with a friend. Pass along an inspiring book or film. Post about a favorite cause on social media. “Meaningful advances usually take informed and sustained involvement, but what’s beyond one person’s capacity can be achieved by bringing more values-aligned people into partnership,” says Seymour.

2. Contact your representatives and voice support for important causes.

One first step could be encouraging them to co-sponsor global health-related legislation, such as the Paul Farmer Memorial Resolution.

3. Write a letter to the editor of your local newspaper.

This guide details the importance of such letters and gives tips on how to write one. Politicians and government agencies routinely clip and circulate such letters around their offices as proof of what matters to constituents.

“If you reference an elected official, it’s likely that your published letter will end up on their desk!” says Seymour. “Because many other constituents will have read it, the visibility pressures them to take action.”

4. Open browser tabs and support your favorite cause.

Tab for a Cause is a free, secure browser extension that allows you to raise money for PIH and other causes with every tab you open.

5. Volunteer in your community.

Consider social justice-minded organizations or grassroots groups such as PIH Engage, which recruits volunteers and mentors them on how to take meaningful actions in the global right to health movement. There are more than 500 members across 61 cities. Join an existing PIH Engage team or apply to start your own.

Stay Informed

6. Watch How To Survive a Plague.

It is a documentary about the early years of the HIV/AIDS pandemic. Seymour finds it moving and a clear-sighted reflection on the sacrifices and losses incurred to push for treatment to advance HIV/AIDS. The film also serves as a reminder that the road to systemic change usually involves struggle, but that—ultimately—the results can be life affirming.

It’s a “deeply inspiring film about what a relatively small, but well-organized group of activists are able to accomplish when literally fighting for their lives,” says Seymour. “The film also articulates how a successful advocacy strategy requires not only rigorous evidence, but also creative public pressure.”

7. Read Why David Sometimes Wins: Leadership, Organization, and Strategy in the California Farm Worker Movement by Marshall Ganz.

The book “presents a recipe for an antidote to despair amid structural violence,” says Seymour. The book details the story of the United Farm Workers and how “rethinking relations of power can lead to structural change determined by the exploited, rather than the exploiters.”

Possibly most notable for future advocates, Ganz highlights three elements that lead to organizers’ success: motivation of the movement’s leaders, their diversity of approach, and their creative decision-making.

8. Read An Introduction to Global Health Delivery: Practice, Equity, Human Rights by Dr. Joia Mukherjee, PIH’s chief medical officer.

Seymour calls Mukherjee’s book a solid resource to become a more informed advocate for global health equity. And John Green, a bestselling author, vlogger, and PIH supporter, found it key to his own education as an advocate.

It is an “excellent overview of the forces that have created and exacerbated inequities in global health, the components of a strong health system, and programmatic and political interventions to begin to heal the wounds of racist and exploitative forces that have led to clinical and public health deserts,” Seymour says.

9. Enroll in online courses to further your education about a favorite cause.

If that entails global health, one resource is PIH Engage’s Crash Course. The self-paced, online course provides an overview of the history and current state of global health inequities, PIH’s mission and values, our theory of change, and resources to get involved with PIH Engage. Seymour explains the course is designed to “serve as a launching pad to long-term engagement in organizing for the right to health.”

Examples of Successful Advocacy

Since Partners In Health’s (PIH) inception in 1987, social justice work—which requires understanding the harm done to communities and working to remediate that harm—has played a key role in our clinical care.

Together with partners around the globe, PIH advocates for policies and practices that lead to stronger, more just health care systems in impoverished communities. From advocating for access to treatment for patients living with HIV/AIDS in the 1980s to more recently pushing for equitable access to COVID-19 vaccines, advocacy helps drive change to save lives. It takes many different forms: grassroots organizing, congressional calls and emails, fundraising events, educating the public, and more.