When a pregnant woman in rural, southeast Liberia visits a public health clinic near her home, here’s an example of what she might find.

The clinic has no plumbing, so buckets of well water are brought in to try to keep things sanitary. Ever since someone stole the diesel generator a couple of months earlier, it hasn’t had electricity either. Women give birth at night by the glow of a kerosene lamp. Those delivering during the wet season have it even worse. “The rains come through a hole in the roof and flow into the delivery room, so the floor is slippery,” explains the 28-year-old nursing student in charge, while demonstrating the wide stance he uses to maintain balance during deliveries. It also doesn’t have a simple squeeze-bag resuscitator for babies who are born ill or premature and is missing all but a handful of essential drugs.

In an emergency, help is, technically, a call away. The district ambulance—when not already in use—must travel an hour down a rutted and boggy 4x4 track, and then at least another hour to the nearest emergency room. Of course that assumes the driver can be reached. The only place to get cellphone reception is in a palm tree behind the clinic. A person plugs earbuds into his cellphone, dials, places the phone high in the tree, and hopes for a ringing sound.

The clinic is not atypical. Many public clinics, health centers, and hospitals in Liberia face similar problems. Credit the upheavals caused by an Ebola epidemic and a 13-year civil war, and a national budget that can’t afford to spend even $50 on health care per citizen. The Liberian landscape might be all creeper vines and primordial trees, but the health care system can be a desert—especially for millions of pregnant women.

Partners In Health’s Community Health Supervisor M. Hnede A. Kondy—or “Mommy Mary,” as she is known—has been a nurse and midwife in southeast Liberia since 1984. “I don’t know how many hundreds of babies I have delivered,” she says. “I have a lot of them around here who are even having their own children now.”

I don’t know how many hundreds of babies I have delivered.

Mommy Mary says that most soon-to-be-mothers in rural Liberia are poor, in their early 20s, and have a couple years of primary school education. When labor starts, women get busy. “They work harder—splitting wood, fetching water, cooking for that day, washing clothes,” she says. “They do this because they say they want the labor to be fast.”

Many women give birth at home—often in mud-walled, dirt-floored houses surrounded by traditional midwives, mothers, sisters, or aunts. If anything goes wrong, a neighbor might be able to drive the woman to a clinic on the back of his motorcycle, but, says Mommy Mary, many complications are taken care of on the spot. Say a baby’s body is too large to fit through a woman’s pelvis. Without an ultrasound, no one knows this, so a woman will be encouraged to push.

“Sometimes they will call some men to take care of you,” says Mommy Mary. “The men will beat you with sticks. Or they will bring red ants from the tree and put them on you. While the ants are biting you, you are yelling, you will deliver.” Pushing too early can tear the vagina, risking the life of mother and baby.

Those who opt not to give birth at home sometimes visit their nearest public health clinic, such as the one mentioned earlier. But few make the hour-plus walk. As the officer in charge there admits, “Most women don’t want to deliver in the clinic.”

Instead, a woman might opt for a public health center, which is farther afield but more likely to have a certified nurse, a couple dozen medications, electricity, and running water. Unfortunately, even if all goes well at a health center, all doesn’t necessarily end well.

Take Pleebo Health Center, a small PIH-supported public health facility in southeast Liberia that has four beds in the post-natal room and serves all 20,000 people in the town of Pleebo, and another 30,000 in the surrounding area. “By rights, we should keep them 24 or 36 hours to see that the baby is sucking well, to see that the bleeding is being monitored, to see that they are urinating regularly,” says Mommy Mary. But no sooner did Pleebo get a reputation for safe births than it was crowded with laboring mothers. One night not long ago, nurses at Pleebo successfully delivered eight babies. The new mothers ended up two-to-a-bed and on mattresses on the floor. After half a day, other women needed it. The first group and their infants had to be asked to hit the road.  

The new mothers ended up two-to-a-bed.

The final choice for a pregnant mother is a big, usually white-painted public hospital. Doctors and nurses at many safely perform cesarean sections, treat women convulsing from malaria, and more, which is especially helpful because they’re responsible for patients referred from clinics and health centers. The rarest few hospitals have blood banks with a couple liters in stock, so family members don’t have to be asked to donate on the spot during emergencies. Some even have functional pharmacies.  

But unfortunately a government hospital isn’t always equipped to offer proper care. Liberia, population 4.2 million, has 1,400 nurses; a U.S. state with the same population, such as Kentucky, has 40,000 nurses.

Understaffing plays out badly. The situation in the obstetrics unit of nearby J.J. Dossen Memorial Hospital, which PIH supports, is typical. Women lie on benches waiting their turn. Each of four nurses, earning roughly $1.25 per hour, gives antenatal check-ups to an average of 46 patients per day—a pace that hardly allows them enough time to give each woman a physical, let alone follow up on danger signs.

Technology doesn’t ease the exhaustive pace. The ward at J.J. Dossen doesn’t have fetal dopplers, devices that electronically measure a baby’s heart rate. Instead, nurses are forced to use fetus cups, cheap metal cones that they place on the woman’s belly to listen for the faint sound of a tiny heartbeat.

“I’ve seen such bad things,” says J.J. Dossen Nurse Norah Quiwea.

The previous month, when she was working at a hospital in a neighboring district, a pregnant woman was grossly misled. Quiwea says the woman arrived for her prenatal visit, and the nurse—well-intentioned but harried, using a fetus cup and straining to hear over the commotion in the hallways—probably confused the thup-thup sound made by the mother’s abdominal aorta with the thup-thup of the fetus’s heart.

“She carried that fetus until she went into labor,” Quiwea recalls. “But at the end of the day, we found out that the fetus had died a week earlier.”

If the hospital hadn’t happened to have the right antibiotics on hand, an intrauterine infection would have killed the mother, too.

Given all this, it’s no surprise that Liberia has one of the worst maternal mortality rates anywhere outside of an active war zone: 1,072 deaths per 100,000 live births. Put in plain English, roughly 1 in 28 Liberian women die in the weeks before, during, or after childbirth.

They saw opportunity instead of tragedy.

This is depressing, no little bit to Liberian women, 47 percent of whom recently replied in a survey that maternal health was “a very serious problem.” (Another 42 percent perceived it as “somewhat serious.”) But it’s worth remembering that not so long ago, Rwanda was in a similar fix. In 2000, its maternal mortality rate was 1,071 deaths per 100,000 live births, virtually identical to Liberia now. But local leaders and concerned partners, including PIH, saw opportunity instead of tragedy, and over two decades, they acted with grit and faith and unchecked compassion. To what end? The number of Rwandan women who die from pregnancy or delivery has decreased 80 percent.

PIH is working with Liberia’s Ministry of Health for the same transformation. We applaud President Sirleaf’s pledge to tackle maternal mortality, reviewing many cases personally. We are supporting the Ministry of Health’s “Accelerated Action Plan to Reduce Maternal and Newborn Mortality” and taking the lead in a number of facilities in southeast Liberia, the remote area that is our focus. We are topping up the drug supplies in  health clinics and mentoring and training clinicians. We have renovated, and will soon expand, Pleebo Health Center. And we’re midway through major renovations of J.J. Dossen Memorial Hospital. Which is to say nothing about working with the county health team to operate an ambulance, check up on hundreds of expectant mothers in their homes via community health workers, and more. Our five-year goal is for all PIH-supported public facilities to have zero maternal deaths.

For more about how PIH is helping the Ministry of Health, see:

New Health Center Opens in Liberia
On TB's Trail in Liberia
Liberia's New Nurses, New Hope
How to Stop Epidemics: Spend Billions to Save Trillions
Liberia country page

Please check in again soon for articles about our remodel of J.J. Dossen Memorial Hospital and more.

Carmen Contreras has seen tuberculosis patients at their worst. They have endured daily injections and swallowed fistfuls of pills for years. As reward for their diligence, some have lost their hearing and their minds as side effects of the toxic medication. One 19-year-old patient she knew, depressed and bone-tired from his years-long struggle, attempted suicide.

At times, it made fighting TB seem like a hopeless endeavor. Until now.

For the first time in 50 years, two new drugs are available to patients battling the most trenchant forms of the disease, known as multidrug-resistant and extensively drug resistant tuberculosis, or MDR- and XDR-TB. Bedaquiline and Delamanid have been used sparingly so far, but their results border on miraculous. So far, patients say they breathe better. They gain weight. And those who tested positive for TB for years have seen their results flip after a couple months of treatment.

Contreras, director of intervention projects with Socios En Salud, as Partners In Health is known in Peru, knows the promise these new drugs hold for her patients.

“When you see with your own eyes how people suffer,” she says, “your happiness is greater when they recover.”

TB is not pretty. And it’s definitely not a disease that only troubled past generations. The World Health Organization named it the most deadly infectious disease after it surpassed HIV in 2014, when it caused 1.5 million deaths worldwide compared to HIV’s 1.2 million. Perhaps most alarming, experts have seen a dramatic increase of new infections that are drug-resistant—some 480,000 in 2014 alone—and therefore harder to cure.

PIH has a long history of combatting MDR-TB, especially in Peru. In the mid-1990s, staff discovered that the first, and usually most effective, line of antibiotics were not helping many of their patients in the slums around the capital of Lima. So they began treating patients with harder to access second-line antibiotics and assigning each a community health worker, who ushered them through care.

The change was immediate and remarkable. Patients who had been treated for years with no relief returned to full health. PIH in Peru has since treated more than 10,500 people for MDR-TB with cure rates of greater than 75 percent—some of the highest in the world. In response, the WHO revised its treatment protocol for MDR-TB in recognition of PIH and other organizations' innovative approach.

With new TB drugs on the market, PIH could again provide a worldwide example for effective, compassionate care—this time for XDR-TB patients too. As the lead of a groundbreaking program called endTB, PIH is working with nongovernmental organizations Médecins sans Frontières and Interactive Research & Development to offer new treatment regimens that include Bedaquiline and Delamanid to more than 3,000 people across 15 of the most TB-plagued countries—including Peru, Lesotho, and Kazakhstan—over a four-year period. UNITAID is funding the global effort, which launched in April 2015.

Ultimately, endTB partners hope the new drugs will prove to be safer and more effective than other second-line medications, and thus allow treatment periods to be cut in half.

Launching endTB

Peru is one such testing ground. There, PIH is collaborating with the Ministry of Health to include nearly 600 patients in endTB. Of this total, 420 patients will follow the WHO-approved two-year treatment regimen, which entails daily injections for 12 months and a cocktail of pills that will now include one or both of the new drugs. Starting in November, an additional 150 patients will be enrolled in a clinical trial that includes the new drugs, but eliminates injections and shortens patients' treatment period.

Since both groups will receive the new drugs, ideally both will get better. But success in the clinical trial group would prove that drug-resistant TB patients no longer have to endure daily injections and could take medication for less time—a double-coup for clinicians and patients battling the disease.

Peru staff began contacting the first endTB participants in March, but only after overcoming logistical hurdles. National officials had to be reassured that the new drugs were not more toxic than the current course of treatment. The government then had to formally register and license Bedaquiline and Delamanid. And PIH’s TB team had to figure out how to source and import the new drugs, which are not yet mass-produced. In fact, the team is still awaiting its first order of Delamanid.

Then there is the challenge of locating patients. Peru’s National Committee on Evaluation and Treatment combs through a list of TB patients on a monthly basis to determine eligibility for endTB. If their medical records show long, unsuccessful treatment periods, they become top contenders. Most patients live in and around Lima. Those who don’t are brought to the capital, and PIH finds them and any accompanying family members a place to stay for the long haul ahead.

Once patients agree to participate, they visit their closest health center and meet with a clinician and a PIH health professional, who helps them through treatment. Their first trip is often to the hospital for a day of exams and lab work. Some TB medications have caused deafness and cardiac problems, so patients meet with an otologist and cardiologist for base assessments. Once all results are in, doctors prescribe patients medications that will most effectively combat their specific strain of TB. PIH and its endTB partners source some of these drugs, others are provided by Peru's Ministry of Health.

The PIH pharmacy receives all the medications, including Bedaquiline and the soon-to-arrive Delamanid, which staff members painstakingly divide into patients’ daily morning and afternoon dosages. Field technicians visit their patients in the morning and at night to ensure they take their drugs. They also note patients’ general health and record adverse reactions, such as anxiety, hearing loss, cramps, and neuropathy.

Slow, steady progress

Lourdes Cruzado, PIH’s endTB field coordinator in Peru, says her staff has enrolled 27 participants so far. These men and women, who range in age from 19 to 56, are the sickest of the sick and often dealing with multiple issues. Nine suffer from drug addiction, six from depression. Two are in prison. Another is diabetic, and still another is HIV-positive. Two extremely sick patients, who simply didn't have much fight left in them after battling the disease for years, died shortly after starting the regimen.

PIH staff help in every way possible. They get them access to mental health counseling and—especially for those coming from rural parts of Peru—connect them with food and transportation to and from doctors’ appointments. They ensure the homes of Lima-based patients are secure and have proper ventilation to control infection. They work to earn the trust of patients who have endured years of unsuccessful, and often debilitating, treatment. And they go along on appointments at health centers, where local staff aren’t always welcoming.

“In some cases, they have told us that patients shouldn’t come, that they could get other people sick,” Cruzado says.

Cynthia Dueňas, an endTB field technician, remembers meeting one patient, whom she greeted with a hug and kiss on the cheek. Seconds later, she noticed the woman was crying and asked what was wrong. “’All this time,’” the woman told her, “’people don’t come close to me and they don’t hug me that way unless they know me.’”

Cruzado tells patients that they will come out ahead of this and be okay. “You truly feel the most sincere hug,” she says. “It’s as if they take refuge in you, they trust you, and those words help them.”

Although endTB was launched in Peru just two months ago, PIH staff already see improvements among their growing group of patients. They have gained weight. They say they feel better, calmer. And they smile more often. Some patients' sputum samples have even tested negative for TB.

“One of the patients told me, ‘I feel like running!’” Contreras says with a laugh. “I told her, ‘Hold on, please. Don’t do it yet. Very soon, you will.’”

Dueňas understands why patients might have a hard time curbing their enthusiasm about the new drugs available to them now through endTB. “They’ve spent years battling the disease and can’t beat it,” she says. “For them, it’s a leap of faith that this medication is going to save them.”

Dear PIH Community:

Together, we mourn the great sadness caused by the murders of so many in Orlando this weekend. In the dark shadow of this tragedy, our hearts go out to the families and friends of those who were lost and all of our thoughts and prayers are with those who are fighting to recover from their wounds.

Our souls are united with the people of Orlando and we stand in solidarity with the LGBTQ community there and throughout the world in the face of this grotesque act. In our work, we often bear witness to the consequences of violence driven by hate and the scars of intolerance. We must be certain that this madness is a catalyst to bring all of us together in service of peace and not a misguided tool to further divide us.

May our collective love of humankind help all of us to find a pathway to real and sustainable healing.

With love,

Gary

Gary L. Gottlieb, MD, MBA

Chief Executive Officer

Partners In Health

Occasionally we ask colleagues to share their experiences working in global health. This month, Nandi Bwanali, Partners In Health’s public relations coordinator in Malawi, wrote about her upbringing in Malawi and what it’s like to work in Neno District. She’s from the country's capital, Lilongwe, and came to us through a fellowship with the nonprofit organization Global Health Corps.

My mother had me when she was 14, so my grandfather and grandmother raised me while she continued her education.

I grew up during a time when not much was known about a lot of things, and once they were discovered no one would say anything about them. Diseases were not really an everyday topic. Malaria was something I knew people could get but not really die of. HIV/AIDS was what TV advertisements went on and on about, but it wasn’t anything we had to bother ourselves with. It didn’t help that apart from the ads, HIV/AIDS was the main topic of Kenyan movies played on repeat on the local station. I have an early memory of my uncle begging my grandmother to change the channel: “Even Nandi could tell you what causes HIV. It’s all they show these days!” he said gesturing to 10-year-old me.

As far as I was concerned, people with HIV had hair falling from their scalps and ribs poking out of their chests and were nobody I knew or had to concern myself with.

Diabetes and hypertension—or “sugar” and “BP,” as I knew them—were more familiar terms in our household. My grandpa was unfortunate to have both. My grandmother was terribly afraid of needles and, in hindsight, I think so was my grandpa because he quickly taught me to give him injections. It was a fun activity for me. I would jump up to my task every day, and we would have long talks about how I would one day be a doctor and help others too.

I never took these diseases seriously. In my view, my grandpa was everyone’s superhero who just needed a little shot twice a day, much like Popeye needed his spinach. That was until diabetes eventually took him away from us in 2005.

“Bambo” means father in Chichewa and was the name I gave my grandpa. He was the only father figure I knew. At his funeral I heard people say that if someone had just given him something sweet he would have lived. This got me thinking about the fine line between life and death. For the next couple of months, I thought about this constantly. Months turned to years, and more familiar faces passed away from various ailments. My grandmother, a woman with a thousand stories, would explain to me what happened after we came back from every funeral of neighbors, friends, and family.

I realized diseases like HIV/AIDS were not just limited to radio and TV ads, and that, in fact, there was little known about the diseases that plagued the country. There were also no treatment options for people who contracted them. Wives were buried because of their husband’s infidelities, and children were left in the care of relatives who knew nothing about how to fight these diseases. I learned that “AIDS is a Killer” was not a song we merely sang as we played with clay dolls and wire cars, but a statement that stood for the countless people who were dying every day with little hope. Suddenly the Kenyan movies whose lines I had come to memorize reflected people who had died around me—a young, oblivious girl.

My grandpa’s death is a heavy memory I carry every day, but his life has been my constant motivation. I did not become a doctor. I was selected to go to university at 15 to study education. It became clear that teaching was not the path I wanted to take in my search for service. The injustices that rattled me were related to gender issues and disease. Having an English literature teacher as a mother had its effect. I understood the power of narratives, and I knew I wanted to tell stories.

I went on to study marketing, specializing in communications. I worked with the British Council in Malawi as the lead for customer service and communications. As a diversity and inclusion volunteer, I also coordinated projects to create equal opportunities in the organization. In November 2014, my boss sent me a newsletter about Global Health Corps’ fellowships for young professionals. She encouraged me to apply.

I didn’t think I would be selected without knowledge about global health, a term I did not fully understand. But I knew I wanted to contribute to a cause that would ensure that years on, I would not live in a country where the majority of people were burdened by disease and poverty. I wanted to play my part with the best of what I could contribute. 

I gave it a shot and was fortunate enough to be among the 2 percent of applicants selected. I can proudly say I am now a Global Health Corps fellow placed at Partners In Health’s office in Neno, Malawi. My words are my weapons to curb inequality.

My grandmother thought I was crazy when I told her about my interviews and that I had been selected to work in Neno. She repeated Neno a couple of times and asked me if I even knew what the place was like. She described it as a forest in the middle of nowhere with no roads and basically the last place any sensible person would volunteer to go. Neno is indeed a forest and the bad roads and mountains play a part in making it immensely isolated, but it was where I wanted to go.

Unlike most people that work for PIH, known locally as Abwenzi Pa Za Umoyo, I did not know Paul Farmer. Nor had I read Mountains Beyond Mountains. But PIH stood out from other organizations because it stayed in the areas it worked. It pledged itself to a portion of the 80 percent of Malawians facing extreme poverty in rural areas. This was the type of commitment I wanted to be associated with and the population I wanted to serve.

I had fears when I first started out, but every day I learn something new as I meet patients and hear their stories, which I share with partners who support us. Days contain small and special moments as foreign and local mix together. Chickens roam the office. American slang and Chichewa conversations fill the hours of long car drives to villages. Skype calls to Boston are common. I always spell check in Word, converting “programme” to the American “program.” And I have learned, to my surprise, I’m just as exotic as the organization I work for. At least three times a week I’m asked, “Are you Malawian?” as my accent reflects my town life. It has been a great conversation starter.  

In the 10 months I have been here, I have made new friends, some of whom have appeared in PIH stories. HIV prevalence rates and malnutrition statistics are not simply figures, but apply to Malawians I now know. They represent people and their burdens. I have seen health structures rise up in parts of Neno where people used to die without places to go for health care. I have seen pregnant mothers who once risked their lives by delivering at home rest their worries when PIH provided maternal waiting houses closer to their homes. I have watched the array of professionals who make this work possible—doctors, nurses, construction workers, transport officers, accountants, and many others—come together with a common goal to provide a preferential option for the poor.

Looking back, I laugh at the irony of life. Now I am the one sending out health messages on TVs, radios, newspapers, and digital channels. I am sure my grandfather would be proud of me and my cause. 

Dr. Enrique Valdespino had no idea a man lived locked inside a shack three blocks from the clinic in rural Reforma, Chiapas, where he practiced medicine. Nor that the man, 52-year-old Rosemberg Lopez, had been living there for years.

The news floored him. Especially since Lopez’s parents came in for monthly checkups and his sister visited his clinic regularly.

“They were not talking about him, asking for help, considering we could do something for him, or trying to incorporate Rosemberg into society again,” says Valdespino, who was just out of medical school at the time and working with Compaňeros En Salud, as Partners In Health is called in Mexico. “For everyone in Reforma, Rosemberg was dead.”

Unfortunately, Lopez’s story is not unique. Few patients living with schizophrenia in the highlands of the Sierra Madre have ever received a proper diagnosis or consistent treatment. Their families, mostly poor coffee farmers, know something is wrong and do what they can.

Sometimes that means traveling hours by public transportation to the closest psychiatric hospital, where their loved one receives a diagnosis and a prescription for psychotropic medication. Other times they go to a traditional healer who provides them with a “cure” against witchcraft. But when families can’t afford the medicine or transportation or traditional remedies fail, they are left with few viable options. And so they chain or lock up their family member to protect themselves and others from harm. It’s meant as a temporary measure, but can become a life sentence.

For everyone in Reforma, Rosemberg was dead.

Doctors like Valdespino have seen this story play out time and again in the 10 clinics PIH supports in rural Chiapas. They discuss schizophrenia with patients’ families and their cases with mental health specialists so patients are formally diagnosed. They and a cadre of community health workers monitor patients’ progress once they return home. The team’s work is supervised by PIH’s mental health coordinator in Mexico, who is in turn supported by a Boston-based mental health team.

Schizophrenia afflicts four of every 1,000 people in Mexico, according to the World Health Organization. Symptoms typically start in patients’ 20s and can include delusions, hallucinations, disorganized speech or thinking, and social isolation. Medication and psychosocial therapy help patients manage the condition, but they are rarely available in poor, rural regions of the world. In 2012, only four psychiatrists were working in public facilities in Chiapas, a southern state with 4 million people.

Descending into darkness

Lopez was 25 when his symptoms emerged. He had hallucinations and grew increasingly paranoid. He ran along the streets, sometimes naked, cursing and throwing rocks at people. He carried a machete and menaced children and teachers at the elementary school. Sometimes he ran away for days at a time to live in the grassy hills encircling the small community.

“He mistreated us, threw food, and ran after children,” says his sister, Mirian Lopez. He got so angry once that he punched their mother, Erminia Borralles, in the face.

“Everyone in the community was afraid of him,” Boralles says.

His family thought Lopez was possessed by an evil spirit, so they took him to a witch doctor and tried to treat him with herbs and other natural remedies. When that didn’t work, they traveled to doctors in neighboring communities. Some wanted to operate on him. Some claimed there was nothing wrong. Others said what he needed was good, hard work.

Once back home, though, Lopez lost the gains he’d made. Paranoia made him think his pills were poisonous, and that his family was trying to harm him. His medication was also expensive, more than the family could afford on their limited coffee income. And the local clinic wasn’t functioning at a level to provide consistent care. Whenever the situation got out of control, his family returned to Tuxtla-Gutiérrez to have him admitted for treatment. But this, too, was hardly a sustainable solution.Nothing helped. Finally, they sedated Lopez with help from neighbors and traveled five hours via public transportation to the state capital of Tuxtla-Gutiérrez, home of the nearest psychiatric hospital. He was diagnosed with schizophrenia, put on psychotropic medication, and experienced a dramatic recovery during his two-month stay.

Feeling ashamed and helpless, Lopez’s family decided there was only one thing they could do to keep him close and safe; they built a mud-brick shack behind their home and locked him inside. There he stayed for six years, a small window his sole source of light and contact with the outside world.

'A sickness that has a name'

Eudeli Velasquez was a schoolgirl in the early days of Lopez’s illness and remembers him wandering around Reforma with a machete. She says she used to walk by the locked shack years later and think: “When I’m big, I want to earn a lot of money to get him out of there.”

Velasquez, now 23, was among the crowd of onlookers the day PIH and Ministry of Health staff came and coaxed the man out of his shack one bright day in September 2014.

Lopez walked unsteadily into the sunlight. His unkempt hair stretched down his back. His beard reached his waist. Every rib jutted out from his emaciated chest. He cringed at the attention, his sister remembers, and begged to go back into the dark and stagnant space where he had eaten, slept, and relieved himself for so many years.

PIH staff beckoned Lopez forward and walked with him to a nearby Ministry of Health ambulance, which they drove directly to the same Tuxtla hospital he’d visited years earlier. This time, he stayed 16 weeks and returned home a changed man—his hair trimmed, his beard gone, and his weight back to normal.

The community had changed too. Valdespino had finished his service year, so another PIH-supported doctor staffed the local clinic. And a group of 10 women, including Velasquez, was training to become Reforma’s first community health workers. Their primary task was to monitor the health of patients diagnosed with chronic diseases like diabetes, hypertension, or mental illness.

Velasquez knew right away she wanted Lopez among her patients. Early on, she made multiple daily home visits to ensure he took his medication. And she regularly swings by now, a year and a half later, to check on him.

“People said that he was crazy, but it’s a sickness that has a name,” she says.

An empty shack

On a scorching morning in March, Velasquez popped into the Lopez family home to check on her patient. Lopez was stretched out in a hammock, gently swinging in the shade of the back porch. He broke into a guileless smile when his community health worker took a seat beside him.

His mother and sister hovered in the doorway, while Velasquez opened each lid on Lopez’s pillbox to review his medication. Their voices dropped when they talked about the dark days of his illness. About their shame and sadness. And about the violent episodes that hardly seemed to have come from the quiet man relaxing nearby.

Velasquez walked with mother and daughter back to the shack, still standing though vacant, in their backyard. A thick, rusty chain snaked across the red dirt nearby. Mirian and Velasquez picked it up and demonstrated how it used to link Lopez to a nearby tree. His mother looked sadly at the chain, but didn’t touch it.

“Thanks be to God for the doctors,” Boralles says. “He now lives together with us; he eats with us. He’s not returned to how he used to be.”

Give now

The baby boy arrived 14 weeks early and weighed less than 2 pounds. Nurse Thamar Julmiste received him from labor and delivery staff at St. Thérèse Hospital in Hinche, Haiti, and immediately noticed he wasn’t breathing. She and Nurse Nathalie Casimir luckily knew what to do. They performed CPR on the impossibly tiny newborn and were relieved to see his birdlike ribcage rise and fall on its own.

“People didn’t think he was going to live,” Julmiste recalled.

But he did. Julmiste followed what she and seven of her colleagues had learned during a training for nurses on neonatal intensive care organized by Zanmi Lasante, as Partners In Health is known in Haiti. Now, a new cohort of 26 nurses from around the country are following in her footsteps by studying neonatal and pediatric intensive care. The free, 24-week-long training at University Hospital in Mirebalais, which PIH supports, will provide them with a foundation in theory and clinical skills in both neonatal and pediatric intensive care.

Graduates will receive certification in July from the Haitian government and—if PIH’s efforts prevail— be the first among a growing group of neonatal and pediatric intensive care nurse specialists in Haiti.

“Everyone deserves the best level of care,” says University Hospital’s Marc Julmisse, the chief nursing officer who is spearheading the training. That’s only possible when clinicians receive the best training available, so she’s helping prepare this group of nurses to think critically and develop the specialized skills necessary not just to follow orders, but to “become a valuable member of the patient care team.”

A typical nurse’s training in Haiti includes four years of university education. After that, opportunities exist to specialize in midwifery or community health. If they want other types of advanced training, they must travel outside the country, and most stay to work there afterwards. It’s all part of the brain drain that has afflicted Haiti for decades, as the country’s brightest minds leave in search of higher education and better job opportunities. PIH clinicians in Haiti are definitely an exception, considering they have chosen to stay and practice medicine in their home country while training the next generation.

Our expectation is that you’re going to be a leader.

An expert neonatal nurse herself, Julmisse understands this reality and is part of a team working to build in-country specialized training for PIH nurses and, for that matter, all nurses throughout Haiti. She launched a pilot program in neonatal intensive care last year from which 25 nurses graduated. Lessons learned from that pilot informed the current neonatal and pediatric intensive care training in Mirebalais.

The Haitian Ministry of Public Health and Population chose from which hospitals to recruit trainees. Then Julmisse and her team sent out invitations to 11 locations (many of them PIH sites), including: Gonaïves, Jacmel, Jérémie, Saint-Marc, Petite-Rivière, Hinche, Mirebalais, Belladère, Cange, Diquini, Jean Denis. Interested nurses filled out an application and wrote a personal statement about why they wanted to be chosen. To qualify, they had to be licensed, have worked at least one year in pediatrics, and have dealt with critical cases at their hospitals.

In late January, 26 nurses began their training in University Hospital, where they have one day of lecture followed by a day of clinical practice in the wards. They return home the rest of the week to their regular jobs and apply what they have learned.

Julmisse recruited PIH clinicians to help teach, such as Dr. Christophe Milien, the hospital’s director of obstetrics and gynecology, and Meredith Jean-Baptiste, the hospital’s maternal health coordinator. She pulled from contacts she has made over the years at Ohio State University and Boston Children’s Hospital. Together they designed the curriculum and have taken turns lecturing and mentoring the nurses. Last year’s graduates based at University Hospital, such as Nurse Lauria Cadet and Nurse Manager Alexandra Millien, also co-facilitate and serve as translators for English-speaking instructors who aren’t well-versed in Krèyol. And PIH’s Boston clinical team helped manage logistics from afar.

Nurse Lauria Cadet (left) observes Nurse Joseberth Joseph as she draws blood from a newborn inside the Neonatal Intensive Care Unit at University Hospital in Mirebalais, Haiti.

Nurses study increasingly complex information and techniques as the weeks pass. In neonatal care, for example, they first learn how to properly assess a mother’s prenatal history to anticipate complications during labor and delivery, and they monitor a baby’s vital signs as the newborn transitions to life outside the womb. Deeper into the training, they learn symptoms of cardiac anomalies and respiratory distress in newborns and how to treat them.

Instructors assess the nurses based on their knowledge, skills, and attitude. It’s a pass-fail system. And that’s as it should be, considering lives literally hang in the balance based on the nurses' ability to perform under pressure.

Julmisse sets a high bar for nurses from their first day. “You’re not in the training because you had nothing better to do,” she tells them. “If you can’t keep up to expectations, then this is your time to leave.”

So far, no one has looked for the exit. Possibly that’s because they feel just as strongly Julmisse does when she asks: “Are we here to prolong a death, or are we here to save a life?”

Still, Julmisse knows that 24 weeks is not enough time to turn these nurses into experts in neonatal or pediatric intensive care. She does believe that if they put in the time and work, they will leave competent to handle complex situations and serve as examples for junior staff.

“Our expectation,” she tells them, “is that you’re going to be a leader.”

Their July graduation isn’t the end of these nurses’ professional development. Julmisse says her team will follow up with each graduate for a post-training evaluation after one month, six months, and one year to see if, as she says, “the concept has been transmitted.” She heavily encourages them to become members of Haiti’s National Nursing Association and soon-to-come Critical Care Nursing Association. She is even encouraging them to attend the first neonatal conference to be held in Haiti around this time next year.

Back in Hinche, Julmiste and her colleagues who took last year’s training know they are doing good work. She thinks of the premature baby whose life she helped save and understands the importance of continuing education.

“Nurses should take this training,” she says, “because with more nurses knowing [how to handle these situations], we will save more children.”

It seemed like Arinda Roblero had been waiting forever to see her baby’s face. The single mother wasn’t sure when she was due, but estimated it was soon. She visited her clinic in Capitán, Chiapas, and the doctors there recommended she travel with them to Jaltenango, where she could get an ultrasound through Compaňeros En Salud, as Partners In Health is known in Mexico.

It’s a good thing Roblero did. She learned that her amniotic fluid level was low, and PIH staff recommended she stay in a maternal waiting home an hour away in Revolución Mexicana, where professional midwife Carolina Menchú could closely monitor her. The next day, another ultrasound revealed her fluid level had dipped into the danger zone.

Menchú spoke with obstetricians in the hospital located just behind the home and got Roblero scheduled for a cesarean section the following morning. Within hours, the new mother was cradling her daughter in her arms.

Although tired, Roblero said she felt good: “I’m happy, because now I’m a mom.”

Roblero and her daughter are among a growing number of success stories coming from the Unidad de Parto Humanizado, or Humane Birthing Center, in Revolución Mexicana. PIH is partnering with the Ministry of Health at this maternal waiting home and birth center to pilot a program that promotes culturally appropriate and respectful births attended by trained professionals. The 10-bed facility sits directly behind a hospital staffed with physicians who can attend to complicated deliveries.

The exterior of the Humane Birthing Center, located directly behind the hospital in Revolución Mexicana.

The facility will be fully staffed and equipped by August, yet Menchú has already attended 75 births since PIH started supporting the facility in August 2015. PIH’s ultimate goal is to prevent tragedies leading to the death of a mother or newborn.

Within five communities where PIH operates clinics in rural Chiapas, 60 percent of women surveyed said they delivered at home under the care of local traditional birth attendants, said Dr. Andrea Reyes, PIH’s maternal health program coordinator in Mexico. That percentage falls into the single digits in nearly every other part of the country. When complications arise, home birth can lead to life-threatening situations for mothers and newborns. So it’s possibly no surprise that Chiapas also has the second highest maternal mortality rate in Mexico, with 68 deaths for every 100,000 deliveries compared to 39 per 100,000 nationwide in 2014, according to the United Nations Millennium Development Goals.

Women living in remote communities of the Sierra Madre, where donkeys are more numerous than cars, stand the highest risk. Should a delivery turn too complicated for local birth attendants, a woman’s family scrambles to get her down the mountain to the nearest hospital, sometimes five hours by car.

“If a woman has a profuse hemorrhage,” Reyes says, “it can cost her life.”

Even if a woman lives relatively close to a hospital, that doesn’t mean she will receive respectful, quality care during labor and delivery. For example, expecting mothers often aren’t allowed accompanying family members or friends inside a hospital, so they endure one of the most trying experiences of their lives alone. Only hours later are visitors allowed.

Birth should be a totally unique experience.

Many women coming from rural regions in Chiapas also believe in keeping warm immediately following childbirth to ensure they can breastfeed, so they and their babies avoid cold water and wrap in thick blankets—even on the hottest days. These practices aren’t always respected in urban hospitals.

“We have seen that having a child has turned into a painful experience in all aspects—physically, socially, emotionally, and economically,” Reyes says. “It doesn’t have to be that way. On the contrary, birth should be a totally unique experience.”

Under PIH’s watch, it will be. Patrick Elliott, clinical director for PIH in Mexico, says that quality maternal care is a result of improving supply to better meet the needs and hopes of expectant mothers. Hospitals and maternal waiting homes must be well-stocked and have adequate space with well-trained staff to guarantee a good birth experience. And more expecting mothers will be open to clinic or hospital-based births, he says, when access to transportation, food, housing, or improper medical practices are no longer barriers.

PIH is laying that groundwork at the community level. First-year doctors, called pasantes, identify and closely monitor pregnant women living near the 10 clinics PIH supports throughout rural Chiapas. Community health workers who specialize in maternal health will soon be recruited and trained to coach and connect women with care throughout their pregnancies. And PIH staff are reaching out to local traditional birth attendants to ensure they have improved training and equipment for the births they do attend, while encouraging their improved integration into the health system as part of the care team at PIH-supported clinics and the maternal health center.

Reyes recognizes the delicate balance PIH must strike between supporting midwives, while advocating for facility-based births. “In the end, local midwives have done this their entire lives,” she says. “They have the women’s trust; we can’t be against them. It’s more like we are going to be one big, capable team and work together.”

Reyes (right) carries Roblero's newborn to a nearby PIH vehicle to begin the journey back to the mother and daugther's home in Capitán.

Meanwhile, Reyes and staff are preparing the maternal waiting home and birth center in Revolución Mexicana, which previously stood empty and unused. Should all go according to plan, expecting mothers from remote communities will arrive at the house days in advance of their due dates. Once labor begins, Menchú is on hand to care for women through the labor process, offering massage, music, or simply soothing advice and support. The midwife then escorts the women to the hospital immediately before birth. Should complications arise, specialized staff assist with the delivery.  

A refrigerator and more cooking utensils will soon occupy the kitchen, where a cook will make meals for guests. A boiler is being installed so that women and their children have access to warm water out of respect for their beliefs about breastfeeding. Cots are being brought in for those accompanying an expecting mother. Emergency kits are being assembled for rapid care if complications arise.

More nursing staff will join Menchú in coming months, and a clinical supervisor will be hired to coordinate and mentor staff. Eventually, nurses and midwives will use an electronic medical record system to follow patients’ progress. Mobile tablets will also be loaded with an app covering Mexico’s version of the World Health Organization’s Safe Childbirth Checklist, which clinicians can use as a reminder of proper steps to follow during labor, delivery, and postpartum care of mothers and newborns.

All of these pieces will be in place for the maternal waiting home’s official August opening. Until that time, Reyes hopes patients like Roblero will share their stories.

“Clearly we have to do our part to promote the center, but I think it’s worth more when the women themselves pass along their experiences,” Reyes says. “Especially when just a couple of hours could mean the difference between life and death.”

This #NursesWeek, join Partners In Health in recognizing the tremendous care nurses provide to people around the world. Nurses make up the large majority of the global health care workforce and deliver the bulk of all health care services. At PIH, nurses represent 84 percent of our clinical staff.

In many of our remote locations, nurses are often the sole care providers for their communities, treating chronic diseases, caring for pregnant women, and helping to manage emergencies. They play an enormous role in delivering health care and strengthening health systems in areas with limited resources.

A group of nursing students at J.J. Dossen Hospital in Maryland County, Liberia. (Photo by Rebecca E. Rollins / Partners In Health)

JOIN US FOR A FACEBOOK LIVE SESSION
PIH Chief Nursing Officer Sheila Davis will talk about what it’s like to be a nurse in the field of global health—including her experience leading PIH’s response to the Ebola epidemic in West Africa, and the importance of leadership and mentoring.

DATE: Wednesday, May 11, 2016

TIME: 12:15 p.m. EST

Watch it here

Sheila Davis, DNP, ANP-BC, FAAN, has worked in the field of HIV/AIDS since the mid-1980s and in global health since 1999. From 2004 through 2010, she helped co-found a nonprofit focused on nursing and feeding programs in South Africa and Boston. Davis joined PIH in 2010 and since September 2014 has led PIH’s Ebola response efforts in West Africa. She is a frequent national speaker on global health, various clinical topics, and the role of nursing in human rights.

PIH's Chief Nursing Officer Sheila Davis disembarks a U.N. helicopter in Monrovia, Liberia, while responding to the Ebola outbreak in October 2014. (Photo by Rebecca E. Rollins / Partners In Health)

Learn more about nursing at Partners In Health

Stories:

Maternal Waiting Home Key to Safe Childbirth in Chiapas, Mexico

Meet a Leader Transforming Nursing in Haiti

House Calls Help Mother Continue Treatment in Russia

Liberia’s New Nurses, New Hope

Haitian Nurse Looks Back on Storied Career

Nursing in Navajo Nation

Nurse Cheedy Jaja: Why I Serve in Sierra Leone

Why I Nurse: Gedeon Ngoga

Matumelo Seiiso was expecting her third baby last fall. The 30-year-old mother lived in Nkau, a remote region in the mountains of southern Lesotho. Throughout her pregnancy, Seiiso’s maternal health assistant, Mamopeli Chabana, made regular house calls to check up on her. She also traveled with her to her prenatal appointments at Nkau Health Center, a clinic supported by Partners In Health—known locally as Bo-Mphato Litšebeletsong tsa Bophelo.

One night near the end of Seiiso’s pregnancy, Chabana received an alarming phone call. Seiiso was bleeding profusely. Chabana rushed to her house and became frightened as soon as she saw Seiiso, unsure if the baby was coming, but certain something was wrong. A neighbor drove them to the clinic in Nkau, 30 minutes away. Seiiso continued to bleed.

An ultrasound revealed Seiiso had a placental abruption, a serious complication that could mean her baby would become deprived of oxygen and nutrients. She needed a cesarean section, but the clinic didn’t stock her blood type. So staff members prepared to send her to a hospital in the capital city, Maseru, and hooked her up to an IV. But before the ambulance arrived, Seiiso began to deliver her baby. Nurses and nurse-midwives got to work, and shortly after, Seiiso gave birth to a healthy girl, Lineo.

Despite her mother suffering a placental abruption, Lineo Seiiso was born safely thanks to staff at Nkau Health Center. Photo by Rebecca E. Rollins / Partners In Health

Many women in Lesotho cope with the risks of pregnancy alone, receiving no skilled health care while pregnant and often delivering at home. For this reason, maternal mortality in the country is one of the highest in the world. More than 20,000 women die every year from pregnancy-related complications. PIH has been in Lesotho since 2006 working to change this. By supplying rural clinics with proper medicines and equipment, training doctors, nurses, and midwives, and recruiting community members as maternal health assistants, PIH staff ensure women are properly cared for throughout their pregnancies.

PIH’s maternal health work was recognized by Lesotho’s Ministry of Health as a promising model to apply to the rest of the country, and now similar programs are developing at other public clinics.

However, we know there is more work to do. Continuing to train maternal health workers to care for women, and further equipping clinics with necessary items—including limitless stocks of blood types for patients—are ongoing goals. But Seiiso’s story shows what an attentive assistant, trained clinicians, and a clean nearby health center can do. They ensured her and her baby’s survival.

Seiiso spent several days at Nkau to rest and recover. Six weeks later she returned for Lineo’s final postnatal checkup. While waiting for her appointment, Seiiso recalled the terrifying moments at the clinic and her relief when it was all over.

“I was happy, because I was still alive and had a live baby.”

A statement from Partners In Health:

The U.S. Department of Agriculture recently announced a deal to ship 500 metric tons of peanuts grown in the United States to school children in Haiti later this year. We believe this action is wrong. Shipping excess U.S. peanuts to Haiti—known as “crop dumping”—will be a disaster for Haitian peanut farmers, and ultimately won’t help the people USDA intends to serve.

Levels of food insecurity and hunger are extremely high in Haiti, and we have a responsibility to act. We agree that providing assistance to hungry people is critical, but it shouldn’t come in the form of food that is currently being produced by local farmers.

There is precedent that supports our concern. Flooding local markets with outside crops has a profoundly negative impact on the Haitian economy and the well-being of the Haitian poor. It undermines local food production and forces farmers whose livelihoods have failed into rapid and uncontrolled urbanization to city slums. Perhaps most importantly, crop dumping has not produced a positive outcome in the nutritional status of Haitians who are poor.

There is a long history of food assistance to poor countries; the export of rice to Haiti in the 1980s is just one example. But that particular effort was a mistake, as former President Bill Clinton acknowledged in 2010: “It may have been good for some of my farmers in Arkansas, but it has not worked,” he said. “I have to live every day with the consequences of the lost capacity to produce a rice crop in Haiti to feed those people, because of what I did. … We should have continued to work to help [Haitians become] self-sufficient in agriculture.”

In contrast to U.S. farmers, Haitian farmers have no entities lobbying on their behalf, and the Haitian government doesn’t have the financial resources to subsidize farmers and protect them against imbalanced trade agreements, fluctuations in the market, and adverse climate events. Rather than cope with excess crops from the U.S., Haitian farmers instead need financial protection. They need monetary and technical support to continue and increase their production, and a guarantee their crops will fetch a decent price. They—and Haitian leaders—have advocated for decades for intentional investments that support rural development, including agricultural development.

For us at Partners In Health, peanut farming is at the center of this discussion because peanuts are a crop that can be used to markedly improve the nutrition of children. In addition to being widely grown and eaten as part of a regular diet, we use locally grown peanuts to make ready-to-use therapeutic food—a lifesaving treatment for children with severe malnutrition. We purchase these peanuts from local farmers to make the nutritionally fortified peanut product that is the medical treatment for children who are dying of starvation.

This collaborative effort—which supports better farming and increased crop yield, guarantees farmers a stable, paying market for their crop, and utilizes their crop to provide lifesaving malnutrition treatment—creates a virtuous cycle for the rural poor. Peanut dumping will destroy this cycle—as well as the livelihoods of many peanut farmers—in the areas where we work, as well as across the country.

We can’t let this happen.

We have worked side by side with the Haitian poor for more than 30 years, and we have seen crop dumping result in the progressive loss of food security and food sovereignty for the Haitian people. We know that better alternatives exist, and many of them are being supported by the U.S. government already. We welcome and encourage expansion of these initiatives.

We applaud efforts to provide aid in the form of technical and monetary support to farmers to increase their local production, in the provision of cash transfers, and in the provision of vouchers or locally procured food commodities that can support local markets.

We urge that the USDA reverse its decision to send U.S. surplus peanuts to Haiti. Dumping peanuts will undermine the price local peanut farmers will receive for their goods, diminishing their ability to subsist and eliminating their livelihoods. Instead, Haiti needs humanitarian support that does not undermine the livelihoods of the rural poor.

Dr. Gerardo Murillo didn’t get what he wanted when he came to the remote town of Reforma in Chiapas, Mexico. He got more.

When the 24-year-old applied to do his social service year through Compaňeros En Salud, as Partners In Health is called in Mexico, Murillo thought he would be practicing medicine in a clinic where running water and electricity were distant dreams.

Instead, the easygoing first-year doctor from Puebla with a shock of thick, black hair landed in Reforma, a community of 1,440 people about 45 minutes from PIH’s base in Jaltenango. His clinic and living quarters—which are in the same compound—have running water, electricity, and even wifi. Most residents’ homes have electricity as well, although not all have easy access to water. A single phone serves the entire community, and public announcements echo every couple of hours from a loud speaker located in the center of town.

This was the first dose of reality among many Murillo would receive during his service. His is one of the busiest of 10 clinics throughout rural Chiapas that PIH supports in partnership with the Ministry of Health. He sees as many as 350 patients every month, many of whom deal with chronic illnesses such as hypertension, diabetes, and depression. In fact, he cares for a quarter of PIH’s patients living with high blood pressure. He closely follows everyone’s progress with the help of nurse Andrés Ríos, nurse’s assistant Adriana Martínez, and nine dedicated community health workers.

Patients line up at the clinic’s metal gate before it opens and come knocking with emergencies late into the night. Many are locals. But patients regularly come from surrounding rural communities and urban areas like Tuxtla-Gutiérrez, the state capital located three hours away—where hospitals and clinics are hardly in short supply. They arrive in Reforma because they know they will receive quality care and get connected with specialized services in larger cities.

Eight months in, Murillo sat down over a lunch of vegetarian tacos at his host family’s home to reflect on how he now views medicine, to share lessons learned, and to discuss his plans for the future.

Before coming to Reforma, you had an idea of how daily life would be. Did the reality match up?

Among PIH’s sites in Mexico, Reforma is one of the most privileged and most urbanized. Honestly, I had a completely different idea of how it would be. I imagined fetching my own water, using an outhouse, that there wouldn’t be electricity and I would be doing everything by the light of an oil lamp. But no, that idea was based on myth and prejudice, because in reality Reforma has most modern conveniences. But this is specific to here, not to all PIH sites, and not to all of rural Chiapas.

I was also thinking I’d arrive in a place where no one would know anything about health. I would talk about how to have a balanced diet, the importance of vaccinations, and things that would be completely innovative. And it wasn’t so. Instead, they know all the health indicators perfectly well—probably better than me. And they know how to follow a balanced diet even better than I would indicate. However, the problem is that there aren’t the means to achieve it. It’s not that they don’t know how, but that the barriers to achieve it are too big. So it’s not just about arriving and presenting an idea, but about seeing how that idea could possibly function.

Murillo reviews the progress of patients under the care of  Eudeli Velasquez, a community health worker in Reforma. (Photo by Leslie Friday / Partners In Health)

Has your perspective on your profession changed at all?

I began to think of medicine as focused on the patient and not on the doctor. I began to realize that it’s not just about giving instructions and waiting for the patient to follow them, and then scolding them if they don’t follow your instructions. On the contrary, you need to explain to patients why it’s important that they do something, validate their opinion, and make them completely participatory in their treatment. Because if they feel that you are only giving instructions, then they aren’t going to follow them. They have to feel that it’s in their best interest to get better, and that it’s their decision to take care of themselves.

Have you had a patient who taught you a specific lesson about medicine or life in general?

Less than a month ago, I had a baby come who had had many problems since the moment he was born. The problems were about more than health. Many were due to structural violence, discrimination, or not having the funds to access the health system.

His parents had had a bad experience at the hospital when he was born. When the boy later became malnourished and required surgery to swallow and digest milk, they didn’t want to take him to the same hospital, even though we ensured them access to the procedure. It was very difficult to convince them to go, because they had been mistreated by other clinicians and they couldn’t afford care in the private sector.

Each time we achieved a small victory, there were still all the other conditions that made him fall behind. In the end, the boy died. And he died for a reason that he shouldn’t have—because of malnutrition. A child with all the economic means and ability to access better health care would have been able to conquer this problem.

He wasn’t able to get better precisely because the boy lived in conditions of poverty. We have to work harder to solve these inequitable situations. He was a boy who shouldn’t have died from a situation that was completely fixable. He died because of his economic situation, social position, and marginalization.

What do you hope to achieve in your remaining months here?

I wouldn’t like it if patients lost any advances they’ve made. So my interest now is in leaving the clinic with the best possible amount of information about the patients who have come and try to pass along the vast majority of outstanding issues to the new doctor.

I have my diabetic and hypertensive patients whom I would like to help get to controlled numbers. I don’t want to leave any patients in limbo, but to see that they are already receiving some type of care and only require follow-up.

I would also like to do more prevention campaigns on topics such as family planning and nutrition. Reforma is a clinic that functions at a decently high level. So I don’t feel as if I’d have to start addressing any of these issues at the ground level, but perfect them so that I leave the clinic in a better condition than before.

Murillo visits with Maria Roman, a patient living with diabetes and hypertension who can no longer walk to the clinic for care. (Photo by Leslie Friday / Partners In Health)

What did you want to do after your social service year and have your plans changed?

I swore that after my social service year I was going to start my specialty and do my residency to become an anesthesiologist. That was my immediate plan. It continues to be my plan in the long term. But I don’t plan to do it this year, because I would like to dedicate a bit more time to working in a community and continue working with PIH. It would be a great opportunity. And if that opportunity presented itself, I’d take it.

I feel like one year is not enough. Maybe an entire lifetime is not enough to be able to make all the changes that need to happen. It’s something that I fell in love with, and I know it wouldn’t be easy to return to the life I had before.

Have you gone home to Puebla during your service year?

Yes, I went one time.

And how was that?

It was an emotional shock to arrive and return to see medicine as it shouldn’t be practiced, centered on the doctor, and thinking about where to lay blame, completely throwing it all on the patient as the sole person responsible for their own health.

And you begin to see more frivolous things and think that they are overvalued monetarily. For example, there are people who could eat for an entire week on what someone is spending in the most ridiculous way. Or that there are people who think and say that they are “so poor” because they don’t have money to travel abroad. Poverty is perceived as not getting everything that you want, while there are people who literally are dying of hunger, who don’t have money to even eat. You begin to have these emotional shocks from the world that you knew and thought was normal and the new reality that you now know. I missed being here more than I did being there.

Anything else you wanted to add?

Truly I feel that I am still learning a lot, and that there is still so much to learn. I don’t think that my experience can compare with whomever has been in PIH for a long time, especially those who’ve been in Haiti or have been in Africa, where the health disparities and economic barriers are much larger than those that I encounter.

But that also says something. It means that I can keep working in this. I can keep throwing all my effort into making a change and continuing to improve the situation. And if I can handle a little now, I will be able to handle more difficult situations in the future.

Dr. Emily Wroe of Abwenzi Pa Za Umoyo—as Partners In Health is known in Malawi—wrote this week with a fantastic update. Wroe is director of clinical services at APZU.

Dear colleagues, friends, and supporters,

It is with tremendous joy that I write on behalf of Abwenzi Pa Za Umoyo to tell you that today, April 25, Dambe Health Center opened its doors to its first patients—108 of them, to be exact.

You all understand the long road and the impact behind this day, so you know how utterly overjoyed our team is to write to you now. Dambe is home to our most vulnerable and hard-to-reach patients—it’s a region plagued by prohibitive user fees and little access to care for years, except for those able to walk many hours to the hospital. The community has met floods, drought, typhoid, and a destructive fire—all in just the past year. When very sick patients are presented at our morning hospital rounds and the nurse mentions they are from Dambe, everyone nods their head in recognition and respect for the reasons patients arrive in such late stages of their illnesses.

We saw 108 patients today, a number we expect to double or triple in the coming days. Our staff tested 32 of them for HIV. They found five patients with hypertension so severe they are at risk of stroke. They found four cases of suspected tuberculosis and sent two severe malaria cases for hospitalization. They found one thyroid mass and screened five patients for cervical cancer. In a testament to the patients’ previous lack of access to health care, two-thirds of the patients tested for HIV had never previously been tested, and 47 of the 61 malaria tests were positive—and it is not malaria season.

Our passionate and energetic interdisciplinary team has plans right out of the gate to make Dambe a model health center, with programs such as integrated women’s health services and integrated screening for chronic conditions for all patients, and they are already talking about universal health coverage targets to reach 100% coverage for HIV and child malnutrition.

Today, we celebrate access to quality care for people who have needed it for a long time. We celebrate our partnership with the Ministry of Health and our passionate team. We celebrate and are thankful for the support from all of you to make it possible. We celebrate the essence of why we do this work and note that it was shining through in everyone’s smiles today.

Thank you, and with love from Neno,

Emily Wroe, on behalf of the APZU family

64-year-old Matilda Nikolasi talks with clinician Joe Lusaka at the newly opened Dambe Health Center. She was the first of many patients seen on opening day last Monday. Photo by Nandi Bwanali / Partners In Health

Partners In Health staff move equipment into Dambe Health Center in Neno, Malawi. The new clinic will provide health care to nearly 30,000 people. Photo by Lila Kerr / Partners In Health

I remember when I got the job offer from Partners In Health. I was on my way to New Hampshire to go camping for a few days. My mother was with me and heard the excitement in my voice.  She was so ecstatic and overjoyed, you would have thought she had just received a million dollars.

For my Haitian mother, this call was more important than money. She often tells me that I am alive because “dokte nan Cange yo te konn banm bon swen,” or “the doctors in Cange knew how to provide good care.” For her, that was the greatest satisfaction— having her daughter work for an organization that is so dear to her heart. 

I was born in Thomonde, Haiti, so I always knew about Zanmi Lansante, as PIH is called in Krèyol. I loved to listen to my mom’s stories of how she and her twin sister used to walk from Thomonde to Cange, where PIH established its first clinic nearly 30 years ago, and camp there to be seen by a doctor. Growing up in Port-au-Prince and the U.S., it is unconceivable for me to think that people camp for days to be seen by a doctor, but this is the reality for so many people around the world.  From hearing these stories, I knew I wanted to work for PIH.

Before I started working here, I did not fully understand the term “global health.” I had always associated it with clinicians. Now I understood the true meaning. It is much more than providing health care; it is about reducing disparity at all levels.

Everything I have been involved in, I have wanted to have meaning.

This ideal of selfless service—or as some people say around PIH, "a preferential option for the poor"—is something I’ve lived by ever since I was a child. In Port-au-Prince, I used to gather a few neighborhood children and feed them because I knew that many of them would otherwise spend the whole day without food.

My father moved to the U.S. first and got many opportunities to be able to take care of me and my family back in Port-au-Prince.  Shortly after I moved here, I went to college and joined the military as a way to pay back the comfortable life I had had in Haiti. I also joined the board of a Boston-based nonprofit that recruits underprivileged children in Thomonde and sends them to school free of charge. Even if parents are able to send their children to public school, many still cannot afford to buy the uniform and shoes their children need to attend class. These most basic expenses are what the nonprofit covers.  

Everything I have been involved in, I have wanted to have meaning. I do all of these things because I believe the biggest gratification in life is to give of yourself without expecting anything in return. So has been the mission of most organizations I’ve worked and volunteered for throughout my career.

Even though I am not a clinician, I feel I have been contributing to PIH’s mission since joining the human resources team as a senior human resources coordinator in 2014. I collaborate with human resource colleagues at all PIH sites to resolve issues relating to expatriate employees. I assist employees with transitioning into and out of PIH, understanding their benefits, and interpreting PIH policies. And I manage our job evaluation committee, which practices fair decision-making regarding compensation.

HR can be very challenging. I started during the Ebola crisis in September 2014.  Our department worked tirelessly to recruit competent clinicians and support staff to work in Liberia and Sierra Leone. We worked before hours, after hours, and on weekends. We had a mission and accomplished it together.  And we developed a bond with the employees.

I used to refer to these recruited clinicians as “soldiers,” because they knew Ebola had to be eradicated and that they could not do it alone. As a solider myself, I know that service is like signing a blank check and giving it to the government. Many times you don’t even know where you are going or the amount of danger you are going to be in. Our clinicians were in the same situation. They knew that Ebola was very dangerous, yet they agreed to serve without hesitation, which is the true meaning of selfless service.

Working for PIH is really a dream come true.

Anyone aspiring to work in HR in global health should know that it can be very rewarding, but you must be flexible and adaptable. Often you have to be ready to do work that is outside of your scope of duties. I can recall the meetings we had to commemorate the 2010 earthquake in Haiti. Time and time again, Boston-based employees talked about their experiences and how they supported their Haitian colleagues at every level. Even if you are not a clinician, you are saving lives. Proper management is critical to providing high-quality health care. You get to develop and implement policies, which in turn are needed to achieve better outcomes. You are exposed to real-world issues, and you realize that the scope of poverty is beyond imagination. But instead of despairing, this knowledge can give you purpose, determination, and motivation to change your community and even the larger world.

Learning a new language will allow you to work or volunteer in multiple countries all over the world, immerse yourself in cultural experiences, or deepen your understanding of global health. Having a mentor is also important. I have been fortunate to have had a good mentor who has been instrumental in every step of my career. Knowing what I wanted to do in life, she thought it was a match made in heaven when I informed her of my job opportunity here.

Working for PIH is really a dream come true, because the organization has contributed so much to my country, my town, and—mostly—my family. My mother is fortunate, because now she lives in the U.S. and gets the best care. She always thinks of her family members back home who do not have that opportunity. Knowing that Zanmi Lasante is still there brings her comfort, because she knows they can rely on the organization to get good care. We often talk about how one day both of us will go back to Thomonde and give back to our community.

Vanessa Colchado couldn’t believe what the doctor was saying. True, her 6-month-old son, Hans Veliz, wasn’t thriving like other babies his age and occasionally had a fever. But he didn’t have a cough. So how could the doctor point to small spots on her son’s pulmonary x-rays and say it was tuberculosis? That was the same disease ravaging her boyfriend.

“I started to cry,” says 29-year-old Colchado, vividly remembering the day. “I ran to the car and I cried and I held my son.”

Tragedy struck again just weeks later. Colchado’s partner, Francisco “Rudy” Veliz, died on December 31, 2013, of extensively drug-resistant tuberculosis (XDR-TB)—the worst form of the infectious disease. Seven days later, their son was admitted to the National Institute of Children’s Health in Lima, Peru, to begin his two-year battle against the same disease. The mother and son were not alone. Socios En Salud, as Partners In Health is known in Peru, was with them every step of the way.

PIH has a 20-year history of collaborating with Peru’s Ministry of Health to treat multidrug-resistant tuberculosis (MDR-TB) in children and has reached cure rates of more than 80 percent, in line with the best programs in the world. The program is based on sound diagnosis, thorough treatment, and the compassionate care of community health workers, who visit patients at home to ensure they take their medication and have everything they need—food, housing, and transportation to doctors’ appointments. In fact, PIH has been so successful treating MDR-TB that it, among other organizations, influenced the World Health Organization to adjust its treatment guidelines in 2001.

Identifying TB in children

PIH staff have seen all forms of TB in Carabayllo, the urban slums where they work on the outskirts of Lima. Some of the most challenging cases to diagnose and treat, however, have been among children.

When adults contract TB, they typically develop tell-tale symptoms. A cough that lasts for more than two weeks. Fever. Night sweats. Weight loss. Fatigue. The infectious disease often settles in the lungs and is slow and stealthy, killing 1.5 million people every year and making it the world’s deadliest disease.

TB develops outside the lungs much more frequently in children.

When children develop TB, it’s often asymptomatic. They might never have a cough, but have a distended stomach or lumps in their neck or armpits. And they might act as mischievous and energetic as ever, while the disease spreads through their entire bodies, manifesting in their brains, kidneys, intestines, bones, and skin.

“TB develops outside the lungs much more frequently in children,” says Dr. Leonid Lecca, executive director of PIH in Peru and an expert in pediatric TB. “Their defenses are more vulnerable, because they’re still developing their capacity to protect themselves.”

TB is most often diagnosed through a sputum sample, which adults usually have no problem producing. But infants and young children can’t cough and spit voluntarily, so doctors conduct more advanced or invasive exams to arrive at an accurate diagnosis.

Among the best diagnostic options is an x-ray of the child’s chest and back. The problem in Peru, Lecca says, is that doctors don’t always have the expertise to read children’s x-rays. And doctors who refer children to pulmonary specialists often don’t realize that their patients will never follow through, because they can’t afford transportation to Lima-based hospitals or fees for advanced tests.

Peru’s Ministry of Health estimates that 7 percent of the 30,000 people diagnosed annually with TB are children. Lecca believes that, if cost or transportation to reference hospitals were not an issue, that number would be much higher, considering that 20 percent of all TB cases worldwide are pediatric.

“There’s a gap,” Lecca says. “How much is that gap? As many as 500 or 1,000 children?”

Losing a battle

Hans could easily have fallen into that gap. For months, Colchado had been living with Veliz, whom she knew was being treated for MDR-TB. PIH had helped him get an accurate diagnosis and start treatment in early 2013. His health improved after several months of daily medication. Once he was no longer contagious, staff helped him get a loan through its income generation program, which he used to open a video store and start a mototaxi service.

Oscar Ramirez, the program officer for PIH in Peru, got to know Veliz during that time and saw him as an energetic young man who had turned his life around—a steady income, a girlfriend, and a newborn son. Ramirez visited him off and on throughout the year. The last visit he made was in December to check why he had fallen behind repaying his loan. One look spoke a thousand words.

With TB patients, sometimes there are only a couple of weeks that you have to act.

Weak and emaciated, Veliz shuffled out of his bedroom to greet Ramirez. It was clear he had fallen ill again and was likely contagious. Ramirez and his colleague, field supervisor Genaro Ancco, tried to convince the young man of the importance of getting back on medication. Then they thought of Hans.

“Where is the baby sleeping?” Ramirez remembers asking. Colchado told him, “’We’re all sharing the same room.’”

Ramirez advised Colchado to keep the baby away from Veliz while he was sick and promised to return after Christmas vacation to follow up. He didn't realize how little time the young father had left. When he returned a couple weeks later, he learned that Veliz had died on New Year’s Eve.

“With TB patients, sometimes there are only a couple of weeks that you have to act,” Ramirez says, filled with regret. “Attention needs to be given now, immediately.”

Seeking a cure

It was a painful lesson to learn, for Ramirez and the entire organization. Instead of despairing, he focused on getting Hans the care he needed following his TB diagnosis. Considering Veliz’s MDR-treatment had been irregular, doctors assumed he had developed the more potent form, XDR-TB, which he then unknowingly passed on to his son.

PIH advocated on Hans’s behalf and quickly got him admitted to the National Institute of Children’s Health in downtown Lima on January 7, 2014—one week after his father’s death. Colchado barely left her son’s bedside for more than three months. Her mother brought her dinner most nights and relieved her occasionally so that she could go home, shower, and rest. PIH staff brought diapers and supplies to the hospital. Mostly, though, they provided much-needed psychological support for the newly single mother.

Treatment for drug-resistant TB is brutal. Nearly a quarter of children permanently lose their hearing from the daily injections they receive for months on end. They take thousands of pills that cause side effects ranging from nausea to temporary psychosis. This goes on for up to two years. Because no drug trials are allowed on children, doctors use guesswork to determine proper dosage and length of treatment.

“Many times, doctors treat children like tiny adults,” Lecca says. That’s a problem, because children metabolize drugs differently. Luckily, children tolerate even high doses of medication quite well.”

Colchado happily reports that Hans is a "completely normal" boy, holding him close near their home on the outskirts of Lima, Peru.

That was the case for Hans. He was eight months old when he started treatment in February 2014. A brief allergic reaction disrupted his care for several weeks as doctors tried to determine its origin. Other than that, he had few complications from his shots and pills.

“That little boy never complained,” Ramirez says. “When you’re born in that type of reality, I imagine you don’t complain as much.” The only thing that seemed to bother him was his stomach. Occasionally, Colchado told Ramirez, Hans wasn’t hungry in the afternoons and refused to eat.

Now, two years after starting treatment, Hans is cured. Colchado can finally talk about the ordeal with more ease. It’s been a long road—one that robbed her of her partner, forced her to her knees alongside her son’s bedside, and tested her faith.

She watches Hans, who turns 3 in June, scribble on a scrap of paper as she recounts his story. He’s busy enjoying his terrible twos. He’s gained weight, is constantly in motion, and grabs at everything within reach.

“The medications he’s taking are very strong and that might be why he’s a little hyperactive,” Colchado says, trying to explain his turbulent nature. “The doctor told me that he’s completely normal.”

Completely normal, for a boy who conquered a life-threatening illness within months of being potty-trained.

For nearly 30 years, Partners In Health has delivered health care to some of the world’s poorest communities by partnering with local governments, training local health professionals, and building health systems.

When we started work in the rural district of Neno, Malawi, in 2007, the district had no hospital and 10 existing clinics had fallen into disrepair. Since then, PIH has built Neno District Hospital, which serves about 150,000 people, and a community hospital. We’ve also revitalized those 10 clinics, and built two more.

Now, we’re about to embark on a new, major improvement to Neno District Hospital. With the help of partners the 30/30 Project, Plus One, and Construction for Change, we plan to rebuild the outpatient department to significantly improve and expand the level of care we’re able to provide people in Neno District.

The new single-story building will include a larger patient registration area with sufficient seating, and additional, larger consultation rooms with better ventilation and infection control features. The expanded waiting area and adjacent rooms will allow staff to screen patients for conditions such as malnutrition, HIV, and cervical cancer, and discuss topics such as family planning options. The exam rooms will also allow for on-the-job training through bedside teaching for medical students and other staff members.

Patients also will be connected during their visits to community health workers and a program that addresses their financial and nutrition needs.

We’re already working with an architectural firm to design the facility and plan to begin construction in June 2016. Our goal is to begin seeing patients in late 2017.

Please join us in making this vision a reality—your support will provide a lasting contribution to the people of Neno District.

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Read about our newest clinic in Malawi.

PIH also works in Haiti, Rwanda, Lesotho, Liberia, Sierra Leone, Peru, Mexico, Russia, and the Navajo Nation. See our principles to learn more about us.

The sun beats down on the red tin roof of Dambe Health Center in Malawi, boiling the concrete entrance step. Across the threshold, a dark, cool room overlooks tree-scattered hills and plumes of blue smoke rising from unseen villages.

Inside, staff members have installed the last examination bed, connected the electricity, and turned on the water. Wooden benches now wait expectantly for patients, who will arrive when the facility opens this month.

“It’s going to be busy. A lot of people are sick in Dambe,” said 47-year-old Steve Mtewa, the PIH infrastructure manager who led the clinic's construction.

The 6-foot-tall man with a closely shaven head, collared shirt, and warm eyes has fond memories of Dambe. His grandparents used to live here, and he visited them during school holidays.

It’s also where he came to die nine years ago with a severe form of meningitis.

Searching for care

Dambe is a region in Neno District, where PIH, known locally as Abwenzi Pa Za Umoyo, has worked since 2007. The area sits atop a mountain near the border with Mozambique and has a population of 14,000. Life is not easy here. Most people are subsistence farmers, relying on good weather to feed their families. Housing is modest; a family of seven is likely to live in a mud hut. Getting ill is possibly the worst challenge people face because reaching clinics is time-consuming, costly, and an arduous journey over mountainous terrain.

Mtewa knows better than most what people in his community face when they’re sick. He became ill in 2007 and tried for months to find proper treatment. He was working outside the country at the time, and when he didn’t get better his friends, fearful he would die away from his family, brought him home to Malawi. They first took him to a hospital in Mwanza, a district next to Neno.

“It was a nightmare,” said Mtewa. The facility was filthy, had no medicine, was more likely to make him sicker, and was nowhere he wanted to stay.

So his mother cared for Mtewa at home instead. When he grew stronger, he traveled with her to a clinic where she worked in Neno. Although he regained some weight, his condition eventually worsened. His final option was another hospital, in Neno Boma, the district’s town center. Exhausted and with the previous hospital visit fresh in his mind, he refused to go.

“It was a fight,” he said. “I told them, ‘I don’t want to go there. I just want to die here.’”

Mtewa does not remember how he reached Neno District Hospital—much of his sickness is a blur—but once there, he couldn’t believe he was in Malawi. The hospital, supported by PIH, was a small, three-room building staffed by a doctor and a couple of nurses. It was stocked and clean. He was given a bed, put on effective medication, and immediately started getting better.

He was discharged after a month, but returned regularly for checkups. He was nothing like the skeletal man lying in bed weeks before. At each appointment, Mtewa said, staff stopped what they were doing and exclaimed to each other, “‘Come and see Steve!’”

A new start

After getting to know PIH staff at the hospital, it wasn’t long before Mtewa was invited for a job interview. He was selected to be PIH’s pharmacy coordinator in February 2008 and managed stocks of medicine in the hospital’s warehouse.

Three years later, PIH promoted Mtewa to manager of the infrastructure team. He had a lot to do and work stretched beyond normal hours. PIH was building another hospital and revitalizing 10 public clinics in the district.

“Neno has changed so much,” said Mtewa. “There are houses everywhere. Because of Partners In Health, it’s growing fast.”

Mtewa played a big role in this growth. He led several building projects, including a maternity ward near the hospital, where pregnant mothers could stay before and after delivering their babies. And then in 2013, he managed his most personal project back in Dambe.

Building a mountaintop clinic

That year, the need for a health center in Dambe suddenly became urgent. After agreements between the government and two other clinics in the region expired, the two clinics began charging patient fees. With an average income of 84 cents a day, residents simply couldn’t afford between $1 and $3 for an appointment and medicines. Patient visits plummeted by 70 percent.

Neno District Hospital was still a free option, like it had been for Mtewa, but it was too far away for most people. And during the rainy season, mud made the road impassable for vehicles. Those journeying on foot were stopped by an overflowing river.

“You can’t cross here,” Mtewa said, gesturing to the same road from a PIH truck. “On this side, there are all clinics that charge,” he said, pointing to the surrounding hills of Dambe where residents would be forced to remain until the rain dissipated.

“The situation demanded drastic action,” said Luckson Dullie, PIH’s executive director in Malawi. “For the level of poverty in that area, fees were an immediate barrier to care.”

Mtewa was charged with coordinating efforts among contractors and teams. He discussed the potential new clinic with Dambe community members. PIH staff knew he was the right man for the job. “Steve understands from a different perspective how far Dambe is,” said Dullie. “It’s a project he oversaw from inception.”

PIH partnered with Construction for Change, a Seattle-based nonprofit with the mission of increasing access to health care, education, and economic growth in under-resourced communities. Deerfield Partnership Foundation also provided vital support.

It was not an easy task. Tons of heavy equipment had to be hauled over a battered, barely existing road to the top of the mountain. When it rained, it was impossible to continue. When it didn’t rain, there was no water in Dambe for construction. It had to be transported bucket by bucket to the site from a nearby river.

Construction of Dambe Health Center under way in the mountains of Neno, Malawi. Photo by Tyler Weinbrecht / Construction for Change

Two years of slow progress eventually yielded a 13-room clinic with staff housing, a borehole to supply water, a generator for electricity, a delivery room for expecting mothers, and a postnatal ward.

It is a great achievement for PIH and the Malawian government, with whom the organization collaborates on all its projects.

“Dambe Health Center will be a source of joy for the people in Dambe and Neno as a whole,” said Dr. Lawrence Nazimera, the Neno district health officer. “The facility will serve numerous people who have been denied quality and equitable health services due to long distances and geographical constraints.”

Nazimera and PIH staff hope the clinic will not only meet the needs of Dambe residents, but serve as a model for providing comprehensive and high-quality primary health care in Malawi. Its construction, the partnerships created in the process, the community-wide collaboration, and its all-round success will stand as proof for building many more like it. The government’s goal is to ensure no Malawian lives more than 5 miles from a health facility.

“Dambe has helped us redefine quality and what is possible in these settings,” said Dullie.

Mtewa is already thinking about what’s next. He envisions more staff housing at the Center and more rooms at Neno District Hospital, among other ideas. There is a great need for health care in these remote Malawian hills he calls home. Right now, though, he’s proud of this project.

“It’s going to save a lot of people,” he said.

Partners In Health staff move equipment into Dambe Health Center in Neno, Malawi. The new clinic will provide health care to nearly 30,000 people. Photo by Lila Kerr / Partners In Health

When the Ebola epidemic in Liberia began to wind down a year ago, the journalists folded their notebooks, the aid workers helicoptered off for other emergencies, and Partners In Health staff got busy. In a small district surrounded by rubber tree forest, they started renovating “New Pleebo,” a nine-bed  public health center that was our first major infrastructure project in Liberia.

The need for New Pleebo wouldn’t surprise anyone familiar with the country. Tuberculosis spreads quickly. Pneumonia kills scores of children. Roughly 1 in 100 pregnant women die during childbirth.  The list of illnesses and ailments that could be cured at modern health centers goes on and on. “The health care system is still, by most measures, weak, in spite of the massive influx of funding to control Ebola transmission, as much of the funding went into emergency, temporary structures,” wrote PIH Liberia Policy and Partnerships Director Cate Oswald recently.

For 50,000 people living in the far southeast of the country, the original health center, now dubbed “Old Pleebo,” hardly sufficed. A narrow hallway encircled a couple of moldy, windowless consultation rooms. Rainwater poured down through the collapsing corrugated-metal roof and onto the single labor and delivery bed. Like many buildings in the district, the clinic lacked reliable electricity.

Part of the old Pleebo Health Center.

New Pleebo, located just up the road, was a shell of a building when PIH arrived. Working closely with the county health team, PIH developed a plan to quickly open it. PIH carpenters hung windows and laid tiles in the consultation rooms. Bricklayers built an addition for a lab, and drivers and movers helped equip the whole thing—including special rooms for tuberculosis, mental health, and pregnant patients—with beds, exam tables, desks, sinks, toilets, lab equipment, instruments, and other supplies shipped in from Monrovia. An operations coordinator stocked the pharmacy. Data clerks who had never clicked a mouse learned how to register patients in a computer. PIH doctors and nurses mentored local nurses and midwives and physician assistants. Friendly neighbors went door-to-door to get the word out; one spoke on a local talk show. “It doesn’t sound like a lot of work,” says Nurse Clinical Lead Mary Micikas, “but it ended up being just that.”

Midwives Sophie W. Chea (right) and Habibatu M. Alu in the new labor and delivery area of New Pleebo.

Staff predicted a chaotic July 1 opening, and how right they were. Registrars welcomed patients from 7 a.m. to 3 p.m. Clinicians treated emergencies around the clock. In the first month, they saw 2,019 people. Despite the fact that few pregnant women had visited a clinic in the previous months, roughly 50 ended up delivering (safely) in New Pleebo that month. Many more came for prenatal visits.

Alas, crunching the numbers from New Pleebo’s electronic records revealed that a pregnant woman typically spent half the day waiting on the porch to see a nurse or midwife. “And anecdotally,” PIH Liberia Director of Monitoring and Evaluation Eugene Wickett wrote in a report, “even though all patients are allowed in, it seems many are sent home without seeing a clinician.”

But if New Pleebo was a victim of its own success, if it was flooded with eager patients, it was also a powerful symbol of PIH’s unique commitment to Liberia. PIH didn’t just try to quash Ebola. We are dedicated to helping the government create a great health care system, the one that Liberia deserves, over decades to come.

PIH has already begun improving New Pleebo. Last month, staff were able to deliver 89 babies, almost twice as many as originally. This month, PIH County Director for Maryland County Patrick Ulysse takes another step forward, creating a sort of fast-pass lane for pregnant women and children under 5. They will soon enter through a separate gate, meet a dedicated registrar, and maybe even consult their own lab technician, if necessary. “We did this in Haiti,” says Ulysse. “And by 8 a.m., the pregnant women already had their test results.”

Melva Fernandez has spent nearly all her six years in hospitals. She was 1 when she was first diagnosed with tuberculosis and placed on medication at a clinic near her home in rural Cusco, Peru. The potent TB drugs, some of which can cause permanent hearing loss, made her feel better and restored a flicker of hope to her family. But then she fell ill again.

Her doctors tested Fernandez and saw she still had active TB. They tried a new combination of treatment and got the same results. She got better, but within months would be back to where she started with a distended belly and palpable lumps in her neck and armpits. It was a puzzling cycle that would repeat itself for years until she landed two years ago at the National Institute of Children’s Health in Lima, Peru. She and her two dolls have been there ever since, with only occasional visits from her father. Her family simply can’t afford the transportation costs to visit more often.

That’s where Dr. Leonid Lecca found her. The specialist in pediatric TB and executive director of PIH in Peru, known locally as Socios En Salud, is a regular face around the children’s hospital and a doctor who believes everyone, everywhere, deserves the best care possible. Many of the pediatric patients PIH treats for TB were discovered during his rounds. As many as 73 percent of these children have been cured—an incredible rate compared to the global benchmark.

Hospital staff took Lecca to Fernandez’s bedside for a consultation. They were puzzled by the little girl with a long pony tail and tired smile whose TB had spread to her intestines, abdomen, spinal column, and other parts of her body. They treated her for extensively drug-resistant tuberculosis (XDR-TB)—the worst form of the disease—with the best combination of medication available in Peru. But still her health didn’t improve.

Lecca and his colleagues suspected something else was going on. They conducted a series of advanced genetic tests over several months to see if they couldn’t pinpoint a complication that might be preventing a cure. And they found one.

In January, doctors diagnosed Fernandez with a unique immunological disease caused by a genetic deficiency in her IL-12 receptor, which limits her body’s ability to respond to the germ that causes TB, Mycobacterium tuberculosis. No matter how many times her doctors threw the best medicine available at her illness, her body would not be able to launch a proper defense.

This is the only option for Melva.

That left her doctors with two options, neither one viable for a family of subsistence farmers living in poverty. They could place Fernandez on Interferon-gamma, an artificial protein that costs $14,000 each week. The drug would also have to be imported from the United States and kept between 2 to 8 degrees Celsius to remain effective.

The only other option was for Fernandez to receive a bone marrow transplant. Dr. Joia Mukherjee, PIH’s chief medical officer, says that such a procedure generally works for rare diseases, such as Fernandez’s. The new marrow will produce blood cells that churn out the necessary proteins to respond to bacterial diseases like tuberculosis. But how was PIH going to make that happen?

Lecca wasn’t about to give up. Several weeks ago, he began contacting international colleagues in the hope of finding someone who could help. He did, in his colleague Dr. Silvia Chiang, a pediatric infectious disease fellow at Texas Children’s Hospital. Chiang contacted other colleagues, Drs. Steven Holland and Alexandra Freeman, who agreed to perform the transplant and provide all follow-up care, pro bono, at the National Institute of Allergy and Infectious Disease in Bethesda, MD. The response was an answer to their prayers.

All Lecca had to do was get Fernandez and her father, Carlos Fernandez—neither of which had passports or visas—to Washington, D.C. Since early March, that goal has been the PIH team’s singular focus in Peru. They launched a campaign in Lima on March 30 to raise the necessary funds to cover airfare, lodging, and food for the daughter and father during their stay abroad. The money will also support the rest of Fernandez’s family, including her mother and two younger siblings, who will remain in Peru.

Lecca is confident they will reach their goal, mostly because they have to.

“This is the only option for Melva,” he says, “an option that will change and save her life.”

Zika cases have been reported in dozens of countries so far, including Haiti, where Partners In Health has thousands of staff and serves thousands of patients every day.

A small percentage of people infected with the virus experience fever, headache, joint and muscle pain, or red eyes. There are also reports of Zika-associated Guillain-Barré syndrome, a serious neurological complication.

But far more worrisome is that it appears Zika can be transmitted from a pregnant woman to her unborn fetus. About 32,000 pregnant women visit our clinics each year, which means that as many as 32,000 women and their newborns are at risk of infection. We anticipate a rapid increase in the number of Zika cases in the coming months.

We’re working with Haiti’s Ministry of Public Health and Population and several international organizations to address this increase by focusing on six areas of work:

Mobilizing communities. Our 3,500 community health workers are spreading information about the virus and encouraging women of childbearing age to use family planning during this period of rapid transmission. They’re also urging pregnant women to visit their local health facilities for prenatal care, to get a Zika test if they’re symptomatic, and to receive a Zika prevention packet, which includes a three-month supply of DEET, a bed net, and condoms to protect against the sexual transmission of the virus.

Preventing mother-to-child transmission. We’re ensuring that mothers who show symptoms of Zika get the prenatal care and support they need to deliver their babies safely, and that any baby born with the effects of Zika is properly cared for.

Prevention supplies. In addition to providing Zika prevention packets, our community health workers are encouraging the use of insecticides and the creation of “mosquito brigades” to eliminate standing water around homes and work areas.

Care for the sick. We’re providing critical care for those who have developed complications after a Zika infection—including Guillain-Barré syndrome—and establishing a case registry to ensure they receive ongoing help.

Staff safety. We’re working to eliminate spots around our facilities where mosquitoes can breed and live, ensuring that all of our clinics and hospitals have window screens, and providing staff members with insecticide and mosquito repellant.

Research. We’re collaborating with the Centers for Disease Control and Prevention on a study of Zika-positive pregnant women to better understand how the virus affects their infants.

Your gift today sets this plan into action—and protects mothers and babies who are too poor to afford care. Please give today. Every penny saves lives.

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To learn more:

Read about Zika’s origins from Dr. Joia Mukherjee, PIH’s chief medical officer.

Read what PIH Senior Health and Policy Advisor Dr. Louise Ivers and others are doing to prevent Zika infections.

Joseph Jeune used to carry a folded pamphlet from the World Health Organization in his back pocket. It described the international body’s "3 by 5 Initiative," dedicated to getting 3 million people on antiretroviral therapy (ART) for HIV by 2005. On the left was a picture of a wide-eyed, emaciated patient who teetered on the brink of death. On the right was the same man, this time smiling, 30 pounds heavier, and proudly balancing his niece on a sturdy hip. The transformation was breathtaking.  

“‘That was me!’” Jeune would say while pointing to the pictures, according to a doctor who knew him well. “‘Look how sick I was!’” And whenever someone brought up the same poster in conversation with him, he proudly and playfully boasted, “‘Yeah, I’m a star.’”

Jeune was a star to his family and friends, and particularly to his doctors working in clinics supported by Zanmi Lasante, as Partners In Health is known in Haiti. The illiterate peasant farmer and shoe shiner turned community health educator was an iconic symbol of the power of ART and the importance of delivering it to patients all over the world—regardless of income or social status. His recovery, and resulting fame in the global health world, earned him a platform from which he advocated for the compassionate care of poor people living with HIV and tuberculosis.

The treatment Jeune received brought him another 13 years of life. Many would say that was too little time for such a grand personality. Ti Joseph, or “Little Joseph” as he was affectionately called by the PIH doctors who loved and cared for him, died on January 21, 2015, at 37.

Lazarus lives

Jeune (left), seen here in March 2003 shortly after his diagnosis, got up from his hospital bed within weeks of beginning treatment.  One year later, Jeune (right center) stands between his parents near their home in Lascahobas, Haiti.

Jeune’s family had already hired a carpenter to build his coffin when they saw his health drastically decline more than a decade ago. The man methodically sawed and hammered away, all within earshot of Jeune, who lay skeletal and lethargic on the dirt floor of his family’s hut near Lascahobas. His parents had tried everything to cure the mysterious illness that slowly ate away at their eldest son. His father sold their crops, land, and livestock to pay for the services of a traditional healer. None of the treatments worked.

“I kept getting worse,” Jeune told PIH Co-founder Dr. Paul Farmer, who later retold the story in his book, Partner to the Poor. “My mother, who was caring for me, was taking care of skin and bones.”

Having heard about Jeune’s case, a PIH community health worker visited the distraught family and urged them to bring him to the public clinic in Lascahobas five miles away.

On the afternoon of March 17, 2003, Jeune arrived at the PIH-supported clinic on a makeshift stretcher carried by four men. The trip had taken four hours on foot under the punishing sun of the Haitian dry season.

Dr. David Walton, a fifth-year medical student at the time and current PIH board member, was there to admit Jeune, who was dehydrated and emaciated. Jeune and his brother spoke of a litany of symptoms that had persisted for months. Cough, intermittent fevers, diarrhea, weight loss, weakness.

“The laundry list of things that cause a young man to look skeletal in rural Haiti is very small,” Walton says. “It’s HIV. It’s TB. It’s both. It’s diabetes. It’s malignancy or some other zebra, some rare thing.

“We suspected he probably had HIV or TB, and that it was untreated.”

While he awaited test results, Jeune was admitted to a nearby hospital. His diagnoses came in short order; he was HIV-positive and had a form of TB that could be treated with first-line antibiotics.

My mother, who was caring for me, was taking care of skin and bones.

Jeune wasn’t an easy patient at first. He barely gagged down his drugs and shot surly responses at caregivers those early days in Lascahobas. He was depressed, hopeless, and sick of being sick. “I’m dead already,” he told them, “and these medications can’t save me.”

But Walton and his team, consulting with Farmer, were persistent. Jeune started a daily regimen of medications for his HIV and TB. His appetite returned within six weeks. He got up from his bed and walked around the ward. His true personality soon emerged. He became once again the outgoing jokester and avid storyteller his family and friends knew and loved.

With that, Jeune joined a growing number of Haitians who had access to lifesaving ART and had risen, much like the biblical Lazarus, from their deathbeds.

Up until the late 1990s, most people who were HIV-positive and lived in poor countries simply didn’t have access to the cocktail of medication that stalled the virus’ advance in the body. In 1998, the average cost of a year's supply of antiretrovirals in the United States was more than $18,000. That was simply too high a cost to pay, in the opinion of global policymakers, for the many thousands of people who needed, but couldn’t afford, it.

This policy wasn’t just founded in budgets; it was strongly backed by prejudice that extended to the highest rungs of international development. Andrew Natsios, who led the U.S. Agency for International Development at the time, was infamously quoted saying that Africans ''don't know what Western time is. You have to take these [AIDS] drugs a certain number of hours each day, or they don't work. Many people in Africa have never seen a clock or a watch their entire lives. And if you say 'one o'clock in the afternoon,' they do not know what you are talking about.''

PIH refused to share that opinion. So in 1998, staff members began providing ART free of charge to HIV-positive patients in Cange, Haiti, through what it called the HIV Equity Initiative. The impact was nothing short of a miracle. Formerly moribund patients got up from their sick beds and returned to their former lives. They became instant advocates for universal access to ART and penned their personal testimony in the Cange Declaration, which rebutted global policy and buoyed the hopes of other HIV-positive people around the world.

An international icon

A community health worker visits Jeune at home in 2014 to ensure he takes his treatment.

By September, Jeune had returned to his home and gained 45 pounds. His TB was cured. And he religiously took his ART. He was doing so well that he started taking classes in community health education at the Lascahobas clinic. PIH offered him a job and he soon became a jack-of-all trades there.

“He was an extrovert in the truest sense of the word,” says Walton, who became a close friend and took pictures of Jeune—with his permission—throughout his treatment. “In a time of significant stigma, he was always very open about his disease.”

So when Farmer approached Jeune about sharing his before-and-after pictures with the World Health Organization, where fellow PIH Co-founder Dr. Jim Yong Kim was working at the time, Jeune jumped at the chance.

“‘Show my pictures. Tell my story. I want people to be able to have the same opportunity for treatment that I did,’” Walton remembers Jeune saying. “He was a really fiery advocate about health equity, particularly around HIV.”

And that’s how Jeune, a peasant farmer and shoe shiner from a tiny village in Haiti, became the face of the WHO’s roughly $5 billion "3 by 5 Initiative." His before-and-after pictures were printed side-by-side on all manner of promotional materials, including pamphlets, which the WHO sent to ministries of health everywhere from Russia to South Africa, and Haiti to Indonesia.

“There’s no question that Joseph Jeune’s before-and-after pictures changed the way many, many people thought about the possibility of ART in Africa and other parts of the developing world,” says Kim, who led WHO’s "3 by 5 Initiative" and is now president of the World Bank Group. “It changed the hearts and minds of the White House, the HIV docs at Harvard, and folks around the world when we put them into the World Health Report in 2003.”

There’s no question that Joseph Jeune’s before-and-after pictures changed the way many, many people thought about the possibility of ART.

“Those photos were iconic,” Walton says. “Ti Joseph knew it, he loved it, but he didn’t love it because he was a narcissist. He loved it for what it represented, which is for others like him who had been so viciously ignored in the past to really have a chance to gain access to treatment.”

PIH staff soon discovered the extent of the campaign’s reach. Farmer remembers traveling to Kenya with Ophelia Dahl, a PIH co-founder and current board chair, to advocate for the use of ART in rural areas. They visited a clinic run by nurses in a remote community on the shores of Lake Victoria, where running water and electricity simply didn’t exist. On the wall was the WHO poster with Jeune’s images.

“Look! There’s our patient,” Farmer remembers saying to his hosts. They kindly corrected Farmer, explaining that the man was Kenyan. But Farmer insisted. “No, he’s Haitian.” And he pulled out his laptop to show them the original images.

“It didn’t matter to the people who were looking for treatment whether he was Haitian, or Kenyan, or Malawian,” says Dahl. “He was a symbol to them of what it is to be very sick and to be hopeful about getting well.”

Two years after the campaign’s launch, PIH Chief Medical Officer Dr. Joia Mukherjee had a similar encounter in Rwanda when a community health worker learned that she knew Jeune. The woman was clearly touched. “’I want to meet Joseph,’” Mukherjee remembers her saying. “’He’s my hero!’”

A fiery advocate

The summer of the WHO campaign’s launch, Jeune spoke to nearly 700 patients, health care providers, and policymakers at the 10^th International Seminar on Health and Social Justice in Cange. He talked about his HIV-positive diagnosis and his miraculous recovery after being placed on ART.

Mukherjee remembers Jeune standing in front of a poster of his before-and-after pictures, sharing his story with a receptive audience. He also poked fun at himself, saying that he looked like a “dead man” and a “corpse.” That was Ti Joseph.

“He understood that he was an example,” Mukherjee says.

If you don't have anything to eat and you have HIV/AIDS, you've got two diseases: HIV and hunger.

That was just the first of several appearances Jeune made, locally and on an international stage, to share his story with the world. He left Haiti for the first time in August 2006, when he spoke alongside Farmer at the International AIDS Conference in Toronto, Canada, about the importance of providing food to HIV-positive patients as part of their care.

"If you don't have anything to eat and you have HIV/AIDS, you've got two diseases: HIV and hunger," said Jeune at the time. “These medicines, when you start taking them, they whisper in your ear, ‘You need to eat, you need to eat.’ They make you hungry.”

Jeune eventually became an invaluable HIV/TB peer educator upon whom PIH staff in his community relied. He spoke to patients, in groups and individually, about his recovery and the importance of adhering to their medication.

“I care as much about my medications as I do about myself,” Jeune once told a reporter about his ART. “There may be other illnesses that can break you, but AIDS isn’t one of them. If you take these pills, this disease doesn’t have to break you.”

A medical miracle

Dr. Martineau Louine, who once directed the HIV/TB program in Lascahobas, remembers Jeune as a fierce patient advocate who never minced words. A specific conversation stands out from one of his first days at the clinic.

“When it was Ti Joseph’s turn to see me in consultation,” Louine recalls. “He told me, ‘You know, Martineau, you spend too much time with patients for consultation. You have to go quickly, because you have a lot of patients.’”

Jeune was a straight shooter, and he demanded the same of others. He didn’t rest until he had an answer, whether it was for a patient he mentored or himself. That’s why, when he complained of an intermittent cough, night sweats, and fever, he told Louine about it during one of his regular HIV check-ins in early 2008.

“I thought of pneumonia or malaria,” Louine says. “I tried to give antibiotics, to give medications for malaria. But every week he kept on returning to see me with the same complaints.”

Suspecting TB, Louine ordered a sputum culture for Jeune. But it was negative. A chest x-ray revealed something new. He consulted with Walton and then with Farmer for advice. Farmer suspected it was multidrug-resistant TB, and recommended Louine perform further tests to confirm his hunch.

Sure enough, Jeune had contracted TB again. This time, it was a nastier form of the disease. Louine knew he needed to be hospitalized in Cange, an hour’s ride away. So he offered to pay a neighbor to farm Jeune’s beloved maize and bean crops.

The solution worked for about three months, and then Jeune wanted to return home to Lascahobas. “Ti Joseph was a really strong person,” Louine says. “When he decided to do something, it was really difficult to convince him to do the opposite.”

It’s an amazing story medically to survive AIDS back then and to survive TB the first time around and then MDR-TB.

Louine anxiously welcomed his patient. He remembers telling Farmer that he didn’t know how to treat such a complex case. Not skipping a beat, Farmer replied: “’Martineau, I think you are not curious,’” Louine remembers his mentor saying. “It’s a great opportunity for you to know how to treat MDR-TB.’”

And with that, Farmer arrived in Lascahobas on a Sunday to sit at Jeune’s bedside and explain, in detail, what to expect from and how to respond to the medications’ harsh side effects. Two years later, in 2010, after many injections and hundreds of pills, Jeune was cured.

“It’s an amazing story medically to survive AIDS back then and to survive TB the first time around and then MDR-TB,” Farmer says.

A big loss

Healthy and stable on his ART, Jeune returned to his full life. He worked his fields. He fell in love. He had a daughter, who never contracted HIV thanks to his dedication to treatment, and a new home in Lacolline. He dreamed about his future (and about how he desperately wanted to learn to read). He provided guidance to patients. And he visited the Lascahobas clinic for his regular check-ups.

It was on one such visit in late 2014 that Jeune again complained of a fever, cough, and chills. The on-call doctor screened him for TB, but the lab exam and chest x-ray both came up negative. Something wasn’t right. So the doctor recommended he be hospitalized for further tests.

Jeune knew what that meant and refused. After all, how was he going to take care of his family or his fields from the hospital? The doctor didn’t insist; he assumed there would be time to convince his patient.

The greatest thing is that his life was not in vain.

But after 13 years on ARTs, after having twice conquered TB in various forms, Jeune had no more time. He died in his home at 2 p.m. on January 21, 2015.

News of Jeune’s death slowly spread around his community, then Haiti, and then across oceans. Farmer was in West Africa helping battle the rampant Ebola epidemic when he heard his friend had died. He thought at the time that it should have been 30 years, not 13, that Jeune had gained.

Still, “it gave some of us strength,” Farmer says, “because everybody had given up on Ti Joseph except for family and the medical people who came to know him very well.

“It’s a big loss,” he adds. “We all loved Ti Joseph.”

Mukherjee was in West Africa too when she heard the news. A Sierra Leonean community health worker confessed that the poster with Jeune’s pictures had inspired her to continue living following an HIV diagnosis, thinking that if “’my brother did it, I can do it too.’”

That was the thing about Jeune; he popped up when you least expected it. His posters, and his legacy, remain alive.

“The greatest thing,” Mukherjee says, “is that his life was not in vain.”

On March 16, 2016, Dr. Paul Farmer, co-founder and chief strategist for Partners In Health, took questions on Reddit.com's "Ask Me Anything." Reddit.com is an entertainment, social news networking service, and news website. The "Ask Me Anything" event allows registered community members to ask questions on any topic. Dr. Farmer then answered the most popular questions, as determined by votes from the Reddit community. 

During the two-hour event, Dr. Farmer answered 28 questions, of the 247 asked. Questions covered a variety of topics--from advice on starting a career in global health, to a question from Microsoft co-founder Bill Gates about how to prepare for the next epidemic, to the J.R.R. Tolkien novel, "Lord of the Rings."

Some highlights:

• As one Redditor observed, "You know it's a big deal when Bill Gates shows up."

• Dr. Farmer's take on staying positive in this line of work:

• A "Lord of the Rings" question to keep things light:

• On how to help without doing harm:

• On how to start a career in global health:

• On how to balance work and family:

• A few reactions from Reddit users:

• We also saw some great Facebook comments and tweets going around before, during, and after the AMA itself:

You can read Dr. Paul Farmer's full Reddit "Ask Me Anything" here.

Small acts translate into big changes in Haiti. So when Partners In Health staff members receive the keys to a new laboratory in April, it will be more than a simple transaction.

The opening of Mirebalais Reference Laboratory for Diagnostic and Research means that thousands of patients every year will receive highly accurate diagnoses and the quality care they need. It means more Haitian lab technicians will receive advanced training in their fields. And it means more original research will be conducted to expand the existing body of knowledge on infectious and chronic diseases worldwide.

Zanmi Lasante, as PIH is known in Haiti, broke ground last spring on the two-story, 15,800-square-foot building opposite University Hospital and anticipates that construction will be completed this April, just weeks from the three-year anniversary of the hospital’s opening. The facility—built in partnership with Build Health International, a Massachusetts-based construction company, and Haiti’s Ministry of Public Health and Population—will eventually house a range of services and become a hub for PIH’s network of clinics throughout the Central Plateau and the lower Artibonite.

The reference laboratory will open in phases over its first year, with priority going to pathology services. This section of the lab will open in June and primarily focus on the preparation and analysis of tissue biopsies for cancer diagnoses. The Biosafety Level 3 (BSL-3) section, which typically deals with airborne infectious disease, is scheduled to open at the end of this year and will aid in the diagnosis of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB). The remaining sections will be phased in over time and include serology, microbiology, parasitology, chemistry, and hematology.

“Technologies are available today in the world to provide better and highly accurate diagnostic capacity, but people don’t have access to them,” says Daniel Orozco, PIH’s director of laboratory services and a globetrotting microbiologist who spent the last 18 years with Doctors Without Borders and FIND Diagnostics. “Our aim is to bring those technologies closer to patients and clinicians and to strengthen the overall diagnostic capacity in the PIH-supported laboratory network in Haiti.”

A national model

Painter Edel Quittere prepares to work in a second floor conference room at the new reference lab. Photo by Liz Cherchia/Build Health International

The reference laboratory is the only public facility of its kind in the region. Private laboratories exist, Orozco says, but they charge high fees and are mainly located in Port-au-Prince—factors that make such services inaccessible to many Haitians, who make less than $1 per day.

University Hospital currently houses three small laboratories that serve the in-patient department, women’s health, and the outpatient clinic. These labs often lack necessary resources, use obsolete technologies, and face constant stock-outs and frustrations when instruments malfunction or can’t be fixed.

These problems surfaced once the labs began operating at full capacity. As the number of patients seeking care grew and the complexity of their cases magnified, the labs struggled to keep up through existing “stuff, space, and staff.” The new laboratory will completely change that scenario, allowing PIH to offer more advanced and appropriate treatment options to a greater number of patients.

The responsibility of having everyone on the same page and up to international lab standards falls on the shoulders of Orozco and his lab team in Boston, and PIH leaders—such as lab network coordinator Betty Alexandre—and their partners in the Haitian government. Together, they see the reference laboratory as an opportunity to consolidate diagnostics at University Hospital under one roof and provide referral and research capacity to the national health system.

Establishing a network of labs requires precision. The reference laboratory and its network of PIH labs will need to establish protocols and procedures required by national and international standards, including uniform documentation, data management, biosafety, quality assurance, training, and a regular supply chain across all locations. This is a constant process and, through step-by-step quality improvement, Orozco hopes the lab will meet accreditation standards set by international organizations, such as the International Organization for Standardization, as proof as its solid work.

“How we are going to reach that,” Orozco says, “is by starting today.”

Once fully functioning, the reference laboratory will house ambitious technology upgrades, expanding testing capacity, and surveillance and research projects. It will also serve as a training grounds for pathology residents—much as University Hospital is for Haiti’s future doctors and nurses. And it will be a hub of continuing education for PIH lab staff, and a home for regional seminars uniting PIH staff with partners in the Haitian government.

Pathology as priority

The nearly finished reference lab sits across from University Hospital in Mirebalais. Photo by Caitlin Candee/Build Health International

Together with PIH leaders in Haiti, Orozco and his lab team identified as a top priority the opening of the lab’s anatomic pathology department. There are less than 10 pathologists in all of Haiti, and only one works in the public sector. Right now, University Hospital doctors remove a sample of potentially cancerous tissue from patients. Through a unique collaboration with Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Newton-Wellesley Hospital, pathologists analyze patient biopsies on a pro-bono basis and provide a diagnosis that is sent back to Haiti, where PIH clinicians begin treatment.

In 2011, PIH’s oncology team in Haiti sent 90 biopsies for diagnosis. That number has grown exponentially each year, to the point that surgeons performed nearly 1,600 in 2015 alone.

Before University Hospital opened, patients had little access to a proper pathology diagnosis. They now are directly linked to some of the best pathologists in the United States, but still wait weeks for a proper diagnosis. With the new lab’s opening, the pathology team will achieve similar diagnostic standards as in the United States, where patients typically wait a maximum of seven days for the same information. The difference can be a matter of life or death.

“For cancer patients in particular, the diagnostic component of care is critical,” says Lauren Greenberg, PIH’s oncology program associate. “For most cancers, you cannot begin to treat with chemotherapy until you have a pathology diagnosis.”

Lengthy waiting periods also mean that patients simply don’t return for their results. It’s a big challenge for Greenberg and the entire oncology staff. “If we can improve our lab,” she says, “we can decrease the wait time for these diagnoses and decrease our loss to follow-up.” And get patients on treatment much quicker.

With pathology services opening, reference laboratory technicians will start processing biopsies performed by surgeons just meters away at University Hospital. Through collaboration with Boston-based partners, technicians will be trained to slice and transfer tissue samples to microscope slides for diagnosis by a pathologist. The goal is to have all biopsies prepared, processed, and diagnosed in Haiti.

Scaling up

By December, the BSL-3 section of the lab will open and technicians will be trained to process sputum samples for the diagnosis of TB and MDR-TB, as well as monitor how effective therapy has been for patients.

Properly identifying TB strains is key to treatment and the prevention of drug resistance. If patients are infected with a TB strain that is susceptible to common antibiotics, they can be put on the right treatment and their case properly managed, eventually leading to a cure. If patients are misdiagnosed, then they could be taking medication that doesn’t kill the bacteria, but makes it more resistant. Resistant TB strains require months of daily injections and a cocktail of antibiotics that could cause debilitating side effects.

Clinicians often have to wait weeks or months to appropriately diagnose a TB or MDR-TB case. But new technologies exist that can shrink that time to a few days or even hours. “It’s challenging, but it’s not impossible to do in Haiti,” Orozco says.

Other parts of the lab will be phased in gradually, with the microbiology section next in line. There, lab technicians will analyze blood, urine, stool, and other cultures, which are essential in providing more accurate and targeted therapies for children and adults with deadly diseases.

Diagnosis of infectious diseases—including HIV, hepatitis, meningitis, cholera, Zika, or chikungunya—will be possible in this new facility, as well as the monitoring of treatment for HIV-positive patients on antiretroviral therapy.

This array of advanced diagnostics simply hasn’t been possible before in Mirebalais. Having such a wealth of laboratory expertise within a stone’s throw is a clinician’s dream. 

"When you have a lab with the capacity to do tests that meet physicians' needs," Alexandre says, "you improve the system of care."

Just as Ebola fades from the headlines, another infectious disease, the Zika virus, has captured the world’s attention. Zika, which is suspected of leading to complications for pregnant women and their children, was declared a global health emergency by the World Health Organization in February. The extent of the threats the virus poses are still unknown.

Zika is just the latest public health crisis Partners In Health has worked to address. We treated thousands sickened by the Ebola virus in Liberia and Sierra Leone. We tackled a tuberculosis crisis in Russia's prison system. We fought cholera in the most impoverished regions of Haiti. And now, we're implementing a comprehensive plan to address the Zika virus in Haiti, from providing our patients with DEET and bed nets, to gathering frontline data to help learn how to battle the virus and its complications.

For nearly three decades, we’ve been caring for people sickened by illnesses that are easily treatable, and we’ve worked to build health systems in poor communities so that care is available to those in need. We believe this is the only way to be prepared for the next epidemic.

Early during the Ebola crisis, PIH co-founder Dr. Paul Farmer said the only “formula” to counter Ebola is strong, functioning health systems that provide quality care.

This is the core of our work—and it’s a lesson the global community is learning again with the Zika virus. In Brazil, the virus is spreading where poverty is concentrated. Mosquitos breed in the stagnant water of dirty canals or the dumped garbage of shantytowns. Poor people without access to running water store their own—and thus are at greater risk of contracting Zika.

We believe that strengthening health systems—building clinics and hospitals, training nurses and doctors, conducting research, and partnering with local governments—will raise the standard of care available to poor communities. It is also the way to prevent debilitating epidemics such as Ebola and Zika in the future.

Help us provide our patients with the health care they deserve. Join us in this fight.

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See our mission.

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Starting a career in global health can be intimidating. It’s a diverse field that evolves quickly and demands collaboration across disciplines, from finance to supply chain and logistics, to computer programming.

Occasionally we ask a seasoned colleague to share advice for those interested in forging a career in global health. This month we asked Adam Bernstein, our web production manager, who’s been working on PIH’s communications team for two years.

I remember walking past many closed-door meetings at Partners In Health’s office in Boston in the fall of 2014, feeling that things were markedly different from the norm. The atmosphere was eerie and serious. PIH leaders had just announced that the organization would be aiding the effort to contain the world’s deadliest and most pressing health issue at the time: Ebola.

A daunting proposition in its own right, but it was especially true for me—a web developer and administrator, accustomed to the safe confines of a desk. I wondered how my role would be relevant in this immense and medically-focused public health effort. It seemed that my skillset had no obvious connection to global health until I was called on to help send clinicians to West Africa. We desperately needed to modify our web-based recruitment platform to hire clinicians to prevent the rapidly spreading disease. It was something I never imagined I’d be doing, but looking back, by following my interests, I’ve ended up in a fascinating intersection of web development and nonprofit global health work.

In 2006, I graduated from Northeastern’s College of Computer Science and had the great fortune of then finding work at Facing History and Ourselves, an educational nonprofit. I spent eight years there developing internal- and external-facing websites using everything from the outdated Lotus Domino to the then-new HTML5 standard.

I learned of PIH in 2010, when Haiti was struck by a 7.0 magnitude earthquake. I felt I needed to help in some way and asked around for the best organization to which to donate. Partners In Health kept coming up. Almost four years later, in December 2013, I noticed PIH was looking for a web developer. I was hired some months later.

I arrived at PIH without much knowledge of the global health sector. Like many others, my first real exposure was reading Tracy Kidder’s Mountains Beyond Mountains. While settling in, I would steal chapters of the book at my desk during lunch breaks and became star-struck when I realized one of the main characters, Ophelia Dahl, sat in an office within eyeshot—a truly humbling and unique experience.

Working alongside the heroes of the field, even indirectly, opened my eyes to the meaning of doing selfless work to aid the poor. Quoting an experienced colleague and a personal mentor, Ellen Ball, “At Partners In Health, and many other nonprofits working to improve global health, it’s not about making the most money for shareholders and chasing bigger paychecks. It’s about social justice and human rights. The passion and dedication are indescribable.”

This attitude was never more apparent than during the Ebola crisis. PIH staff rallied together to do whatever was needed. Reconfiguring a recruiting platform wasn’t within my job description, nor were other tasks that colleagues had taken on. PIH’s recruitment platform wasn’t set up properly to handle the type of recruiting we needed to fulfill the demand for rapid deployment of skilled clinicians to West Africa. With no one to provide guidance and not enough time on my hands, I came up with an interim solution of “hacking” a totally separate system to handle employment applications. It was not ideal, but it worked long enough to allow me to enhance our main platform in the meantime. Within two months, we’d received more than 2,500 applications and recruited over 370 clinicians.

That was the moment I realized global health is about much more than just medicine. It’s about teamwork, selfless collaboration, and finding the not-so-obvious applications of your trade to make the world a healthier place for everyone to live.

Since then, I’ve continued to learn on the job in order to best serve my team and the organization. The best advice I have to give the aspiring web developer is to keep your finger on the pulse pulseof the industry and standards. It’s not only fun, but obligatory. And it’s an honor to be able to bring the best of the web world into the field of global health and to PIH.

I was eventually lucky enough to meet a few nurses recruited through the platform, who were in Boston for training. I asked what they thought of the process. Their response was along the lines of: “We actually chose PIH because the application was so easy to understand. We had a difficult time finding a place to apply until we saw yours!” I felt an immense sense of surprise, relief, and pride to have been a tiny part of an immense effort to treat those in great need. I can’t think of better motivation to stay with this work for a very long time.

To recognize International Women’s Day, we asked some of the inspirational women at Partners In Health to tell us about a woman in their lives who has inspired them. Here are their answers:

Photo by Seneq Pierre-Martelly / Partners In Health

Marie Mellande Tulme, “Miss Tulme,” community health coordinator, Haiti

“The first person that comes to mind is my mom. She was very dynamic and loved people. My mother was someone who would always give to others; she was always involved. I can’t remember a time when our front porch wasn’t full of people waiting for food or advice. She was always there for those who didn’t have much. Even older people would call her ‘mom.’

This vision of her helping others was ingrained in me at a young age, and as I got older I felt like it was my calling to help others. It shaped my own work, I knew I wanted to help others not only improve their health, but also their lives.

People who knew my mom say, ‘Marie Mellande, that’s Jaqueline Michel’s daughter. She’s just like her’—and that makes me feel good. It’s as if my mom passed down her gifts to me.”

Photo by Elena Devyashina

Alexandra Solovyeva, patient accompaniment program manager and training specialist, Russia

“Faina Lisiyenkova, my grandmother, played a big role in my becoming a doctor. She worked as a nurse, then a doctor’s assistant, and after graduating from medical school, she became a general practitioner. While she studied medicine, she worked very hard as it was post-World War II and people were starving and sick.

As a little girl, I watched her examine her patients and answer their questions, and how grateful they were to her for the care she provided. I always played the role of a doctor with my dolls. Of course, she encouraged it.

My grandmother’s story made me realize how important it is to follow your dreams despite misfortune, and not to be afraid of hardship.”

Photo by Nandi Bwanali / Partners In Health

Getrude Daluni, hospital attendant, Neno District Hospital, Malawi

“In 2002, I was diagnosed with HIV. Since then, I’ve tried to help people who are also infected. A woman called Irene Kudethe helped me through this journey. She shares her story in awareness campaigns and encouraged me to proactively advocate and to be open about my life and status. She told me to live and work just like everyone else because being HIV-positive does not make me less human. We are still in touch and constantly motivate each other in our work.”

Photo by Aaron Levenson / Compañeros En Salud

Miriam Morales, secretary for Right to Health program, Mexico

“My mother: Flor de Maria Camas Briones. She is a very special person who has always been with me to support me. She is a woman who despite all complications in life always has a big smile. She’s a monument of a woman.”

Photo by William Castro Rodriguez / Socios En Salud

Teodosia Asto De La Cruz, field supervisor for the TB Zero project in Carabayllo, Peru

“The woman who influenced my life was my mother. Since I was very little, I learned from her how to live in solidarity with people, to have values that influenced my personal life. All of this helps me daily in persevering at work.”

Photo by Gibrilla Sheriff / Partners In Health

Rebecca E. Rollins, Interim Chief Communications Officer

"Thousands of Ebola survivors have influenced my life more deeply than I ever imagined. Their effect on me is personified by three powerful and generous women who have become close friends. Yabom (left), Hawanatu, and Hafsatu: Thank you, cheers, and cheers."

Ubaldo Roblero, 34, lived locked inside a shack behind his family home in rural Chiapas, Mexico, a prisoner to his diagnosis of schizophrenia. A square hole in the door served as his portal to the world for nearly a decade. Beyond giving him his medication, his parents didn’t know how else to respond to his violent spells. That is, until Dr. Luz Valderrama visited in February last year.

Valderrama recognized Roblero was reacting poorly to his medication. Twice in four months he got so sick she feared he might die. With the help of her supervisors, she got him admitted to a hospital in Tuxtla-Gutiérrez, eight hours away from his home in Buenos Aires, where he could be under the direct observation of a psychiatrist.

Such an intervention likely never would have happened if Valderrama, and Partners In Health, had not been there.

PIH started working with Mexico’s Ministry of Health in 2011 to place pasantes, or first-year doctors, like Valderrama in remote clinics in Chiapas. Now 10 clinics have doctors, which significantly improves residents’ access to health care. With support from PIH staff, these young physicians provided more than 10,000 patient visits in 2012 and about 28,000 in 2015—a nearly 170 percent increase.

Historically, pasantes have preferred spending their social service year in urban hospitals or research institutions. But public clinics—the ground floor of the nation’s health care system—are exactly where they’re needed most. The clinics are often inactive, because the government doesn’t assign a doctor to the locations or does so temporarily. It’s a pattern rural Chiapanecans have seen often, so they’ve struggled to cope with irregular care.

PIH changed that. Our unique training program attracts pasantes who graduated near the top of their classes. The Ministry of Health assigns them to one of 10 clinics we support. And our supervisors visit them several days each month to provide mentorship and help troubleshoot complex cases. Pasantes also return to our headquarters in Jaltenango for monthly seminars created by instructors from Harvard Medical School and accredited by Tecnológico de Monterrey, a highly regarded medical school in Mexico. 

Mental health is one area in which pasantes receive regular supervision and advice from trained professionals. The first-year doctors are true pioneers in providing community-based mental health care where access was nonexistent, and where stigma prevented patients from seeking care. Theirs is essential work, considering that the World Health Organization estimates depression alone will be the leading cause of disability globally by 2030—outpacing heart disease, cancer, and HIV.

Valderrama stocks a PIH-supported clinic in Soledad, Chiapas.

Support doesn’t end at mentorship. Our staff always ensures pasantes have “the stuff” they need to do their jobs. Each clinic pharmacy is fully stocked with medications and supplies. And every clinic has a laptop loaded with an electronic medical record system to track patient visits.

A complex case

While following Roblero’s case from afar, Valderrama visited another patient struggling with mental illness in Soledad. She walked the short trek to his house trailed by her dog, a stray she’d named Terry. The doctor with a lip ring and a pink streak in her hair has a warm personality and seems undaunted by any challenge. This patient, though, tested her.

Valderrama was told that Humberto* had begun showing violent behavior nearly two decades ago. He regularly beat his wife and was so abusive toward family and friends that they eventually chained him to a shed adjacent to their home.

There was no other option at the time. Psychiatrists didn’t make house calls in that part of Chiapas. And his family, like Roblero's, had traveled in vain to Tuxtla and Mexico City several times in search of care and could no longer afford further trips. So they kept him locked away, caring for him as best they could.

After talking to his family, Valderrama learned Humberto had also suffered a machete blow to the head around the same time his schizophrenia surfaced. She suspects her patient’s mental illness is aggravated by this brain injury. It’s a complex case. And so far, neither she nor the other pasantes who preceded her has found the perfect combination of medication that “helps him connect with the world,” she says. But through constant communication with PIH’s mental health coordinator based in Jaltenango and support from PIH’s cross-site mental health team, she knows she’s not alone.

And Valderrama hasn’t given up. Her goal is to get her patient to the point where he can live free physically and have an improved quality of life. And she thinks it’s possible considering the support she receives through PIH. “Here we have the opportunity to treat patients with schizophrenia because we are in touch with psychiatrists, with someone more specialized who helps us,” she says. Pasantes working in other remote parts of the country aren’t as lucky.

For now, though, Humberto continues to pace back and forth, a chain linked to his left ankle as he methodically etches a shallow groove in the dirt bordering his home.

A long road ahead

Meanwhile, Roblero fared better. Specialists at the Hospital San Agustín in Tuxtla discovered he is one of extremely few people who suffer adverse reactions to haloperidol and olanzapine.

Two weeks after starting on a new drug, Roblero returned home a changed man. His parents noticed the transformation. His father, Francisco, says that he became more conscious, didn’t talk to himself, or rip at his clothes.

“He didn’t even come and sit and talk to us before,” says his mother, Idolina. “What do you think about that? That’s what bothers me.” Her words trail off as she thinks about the 10 years of life her son lost to mental illness.

Valderrama, center, visits Roblero, right, at his home and checks his medication.

But like many people who struggle with mental illness, Roblero is engaged in a lifelong battle. After several weeks on his new medication, he started having violent spells again while working in his father's coffee fields. Afraid his condition might worsen and fearful that he'll have a crisis they can't control, his parents reluctantly decided to chain him again.

Now that Valderrama's social service year is over, she has trained a new pasante who continues to visit Humberto and Roblero at home to oversee their treatment twice each month. Meanwhile, PIH has taken this as an opportunity to train staff in psychological strategies to help patients transition from living chained and isolated to being part of the community.

There's a long road ahead for these patients and their familes, but pasantes—and the entire PIH team—will be there every step of the way.

*The patient's name has been shortened.

Dr. KJ Seung is something of a tuberculosis maverick.

He has worked at Partners In Health since 2001, when—fresh out of residency in internal medicine—he went to Peru to battle TB, which was devastating poor families living in shantytowns near Lima. He made sure patients got proper care despite out-of-touch policies that considered drug-resistant TB patients too difficult to treat.

He’s currently doing the same in North Korea, which is experiencing a surge of multidrug-resistant tuberculosis.

Seung now co-leads a project aimed at revolutionizing treatment for multidrug-resistant tuberculosis. endTB, a UNITAID-funded initiative that started in 2015, is implemented by Partners In Health, Médecins Sans Frontières (MSF), and Interactive Research and Development (IRD). It’s bringing new drugs and treatment regimens to 15 countries with among the highest rates of multidrug-resistant tuberculosis in the world. PIH is responsible for implementing the program in six of them: Lesotho, Kazakhstan, Peru, North Korea, Ethiopia, and Nepal.

Seung, who appeared in Boston’s “Top Docs of 2015,” traveled to Lesotho recently, where the first patients have just been enrolled. He explains the endTB program and where we’re headed.

You've worked on many TB projects throughout your career. How significant is this one?

Bedaquiline and delamanid are the first new TB drugs in 40 years. There hasn't been any real TB drug development for a very long time. And it's really only because of drug-resistant tuberculosis and our old drugs not working that there has been more research. So this is exciting for everybody who works in TB. These drugs look really effective and could potentially change treatment for millions of people per year.

Then there’s the scope of it. Certainly, PIH has never done anything like this before. We're trying to enroll a lot of patients on treatment with these drugs—patients who are very difficult to treat because they're infected with highly-resistant strains. They can't be treated in any other way.

There's a really strong research component, too. We're partnering with MSF and IRD for the first time. So there's a lot of very exciting aspects to this project.

Is endTB replacing what a pharmaceutical company would normally do in clinical trials?

No. The drugs we are using have already been developed and tested by pharmaceutical companies. Our project is stepping in where pharmaceutical companies traditionally have problems, because it’s a disease that requires treatment with a combination of drugs.

A good example is HIV. It's really hard to do a clinical trial of a multidrug regimen if the drugs are made by different companies that may not want to cooperate with each other. With Hepatitis C now, there's some of that going on.

So we’re stepping in at a stage of development where there are inherent difficulties.

On to Lesotho. Where are we with the project?

We have enrolled 17 patients so far, just a small portion of the 150 we expect to enroll in Lesotho and the 2,600 that will be enrolled in all 15 countries. But a lot of these patients are very difficult to treat. Some of them have been in treatment for years without being cured and are well-known to our medical team. We want to make sure everything is going OK.

To use these drugs the way the World Health Organization recommends requires close monitoring for any potential side effects.

For example, one of the things that has to be done [for each patient] is an electrocardiogram, a record of the heart rhythm. This is not something we had to do with other TB drugs. We need to teach our staff how to use an EKG machine and make sure we have all the proper supplies there.

What will the clinical trial involve?

This is where we're testing completely novel regimens—new combinations of drugs, much shorter regimens.

In the standard WHO regimen, you're taking five or six drugs that include an intramuscular injection for eight months. Nobody wants to get an injection every day for eight months, and it has some nasty side effects. So that gets stopped after eight months, and you take the rest of the drugs for another 12 months. The rest of the drugs are mostly old and have a lot of nasty side effects of their own. So it's a very difficult regimen for patients to follow.

In this new clinical trial, patients will be randomized to regimens that are only nine months long, with no injection.

What is the greatest challenge you've come up against in Lesotho?

Honestly, the greatest challenge so far has been getting the new drugs. The project started April 1, but we didn't actually have any drugs in Lesotho until October. And we only have one of them—bedaquiline. We still don't have delamanid. But we're closer now, and we're going to start shipping that, too.

I think it's been very challenging for everybody—from the manufacturer who has to scale up production, to the distributor, the Global Drug Facility. It's a new drug, and they're getting orders from all over the place.

Are we making progress with the project as a whole?

Yes, we have drugs in almost all PIH sites. We started treating patients in four out of six countries—Lesotho, North Korea, Kazakhstan, and Peru—and are close to starting in the other two. And we've had some really good discussions with Ministries of Health in these countries.

The Lesotho government has been really receptive. Patients have been really interested. That just shows we need to work harder and overcome all of these challenges and get these drugs out there.

Jump ahead to February 2017. Where would you like to be in a year?

We want to have a really good comfort level with the drugs—meaning all of our doctors and nurses understanding how to use, monitor, and prescribe them.

We'd like to have data about patients improving clinically, and certainly any data on unexpected side effects that haven't been found in previous trials.

We want everybody in our countries, including governments, to be really comfortable with the drugs and planning to use them in the future.

Partners In Health serves 32,000 pregnant women in Haiti every year, which puts it front and center in the debate over how to deal with the Zika virus and its carrier mosquitoes, the Aedes aegypti and Aedes albopictus. After seeing thousands of cases, experts are investigating a link between babies born with small heads, a condition called microcephaly, and Zika contracted during the mothers’ pregnancies.

Many questions remain about Zika and its current impact on the Haitian population. Until more answers surface, PIH staff strive to find the best solutions for women, men, and children who may be adversely affected by the virus.

We spoke with Dr. Louise Ivers, PIH’s senior health and policy advisor and an infectious disease expert, about the mosquito’s resiliency, efforts to control it in Haiti, and how PIH is working to prevent Zika infections and treat those who might be suffering from complications.

What about these mosquitoes makes them unique?

These mosquitoes are different than the mosquito that transmits malaria, so they need a different approach to control. They have a very resilient life cycle. A. albopictus’s eggs, for example, can exist for quite some time even when it’s dry. They’ll just wait until the next rain or water is available and then hatch out. Other mosquitoes typically replicate near bodies of natural water, but these mosquitoes are found in very small collections of man-made water reservoirs near homes. So it could be the water collection bucket people use in their homes. It could be a small collection of water on a banana leaf. It could be water in old, disused tires from vehicles that are sitting around.

So you can imagine urban slum areas where there’s a lot of garbage that can collect water. Even in rural places, this can also be the place where they thrive. It’s difficult to eradicate all of these areas from someone’s home.

How is the Zika virus related to other water issues in Haiti?

There’s an irony here in that we’ve been battling this huge cholera epidemic, which has been related to the lack of water security. People don’t have access to water. They deal with this by collecting buckets of water and leaving them in their houses. These same buckets put them at risk of dengue, Zika, and chikungunya fever because they are locations that these mosquitoes like to use. We have to explain to people how the mosquito can thrive in these water buckets, that they have to cover them, and that they have to examine the water to make sure there’s no eggs or larvae in their homes.

Is it fair to say poor people are disproportionately affected by these mosquitoes?

Nobody’s immune to these mosquitoes, but the poor are disproportionately affected by the consequences of the mosquitoes. It’s not just the poor rural or urban areas that have a problem. But if you have a home that has air conditioning, then the mosquitoes are much less likely to thrive there because the temperature is cold for them. And if you have a home that has screens on the windows, that really reduces the likelihood that mosquitoes are going to get in in the first place, lay their eggs, and reproduce. Again, like with many other neglected diseases, we have the situation where the people with means or resources are less likely to suffer consequences because they can protect themselves better at home.

Also, these mosquitoes do not particularly bite at one time of day or another. They bite both indoors and outdoors. If you’re working for a bank or you’re working in an office with air conditioning and screens, you’re less likely to get bitten. The same isn’t true if you have to work outside or in the fields.

What is generally being done to prevent infection and control the mosquito?

The mainstay of trying to protect against these diseases has been trying to avoid getting mosquito bites. That’s easier for some than others. Wearing long sleeves is just so impractical for a place like Haiti, where it’s over 100 degrees for many months of the year and people work outside and most commerce happens outside.

People are also trying to reduce the number of mosquitoes. One way is through the use of improved environmental sanitation, such as draining standing water, trying to eliminate places where there is standing water, and educating people about what to avoid in homes and their yards to reduce the likelihood that the mosquito can breed there. Those are small, initial steps.

There are some efforts under way to make biological alterations to the bug with the thought that it can be eradicated. There was an experiment done in a part of Brazil where they released genetically modified mosquitoes in an effort to control the epidemic of Zika there. Then we talk about pesticides, and many are concerned about pesticides contaminating the environment and having other unintended consequences. Well, here’s another dramatic activity that could really impact this disease and other diseases but have environmental consequences that I certainly don’t fully understand or know.

Is there a link between pesticide use and microcephaly?

I think everyone is always suspicious of putting harmful chemicals into our environment, and rightly so. The causes of microcephaly are still being investigated, in Brazil in particular. There’s a lot of research that has to be done to understand that.

Part of the issue is that Zika is not really affecting Europeans and Americans, at least not yet. So the amount of money going into research to answer these questions has not been that high. We should know what the link is. We should investigate the causes. We should have the resources to respond to this type of issue with good clinical care for the women and babies involved, and also the resources to respond to emerging infectious diseases with proper research. That means putting resources into diseases that are not necessarily affecting the U.S. and Europe.

It was the same with Ebola. There were not that many resources available for researching Ebola virus until it suddenly became a risk to the U.S. and Europe. This lack of foresight needs to change as a matter of equity and as a matter of common sense.

What is PIH doing to battle Zika in Haiti and prevent infection among staff and patients?

PIH in Haiti (Zanmi Lasante) is working with officials from the Ministry of Health and representatives from the Pan American Health Organization, the World Bank, and several international nongovernmental organizations to create an action plan to address Zika in Haiti. That plan includes six main target areas, including: epidemiologic surveillance, social communication and mobilization, family planning, vector-borne disease control, clinical management, and monitoring and evaluation. Each partner will contribute in their area of expertise.

The only real thing we can do at the moment is try to protect people from mosquito bites by educating them, providing them with mosquito repellent, and working with the government—which will have to include discussions with communities—to answer questions about mass larvicide or insecticide spraying.

There are many, many unknowns, and it’s still a work in progress in terms of what we can do.

Women of child-bearing age, in Haiti and in other countries where Zika thrives, have been told to avoid pregnancy. How sound is that advice?

The issue is: How can women prevent themselves from getting pregnant in a country where access to family planning is still very limited? Women want to get family planning, but they don’t have access to it. Public facilities are under-resourced. There’s not enough staff. There’s not enough supplies. Maternal mortality is already too high in Haiti, and the Zika epidemic is highlighting the lack of access to health care for women.

The Haiti team has been trying to educate and pass on all the information that’s available about the virus, and that would include encouraging women to not get pregnant yet while the information is still not clear. One goal we have, now more than ever, is that every woman in Haiti has access to family planning if she wants it.

How long is the virus present within the body, and do we know if this infection has lasting effects beyond that period?

The virus itself is present for three to seven days, we believe. We can test for the actual virus with a polymerase chain reaction (PCR) test, or we test for antibodies to the virus. Antibodies persist far longer than the virus itself. So you might have antibodies forever. The antibodies are what probably provide you with immunity if you’re exposed again.

We really don’t know a whole lot yet about how long people have the virus in their body, because nobody has been testing them every day for a week to see, and there have not been many research studies yet. Many of the infections are completely asymptomatic, so it’s only afterward when they find antibodies that they realize the women had been infected.

Do you know of any children born in Haiti with microcephaly that might be linked to Zika?

No, we don’t know yet. At least, there’s no official report.

When children are born with microcephaly, what types of services do they require?

Children with microcephaly might have a range of problems from none to very many. The key point is that children need to have individualized care, an evaluation of their abilities and their development, and interventions such as physical therapy or special support to respond to whatever those challenges might be—just like any child with a developmental delay or disability.

Maybe some of the children wouldn’t need anything, and that would be great. And maybe some of them will need a lot of support. A lot of that remains to be determined. The reality is, as of today, that level of individualized care is typically not available in Haiti.

At University Hospital in Mirebalais, we have advanced health care for pregnant women even in normal circumstances. We have neonatal care, pediatricians, obstetricians, and we have antenatal ultrasound. And because we are community-based in terms of our activities, we are planning to set up community-based care for any children who are born with microcephaly—but this will require resources.

There’s growing evidence that Zika infections may also cause Guillain-Barré, which comes with another set of serious complications, right?

This is a neurological problem that is thought to be due to an inflammatory response that affects your neurons. Say you respond to the virus, but the same antibodies affect your neurons.

There’s definitely been an increased number of cases of Guillain-Barré in the countries where Zika has been found. Our own team in Haiti has diagnosed a number of cases. They suspect that it’s also related to the Zika virus, but again we don’t have a lot of resources to do scientific research on this. We would like to have more and be able to do more.

Can the syndrome be cured, or is it a lifelong condition?

It can sometimes be a life-threatening complication. In the U.S., the treatment is largely to support the patient through it. Sometimes they can have paralysis of their breathing. Sometimes they need to be intubated. Sometimes it’s less severe. But mostly the care is supportive, which would be a challenge in Haiti, where there’s not very much access to critical care.

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Since she was a girl, Beatrice Romela dreamed of being a nurse. Today, she’s changing what that means.

Romela is the chief nursing officer for Zanmi Lasante, as Partners In Health is known in Haiti. The role is a culmination of her two decades of experience in nursing, more than 13 of them working for PIH. In this position, created through an initiative to strengthen nursing in the Haitian health care system, Romela travels to all PIH-supported hospitals and clinics in Haiti, working with the nurses and administrative officials to resolve problems, identify training needs, and improve care.

This month, Romela wraps up her master’s degree in nursing education and leadership through a partnership among Regis College, the University of Haiti, and PIH. We sat down with her recently to learn about her story and her work.

Where are you from?

I’m from Baradères, a rural community in the south of Haiti. I grew up and went to primary school there. After that, I left to attend high school in Port-au-Prince. My dad wanted me to leave because there wasn’t a good high school in my hometown. I left my house and my mom, and I lived with my aunt, my father’s sister, in Port-au-Prince. It was hard because I was very young— just 12 years old.

Why did you go into nursing?

When I was 9 years old, I was sick and my mom took me to a health center. I wasn’t hospitalized, but I met with the doctor, who gave me medicine. My mom took me home that same day. But what I remember most is the nurses. They were wearing white uniforms, and they were talking to the patients. I really liked how they looked and how they talked to the patients. I told my mom that when I grew up I would be a nurse like them.

What role do nurses play in the health care system in Haiti?

I’ve worked as a nurse for 20 years in Haiti. In my personal experience, decisions about the health care system in Haiti are made only by doctors, rather than nurses. Nurses aren’t empowered to be part of decisions about the treatment of a patient or the way the health care system operates. In Haiti, the doctor orders the treatment, and it’s the nurse who is responsible for caring for the patient, delivering the treatment, and talking with the patient.

Sometimes, a nurse’s role is to work in places that are remote, where there is no doctor. In those cases, nurses don’t just care for patients but also treat them with medicine, following the guidelines of the Haitian Ministry of Health. If the nurse can’t help, he or she sends the patient to a facility where they have more doctors and nurses.

Nurses are also responsible for educating patients about their health, checking vital signs, providing care in hospitals, and delivering babies where there is no midwife or obstetrician. Nurses also teach in the nursing school.

What do you like about working in rural areas?

I’m a better nurse because I’ve worked in remote areas. I can relate to people and better help them. When you only work in Port-au-Prince, you don’t know the problems of the countryside. When I go to a new health facility, I like to walk to the farthest community that the clinic serves, the place that takes you four hours to get to on foot. It helps me appreciate how far people are walking to reach the health center, and that they need priority because they came from so far away.

Where have you worked with PIH?

Starting in June 2003, I worked in Cange for almost three years in internal medicine. Cange is always in my heart. I had a good experience there, with a lot of HIV and tuberculosis patients. It was the first time I worked with patients who were very sick, many near death. After we began treatment for those patients, they would recover and leave their sick beds. I saw the transformation. In April 2007, PIH moved me to be charge nurse in Thomonde health center. In January 2009, PIH moved me to Lascahobas, where I spent two years working as charge nurse.

What is your role now?

I go to all the sites to see how the nurses are doing. I see what I can do to support the charge nurse, who oversees the other nurses. I identify needs for further training and work with leadership to fix problems that the nurses and patients are facing. I have also some administrative and human resources responsibilities. But my big responsibility is the supervision of nurses in all sites.

Along with Sheila Davis, PIH’s chief nursing officer, we’re forming a nursing leadership team so that we discuss nursing problems. What has to do with nursing, we decide as nurses. It gives us more liberty.

How does it feel to be the first person in this new position of chief nursing officer for PIH in Haiti?

To visit all the sites, all the hospitals and health centers, is hard. I’ve met with other nurses that have a lot of experience in the system to ask for their help. We know that improving nursing is a big job, and I can’t do it alone, so I need the whole team. I tell them, I need your suggestions and your advice. I need your support and your experience. I need your help, so that together we’re a team that can make a change in nursing.

What change do you hope to see?

All decisions about nursing have to be made by nurses, not doctors.  It’s the nurse who knows the patient the best, better than the doctor. That’s why nurses can give their input on what’s best for the patient, and for the entire health system. In hospitals in Haiti, the chief nursing officer is under the chief medical officer. These two professionals should work side-by-side, rather than one above the other.

We have to start to change nursing education in Haiti. We would like all the courses in the schools of nursing to be taught by nurses, but unfortunately some classes are taught by doctors. Regis College in Boston has been working with the University of Haiti to grant the first master’s degrees in nursing. We need more professors of nursing who have master’s degrees so that we don’t need doctors teaching these classes.  

Also, the government has to think about nurses’ salaries. The basic salary for a nurse in Haiti working in the public sector is the equivalent of $377 each month. Only nurses working for international organizations earn more, perhaps $545 each month. In Haiti, the cost of products and services such as food, clothing, health care, and schooling are very expensive. That’s why a lot of nurses leave the country.  After a post-graduate training, the nurses should have a better salary and a better position, but unfortunately they continue to work with the basic salary and the same position.

We need change. I know it is a long process, but we can make it if we nurses put our heads together and work together—not for personal interests, but for the common good. I believe in that.

Dearest colleagues and friends of Partners In Health,

It is with great sadness that I share the tragic news that our friend and colleague, Dr. Max Raymond Jr., died in a drowning accident in Sierra Leone on Saturday, February 6.  Max was working in Sierra Leone in his role as Partners In Health's Director of Leadership Development, deeply engaged in nurturing the work and the careers of our team there.

We have been the beneficiaries of Max’s kindness, his passion and his talent since 2006, when he joined Zanmi Lasante and Partners In Health as a physician in St. Marc, caring for patients with HIV. After earning his master's degree at ITM in Antwerp in 2011, Max returned to Haiti where he helped to design and lead our cholera treatment and vaccination programs, saving and safeguarding thousands of lives in Central Haiti. With equal energy, in 2013, Max joined PIH/Lesotho where he applied his exceptional gifts as a clinical manager at our sites across that mountainous region.

Just this past year, Max moved to Boston to lead the PIH program in leadership development across all sites. As a trusted physician, implementer, and generous teacher, Max was the perfect person to launch our Global Health Delivery Leadership Program. His deep commitment to our mission and to the growth and success of his colleagues inspired all of us. He will be deeply missed.

We honor Max’s life with the work that each of us does in service of those at great need and in the spirit of great generosity and support for one another that he modeled so well for us.

In solidarity,

Gary L. Gottlieb, MD
Chief Executive Officer
Partners In Health

The demands of family and farm leave little time to worry about it. And anyway, it’s probably just from breastfeeding. But after a couple of weeks, the 35-year-old mother walks over to chat with her neighbor, a community health worker, about the hard little knot near her armpit. Concerned, the community health worker suggests she visit a health center down the road.

At the health center later that month, the nurses also aren’t sure what to make of the bulge in her breast or the persistent ache she is now experiencing. They prescribe pain medication. After three return trips to the health center and three failed courses of antibiotics, the woman finds herself referred to a district hospital.

On the day of the appointment, she rides a motorcycle taxi for half an hour and a bus for two hours, carrying her baby on her back. At the hospital, she meets a nurse who listens to her complaint and asks her to remove her igitenge top.

Underneath is a tumor that has been growing unchecked for a year and a half. The mass is three inches in diameter—so large that it has broken through the skin and begun to bleed. Another patient watches the woman’s child while she is biopsied, bandaged, and discharged, to return for her test results in two weeks. Only then—if she’s lucky, if her cancer is not clearly stage four—will a grueling treatment regimen begin.

Such is the confusing, frightening, and exhausting experience of a typical woman suffering from breast cancer in rural Rwanda. Partners In Health—or Inshuti Mu Buzima, as PIH is known locally—and the Ministry of Health have been fighting cancer together for years, even before the 2012 opening of Butaro Cancer Center of Excellence, an oncology clinic offering rare pathology-based diagnosis, chemotherapy, surgery, long-term follow-up and support. Since 2014, PIH has increased its focus on breast cancer, the most common cancer seen at the Center.

The opportunities to improve care are enormous and hinge on timing. Most women currently arrive with late-stage breast cancer, which is difficult or impossible to treat. Early stage breast cancer, on the other hand, is highly treatable. So researchers and clinicians have been working to smooth the long, rocky road to the Center, to get more patients sooner. “This program is our first real push for the early detection of breast cancer,” says Oncology Program Associate Lauren Greenberg. “It’s incredibly exciting.”

People tend to think of cancer as a rich-world problem and in many ways they are correct. A far higher percentage of women in the West end up with breast cancer. In the United States, 753 out of 100,000 women will develop breast cancer in a given five-year period; the corresponding estimate in Rwanda is 54 out of 100,000. But rates in Rwanda seem to be rising. This could be because breast cancer data is getting more accurate or because declines in infectious disease are allowing women to live longer—and die of causes such as cancer.

What’s known for sure is that delays in treatment cause more women to die than should. Between 2012 and 2014, staff from PIH and the Ministry of Health conducted a study that found the median time from breast cancer onset to diagnosis was 15 months, or roughly six times as long as it would be in a country with widespread routine mammograms. The effect is obvious. “So many patients come in with large, painful, fungating cancers,” says Dr. Lydia Pace, an instructor at Brigham and Women’s Hospital in Boston and the Center.

To prevent this, PIH began the current pilot program in 2014. Pace, Cancer Care Nurse Coordinator Vedaste Hategekimana, and colleagues trained community health workers in a handful of locales in the northern Burera District about the basics of breast cancer. “Many in the community took cancer to be a disease that killed a person immediately,” says Hategekimana. So far, they have explained the signs, symptoms, causes, and treatments of breast cancer to 1,100 community health workers.

They also taught nurses at the local health clinics, using a rubber mannequin to practice evaluating symptoms, performing a clinical breast exam, and more.

Lastly, PIH set up a special clinic within the Center to expedite management of breast cancer patients. This month, nine clinicians are mastering a new ultrasound device that will allow them to quickly distinguish between cancerous and non-cancerous breast masses, speeding up treatment and discharge.

Comprehensive results of the program are forthcoming but look promising. Nurses scored an average of 92 percent on their training exams. And community health workers and nurses are sending 10 to 20 patients per week to the Center. The Ministry of Health is of course interested in a nationwide rollout of the program but knows it must be cautious. Rwanda has just two full-time oncologists and must send patients to Uganda for radiation therapy.

“The more you educate people about their health, the more they seek care. And the more they seek care, the more care you have to provide,” says Rwanda Program Officer Emmanuel Kamanzi. “These are the best problems to have.”

No one knows exactly how prevalent breast cancer is among women in Haiti, but clinicians who treat the disease see its toll on a daily basis. They say it is aggressive, often strikes young women, and is well-advanced by the time of diagnosis.

In 2015 alone, 1,600 biopsies were performed on patients visiting the oncology department at University Hospital in Mirebalais, which Partners In Health (known locally as Zanmi Lasante) opened in 2013. Nearly 40 percent of these biopsies were breast-related. Women diagnosed with cancer feel the news like a heavy blow, yet they can take comfort in knowing they will receive the best breast cancer care in the country.

University Hospital is the only facility in Haiti—public or private—where patients get a free CT scan and a pathology report that identifies their specific type of breast cancer. Women who come with early stages of the disease have a better chance of an accurate diagnosis and effective treatment. That isn’t true everywhere in Haiti. There simply is no cancer care in many parts of the country. Where it does exist, patients receive inadequate treatment or can’t afford the high fees charged by private institutions.

Every cancer patient who visits University Hospital meets with Dr. Ruth Damuse, PIH’s oncology program director in Haiti. She started treating cancer in Cange in 2010 and has been working in Mirebalais for the past two years. Although she is the hospital’s sole oncologist, Damuse is supported by a fellow internal medicine doctor, a social worker, a psychologist, and a handful of nurses, many of whom have been trained and mentored to provide basic oncology care, such as administering chemotherapy and managing side effects. She also works closely with Dr. Michelson Padovany, who performs most of the hospital’s cancer-related surgeries.

Patients thought to have breast cancer typically undergo a CT scan and a biopsy. Damuse’s team sends the scans to a network of volunteer radiologists based throughout the United States, while biopsies go to the Dana-Farber Cancer Institute and Brigham and Women’s Hospital for pathology tests.

On Fridays, Damuse and her staff connect via teleconference with PIH’s Boston-based oncology team for what they call tumor boards. Referring to case notes and reports from the volunteer radiologists and pathologists, the group decides on a proper treatment plan for up to 15 patients each week. Damuse and her staff then carry out the plan in Haiti.

Depending on the stage of their disease, patients receive a combination of chemotherapy, surgery, and tamoxifen (a drug used to treat and prevent some types of breast cancer). Some women’s cases are so far advanced that the only real option is to ease their pain through palliative care. Whether they have curable or terminal cancer, all patients are encouraged to participate in support groups at University Hospital, where they comfort each other and find strength for the path ahead.

Read more about cancer care in Haiti here.

Global health has occupied the news this year. In January, the World Health Organization announced an end to Ebola in West Africa, only for a new case to emerge in Sierra Leone the next day. This week, the Zika virus was declared an international public health emergency as it runs rampant in Brazil and spreads to neighboring countries.

Global health experts are not surprised. Partners In Health Co-founder Dr. Paul Farmer is among them. He and 16 others—including university presidents, finance executives, and disease control specialists—forecast in a 130-page report that pandemics are inevitable as new infectious diseases emerge alongside ever-increasing international travel and trade.

The authors, who comprise the Commission on a Global Health Risk Framework for the Future, say the solution is proper investment in countries’ health systems.

This is at the core of PIH’s work. Early during the Ebola crisis, Farmer said the only “formula” to counter Ebola is a “comprehensive model of prevention,” meaning strong, functioning health systems that provide quality care.

The global community is learning this lesson again with the Zika virus. In Brazil, it is spreading where poverty is concentrated. Virus-carrying mosquitos breed in the stagnant water of dirty canals or the dumped garbage of shantytowns. Poor people without access to running water store their own, and are at greater risk of contracting Zika.

According to the commission, the public health community should view infectious diseases as important as other security threats. They recommend spending $4.5 billion per year on helping countries prepare for pandemics, growing funds for emergency responses, and accelerating research and development of drugs, vaccines, and diagnostics for infectious diseases. While a large figure, the commissioners say it’s a wise investment—pandemics could cost the global economy $60 billion a year. A fraction of that could prevent a $6 trillion problem over the next century.

PIH has been investing in the health systems of poor countries for nearly 30 years. And we’re beginning the long road to building robust health systems in West Africa, where we’ve been at the frontlines of the Ebola crisis since September 2014.

We believe this work—building clinics and hospitals, training nurses and doctors, conducting research, and partnering with local governments—will raise the standard of care available to poor communities. It is also the way to prevent debilitating epidemics such as Ebola and Zika in the future.

Cervical cancer is the most common cancer in women in Haiti, and the second leading cause of cancer deaths among the same group, according to the ICO Information Centre on HPV and Cancer, a data clearinghouse.  

This is true in a day and age when cervical cancer can largely be prevented and treated through timely vaccinations and regular gynecological exams. There is no reason that can’t be true in Haiti.

In November, Zanmi Lasante, as Partners In Health is known in Haiti, launched a two-year program that will dramatically increase its capacity to vaccinate young girls and screen and treat women for cervical cancer. Over the next 24 months, staff will vaccinate 20,000 girls in St. Marc, Mirebalais, and Belladère against human papillomavirus (HPV), which causes an infection that has been linked to more than 90 percent of cervical cancer cases worldwide. They will also screen 20,000 more women for cervical cancer in St. Marc and the surrounding area, while boosting efforts to screen and treat women in Mirebalais and Belladère.

Additional staff will be hired and equipment and materials will be purchased to meet increased demand for these gynecological services, most of which will be provided at St. Nicholas Hospital in St. Marc. Pap smears, biopsies, and colposcopy—a procedure used to closely examine the cervix—will also be available for women whose initial tests indicate they may have cancer.

Dr. Jacklin Saint Fleur, an OB-GYN and the director of St. Nicholas Hospital, says there are a number of reasons cervical cancer rates are high in Haiti. Most women don’t have access to basic health care. And those who do often end up at a clinic without adequate staffing, training, and supplies to provide proper care.

The result, says Saint Fleur, is “you have more women who are dying of cervical cancer.” He hopes the new program will help turn the tide.

Scaling up

For years, PIH staff have seen the toll cervical cancer takes on Haitian women and fought back with the tools and training at hand. Through their women’s health program, or Sante Fanm as its known in Kreyol,  staff have vaccinated 2,400 girls against HPV in the Central Plateau. Staff also have screened 10,160 women for abnormal cervical cells and treated 1,277 of them over the past four years, primarily in Cange and Mirebalais through out-patient clinics. Patients with confirmed cervical cancer were referred to University Hospital in Mirebalais for surgery, chemotherapy, or palliative care.

While these efforts have been impressive, Sante Fanm staff knew that more could be done, especially when it came to educating the community about HPV and cervical cancer, and how the two are linked.

That’s where PIH’s accompagnateurs, or community health workers, step into the equation. With this new program, they will be trained to reach out to adolescent girls and women in schools, markets, churches, or homes, where they can talk about the importance of HPV vaccinations and cervical cancer screenings. If young patients decide to get vaccinated, accompagnateurs will also be the ones who ensure that they complete their series of two shots.

Meanwhile, PIH staff at five hospitals and clinics will receive training or refresher courses on how to properly screen for cervical cancer. Research has shown that visual inspection with acetic acid  is the most effective method where resources are limited. It’s a relatively simple procedure in which a doctor or nurse applies vinegar to a woman’s cervix during a pelvic exam. Any abnormal tissue immediately turns white and is visible with the naked eye.

Screening and immediately treating patients is essential in places like Haiti, where most women don’t have access to regular gynecological care, such as annual Pap smears. Even if a woman did, she would have to take her cell sample to a Port-au-Prince laboratory where it could be tested for abnormalities. She would return weeks later, pay to receive the results, then return to her clinic for a follow-up appointment. This process just simply isn’t feasible for the majority of women, who tend to be caregivers, live far from the capital, and survive on less than $2 a day.

Depending on what clinicians see during a screening, they can treat the patient on the spot or refer them to another facility, such as University Hospital in Mirebalais. Treatment can include freezing the abnormal tissue or delicately slicing it away.

In cases were cervical cancer is confirmed, women are referred to facilities like University Hospital, where they undergo surgery or chemotherapy. Radiation is the preferred treatment, but it doesn’t exist anywhere in Haiti, so patients must travel abroad to receive proper care. PIH’s oncology team has accompanied a handful of patients to the Dominican Republic and supported them with housing, food, and transportation during their months-long stays.

Next steps

PIH knows this is a drop in the bucket. Within reach of PIH facilities, there are 325,000 women of reproductive age who should have regular cervical cancer screenings, and 132,000 girls aged 10 to 14 who should receive the HPV vaccine series, according to Dr. Eddy Jonas, an OB-GYN and the director of the Sante Fanm program. That doesn’t take into account the rest of Haiti, where thousands of women don’t have access to care or can’t afford what is available.

With that in mind, Saint Fleur and a network of colleagues are working with the Ministry of Health to make cervical cancer a national priority.

There’s reason to believe he’ll be successful. He already accomplished the same feat in Rwanda, where PIH has worked for the past decade.

Just as Ebola fades from the headlines, another infectious disease, the Zika virus, has captured the world’s attention. Although it’s been around for decades, Zika’s recent arrival in Brazil has made it a hot topic because of its suspected complications for pregnant women. Since May, 1 million cases have been recorded in Brazil, and nearly 4,000 infants have since been born with microcephaly, or an abnormally small head. The association between this condition and Zika in pregnant women is being investigated.

Zika cases have been reported in 23 countries and territories so far, including Haiti and Mexico, where Partners In Health has thousands of staff and serves thousands more patients on a daily basis. There is evidence that Zika may have been in Sierra Leone and Liberia. Much like malaria, cholera, and tuberculosis, Zika most affects those who can least afford to protect themselves from illness.

We spoke with Dr. Joia Mukherjee, PIH’s chief medical officer and a renowned infectious disease expert, about Zika’s origins, the complications it may cause for pregnant women, and why this virus keeps her up at night.

How is the Zika virus transmitted?

It’s transmitted by the bite of the Aedes mosquito, which is the same mosquito that transmits chikungunya and dengue fever. That mosquito is everywhere in the hemisphere, including the southern United States. The northern United States and Canada don’t have the Aedes mosquito, but Florida, Texas, and the Gulf states do.

Eighty percent of people who have Zika appear not to have symptoms. So they’re just sitting there, a mosquito bites them, and the Zika virus lives in the mosquito until they bite another person. Then they transmit the virus to the other person.

Why has it spread so rapidly?

One hypothesis about why it has spread so rapidly in Brazil is that you’ve got a large, mobile population. And that large, mobile population is also leaving Brazil and going everywhere else. So it’s the mosquito itself, but it’s also our own system of air travel that’s spreading it. Brazil is a major socioeconomic power. People are in and out of Brazil, and they don’t even know they’re carrying the virus.

You said 80 percent of those infected are asymptomatic, but what shows up in the other 20 percent?

Generally the symptoms are headaches, fatigue, some joint pain. Maybe a little bit of rash, but it’s very mild. That’s part of the problem. People are well, they’re walking around, they’re working. They feel OK. It lasts a few days, and then they’re fine.

What are complications of the disease?

In other outbreaks outside of Brazil, there were reports of severe illness with Zika, particularly Guillain-Barré syndrome, which is a paralysis that can be associated with a variety of things. But in general, it’s mild.

With the Brazil outbreak hitting 1 million, health professionals started to see case reports of a severe birth defect called microcephaly. It’s a devastating lack of development of the fetal brain in utero. The link between this birth defect and maternal Zika is being investigated.  

A handful of other viral illnesses in pregnant women may cause a constellation of problems, including microcephaly. I suspect there may be other manifestations of Zika, and that microcephaly is really a tip of the iceberg. All of that is being studied now. That’s why it’s so scary to think about in pregnant women contracting the virus. We don’t know if the virus causes these birth defects and, if it does, at what stage of pregnancy this is happening. We don’t know the spectrum of disability or problems that may be linked to Zika.

Is there a vaccine against or treatment for Zika?

There is no vaccine, no treatment. With viral illnesses, if you get better and you don’t get sick again, that immunity or antibody response we can sometimes parlay into a vaccine. That would be the hope for control of this virus. A vaccine is going to be important, and I’m sure people are looking into it. But do we have any vaccines to prevent mosquito-borne illnesses so far? No.

What preventive measures can people take?

They can wear long pants and long sleeves, and apply any kind of insecticide or insect repellant, such as Deet or eucalyptus oil. People who have day jobs indoors with air conditioning and screens on their windows are going to fare better than people who are peasants and market people, which are unfortunately most of our patients.

What about reducing or controlling the population of these virus-transmitting mosquitoes?

There are countries that have embarked on some level of mosquito control, but it’s very complicated. You need roads, you need to drain swamps, you need to have municipal landscaping, cutting brush and large-scale insecticide application—these are very big hurdles.

What precautions is PIH taking to protect its staff and patients?

We’re taking every precaution. PIH is saying that anyone who’s planning to get pregnant or is pregnant cannot travel to a Zika-affected country on PIH business. And we’re strongly encouraging people to actively use birth control so they don’t get pregnant while they’re in a Zika-affected area.  That’s piece one.

Piece two is: What do we do for the 30,000 women we take care of in Haiti who could now be exposed to Zika? Our classic protections against mosquito-borne disease, particularly malaria, are really only effective with night-biting mosquitoes. The mosquitoes that carry malaria are night-biting.

But this mosquito is day-biting. So for peasant farmers, for market women, how are they going to protect themselves? Well, that would be with Deet, the more potent bug repellent, which is not at all widely available. Protective clothing like long pants and long sleeves also helps. Trying to do some vector control—spraying, brush cutting, things like that—is again beyond the control of individual families or communities. The preventive aspect is really challenging.

I’m hoping we can at least figure out a way to disseminate mosquito protection, like Deet. Can we screen pregnant women? Can we follow up with those women who we think might be at risk? We have to really think about how we care for our patients.

There’s almost no good way to protect the population we care about and serve against this. I’m worried about that.

There are a lot of unknowns about Zika. What are some of the questions you have as an infectious disease expert?

One of the things we wonder about is: At what level do you get to “herd immunity?” Chikungunya, for example, ripped through Haiti. After a certain point, enough people get sick and get well again and get some immunity that they don’t get sick. The disease stops being transmitted, because you have to have a human intermediary for the mosquitoes to keep carrying it. At a certain point, you see a tipping point where there’s some level of herd immunity and the epidemic starts to trend down. The question is: What level is that?

We think there is immunity to Zika. When you have more and more people who don’t get sick and clear the virus from their blood, eventually you break the cycle of transmission and your number of cases goes down. This is a normal epidemic curve. As with influenza patients, you get enough immune people that it starts to go away.

Also, if we really think this association is very strong [between Zika infection during pregnancy and microcephaly among newborns], will there be stepped-up efforts for a vaccine? We could vaccinate pregnant women. But a vaccine can only be developed if protective immunity is understood. 

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Q&A with Dr. Louise Ivers: The Zika Virus in Haiti

Partners In Health staff have long seen how poverty can make a person sick—how a crumbling house can increase the likelihood of contracting malaria, for example. Last month, a paper in PLOS Neglected Tropical Diseases quantified how poverty contributed to the Ebola epidemic.

Specifically, the study examined the role that poverty played in spreading the hemorrhagic fever throughout Monrovia, Liberia, in 2014. To do so, five colleagues at Yale University’s Center for Infectious Disease Modeling and Analysis began by establishing criteria to evaluate the wealth of neighborhoods in the capital. (Communities were categorized as relatively rich, for example, if a third of homes had access to latrines.)

They then compiled Ebola case information for more than 300 communities within the city. Lastly, they used statistical modeling to look at the infectious disease’s spread, from person to person, between February and December of 2014.

What did they find? Slums quickly became Ebola hotspots—that turned into hubs of disease. Ebola sufferers living in shanty towns infected 3.5 times as many people as those living in rich areas. And poor people were more likely to “export” the disease to rich neighborhoods.

The study focuses mostly on number crunching but does hint at why poor people passed the disease on more often and farther afield. And it has nothing to do with the people. Slums are, by definition, densely populated, lacking in sanitation and health care facilities, and places people must leave daily to find work—all conditions that increase the spread of an infectious disease such as Ebola.

The takeaway is clear, the authors say. Invest in medical care for Sinkor’s 12th Street, Peace Island, and other rundown neighborhoods in Monrovia. “Our findings suggest that targeting areas of extreme poverty would have the greatest impact,” they write. And don’t just build hospitals. “Focusing on sustainable development in urban slums and other communities of low and middle [income] could significantly reduce the risk of future infectious disease outbreaks.”

Or as we at PIH might say, "Poverty makes people sick; treat both."

There are times when Manoucheca Ketan collapses at the end of a long day, her muscles tired from the strain of running after her triplet daughters. Just over 1 year old, Marian, Michelle, and Tamar are starting to walk and can be a handful for the 35-year-old mother. But she wouldn’t have it any other way.

Ketan came to University Hospital in Mirebalais, Haiti, a 300-bed facility PIH opened in 2013, about halfway through her pregnancy. She knew she was carrying triplets and that two of them were likely conjoined. Dr. Christophe Milien, the hospital’s director of obstetrics and gynecology, confirmed that two of the girls shared a liver.

At left, the ultrasound image revealing that the twins were joined at the abdomen. Dr. Christophe Milien, right, delivered Ketan's triplets.

It was a weighty case for the young hospital, but staff stood up to the challenge. After months of bed rest and specialized care, Ketan delivered the triplets four weeks early by cesarean section in November 2014. None required ventilation, and all were at least 5 pounds. Nearly six months later, the twins were separated during a seven-hour procedure conducted by a national and international team of experts.

The girls’ birth and the conjoined twins’ separation were welcome and unprecedented successes in a country like Haiti, where even basic medical care is a luxury. PIH has proven it doesn’t have to be that way. We’ve been in Haiti for nearly 30 years, after sprouting from a small rural clinic in Cange and spreading to 12 communities across the Central Plateau and Lower Artibonite—two of the country’s poorest regions.

University Hospital is the latest example of that long-term commitment. The facility is home to a host of specialty services, from surgery and pediatrics to physical therapy and obstetrics and gynecology. All were necessary to provide quality care for the triplets.

Our team of doctors and nurses collaborate with visiting clinicians to perform pediatric heart surgery at University Hospital in Mirebalais, Haiti.

Our work in Haiti isn’t done. We’re busy recruiting and training the next generation of specialists, doctors, and nurses who will no doubt perform their own medical miracles. We’ve taken our approach in Haiti and adapted it in other countries around the world—from Peru to Russia, Rwanda to the Navajo Nation—where we work with local governments to make lasting improvements to health care systems.

Ketan is part of PIH’s mission; she recently started teaching mothers how to care for their newborns. She’s an expert, after all—three times over.

Ubaldo Roblero, 34, lived locked inside a shack behind his family home, a prisoner to his diagnosis of schizophrenia. A square hole in the door served as his portal to the world for nearly a decade. Beyond giving him medication, his parents didn’t know how else to respond to his violent spells—that is, until Dr. Luz Valderrama visited.

Valderrama met Roblero her first week in Soledad, a village in rural Chiapas, Mexico, where she’s spending her first year after medical school. She recognized Roblero was reacting poorly to his medication and helped him get to specialized care eight hours away.

Partners In Health started working with Mexico’s Ministry of Health in 2011 to place pasantes—or first-year doctors—like Valderrama in rural clinics in Chiapas. Now 10 clinics have doctors, which significantly improves residents’ access to health care. These young physicians provided 10,470 patient visits in 2012 and about 28,000 in 2015—a nearly 170 percent increase.

Pasantes fill a chronic gap in Mexico’s health care system. Many new doctors prefer placements in urban hospitals or research institutions. But public clinics—the ground floor of the nation’s health care system—are where they’re needed most. These clinics are often inactive, because the government doesn’t assign doctors to the locations or does so temporarily. It’s a pattern rural Chiapanecans have seen often.

PIH changed that. Our unique training program attracts pasantes who are among Mexico’s top medical school graduates. Our supervisors visit them several days each month to provide mentorship and help troubleshoot complex cases. Pasantes also return to our headquarters in Jaltenango for monthly seminars created by Harvard Medical School and accredited by Tecnológico de Monterrey, a top Mexican medical school.

Our staff ensure pasantes have the right tools by keeping clinic pharmacies fully stocked, so people like Roblero can depend on them. Each clinic also has a laptop loaded with an electronic medical record system to track patient visits.

Valderrama, center, visits Roblero, right, at his home and checks his medication.

This support allows pasantes to go the extra mile. Valderrama regularly visits Roblero at home and oversees his treatment. She’s happy to report that he now works in his father’s coffee fields, shares meals with his family, and visits a psychiatrist in the capital of Chiapas. Locked doors are a thing of the past.

“We’re still watching and waiting,” Valderrama says, “but his treatment has gone really well.”

Athanasie Mukamana rises early, walks across the fertile red soil of her town in eastern Rwanda, and knocks on the door of a familiar house before the sun is up.

“Mwaramutse, mwaraye mute,” or “Good morning, how did you sleep?” she greets her neighbor.

Mukamana, 59, is a longtime community health worker—one of 7,200 Partners In Health supports in the three districts we serve. Elected by fellow villagers, she and her colleagues diagnose illnesses that might otherwise go unidentified, such as tuberculosis. They accompany families to the hospital, spread important messages about vaccinations and other health issues, and help patients complete tricky treatment regimens like those for HIV/AIDS.

PIH pays part of their salaries, reducing the amount they need to earn in their primary jobs, and offers advanced trainings. In return, community health workers ensure that everyone can enjoy the benefits of modern medicine.

Today’s pre-dawn visit is, thankfully, routine. Mukamana’s patient, Theresie Yankurise, was sick with HIV and shunned by her family when Mukamana met her in 2005. “I had to take her by the arm and help her walk to the health center,” recalls Mukamana.

But after just a couple weeks of care, Yankurise’s health improved. She married a year later and is now the healthy mother of two boisterous, HIV-free children. Mukamana hands her pills from the hospital, the two chat for a bit, and then she leaves to eat porridge and farm her banana fields.

Mukamana stands in her living room, where she often sees pediatric patients.

Later, Mukamana’s house transforms into something like a pediatric ward. With training provided by PIH, she treats young children with malaria and other diseases and provides regular checkups.

Mukamana uses a tape measure to confirm that a baby isn’t stunted from malnutrition, slides a digital thermometer under another child’s armpit, and listens for the labored breathing that would signal pneumonia in a third.

All of this and more she logs into a handful of ledgers and patient registries, which are then shared with a nearby hospital. The one for HIV patients—a big grid, with check marks for every time a patient takes his or her medication—looks like a star-filled universe. And for good reason.

“I have been a community health worker with PIH since 2005, and all of my patients are alive and well,” Mukamana says.

When PIH nurses and doctors arrived at Maforki Ebola Treatment Unit last fall, the former vocational school in central Sierra Leone was overflowing with critically ill and dying patients.

“It was more of a death ward than a treatment center,” recalls Sierra Leonean Dr. Bailor Barrie, PIH strategic advisor.

In September 2014, we pledged to “go” to West Africa after the presidents of the World Bank, Sierra Leone, and Liberia asked us to join the global response. At the time, experts were predicting that an unchecked Ebola epidemic would infect millions in the region and possibly beyond. Everyone at PIH agreed we had a moral obligation to do our part—not just during the emergency but afterward, when the countries’ decimated health systems could be bolstered.

Dr. Dana Clutter admits a patient to Maforki Ebola Treatment unit in Sierra Leone.

Over the past year, we transported 200 clinicians, conducted hundreds of safety orientations, supported 21 facilities, and delivered tons of critical supplies by shipping container or suitcase. We remain a strong partner with local organizations and the governments of Liberia and Sierra Leone. While fighting Ebola, we hired 2,000 local residents, including 800 Ebola survivors, and supported staff and community health workers. Thanks in large part to the tireless dedication of our international team, we discharged 168 Ebola survivors from care centers.

 “As a global community, the world should have done more, sooner. But PIH has a lot to be proud of,” says Chief of Ebola Response Sheila Davis. “We went where we were needed most, in solidarity.”

And we’re far from done. We are seeking out, accompanying, and screening survivors for serious post-Ebola health complications, such as uveitis, an inflammation of the eye that can lead to blindness if untreated. Staff at remote mobile clinics and the Lunsar Survivor Eye Clinic have already seen most of 5,000 survivors at least once.

As one of the first steps in rebuilding health systems, PIH is leading infrastructure projects, which include a renovation to the J.J. Dossen Hospital in Maryland County, Liberia, and a similar major upgrade to the once-crumbling Government Hospital in Port Loko District, Sierra Leone. We also continue to support and improve care for pregnant women at the Ebola holding unit at Princess Christian Maternity Hospital in Freetown, the primary maternity referral center in Sierra Leone.

We went, and we’re staying.