Dr. Valeria Macías and Moíses “Moí” Mazariegos, a driver and logistics coordinator, were stuck. They idled in a pickup truck on a remote road in rural Chiapas, Mexico, with a cab full of patients and a renowned doctor from Mexico City. Facing them, a stone’s throw away, stood a large group of people who had erected a roadblock of burning tires and a chain barrier to protest its poor maintenance.

Macías and Mazariegos, who both work for Compaňeros En Salud—as Partners In Health is known locally—completely understood the residents’ frustrations, having traveled the rutted and at-times impassable roads dozens of times. But they needed to get their patients to care on the other side of the barricade.

The big city doctor decided to take matters into his own hands. He got out of the truck, introduced himself to the frustrated Chiapanecans, and asked them to move aside. No one budged. Clearly his titles held no pull here, so he slunk back to the pickup.

Mazariegos then tried to break the impasse. He told them he agreed with their protest, but that he worked for a medical nonprofit that was helping people in their communities, mentioning Salvador Urbina as one example. It just so happened that a resident was among the protestors. He vouched for Mazariegos and PIH, praising the work they’d done in his community, and urged the others to let the truck pass.

Within minutes, 26-year-old Mazariegos was back at the wheel driving through the roadblock.

Macías told the story as just one example of how Mazariegos works magic, and not just with people from the driver’s hometown in Jaltenango, Chiapas. “This magic works everywhere,” she says.

Mazariegos started working for PIH in 2012 and quickly became known for his integrity, solid advice, boundless energy, and playful personality. As a driver, he transports medications, supplies, staff, and patients to and from all 10 public clinics in which PIH operates around Chiapas. And as the logistics coordinator, he ensures the smooth operation of Right to Health Care, a referral program that helps connect patients with specialized care at faraway hospitals. He drives patients to their appointments, sits with them while they receive care, and advocates on their behalf whenever necessary.

His PIH colleagues call him a todólogo, or expert in everything. But he’s known by another name among patients in the communities where PIH operates.

“To the people, he’s a doctor, and he’s Dr. Moí,” says Dr. Azucena Espinosa, director of Right to Health Care.

From coffee roaster to caregiver

Before he was Dr. Moí or a todólogo, he was a bean roaster for a small group of coffee producers in rural Chiapas. He never earned an advanced degree, but he certainly knew everything there was to know about coffee. It was what he drank in the morning, what grew in the fields all around him, and what he worked with at least eight hours every day. But after inhaling the dust and smoke from roasting machines for four years, he’d developed a fever and a nasty cough. He needed a doctor, but was afraid of what might be found.

At a mobile health clinic, Mazariegos met a U.S. nurse who recommended he visit a nearby PIH-supported clinic staffed by Mexican and foreign doctors. “’Go see them so that they can review your case and help you get better,’” he remembers her saying.

So Mazariegos did. Dr. Jafet Arrieta, PIH’s director of operations at the time, and Dr. Daniel Palazuelos, PIH's chief strategist in Mexico, examined him and believed he suffered from “coffee lung,” a disease similar to miners’ lung that sometimes plagues workers in coffee processing plants. The only cure was to stop roasting beans, which seemed an impossible prescription to fulfill. They recommended he switch to a different job at the processing plant and that he come back in two weeks for a follow-up appointment.

But before he could ask his supervisor about changing jobs, Mazariegos cut his finger at work and was put on leave until it healed. His health improved during the 20-day break and he immediately told his doctors, who were convinced his illness was linked to coffee roasting. They chatted with him about working at PIH’s office in Jaltenango and, in early 2012, he was hired as the first non-medical employee in Mexico. He was a quick learner and soon was doing much more than driving PIH’s three routes throughout Chiapas.  

Mazariegos’s local connections and deep understanding of the culture and people come in handy in sticky situations. PIH’s executive director in Mexico seeks his advice on questions related to regional politics. First-year doctors, called pasantes, turn to him to understand patients who fail to show up for appointments or to follow tricky drug regimens. Most patients are coffee farmers, which means Mazariegos knows they are poor, are forever linked to their land, and live far from the nearest clinic. He’s often the one encouraging pasantes, who mostly come from large cities in Mexico, to consider patients’ unique situations and not think of them as simply “difficult.” But it goes both ways. He also explains to patients the seemingly mysterious actions of the young doctors.

 “We are considered gringos there,” says Macías, who was among PIH’s first pasantes.

Coffee beans dry in the sun at a processing plant in rural Chiapas, Mexico. (Photo by Rebecca E. Rollins/Partners In Health)

A problem solver

Mazariegos began working with PIH when Macías was halfway through her service year. She had no way of knowing the driver would become like her “right arm” for two years as they built Right to Health Care from the ground up.

It all started with Macías having what she calls a “tumor week.” Patients from miles around flowed through her small clinic in Honduras, Chiapas, almost everyone with an inexplicable mass growing somewhere in their bodies. Many had been living with health problems for months, even years, but never had had access to a doctor like Macías. She could do little beyond refer them to specialized care in a hospital hours away by car, knowing that few—if any—would follow up. Most couldn’t afford the trip. And even if they could, they weren’t accustomed to navigating the Mexican health care system, and were often discriminated against when they did.

Frustrated, she talked to Flores and Arrieta to figure out a way to get patients the specialized care they needed. From those talks sparked Right to Health Care, of which Macías was the founding director. Mazariegos became her constant sidekick.

After she finished her service year, Macías worked with Mazariegos for two years to forge paths through the complex, and sometimes confusing, Mexican health care system. Each patient presented a new problem to solve. One day, they focused on getting chemotherapy for a breast cancer patient. The next day they tracked down a plastic surgeon for a woman with a debilitating physical deformity. Over time, they developed solid connections with hospital staff, nurses, social workers, and specialists in several cities in and around Chiapas who helped usher patients through the system.

Mazariegos was key in forging these relationships. “Without him, this program would not have been possible at all,” Macías says.  

A tireless advocate

Patients rely on him as well. As part of the Right to Health Care team, Mazariegos arrives at their door before dawn to drive to the closest hospital in Tuxtla Gutiérrez, the capital of Chiapas. Along the three-hour drive, they chat and tell stories to pass the time. Sometimes ghost stories slip into the mix. (His colleagues say he has an impressive collection.) Once at the hospital, he goes along to morning and afternoon appointments to ensure doctors are offering patients the best options for care.  

“Moí has an impressive warmth and treats patients like family,” Espinosa says. “It’s really clear in how he acts around them. If one of them becomes seriously ill, he worries a lot.”

Mazariegos works tirelessly and is “on call” even when he’s off duty. People regularly swing by his in-laws’ or his family’s home to ask for help, because they know he has access to good, local doctors. They say they try, but can’t, get care in the Jaltenango hospital. They tell him they need to travel to Tuxtla, Villa Flores, or Tapachula for specialized care, but have no way of getting there. And they ask if he’ll come along for appointments, because they feel lost in the system.

Sometimes, he says, they simply ask: “’What is it I have to do so that PIH doctors in nearby communities can see me?’”

That’s when he used to turn to Macías, and now Espinosa, to plead their cases. “’We need to put this patient on the list,’” Macías remembers him saying about patients with complex medical issues. “Moí has a huge heart.”

Mazariegos is too humble to acknowledge the major role he plays within the Chiapas team. He does know, however, that he loves his job, which he defined simply as “helping without expecting anything in return.”

A constant companion

Espinosa will never forget the time when, as a pasante in Laguna del Cofre, she relied on Mazariegos to get through the most difficult case she’d ever experienced. A woman who was developmentally disabled had had six children, almost all of whom had either died or been taken away from her. Only one daughter remained. The girl was clearly suffering and severely malnourished.

It was Mazariegos, Espinosa says, who tactfully removed all roadblocks once again. He spoke to local authorities about the family’s case to encourage them to act. He visited the mother to explain how giving her child up for foster care was the right thing to do. He found extended family to adopt the young girl. And he was part of the team that got the mother counseling.

 “It was a very difficult, very hard situation that I was not prepared to live through,” Espinosa says. She distinctly remembers the two-hour drive from Laguna to Jaltenango the day they brought the child to live with her extended family. She cried the entire route as Mazariegos drove, silent and calm, beside her. Every now and then, she says, “Moí would look at me and say, ‘Ya, ya, está bien.’”

“’There, there, it’s okay.’”

In the video below, Mazariegos drives the last stretch of a winding road to a public clinic in Reforma, the community closest to PIH headquarters in Jaltenango, Chiapas.

A single book tells the story of tuberculosis in Liberia. The ragged hardcover sits on a shelf in a Ministry of Health office in the capital of Monrovia. In it, hand-drawn charts list patient names, ages, vital signs, contact information, treatment dates.

To those fluent in epidemiology, The National Leprosy and TB Control Program Ledger reads like a horror story. An estimated 22,000 people in Liberia are sick with TB. (Similarly sized Costa Rica has 650 cases.) And only five percent are currently on treatment. Even worse, as featured prominently in the Ledger, 25 of the untreated patients are known to have a nasty, rare, and contagious strain of the respiratory infection known as multidrug-resistant tuberculosis, or MDR-TB.

“In rich countries, if you have one drug-resistant patient not on treatment, there’s a national outcry,” says PIH Policy and Partnerships Director Cate Oswald. “Twenty-five patients was a huge emergency.”

At the urging of their national counterparts, Oswald and Dr. Maxo Luma, also a PIH director in Liberia, set out to do something about it. At 6 a.m. on a Wednesday not long ago, they climbed into a truck, buckled up, and steered for downtown Monrovia, determined to find and treat as many of those 25 MDR-TB patients as possible. 

Liberia’s TB program completely fell apart.

The root cause of the TB disaster was straightforward: Poverty had made the health care system dangerously brittle. Able to spend less than $50 on each citizen’s health care annually, Liberia simply couldn’t stand up to the Ebola epidemic that hit in the summer of 2014. Hospitals had to devote virtually all of their meager resources to combatting the hemorrhagic fever. Equipment broke and was never repaired. Drugs weren’t ordered. Ebola killed some 10 percent of all local doctors and nurses. “Liberia’s TB program completely fell apart because of the Ebola epidemic,” says PIH TB expert Michael Rich.

The collateral damage was enormous. Clinics such as Monrovia’s TB Annex, where a single doctor cared for the nation’s MDR-TB patients, fell into disrepair. Many patients simply gave up on treatment. When PIH staff found 14-year-old Salomé Wesseh, for example, she was wasting away on the floor of her house, her left lung almost completely gone, her cough having accidentally infected her sister, who is 3.

The alternative, trying to find treatment, was no better. Legal TB drugs were in short supply during the year-long Ebola epidemic. Those who bought rifampin and other TB medications at black-market pharmacies could rarely get their hands on more than a dozen tablets. Instead of treating their TB, they ended up increasing their resistance to medication, transforming their TB into MDR-TB, a strain whose treatment is long (up to two years), complicated (requiring daily injections of toxic drugs), and expensive (around $5,000). 

Everyone knew it wasn’t going to be easy.

After winding down its response to the Ebola emergency in June, PIH promptly committed to offering technical and material support to the government’s strategic plan for TB. PIH is currently helping launch an electronic medical record system (which will replace the Ledger), updating treatment guidelines, bolstering care in rural counties in the southeast, and more.

Returning MDR-TB patients to treatment was an urgent need, but everyone knew it wasn’t going to be easy. A simple radio advertisement (“If you have MDR-TB, come on back to the clinic, we promise that murderous Ebola epidemic is over”) was unlikely to attract patients. And calling them was out of the question; the Ledger listed few working phone numbers. Mailing letters was also a non-starter. Most home addresses were listed as simply “Monrovia.”

So Luma and Oswald did what they’d both done while working with PIH in rural Haiti: They went to find patients one by one.

Kamara needed no GPS to find any road in the city.

That first day, they drove around the city—population 1 million—for 13 hours. Big tropical clouds gathered, dumped rain, and broke apart as quickly as they had formed. In lieu of a clue, Oswald and Luma had Varny Kamara, an expert PIH driver, and Nanejae Nagbe, an unflappable physician’s assistant from the Ministry of Health National Leprosy and TB Control Program. Kamara needed no GPS to find any road in the city. Nagbe chatted up everyone from passing motorcyclists to grandfathers, careful not to say anything that would betray patient confidentiality.

“We’re from the clinic and we’re looking for so and so. Do you know this person?” he’d ask.

The best lead often proved to be the name of the original referring clinic, which was sometimes recorded in the Ledger and suggested the neighborhood where the patient might have lived a year or two earlier. Once in Congo Town or Bushrod Island, West Point or ELWA, they could talk with people who might know the patient’s whereabouts.

It was truly a success.

People usually didn’t. But they knew a community leader. Or a phone number. Or some other tip. Or they’d jump in the truck and offer directions to someone who might. “It felt like we were part of a Where’s Waldo book,” says Oswald.

After three long days, they had found and begun treating three patients. John Coleman, a high school student, was typical. Getting him back on treatment also protected 17 relatives who shared his three-bedroom home.

“Finding three patients in three days was truly a success,” says Luma.

Since then, six other patients have been located and returned to treatment, but the search for the rest of the 25 has been put on hold, while the TB Annex undergoes the repairs needed to offer dignified care. PIH and Ministry of Health staff will resume the search early in the new year.

Today we pause to remember the devastating earthquake Haiti experienced six years ago, on Jan. 12, 2010. We remember those who lost their lives, and we stand with our colleagues who are still grieving the loss of their family members and friends. 

"Six years after the sadness and the tragedy of the earthquake, the heroic Haitian people continue to heal and to rebuild. Their great courage is a beacon and their remarkable resilience is an inspiration," said Dr. Gary Gottlieb, chief executive officer of Partners In Health. "We are privileged to walk in their shadows and to be guided by their brilliance and their passion. Together, we must create and provide the superb health care services that every Haitian covets and that we all deserve."

With the help of our staff, partners, and supporters, Partners In Health will continue to work toward building a healthier Haiti.

We invite you to learn more.  

Dr. Alexandre Widner, Partners In Health’s border health activities coordinator in Haiti, has worked along the border of Haiti and the Dominican Republic since 2008. In the essay below, he comments on the current political and medical crisis unfolding in that region, and on how PIH is responding to the situation.

The border that divides Haiti and the Dominican Republic is about 340 kilometers (about 210 miles). After graduating as a doctor in 2008, I had the opportunity to collaborate for several years in improving the health of my Haitian compatriots while working in rural health centers, on empowerment activities for women, and in food security along the border. About three years ago, I began working with Zanmi Lasante, as Partners In Health is known in Haiti. PIH was co-founded by Dr. Paul Farmer in Haiti approximately three decades ago to offer high-quality health care and to fight for social justice, with a preferential option for the poor. Today PIH exists in many countries around the world, including Peru, Mexico, the United States, Malawi, Lesotho, Rwanda, and Russia.

Despite many signs of brotherhood between Haiti and the Dominican Republic, which share the island of Hispaniola, the binational relationship is worsening each day due to a high peak of migratory tension. According to various sources, more than 500,000 Haitians live in the Dominican Republic, more than 75 percent of whom lack identifying documents (a passport or identity card), which leads to constant marginalization, stigmatization, and discrimination—including torture by some authorities along the border. To make matters worse, on September 23, 2013, the Dominican Republic’s Constitutional Tribunal published Law TC 168-13 with a retroactive clause that eliminates the citizenship of thousands of Dominicans of Haitian descent who have lived in the country since 1929.

It’s estimated that more than 65,000 people were deported or forced to leave the country.

Facing this human rights violation, Haiti received support from several countries and organizations in the region and from within the island itself. Meanwhile, President Danilo Medina and his administration in the Dominican Republic enacted a Plan for Standardization of Foreigners that was fueled by profound anti-Haitian sentiment. Following this action, there was a transition period where thousands of migrants were forced to return to their country of origin out of fear and the perceived threat of torture, loss, arson, and theft at the hands of Dominicans.

The government of Haitian President Michel Martelly proved its inability or lack of interest in responding to this situation that threatens global peace, despite the massive deportation its sister nation is contemplating. Through its Haitian Identification Program, the government began delivering identity documents to Haitian migrants who are in the Dominican Republic, even though it can’t deliver the same to its citizens who reside in the country.

Since the second half of last year, Haiti has been focused on completing three rounds of elections to replace an entire class of politicians. These elections have been delayed by more than four years in a country where corruption, violence, and social injustice are increasing.

Despite the fact that mass deportation would expand the humanitarian crisis in Haiti on top of the impact of the major 2010 earthquake, the Dominican migration office started in August the expulsion of thousands of Haitian migrants and Dominicans of Haitian descent (who are now stateless) out of profound xenophobia. Since then it’s estimated that more than 65,000 people were deported or forced to leave the country, causing an alarming situation at several unofficial and official border points, including Ouanaminthe, Belladère, Malpasse, and Anse a Pitres. In Anse a Pitres, the repatriated and stateless live in open-air camps at high risk of extreme poverty, child malnutrition, juvenile delinquency, and an increase in death due to cholera, malnutrition, and malaria—among other diseases.

There’s a significant increase in the number of Haitian families who come for consultations.

In September, Zanmi Lasante signed an agreement with Action and Solidarity Against Poverty, a charismatic organization based in Cap Haitien that supplies us with food, clothing, shoes, and laundry detergent—among other things—to support the repatriated. We’ve established alliances with organizations that are involved directly in migration issues, such as Support Group for Refugees and the Repatriated and the National Office of Immigration, to deliver these goods.

Right now there’s a significant increase in the number of Haitian families who come for consultations. There was a more than 100 percent increase in September at health centers run by the Ministry of Public Health, which are PIH-supported, including Belladère Hospital, Baptiste, and Roy Sec. These clinics are located along the border with the Dominican Republic, where crossing without documents today represents an imminent risk to immigrants’ lives.

Clinicians are providing care to patients primarily for infectious diseases like HIV, tuberculosis, and cholera and for children under 5 suffering from moderate or severe malnutrition. The number of hospital births has increased considerably thanks to a dynamic collaboration between Zanmi Lasante and the Ministry of Health in these remote communities.

Mixed families (Dominican-Haitian) have been immediate victims of the deteriorating binational relationship. Thousands of fathers and mothers are forced to make harmful decisions (be it divorce, forced deportation of a family member, or repatriation), which result in an increase in the number of orphaned children, a break in the family bond, and the loss of social security for those who worked in Dominican cane fields for many years.

Zanmi Lasante’s psychosocial team is supporting many women (who are victims of the inevitable separation from their Dominican spouses) through the purchase of school materials for children born in the Dominican Republic and through small loans they use to start businesses in the Central Plateau’s border zone near Belladère.

What is the future of Santo Domingo and Port-au-Prince? Are Presidents Medina and Martelly whistling in the wind about peace on the island of Hispaniola?

While we recognize the right of the Dominican Republic as a sovereign nation to pass laws or create fair and inclusive immigration policies within its territory, we demand justice for the flagrant violation of human rights executed by a brother country towards thousands of stateless Dominican brothers and sisters. Together we shout: “No to violence, no to racism!”

Long live solidarity between the people!

It’s been a busy year, and Partners In Health has had many stories to tell. We helped quash the Ebola epidemic in West Africa, treated multidrug-resistant tuberculosis in Russia, made house calls in Mexico and Malawi, and trained the next generation of clinicians in Haiti and Rwanda. Here’s a snapshot of some of the year's best, and most trying, moments.

“I’ll clean house, chop wood, haul coal if I have to.”
Betty J. John, a PIH community health representative in the Navajo Nation  

“When you see people dying, you want to do everything you can.”
Dr. Louise C. Ivers, PIH’s senior health and policy adviser, on why she pressed for an ambitious, and controversial, cholera vaccine program in Haiti 

“It’s the right thing to do.”
Karin Huster, on why she decided to volunteer for PIH as a nurse in an Ebola Treatment Unit in Sierra Leone   

“In the 30 years that I've been involved in the provision of health care services to the poor and marginalized, I can think of no more dramatic example of a turnaround than that achieved in Rwanda.”
PIH Co-founder Dr. Paul Farmer 

“The truth is that in most of the places that we work, we are either the first doctors or the first functional doctors.”
Dr. Hugo Flores, PIH’s executive director in Mexico  

“I asked them, ‘Do you believe in God?’ One said, ‘I do believe in God. I just believe that Satan is stronger.' And I had to agree. I don’t know how anyone can deserve this—war and then Ebola, torture on torture.”
Dr. Luanne Freer, a PIH volunteer recalling a conversation with Sierra Leonean colleagues working with her in an Ebola Treatment Unit

“The guarantee I can give you is that we're going to look for help for you so that we can keep these babies alive.”
Dr. Christophe Milien, PIH’s director of obstetrics and gynecology at University Hospital in Mirebalais, Haiti, speaking to his patient who was pregnant with triplets, two of whom were conjoined at the abdomen

“I’m basically leaving the best job in the world for the best job in the world.”
Devin Platt, who quit his position as a nurse in Oregon to work for PIH at a hospital in Sierra Leone

“The other students could not believe that people from a rural part of Liberia were going to sit the nursing exam.”
Malcom Smith, one of the first public university students in decades to earn a nursing license in Liberia, who was tutored by PIH clinicians  

“I only did what I had to do—fight as much as I could for the life of a child.”
Dr. Azucena Espinosa, a PIH social service physician working in Chiapas, Mexico, who helped a boy get treatment for and overcome a severe case of Hodgkin Lymphoma 

Musa Sillah, a nurse who volunteered for PIH in Sierra Leone, puts on personal protective equipment before entering the Maforki Ebola Treatment Unit. Photo by Rebecca E. Rollins/Partners In Health

“My coworker is stunned. I say, ‘She’s dead.’ But it doesn't register. ‘No, I have to change her diaper,’ he says.”
Musa Sillah, a nurse who volunteered for PIH in an Ebola Treatment Unit in Sierra Leone, on a conversation he had with a coworker following a young patient’s death

“My motto is 'whatever it takes.' I have learned from Partners In Health to do whatever it takes in order to save lives and restore health.”
Cyprien Safari, PIH’s medical stock coordinator in Rwanda 

“She was like a guardian angel. She was always by my side.”
Dayana,* a mother living with HIV in Peru, referring to her PIH-affiliated peer sponsor

“It’s been so horrible to hear that every single family has one child that has died. They’ll say, ‘He died of fever when he was born.’”
Dr. Karla Sanchez, a PIH social service physician working in Chiapas, Mexico 

"We need hundreds of these houses, not one, and that's part of the plan. We're writing the manual of operation, the recipe, and will help the Ministry of Health duplicate it and scale up."
Jerome Galea, PIH’s deputy director in Peru, on establishing the first safe house in Lima for women living with schizophrenia 

“Last year, 9 million people became sick with TB. That's more than the entire population of New York City falling ill with a disease that we have largely been able to cure since 1947.”
Dr. Salmaan Keshavjee, PIH’s senior TB specialist and director of Harvard Medical School's Center for Global Health Delivery-Dubai

“The Haitian society was hit from the heart. We had to do something. Everyone was afraid of seeing the burden of mental health increase along the way.”
Père Eddy Eustache, PIH’s director of the mental health program in Haiti, on the country's massive 2010 earthquake   

“I sat for an hour with them, talking about TB and how they could protect themselves. No one had explained it to them. They were very grateful, because they lived in a remote hillside, and no one else came to see them.”
Dr. Leonid Lecca, PIH's executive director in Peru 

Transportation by horse or donkey, perhaps not even possible for a patient like Tebello, would cost the equivalent of $20-$30 U.S. Instead, men from the village took turns carrying her over the rugged hillsides.
Merida Carmona, PIH's Lesotho program associate, about a mother whom PIH helped get to a hospital, where she delivered her son by cesarean section

“I came to understand that if a patient did not want to undergo treatment, it was society’s problem—our problem. I learned to investigate not only patients’ medical conditions, but also their personal issues that could influence their recovery.”
Nataliya Zemlyanaya, PIH’s program manager in Tomsk, Russia

“A typical day starts at 7:30 a.m., when I arrive at the clinic with our team of two nurses and a pharmacy technician. Dozens of patients will be waiting for us, with some having walked from as far as 20 kilometers away.”
Joe Lusaka, PIH’s clinical officer in Malawi, who led an emergency response team during devastating floods in February 

“The first time I met him, I didn’t know 'Farmer' was his real surname. We spent our time planting flowers and digging a fish pond at the health center. After a couple of months, we had an amazing garden around the health center. It became a relaxing place for patients, staff, and local community members, and a favorite area for wedding photos. I thought he was an actual farmer.”
Anatole Manzi, PIH’s director of training, on meeting Dr. Paul Farmer  

“There were days when I would wake up on a horrible mattress, under a mosquito net, and say, ‘What am I doing here?’ But it wasn’t regret. It was just surreal sometimes to wake up in the middle of a forest, in a teeny house, with bucket showers and no Internet, and a terrible phone shared by the entire community. “Even though there was a lot of work, it was by far the best experience of my medical training.”
Dr. Eduardo "Lalo" Peters, a PIH social service physician working in Chiapas, Mexico. 

As has become tradition, we're welcoming the new year by looking back at some of our favorite images from the last one. The photos below capture the ambitions of Partners In Health, the dedication of staff members, and the inspiring dignity and resiliency of our patients. (Plus, a beautiful horse.) We hope you enjoy them. Thank you to everyone who trusted us to work on their behalf in 2015. Best wishes to all for a healthy, happy 2016.

Angelique Nikuzwe* (left), a teenager with four siblings, holds the door for her youngest sister in a house that PIH helped secure for the family in Rwinkwavu, Rwanda.
(Photo by Cecille Joan Avila / Partners In Health)

Community health workers attend a training session on HIV accompaniment in Kirehe, Rwanda.
(Photo by Cecille Joan Avila / Partners In Health)

Nurse Leoncie Mukanzabikeshimana (center), a PIH women's health mentor in Rwanda, visits two mothers who gave birth the night before in Rusumo Health Center. 
(Photo by Cecille Joan Avila / Partners In Health)

One-year-old Shukulu Nibogore sits on her mother’s lap while Athanasie Mukamana, a PIH community health worker in Rwanda since 2005, measures her arm for signs of malnutrition.
(Photo by Cecille Joan Avila / Partners In Health)

Katya Smirnova* (left) receives antiretroviral therapy pills from PIH Nurse Natalya Shtrevenskaya in her home in Tomsk, Russia.
(Photo by Elena Devyashina for Partners In Health)

An 11-year-old boy undergoes heart surgery for a congenital heart defect at PIH-supported University Hospital in Mirebalais, Haiti. 
(Photo by Rebecca E. Rollins / Partners In Health)

During a training, village health worker Eneless Manyamba practices a presentation on the importance of prenatal care in Mwanza, Malawi.
(Photo by Jeanel Drake / Partners In Health)

Nurse Musa Sillah, who grew up in Sierra Leone and returned to the country to help PIH combat the Ebola epidemic, dons personal protective equipment at a treatment unit.
(Photo by Rebecca E. Rollins / Partners In Health)

An Ebola patient in Sierra Leone receives a cup of rehydration solution. 
(Photo by Rebecca E. Rollins / Partners In Health)

Syringes are filled with antibiotics in an Ebola treatment unit in Sierra Leone. 
(Photo by Rebecca E. Rollins / Partners In Health)

As a recruiter for the PIH Survivors Association, Emoze “Moh Moh” Kamara searches Freetown, Sierra Leone, for other survivors and helps them find employment. 
(Photo by Rebecca E. Rollins / Partners In Health)

Yabom Koroma, a mother who survived Ebola at a PIH clinic, walks to meet a friend near her home in Freetown, Sierra Leone. 
(Photo by Rebecca E. Rollins / Partners In Health)

A wild horse grazes at the northern edge of the Navajo Nation, where a PIH program is increasing the amount of wholesome food available to families.
(Photo by Cecille Joan Avila / Partners In Health)

PIH Community Health Representative Betty J. John (left) checks up on Marie Kaya, a fellow member of the Navajo Nation.
(Photo by Cecille Joan Avila / Partners In Health)

Conjoined twins Marian (left) and Michelle, whom PIH staff helped to deliver by cesarean section, rest on their mother’s lap in Mirebalais, Haiti, in April. 
(Photo by Rebecca E. Rollins / Partners In Health)

The twins are prepped before a successful separation surgery in PIH’s University Hospital in Mirebalais, Haiti, in May. 
(Photo by Rebecca E. Rollins / Partners In Health)

The sun rises over Chiapas, Mexico, where PIH supports 10 clinics. 
(Photo by Cecille Joan Avila / Partners In Health)

A PIH community health worker leads a health talk in Liberia. 
(Photo by Rebecca E. Rollins / Partners In Health)

Fresh paint and new doors kick off PIH’s renovations of the J.J. Dossen Hospital in Maryland County, Liberia.
(Photo by Rebecca E. Rollins / Partners In Health)

Makutloano Mochaph (right), a PIH village health worker in Lesotho, visits Motsamai Macheli to deliver his medication for multidrug-resistant tuberculosis, as she does daily.
(Photo by Merida Carmona / Partners In Health)

Janeth Santa Cruz (left), coordinator of PIH’s social protection program in Peru, visits the future home of Rosa Antay Morales (right), a program participant whose family has battled tuberculosis.
(Photo by William Castro Rodriguez / Socios En Salud)

*Some patient names have been changed

Lulls don’t exist in the maternity ward at University Hospital in Mirebalais, Haiti. On average, 270 women give birth there each month. The pace can be intense for the ward’s small group of nurses and doctors, who provide 24-hour staffing to ensure the health and safety of mothers and their newborns. It’s an exhausting—yet rewarding—job and soon there will be more people doing it.

Zanmi Lasante, as Partners In Health is known in Haiti, began training obstetrics and gynecology residents at University Hospital in 2014. Four residents made up the first class last fall, and another four started this year. The additional expertise means more women will receive high-quality care and the hospital’s current staff will be less strained. Plus, another generation of young doctors will gain the training they deserve to thrive in their profession.

These residents join a growing number of young doctors training at University Hospital in other specialties, including emergency medicine, pediatrics, surgery, and internal medicine.

“This is a good opportunity to have a new generation of health care providers,” says Dr. Jean-Claude Ulysse, who directs the OB-GYN residency. He hopes his residents will finish the program solidly trained and inspired to remain in Haiti to serve those most in need.

The hospital’s four-year program focuses on both academics and hands-on experience. Residents take courses, attend lectures, and review cases every week. And each morning they go on rounds with attending physicians to observe patients, ask questions, and provide their own real-time diagnoses. As they gain experience, they begin providing care alongside the hospitals’ veteran mentors.

Competition for admission is fierce, and not just because of the program’s quality instruction. “This is the only program in Haiti where the administration provides food, housing, and financial support twice the amount offered by the state,” Ulysse says.

Eventually Ulysse would like to increase the number of OB-GYN residents he trains each year to meet the high demand for their services at Mirebalais and across the country. But for now, he’s content knowing his program is producing competent physicians who practice “the art of medicine” with a strong foundation in ethics and a priority for the poor.

Meet University Hospital’s first class of OB/GYN residents:

Name: Volf Ricardo Gaby

Hometown: Marchand Dessalines

Age: 27

Why did you choose to become an OB-GYN?

I knew I wanted to be an OB-GYN before I finished medical school.

My mother had three children, all by cesarean section, and during the birth of her third child, she passed away. I was in my fourth year of medical school when an organization came and did a training. It was then that I realized what had happened to my mother during her cesarean section. This made me feel compelled to become an OB-GYN to help reduce maternal mortality.

Has there been a particularly memorable patient so far?

Yes, she was in post-op when I met her. She had gone to a midwife, spent too much time in labor, and developed an infection. She lost her baby. She came to the hospital, and we treated her infection. This patient stayed in my mind, because it was my responsibility to take care of her.

Name: Jean Joel Saint Hubert

Hometown: Aquin

Age: 28

Did you always know you were going to be a doctor?

Yes, I knew since I was 16 years old. My aunt was a midwife and was always delivering babies. There was a time when she was by herself, her children weren’t there, and she called me to help with a birth. There were two people in labor, and she told me to stay in the room, watch the patient, and call her when I saw the baby’s head. I saw the head and called her, but she couldn’t come because she was with the other patient. 

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

How do you like the residency program?

After the construction of the hospital, I always went and looked at PIH’s website. I saw information about the hospital and decided to go to Mirebalais because they have many programs that train Haitian doctors. I attended an orientation that detailed Zanmi Lasante’s story, and physicians talked about how we have to consider patients and give them attention. I like Zanmi Lasante’s philosophy; I’m not just a doctor, I connect with my patients.

Name: James Saint Surin

Hometown: Léogâne

Age: 29

Did you always know you wanted to be a doctor?

I had a different plan, but things changed and then I wanted to become a doctor. I went to a mobile clinic and saw that there weren’t enough doctors and medicine for the patients. That’s when I knew I wanted to be a doctor.

Why did you choose to specialize as an OB-GYN?

I was in my sixth year of medical school and was doing clinical rotations when I realized that I like OB-GYN as a specialty. Delivering babies is a good thing. You are always in contact with patients. I also like that OB-GYN has a surgical element to it in that you get to perform cesarean sections.

Rubens Ulysse (not pictured) is also among the first class of OB-GYN residents at University Hospital.

No one would say a hospital psychiatric ward is a cozy place to call home. Yet in Peru, many patients who have been stabilized after a schizophrenia diagnosis have no choice but to remain institutionalized, largely because they have nowhere to go and lack the skills they need to live independently.

Valeria Ruiz* was one such patient. In October 2014, the 21-year-old was diagnosed with paranoid schizophrenia and obsessive compulsive disorder and admitted to a hospital in Lima, Peru’s capital. By July, she no longer required hospitalization, but her mother—who also was hospitalized for mental illness—was in no shape to take care of her. Her father had abandoned her long ago.

Thanks to a new program sponsored by Socios En Salud, as Partners In Health is called in Peru, Ruiz moved to a safe house for women diagnosed with schizophrenia. She lives there with seven other women who are medically stable, but who have been socially abandoned. Community health supervisors teach Ruiz and other residents how to perform everyday activities, interact with each other, and navigate the outside world with the hope of someday living independently.

PIH’s safe house is the first of its kind in Lima and could serve as an example for other countries facing a similar dilemma. According to the World Health Organization, mental disorders account for 14 percent of the global burden of disease. Most of the people affected—75 percent of whom live in low- and middle-income countries—do not have access to the treatment they need.

That's about to change. Several years ago, Peru's Ministry of health began tackling the nation's mental health care gap—or the number of people who need services, but can't access them. Ministry staff turned for advice to the World Health Organization, which had published a guide in 2010 that helps countries weave mental health care into the services offered by neighborhood clinics, the ground floor of the health care system.

In Peru, most mental health care takes place in three hospitals in Lima. Primary care doctors tackle a range of diseases, but often aren’t trained to identify mental disorders, such as depression and schizophrenia. Up until recently, they also weren’t allowed to prescribe psychotropic medication. This means most patients seeking mental health services receive inadequate care, or none at all.  

While the ministry revamped its approach to mental health care, Congress passed key legislation to push along the issue. The law now states that mental health is a basic right, and that primary care physicians can prescribe psychotropic drugs.

All this was in motion when Jerome Galea, deputy director of PIH in Peru, and Giuseppe (Bepi) Raviola, PIH’s cross-site mental health team leader, met with Peru’s mental health coordinator early last year. They were on a mission. They’d seen how patients living with multidrug-resistant tuberculosis or HIV struggled with depression and psychotic side effects from grueling drug regimens. While they knew PIH support groups had helped patients manage for decades, they wanted a more sustainable solution.

“To our great surprise, we learned that Peru was right on the cusp of a national level of implementing mental health services at a primary care level,” Galea says. “The stars aligned.”

In early 2015, the ministry began training Lima’s primary care physicians and nurses to identify mental disorders so patients can be properly diagnosed and receive care in any one of the capital’s 350 primary care clinics. That was the first step. The next involves extending the same coverage to all of Peru’s 7,000 community clinics. Outpatient community health centers will also be established as specialized facilities for patients who need a higher level of care, but do not require hospitalization.

The ministry requested Galea and Raviola’s help in one area: They didn’t know what to do with chronically ill patients who were ready to transition from hospitals to homes. These women and men—who likely number in the thousands, if they were all identified and treated throughout the country—no longer required the intensive (and expensive) care of a hospital. Yet they couldn’t function as adults capable of completing household tasks or holding down a job.

'We need hundreds of these houses, not one, and that’s part of the plan'

The ministry had a solution, but needed PIH’s help to carry it out. In June, PIH opened Lima’s first safe house, or hogar protegido, for women living with schizophrenia. Peru’s National Institute of Mental Health chose four women from those in its care, aged 18 to 65, to be the home’s first residents. Four more women have since moved in. It’s a small step, but everyone involved is carefully measuring the house’s success with an eye to further expansion.

“We need hundreds of these houses, not one, and that’s part of the plan,” Galea says. “We’re writing the manual of operation, the recipe, and will help the Ministry of Health duplicate it and scale up.”

Six community health supervisors take shifts so the safe house has 24-hour supervision. They teach the women how to complete basic household chores—such as clean, make a bed, and do laundry. Together they go on errands around the neighborhood. They buy bread. They go to the library. And they attend community classes to acquire new skills to enter the work force. While these accomplishments seem small, they are significant.

Rosa Cadena has seen the women grow in their new environment. "My job is to guide them," the supervisor says, "to try to help the women return to a normal life."

One resident has shown marked improvement. When she arrived, she hardly spoke and wouldn't unpack her bags or sit on furniture. Now she helps with chores, sings, and doesn't shy away from a friendly touch.

The supervisors “don’t just make sure residents take their medication,” says Kelly Tamo, a psychologist and PIH’s mental health coordinator in Peru. “Their role facilitates the transition to life outside of a hospital.”

Ruiz, too, has blossomed. She says she feels “more lucid, more normal” since moving into the safe house. There’s a childlike quality, an earnestness about her. Her face is without expression, her voice flat, as she shares her personal victories: bathing herself, cleaning her bedroom, going to church on Sundays.

Someday Ruiz hopes to take classes toward a career. But for now, she’s content transforming empty toilet paper rolls into elaborately designed pencil holders, which she sells in a nearby market. She takes money she earns to her mother, whom she still visits in the hospital.

“When I was a little girl, I learned how to make them from a T.V. show,” she says. “I’ve been practicing ever since.”

*Name has been changed 

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Every year for the past two decades, the World Health Organization has released a Global Tuberculosis Report and it has passed fairly directly into obscurity. This year was different. Published on Wednesday, the 204-page survey of the epidemic was covered by newspapers ranging from The Wall Street Journal to The Times of India. The WHO itself described the moment as a “watershed.”

Why? Largely because improved estimates of TB’s prevalence suggest that TB is the new leader in a ghastly race. The number of people who die from the infectious respiratory disease now outnumber those who die of AIDS. Last year HIV/AIDS killed 1.2 million people, while Mycobacterium tuberculosis was responsible for the death of 1.5 million people.

The WHO emphasizes the positives. As is to be expected from a bureaucracy charged with building consensus and setting standards, they chose to focus on the fact that the death rate from tuberculosis is half of what it was in 1990. Despite low funding, the world has made measured, albeit uneven, progress. “The report shows that TB control has had a tremendous impact in terms of lives saved and patients cured,” WHO Director-General Margaret Chan said in a press release accompanying the report.

Partners In Health’s TB experts view it another way. They are of course pleased to hear of lives saved, but with most TB cases curable since 1947, they find any death a moral outrage, not to mention 1.5 million deaths. Last year, as many people died from TB as from a decade of fighting in the Vietnam War.

They are also impatient with the progress. “Although tuberculosis incidence has declined over the past 25 years, it has done so at a glacial pace of about 1.65 percent annually,” writes Dr. Salmaan Keshavjee, senior TB specialist at PIH and director of Harvard Medical School’s Center for Global Health Delivery-Dubai. “At this rate, it will take another two centuries to eliminate the disease.”

Lastly, while they applaud the WHO for pointing out dramatic shortfalls in funding, they stress that finances are only part of the problem. The end of TB will come not from calls that it be “controlled,” as have long been popular, but from demands that the highly contagious disease be eradicated. “The history of TB is the failed policy of ‘good enough,’” says Dr. Joia Mukherjee, PIH’s chief medical officer.

PIH has been fighting TB for decades, beginning with a successful program battling drug-resistant TB in the slums of Peru in 1996. Currently, we’re supporting patients, improving treatment protocols, and shaping national policy everywhere from Russia to Lesotho. This year, we began a four-year, 15-country program with Medecins Sans Frontieres and Interactive Research and Development to find better treatments for drug-resistant TB. This week, PIH TB expert Dr. Michael Rich is collaborating with the government of Liberia and Keshavjee published “Stopping the body count: a comprehensive approach to move towards zero tuberculosis deaths” in The Lancet. The WHO report is indeed a watershed moment—and a call to do better.

Dr. Joia Mukherjee says her retirement plan involves buying a home in Cap-Haïtien, Haiti, with Père Eddy, the ordained Catholic priest and psychologist who favors tropical-print shirts and directs Partners In Health’s mental health program in Haiti. Her golden years will be filled basking in the warm Caribbean sun and his presence.

“He is the single most therapeutic person on Earth,” says Mukherjee, Partners In Health’s chief medical officer. “If you’re just with him, you feel better. He doesn’t even have to do any of his ‘shrink-y’ things on you.”

Judging by the number of PIH staff who express a similar sentiment, they’d be wise to find a big house. Eddy Eustache, or Père Eddy as he’s most often called, is Haiti’s patron saint of mental health. In the decade since 2005, when PIH (known locally as Zanmi Lasante) hired him as its first psychologist in Haiti, he has trained and expanded his mental health team to include 50 social workers and 13 psychologists who work in 12 clinics across the region. With guidance from PIH’s cross-site mental health team, led by Dr. Giuseppe (Bepi) Raviola, Père Eddy and his team have successfully delivered psychological care in some of the most impoverished regions of the country.

Although Père Eddy maintains a low profile, his influence is global. For years, he traveled to Rwanda to care for PIH staff and victims of the 1994 genocide. He has spoken at international conferences from Toronto to Tanzania about PIH’s innovative, community-based model for mental health care. This month alone he hopped from Geneva to Beijing for conferences, brainstorming new ways to deliver mental health services on a global scale.

His is essential work. The World Health Organization estimates that 14 percent of the global burden of disease is attributed to mental health disorders, yet most people affected (75 percent in low-income countries) don’t have access to the treatment they need.

Raviola has nothing but praise for Père Eddy.

“He’s always inspired me as a teacher,” Raviola says. “He has an infectious energy and enthusiasm for instructing, mentoring, and sharing ideas. He’s a true social justice champion and isn’t afraid to say what he thinks when there’s a problem that needs a solution.”

A path to PIH

Père Eddy found a home in PIH, where he’s combined his three passions—Catholicism, social justice, and medicine. As early as high school, he debated whether to become a priest or a doctor. He turned to the bishop presiding over his high school, Notre Dame in Grand-Riviere du Nord, for guidance. His advice? “’Become a priest first and then you’ll see about medical school,’” Père Eddy remembers him saying, as he shines a characteristic broad smile.

That’s the path Père Eddy followed. In 1982, he enrolled in a Port-au-Prince seminary school and was a fervent student of liberation theology. After graduation, he served as chaplain of Cap-Haïtien’s all-girls Holy Cross High School and earned a spot as associate pastor in the local cathedral. He delivered passionate homilies about social justice to a receptive congregation tired of the nation’s political turmoil and crushing poverty.

Père Eddy also became a trusted confidante of his female students, who shared long-held secrets of physical, psychological, and sexual abuse. “The students needed more psychological support than spiritual counseling,” he says. That led him to apply for a scholarship to St. Paul University in Ottawa, Canada, where he earned his master’s degree in psychology.  

He’s a true social justice champion.

The Haiti Père Eddy left in 1991 was anything but stable, and his students already felt desperate about their future. When he returned with his degree one year later, following a coup d’etat that ousted President Jean-Bertrand Aristide—a fellow priest and out-spoken social justice warrior, his students’ hopes had been destroyed.

Père Eddy threw himself into his work. He returned to Holy Cross to minister, in more ways than one, to his students. He began teaching at his old high school, and started producing radio and television shows about adolescent mental health.

“It was another way to lead the social justice fight,” he says. “But at the same time, I was addressing the same issue with a generation that needed to be more prepared to face the future. Their own future, as well as the future of Haiti.”

Then another coup d’etat in 2004, which again ousted the re-elected Aristide, rocked Port-au-Prince. Père Eddy says the capital “was like a big cemetery;” violence was high, car-jackings were a regular occurrence, and people were attacked in the street. Around that time, a friend asked him to work for Catholic Relief Services to support staff who were dealing with high levels of post-traumatic stress. He agreed, splitting time between the capital and the organization’s southern branch in Les Cayes.

‘Real social justice’ warrior

That’s where Fernet Leandre found him in early 2005. At the time, Leandre was director of Partners In Health’s HIV and tuberculosis program in Haiti and facing a crisis. His patients were dealing with deep depression, and occasionally psychosis, as a side effect of their treatment. Those battling tuberculosis went through long periods of isolation, sometimes up to 24 months; their toxic drug regimens initially made them feel worse; and they couldn’t work while sick, which meant their families sank into abject poverty. Patients diagnosed with HIV faced stigma, social isolation, and were often abandoned by family and friends.

Leandre didn’t have the mental health expertise to help his patients, but he knew someone who did. He and Père Eddy were childhood friends, having attended the same elementary school. They spent their time playing sports (although, Leandre says, his friend wasn’t the smoothest soccer player) and sharing meaningful conversations about their futures, and the future of their country. Although their paths diverged at high school, they kept in touch.

He understood right away what the needs were for both the staff and the patients.

So when PIH needed an experienced, empathetic psychologist, Leandre turned to Père Eddy. His pitch was simple: “You have to come see real social justice in action,” Leandre, now the co-executive director of PIH in Haiti, remembers telling his friend. “You want to really practice this? Come.”

Père Eddy was in. Starting in September 2005, he traveled to every PIH clinic to work with tuberculosis and HIV patients who were learning to live with a chronic illness. He trained social workers how to meet their patients’ psychological needs. And he counseled staff who felt burdened by years of bearing their patients’ pain.

“When I met Père Eddy, I just fell in love with him,” says Mukherjee, who was on his hiring team. “I couldn’t imagine a better person, because he understood right away what the needs were for both the staff and the patients. He understood community-based work.”

Père Eddy understood it so well, in fact, that PIH sent him to Rwanda in 2006 to counsel traumatized staff and women who had contracted HIV after being raped during the genocide. (Some estimates say as many as 250,000 women shared this horrific experience, in a country with only one public psychologist.) For several weeks every year, he returned to help staff and patients deal with the recurring trauma around the genocide anniversary on April 7.

In 2009, Père Eddy and Raviola met for the first time in Rwanda, where they collaborated to get a new mental health team off the ground. Together they forged a strong friendship and professional partnership, based on the commitment to integrate mental health services in every country where PIH works.

A battle horse for mental health

Then disaster struck in Haiti. On January 12, 2010, a 7.0 earthquake shook Port-au-Prince, resulting in more than 300,000 dead and thousands more injured. In the days following the disaster, Raviola joined Père Eddy to plan a coordinated response.

“The Haitian society was hit from the heart,” Père Eddy says. “We had to do something. Everyone was afraid of seeing the burden of mental health increase along the way.”

One of his primary concerns was the impact on PIH staff, many of whom were working when the earthquake struck and couldn’t immediately return to Port-au-Prince to check on family and friends. When they did, many learned their loved ones had been buried alive in rubble. The tragedy denied victims a proper burial, and survivors a well-needed mourning process.

So Père Eddy created one. He, Raviola, Mukherjee, and Leandre traveled to each PIH clinic and conducted memorial services in honor of those who had died. He wove religious, spiritual, and mental health messages into his sermon-like presentations. And he encouraged staff to cry, mourn, and seek individual counseling themselves. Many, Leandre says, took up the offer.

The presentations were later used by PIH community health workers in settlements for displaced people and were adopted by the Haitian government to help mourners nationwide.

Père Eddy (far right) speaks with Paul Mainardi (far left), who now lives a full life in Haiti following treatment for his mental illness.

Père Eddy had long lived a “peripatetic existence,” Raviola says, traveling around Haiti with a small suitcase of his possessions and multiple cell phones ringing. He became adept at holding two conversations, with a phone at each ear, as he served patients or mentored and supported staff. The post-earthquake period intensified that experience.

It became increasingly clear to PIH staff that Haitians needed mental health services. Post-earthquake PTSD wasn’t as much the issue as was long-standing depression, anxiety, and stress developed over decades of poverty, unemployment, violence, and political instability—what Père Eddy calls the “poverty package.”

“The earthquake did not bring mental illness to Haiti,” Père Eddy says. “It has been to everyone an opportunity of awareness raising, where people had to understand that something had to be done, something still has to be done for the burden of mental health. We have a population of more than 10 million with two public psychiatrists. That’s totally under-operational.”

In some ways, the earthquake was a wake-up call. “We always say HIV was our battle horse for building primary health care” in Haiti, Mukherjee says. “The battle was never about HIV itself; it was about using the interest, the money in putting together systems for primary health care.

“Similarly these sorts of episodes of trauma, like the earthquake, have been battle horses to look at mental health.”

A simple, yet innovative, solution

The Haiti team was well-positioned to take a stand. Père Eddy and Raviola expanded the team so that one psychologist was based at each clinic.

A top priority was tackling widespread depression. Raviola—a psychiatrist by training with clinical, global health, and systems experience—recruited some of the best minds in his field to create a culturally appropriate depression screening survey for community health workers. Père Eddy trained his staff how to use the tool to identify community members at risk. The workers then referred those in need to a clinic or hospital, where a psychologist would assess them, begin counseling, and—if necessary—refer them to a physician to prescribe medication.

Innovation should have as a main goal to improve people’s lives.

Meanwhile, Raviola worked on adding at least one trained psychiatrist to Père Eddy’s team. He developed the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery at PIH and Harvard University for early-career psychiatrists interested in global mental health. The first fellow arrived in Haiti in 2011, and more have since cycled through to reinforce the team.

The community-based model was groundbreaking in global health circles for providing long-term care in a challenging setting. The Haiti team applied for a Grand Challenges Canada innovation grant to expand their program to cover a range of mental disorders, including depression, epilepsy, psychosis, and child and adolescent mental health problems. They got it.

When they reapplied last year to expand the program from all PIH sites to across the country—now in collaboration with the Ministry of Health—they landed it again.

“Innovation should have as a main goal to improve people’s lives,” Père Eddy says, “and this is what we’re doing for people living in rural and poor areas in Haiti.”

Because of staunch advocates like Père Eddy, the mental health programs in Haiti and Rwanda demonstrate what is possible in some of the poorest places in the world. But the priest-turned-psychologist doesn’t take this as a sign that his work is done. In some ways, it’s just begun.

Guess that retirement house in Cap-Haïtien will have to wait.

Donate to Partners In Health's 2015 TCS New York City Marathon Team between October 19 and November 2, 2015, and you might win 1 of 10 great prizes!   

Donate to either the PIH Marathon team or an individual runner on the team between Monday, October 19, and Monday, November 2, 2015, and you will automatically be entered in the drawing. There will be 10 winners. Each winner can choose from one of three prizes below. A personalized signature from Dr. Paul Farmer will be included.

Click on the button below to go to the PIH team fundraising page. From there, click "Donate to this fundraiser." Here you can select a runner by name, or you can donate to the overall PIH running team (the first choice in the Team Member drop-down—“Partners In Health”).

Donate to the PIH Marathon Team

Prizes:

1) Partners In Health T-shirt

a) Blue Partners In Health T-shirt (available in Unisex Small, Medium, Large, and X-Large), made of 100% cotton.

b) Orange Partners In Health T-shirt (available in Unisex Small, Medium, Large, and X-Large), made of 100% cotton.

2) Partners In Health Tote Bag 

a) Orange tote bag (approximate size: 16 inches wide x 16 inches tall), made of 100% ripstop nylon and holds up to 50 lbs.

b) Goldenrod tote bag (approximate size: 16 inches wide x 16 inches tall), made of 100% ripstop nylon and holds up to 50 lbs.

3) Book by Dr. Paul Farmer

a) To Repair the World: Paul Farmer Speaks to the Next Generation
A collection of short speeches by Dr. Paul Farmer encouraging young people to tackle the great challenges of our time. A must-read for students, recent graduates, and anyone seeking to help bend the arc of history toward justice.

b) In The Company of the Poor: Conversations with Dr. Paul Farmer and Father Gustavo Gutierrez
A conversation between extraordinary men: Dr. Paul Farmer—a medical anthropologist, physician, and co-founder of Partners In Health—and Father Gustavo Gutierrez—a Dominican theologian from Peru who is widely recognized as one the preeminent voices of liberation theology.

We appreciate your donation. Thank you for helping to raise awareness of Partners In Health's work in 10 countries around the world.

Details of offer: 
The drawing for the 10 winners will take place Tuesday, November 3, 2015. Winners will be notified by email or phone by Friday, November 6. All prizes will ship to winners by November 30, 2015.

Imagine a map of the Navajo Nation, at 27,000 square miles the largest Indian reservation in the United States. Lay it on top of a map of New England and it blankets most of Massachusetts, New Hampshire, and Vermont. Now stick pins at the locations of each of the 13 grocery stores in the Navajo Nation. What do you see? If one Navajo grocery store happens to lie in Boston, MA, then the next closest one lies not across town, but in Concord, NH—some 60 miles away. In other words, the land onto which the U.S. federal government forcibly settled Navajo people in 1868 is more than just an ecological desert. It is also so empty of stores selling healthy groceries that the USDA classifies it a “food desert.”

Residents are not taking this lying down. Since the mid-2000s, a growing number have been fighting for the chance to set a wholesome table, passing a much-publicized “junk food tax” that levies an additional 2 percent charge on nutritionally vacant foods and removes taxes from produce, for example. What’s less well known is that initiatives like that are not part of some ragtag movement. They are in fact the result of careful reflection.

Specifically, three recent academic studies, about 100 pages each, have fueled the Cheeto-crushers and salad-champions.

The first was produced by the Navajo Division of Health, the Centers for Disease Control, and partner organizations in 2013. Researchers surveyed grocery and convenience stores throughout the Nation to better understand exactly which healthy foods were available where. Key finding: “Almost all store managers—91 percent—were interested in offering more healthy foods in their stores.”

The second, published by a think tank, Diné Policy Institute, picked up where that left off. Diné Food Sovereignty compiled in-depth interviews with 230 residents to understand their tastes, spending habits, and more. Key finding: “A prevalent number described the desire for access to fresh produce (vegetables and fruits), as well as access to natural and organic foods.”

The latest study, from May, completed the picture. Members of the Navajo Division of Health, Partners In Health sister organization Community Outreach Patient Empowerment, and the Harvard University Law School spent the better part of six months hacking through a bureaucratic jungle, untangling the twisted ways that government regulations and food production standards affect what ends up in Navajo pantries and fruit bowls. Key finding: “Despite these challenges, the Diné people can rebuild a healthy, sustainable food system.”

Indeed. When the “junk food tax” went into effect in April, it was the first of its kind in America, and the envy of politicians like New York’s former mayor, Michael Bloomberg. It’s unknown how it has affected typical Navajo families, whether they still drive 155 miles to stock up on groceries once a month, as they did in 2014. But with plenty of empirical grounding, the food movement is definitely on the move.

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Grocery shopping in the Navajo Nation isn’t exactly inspiring. The local convenience store sells tallboy cans of Monster Energy Drink at “2 for $3.33!,” but a box of Cheerios can run $6. And never mind the cost of fresh produce; it’s not available at any price within a 50-mile radius of, well, pretty much everywhere.

This month, to return fruits and vegetables to their rightful place of prominence, Partners In Health sister organization Community Outreach Patient Empowerment (COPE) rolls out the second phase of an ambitious, and elegantly simple, program.

In the Fruit and Vegetable Prescription Program (FVRx), doctors give their patients “prescriptions,” in the form of vouchers, for a month’s worth of free fruits and vegetables. Small local shops increase their selection of fruits and vegetables, sometimes from zero. Patients use the vouchers to “buy” the newly stocked items, and COPE reimburses the stores.

The hope? That eating more nutritious food will improve the health of families. Some 50 percent of Navajo children weigh an unhealthy amount. And adults suffer a raft of serious, diet-related diseases. An estimated 22 percent live with diabetes, for example. Eating more vitamins, minerals, fiber, and antioxidants could help reduce the risk of many of those diseases.

The Navajo FVRx program launched at Teec Nos Pos trading post, a local store near the Arizona-Utah border, in April. (Pineapples sold especially well.) This month, the program expands into minimarts, gas stations, and trading posts in the southeast part of the Navajo Nation. The goal is to find funding to roll it out across the Nation, so that more than three quarters of the 175,000 residents have access to good leafy produce in 2017.

It’s too soon to see much of a change in anyone’s eating habits, but success isn’t a wild idea. The template comes from a nonprofit named Wholesome Wave, which began offering FVRx to governments, hospitals, and insurers in low-income neighborhoods in 2012. It now operates the program in 32 states.

While the organization doesn’t have data on how disease burdens have changed over the three years, participants have shed up to half their original weight. In the Navajo Nation, a recent 14-month academic trial, led by a researcher at Johns Hopkins University, found that Navajo residents were five times more likely to lose weight if their local stores were stocked with healthy food.

To help people suffering from long-term debilitating illnesses, Partners In Health partnered with the Malawian Ministry of Health and the Palliative Care Support Trust, a charity based in Blantyre, to launch a palliative care program in 2012 in Malawi’s remote southern district of Neno. Since its inception, the program has provided clinic- and home-based care to 225 patients living with health conditions such as Kaposi sarcoma, cervical cancer, hypertension and stroke, and liver cirrhosis.

Atupere Phiri is the program’s lead clinical officer and a trained health care provider known for his commitment to his patients.

Here he describes a day he and his team spent visiting patients, helping them to manage their pain and discomfort.

At 9 a.m., as usual, our palliative care team gathered for home visits around Neno. There were three of us: Judith Kanyema, a palliative care nurse, Knowledge Chaima, our driver, and me. Five patients expected us today.

Nurse Judith Kanyema measures Rachel Mpakati’s blood pressure, while Atupere Phiri takes notes.

By 10 a.m., we arrived at Rachel Mpakati’s* house in Nyakoko Village, which is about six kilometers from the nearest clinic. After a stroke six years ago, Mpakati suffers from partial paralysis. We visit her regularly to monitor her blood pressure and make sure that she takes her medication for hypertension. Thankfully, Mpakati has very supportive daughters who help make sure she takes her medication, sometimes coming to our offices to fill her prescription.

Since we started seeing her, she has done well. Her blood pressure is always normal, which is good.

Phiri, Kanyema, and Chaima travel to visit their next patient of the day.

Next we visited John Sachali, who has been in the palliative care program for more than three years now, and whose story is a constant reminder to me of the impact of our work.

When Sachali arrived at Neno District Hospital, which PIH supports, in 2012, he was in excruciating pain and was too weak to walk. Doctors diagnosed him with HIV and two forms of meningitis, and referred him to our team to begin physical therapy and treatment for his infections. We also worked hand-in-hand with clergy to counsel Sachali through his depression, and we assisted him financially and helped renovate his home through another PIH program that provides social support.

Phiri and Kanyema talk with John Sachali at his home.

Today, Sachali is walking with the help of an aide and enjoys a happy and productive life. During our visit, we made sure that he is still taking his drugs and provided some pain medications for his aching limbs. He also complained of some problems with his catheter, which he has needed for the past two years during his illness. We made a note to look into referral options for urological care.

As we prepared to leave, Sachali presented us with several tree saplings as a parting gift. Such kind gestures remind me how much patients appreciate the care we provide and motivate me to do more to improve their quality of life.

The road to Mphatso Phiri’s home in Neno District.

It took us about two hours on Neno’s winding dirt roads to reach our next patient, but we finally met Mphatso Phiri and his family at his home around 1:30 p.m. Phiri, a 48-year-old man from Ndoma Village, had completed chemotherapy for Kaposi sarcoma before he joined the palliative care program in 2012. We monitor early signs of cancer recurrence and other complications.

He’s been experiencing muscle contractions in his arms and legs, causing severe pain in his joints, so we’ve been providing pain medication. We were pleased to see that today he was able to walk around his house, a task that proved too painful during past visits. He told us he’d started working in his garden again, which was amazing. We couldn’t believe that. He once thought he’d die or be left crippled, but he’s now living happily.

Kanyema, Phiri, and Mphatso Phiri discuss his progress in the palliative care program.

As we walked back to our vehicle, the family generously offered us “nsima”—a traditional Malawian lunch made with maize flour—but we had to decline to reach our next patient in time.

At 81 years old, Emily Muleso, our fourth patient, suffers degenerative arthritis, so we provide painkillers. She was also diagnosed with hypertension, which we monitor and treat with medication. She’s frail and lives more than 10 kilometers from the nearest clinic, so she would not have access to this care if we did not make the trip to her house.

Today, we checked her blood pressure and resupplied her medication. Mphatso Phiri actually referred Muleso to us. This tells me that we’re doing good work.

An impassable road, washed away by rain, means Kanyema, Chaima, and Phiri can’t reach their final patient of the day.

Our last patient was new; we were enrolling him because he has advanced diabetes. Unfortunately, the road had washed away about 2 kilometers from his house, and we were unable to reach him. I will have to reschedule the appointment and return on a motorbike.

By the time we returned home—about 3 p.m.—we were exhausted. But there is nothing as rewarding as working with these patients. Caring for the chronically ill can be physically and emotionally draining because effective palliative care requires constant empathy and a genuine connection with patients. It requires a heart of caring.

But I take pride knowing how vital these services are to the overall wellbeing of our patients and families. We are not just prolonging their lives, but adding happiness and meaning to them as well.

Kanyema dispenses drugs for patients to take until their next home visit.

*Patients’ names have been changed to protect their privacy.

Maribel Perez is a busy woman. The 38-year-old mother of six gets up before sunrise to cook breakfast, make tortillas, get her children ready for school, and walk them there every weekday. All this happens before she starts her other job as an acompaňante, or community health worker (CHW), with Compaňeros En Salud, Partners In Health’s sister organization in Chiapas, Mexico.

Perez is one of 50 CHWs who visit patients throughout rural Chiapas, but she’s the only one who is trilingual. In addition to Spanish, she speaks the indigenous Mayan languages of Tzeltal and Mam. Her skills come in handy on home visits and when translating for the Spanish-speaking first-year doctor, or pasante, working in Plan de la Libertad’s two clinics. Her patients no longer hesitate to visit their nearest clinic now that they can “speak,” via Perez, with the doctor.

Originally from Guatemala, Perez traveled to Mexico with her father when she was 13 to work in the coffee fields. Her life has been a whirlwind ever since. In 25 years, she’s had a string of odd jobs that took her from Chiapas to California, to Guatemala and back again. Before becoming a CHW one year ago, she used to sell tamales, bread, and chicken in addition to completing her duties as a housewife and mother.

Perez now cares for seven patients, two of whom speak only Tzeltal, and visits them up to two times each week. We spoke with her before dawn one morning, as she cooked tortillas over a wood fire and chicks chirped from a corner of the outdoor kitchen.

Did your Tzeltal-speaking patients come to the clinic before you started as a CHW?

Once I was talking with a patient and I asked her how she got her medication before I started visiting her. She said she wanted to go to the clinic, but she wouldn’t be able to understand the doctor, and he wouldn’t be able to understand her. And her husband works, so he couldn’t go with her. So she just didn’t go.

That’s where I feel like I’m helping a lot, or at least I have helped her. She hasn’t missed a treatment or gone without pills. She’s been really well.

What are the major health concerns in Plan de la Libertad?

The most common illnesses are stomach pains, fever, coughs, and flus—especially for children during the rainy season. There’s a lot of chronic disease. For example, here in the community there’s diabetes, asthma, hypertension, and depression. Then there are other illnesses I didn’t know about before I became a CHW, such as schizophrenia and epilepsy.

Perez (right) returns home with her daughter after visiting one of her seven patients, whom she typically sees up to two times each week.

Do people practice traditional medicine here?

Yes, that’s what they tell me. But the truth is that I don’t know if it has any effect. For high blood pressure, for example, they drink tea made from the boiled leaves of a lime tree. There’s no proof that it works. For the flu, some people drink tea made from bougainvillea leaves and chamomile, boiled together with cinnamon. That’s what we prepare sometimes too. Tea with honey is good when you feel really congested.

Are there any traditional medicines that you discourage?

Sometimes people come from outside the community offering natural remedies saying, “This is really good. This will cure you!” A little while ago, a woman who said she was a naturalist was offering some remedy for diabetes and hypertension, and many said that it was good, that the results were worth it, so they stopped taking their medication. But a little while later, no one was cured. Now they are on the clinic’s medication again.

Has your job helped you in any way?

It makes me happy, because through this job I’ve met people I never thought I’d meet. And it’s helped me a lot because I feel fulfilled. Before I went from my kitchen, to my house, to the school and nowhere else. But with this job, I go to visit my patients. I get some exercise. I get out of my home. I forget about my own housework for a little while. When I’m out for a walk, I meet people along the road and I laugh with them.

What do you enjoy most about being a CHW?

I enjoy helping people who don’t speak Spanish.

Have you applied any lessons to your own health?

Several times we’ve had the chance to take psychoeducation courses with CES doctors. I’d experienced many things since the time I was a child up until just a little while ago. All of the advice and training Compaňeros En Salud doctors gave me, it’s helped me a lot.

Do you think the CHW program benefits communities?

This program should expand to other communities, because there are places where people don’t have family or anyone, but they need medication. Because they don’t have a CHW or aren’t aware of their health, they don’t get treatment. That’s what I would say, that there should be more of this, that the program should continue growing.

Dayana* was in shock. The 31-year-old mother had just learned she was four weeks pregnant—with twins, she’d later discover—and was trying to calm her racing thoughts as she sat in a clinic on the outskirts of Lima, Peru. She hadn’t yet collected herself when a nurse returned with more news. The results of her rapid HIV test, a required part of her pregnancy exam, had just come back. Positive.

“I was crushed,” Dayana recalls. “I felt as if the world was falling in on me. I was hopeless.”

Dayana felt completely alone in that moment, but her situation is not unique. In 2014, there were 1,000 pregnant women living with HIV in Peru and nearly 90 percent regularly took antiretroviral drugs (ARVs), according to a UNAIDS study. Pregnant women who take ARVs lower the amount of virus in their blood and, in doing so, prevent transmission to their child. 

Mother-to-child transmission of HIV can occur three ways: during pregnancy, when the mother shares blood with her developing child through the placenta; during labor and delivery, through exposure to the mother’s body fluids; and during breastfeeding, since breast milk carries trace amounts of the virus.

Global studies suggest that when women regularly take their medication, transmission rates fall to less than 5 percent. Without ARVs, that rate can jump to nearly 30 percent. Other measures help prevent transmission, such as an elective cesarean section or choosing formula over breastfeeding. But these aren’t always options for women living in parts of the world where access to quality health care is limited, and formula is expensive or hard to find.

Even when all these preventive measures are in place, they don’t necessarily stop transmission. That’s because, possibly more than anything, a positive HIV diagnosis is a mental and emotional blow. Women lose hope. They slip into depression and fail to see a path ahead. Some are abandoned or abused by partners because of their status. Others lose jobs if their diagnosis becomes public, and they struggle to make ends meet. None of these situations spark a desire to pay close attention to their health.

Socios En Salud (SES), Partners In Health’s sister organization in Peru, knows this is a reality for pregnant women living with HIV in and around Lima. Its solution? SES, in coordination with the National Program for HIV and the Peruvian Network of Women Living with HIV, launched a unique yearlong pilot program in which peer counselors—all of whom are HIV-positive themselves—contact expectant mothers and help them access the clinical and social services they need. Most importantly though, they are friends to women who, like Dayana, feel completely alone. 

Since February, SES has identified more than 130 pregnant women who tested positive for HIV at a handful of hospitals in and around Lima. Five peer counselors have reached out to them to offer support. The goal is to keep 95 percent of peer-counseled women on ARVs, and the same percent of at-risk infants on preventive treatment and formula for their first year.

While it’s too early to tell whether the newborns will test negative for HIV, SES is encouraged by results from the peer counselors’ interventions.

Take Dayana’s case. She had fallen into a deep depression and stopped taking ARVs. She lost all hope, and with it many pounds. She lived in the home of her children’s father, who helped with expenses whenever he could. That’s how SES peer counselor Katy* found her six months ago.

She was always by my side.

Diagnosed with HIV while pregnant five years ago, Katy intimately understood Dayana’s situation. She called regularly. She visited Dayana at home. She got Dayana to start on ARVs again and connected her with a psychologist at a nearby hospital.

“She was like a guardian angel,” Dayana says of Katy. “She was always by my side.”

And when there was no money for bus fares to her appointments or formula was hard to find, SES staff helped Dayana pay for transportation and found formula for her 6-month-old twins.

Peer counselors like Katy are expecting mothers’ biggest cheerleaders. They go along for prenatal appointments, encourage them to stay on ARVs, and connect them with specialists, such as dieticians or mental health professionals. Anemia is a common side effect of ARVs and can improve with better nutrition, while depression often accompanies a positive diagnosis of HIV.

Many times, pregnant women avoid seeking specialized care at hospitals because they don’t know about it or—out of shame or discrimination—don’t seek it out, says Engerid Chagua, a SES field supervisor for the program. 

More than half of the women in the SES program didn’t finish high school, Chagua says. Their limited education means job opportunities are few and far between, so many try to make ends meet as street vendors. Others rely on the income of their partner, or are single mothers who don’t work outside the home because they can’t find childcare.

That’s why it’s common for peer counselors to connect women with baskets of food, a constant supply of infant formula, and public transportation to doctors’ visits—as SES did for Dayana. These are the favors that families or friends would typically provide their loved ones in Peru, but an HIV diagnosis often strains relationships.

“Sometimes family doesn’t want to get involved,” says Chagua. “We try somehow to get them to understand that they can live alongside a person with HIV” and that their family member “needs a lot of emotional support.”

Dayana had never been close to her family. Katy filled that void and helped her get back on her feet.  

“I already feel better,” Dayana says. “I’ve gained weight. I feel more established. I feel strong enough to keep fighting for my children and everything they need.” Her infant twins are happy and healthy. So far, they—and her other four children—test negative for HIV.

“All the problems that I have, I put them behind me,” Dayana says. “I don’t pay any attention to them anymore, because I know it doesn’t help me. I prefer to look ahead, thanks to God’s will and with the help of Katy and Socios En Salud.”

*Names were changed or shortened out of respect for the women’s privacy.

Partners In Health is fielding its first team of runners to participate in the 2015 TCS New York City Marathon! Our 10 runners will hit the streets of New York City on November 1, 2015, to raise awareness about PIH’s work to provide high-quality health care to people living in poor communities around the world.

Running a marathon is an apt metaphor for the endurance, hard work, and strength this work requires. We’d love your help! Please consider donating to our inaugural team—all proceeds benefit Partners In Health.

You can donate directly to an individual team member, or the overall PIH running team—either way, your contribution is greatly appreciated!

To donate:
When you visit the team's Donate page below, you’ll have the option to select a team member.  You can select a runner by name, or donate to the larger Partners In Health running team (the first choice in the Team Member drop-down—“Partners In Health”).

Donate Here

Please make a donation and help us raise funds for Partners In Health!

Thank you!

Rachel Namazongo lives with her mother and grandparents in Ligowe, Malawi, in the remote district of Neno. The young girl, who turns 6 next month, helps her grandmother at home and pumps water from a well in their garden. When she’s not with her grandmother or at school, the cheerful first-grader plays with other children in their compound.

Her grandmother never thought Rachel would reach this age. At 2, she was HIV-positive and severely malnourished. With antiretroviral therapy and a peanut-based, high-calorie food provided by Partners In Health, she quickly recovered. But last year Rachel was readmitted to the hospital, malnourished and infected with tuberculosis. With more treatment, she eventually became well enough to return home. In all, Rachel has been hospitalized six times for malnutrition.

This is not uncommon. Most rural Malawians are poor subsistence farmers and grow maize outside their homes. If a family isn’t able to harvest enough maize to last them the year, they go hungry.

Without food, an individual’s immune system weakens and the body becomes more susceptible to disease; malnutrition therefore goes hand in hand with diseases such as pneumonia, tuberculosis, and HIV. Illness can then worsen malnutrition, compounding both problems.

This year is likely to be harder than usual for Rachel and others in rural Malawi. January, February, and March—a period known as nthawi ya chilala, the “hunger season”—are often when people run out of food they harvested the previous May.

But the hunger season is expected to come much earlier this year. Excessive rains last January caused devastating floods in many parts of the country and washed away crops and fertilizer, such that maize production has decreased by 28 percent, according to government estimates. The Ministry of Finance, Economic Planning and Development predicts that 3 million people—17 percent of Malawi’s population—will not be able to meet their annual food requirements.

PIH is already seeing the effects. Dolifa, an elderly woman with failing eyesight, came to have her eyes checked at a recent health screening in Matope. PIH clinicians diagnosed her as malnourished. “A lot of people have no food; our crops were washed away,” Dolifa shrugged. “We are just trying to make ends meet day in and day out, letting tomorrow’s worries remain tomorrow’s worries.”

Another patient, a father named John, came to the screening with a persistent cough and learned he was also malnourished. “I am not surprised,” he said. “My family and I usually go days without eating. When we have food to eat, we spare bigger portions for the younger ones.”

PIH provides malnourished patients with bags of blended corn and soy flour, and cooking oil. Patients suffering from severe malnutrition receive nut-based formulas that are high in calories, and they are referred to clinics for further care and medication. If patients are suffering from additional diseases such as tuberculosis or HIV, PIH incorporates nutritious food into their treatment. To prevent malnutrition in HIV-positive mothers and children, PIH provides them food in addition to antiretroviral therapy.

For Rachel and her family, it will be an ongoing challenge to stay healthy. But they’re hopeful. Rachel’s mother, 24-year-old Mphatso, thinks back to a year ago, when she feared she would lose her daughter.

“I remember sitting on the hospital bed and seeing other children die. I was scared Rachel would also die,” she said. Now, Mphatso thinks her daughter will go far in life. To inspire hope in others, she often tells Rachel’s story.

Blessings Banda, PIH’s nutrition manager in Malawi, has watched Rachel grow from a toddler to a young school girl, and helped care for her each step of the way (read more about his friendship with Rachel and her family here and here).

“We track her and act quickly to ensure we support her in all ways possible—both medically and nutrition-wise,” he says.

When did you start working with Partners In Health?

I started working with Partners In Health (PIH) in 2005. Before that, I was working as a math teacher in primary school.

What exactly is your role as a CHW?

Part of my role is to encourage women to be part of family planning, to go for prenatal care, to give birth in a health facility. I encourage community members to check their HIV statuses, people with severe coughs to check if they have tuberculosis, and people without health insurance to sign up for Rwanda’s “mutuelle” health insurance. I also emphasize sanitation, treat children under 5 who have malaria and diarrhea, and teach community members how to prevent malnutrition. I accompany weak patients through their treatments by following up with them and collecting medication for HIV patients.

How many people do you visit?

One community health worker follows up with about 50 families. The ones who have fewer homes still serve at least 30 families. They visit at least two families a day or 10 to 15 families a week.

What is your role as a CHW supervisor?

I visit families to see how they are doing and follow up on cases and see how we can help. I visit CHWs every month to see if they do the work they’re assigned. And we procure medication that the CHWs use to treat patients.

What have you learned from working as a CHW?

I have improved my leadership skills and learned a lot about health. I can even do this for my own family of three children. I have learned how to work well with people and have gained many friends.

What are some of the challenges?

There are so many challenges, especially when urging people to go for family planning. Some think family planning causes cancer and other diseases. There is also so much work. For instance, there are times CHWs need to work in the field and then they get called to tend to patients. They have to ignore their farm. Being able to earn more would be helpful.

What has kept you with PIH for a decade?

I’ve been offered so many jobs, but I am very passionate about my job. I like the people I work with at PIH. I have also gained so many skills at this job. I thank PIH—especially Didi Farmer and Nurse Peter—for it. 
 

Anatole Manzi
Director of Mentorship, Enhanced Supervision for Health Care and Quality Improvement

It was May 2005 when I heard about Partners In Health/Inshuti Mu Buzima (IMB). I was finishing my bachelor’s degree in clinical psychology, but I already had an advanced diploma in general nursing. Poverty, HIV, and other infectious diseases were striking my family members and neighbors. Specific words in the PIH advert, like “preferential option for the poor,” “social justice,” and “human rights,” were key for me and many other colleagues. I didn’t hesitate to submit my application for the nurse position.

After less than a week, I got called for an interview at Rwinkwavu Hospital. The facility was devastated—not enough nurses, no doctor, a limited number of patients, facilities in bad shape. I could not imagine this was the work I had applied for. Nevertheless, my dreams were to be with the sick and poor in a remote community. In my interview with Haitian physician Dr. Fernet Leandre (who played an impressive role in IMB program implementation, replicating the model from Haiti), he asked if I was ready to work in such a remote area. My prompt, sincere response was, “Yes, I am.”

Three days after the interviews, I got an offer letter. This remains the most exciting day of my career. Not many people could understand my reason for wanting to join this organization, but I was thrilled to join a team of people striving for the poor and sick, to rebuild the health system in my country. This was the work that I had long wanted, enabling me to have an impact in my community.

Holding an offer letter in my hands, I called my former employer and informed him about this opportunity. He told me that I should follow my dreams. And he gave me a promise that many employers would not make. He said, “I will keep your spot vacant for three months so you can come back if the reality you find is different from what you expect.”

My first day in Rwinkwavu was very instructive. We had an orientation meeting with Michael Rich who was the country representative for IMB. He mentioned that one of us had to be relocated to a different facility—more remote, with fewer staff and equipment, without public transportation facilities.

As a Christian, my first reaction was a silent prayer: “God, I do not want to be the one to go there. That would be too much.” That was my prayer. I thought God was going to perform a miracle and make Michael choose someone else.

Unfortunately, it did not take him any time to mention my name. It was shocking to me. I tried to bring up many reasons to stay in Rwinkwavu, but all were denied. I was sent to that health center named Rukira.

The first month was very challenging, but I was thrilled to see so many patients coming from all corners of the community. HIV testing and treatment services were new and much more comprehensive. So many patients were now on antiretroviral drugs. I was also amazed by the psychosocial support available to poor and vulnerable patients. I remember a number of them getting back to life after a short period of time.

When I was sent to Rukira, I wrongly thought that I would be alone. Instead, I received weekly visits from IMB physicians and nurses. We could see patients together, share lunch and dinner, and enjoy music together. This spirit of accompaniment kept my morale high. Despite their responsibilities as senior leaders of the organization, Dr. Joia Mukherjee, Dr. Sara Stulac, Dr. Henry Epino, and Dr. Michael Rich made time to see patients every week and boost the morale of staff, which had grown in the first three months.

Dr. Paul Farmer visited the clinic, too. The first time I met him, I didn’t know “Farmer” was his real surname. We spent our time planting flowers and digging a fishpond at the health center. After a couple of months, we had an amazing garden around the health center. It became a relaxing place for patients, staff, and local community members, and a favorite area for wedding photos. I thought he was an actual farmer.

After two years, in late 2007, I joined Drs. Peter Drobac and Patric Almazor in Butaro to officially scale up IMB activities. We had the blueprints for the future Butaro Hospital, but no one could believe that it was real. Within six months we had trained over 1,300 community health workers on HIV accompaniment and more than 150 nurses were trained in HIV management. Past patients performed gorgeous songs and drums at the one-year anniversary.

It did not take long to realize that I was in the right place. Each activity responded directly or indirectly to patients’ needs and gave preferential options to the poor and vulnerable. Seeing a strong system or a patient smiling, being exposed to robust capacity building opportunities—these all brought a satisfaction that I think I share with many colleagues at IMB.

I consider capacity building as part of accompaniment. Many patients have become health care workers. A great number of adolescents infected or affected by HIV have managed to get university degrees. A number of staff have received formal or ad hoc training opportunities.

Like many colleagues, I have received extensive training opportunities that have led to great changes in my career. Completing two master’s degrees and becoming a Ph.D. candidate was not random. It is rather a product of a strong mentorship system that IMB established. I started from scratch in research and scientific communication. The first draft of my first research paper was far from publishable. I always hide my first drafts but use them to measure the change. This was an area that makes IMB a unique site in staff development. My current priority is now to enjoy transferring that capacity to my colleagues.

This letter is dedicated to Toni Habinshuti, Felix Cyamatare, Neil Gupta, and all executive members working tirelessly to keep IMB a best performing environment. I send my humble gratitude to my mentors, mentees, and colleagues who not only believe in IMB but also apply its philosophy and core values in every interaction.

Happy Anniversary.

Andre Ndabarasa
Transportation coordinator

When I joined IMB in 2006, Rwinkwavu was all bushes, a dirt road, and only two PIH cars despite having so many patients and a number of activities that required cars. Transport-wise, it wasn’t easy to coordinate, as there was a high demand for the cars. They were used for all types of activities, including working as ambulances for patients.

The living conditions in Rwinkwavu were terrible. There were no shops, no markets, and transportation was also a big challenge. It was hard to meet basic needs since it was one of the poorest rural areas. On my first day, I had to walk 12 miles on a dirt road to reach IMB.

As the number of staff has increased, so have the living quarters in the area. We started to see development and infrastructure improve too. Three more cars were bought to meet the demand and an ambulance was donated.

I would spend three weeks without going home because of the heavy workload. I remember once staying awake for three days and nights, taking patients between hospitals and picking up emergency cases. I would use the ambulance at night, and deal with other transport issues during the day.

What has motivated me to stay with IMB all these years is the fact that IMB’s work directly impacts local and vulnerable Rwandans. The lives of vulnerable people are transformed for the better. IMB helps people to help themselves. It supports them and teaches them to be self-reliant. I am glad to be working with an organization that goes to the needy and brings positive change to thousands of lives.

I have a lot to celebrate since joining IMB. I can now speak English confidently, which I learned from IMB, and I can now use a computer and do some of my work on a computer. I am also motivated by the fact that IMB recognizes my hard work and dedication and rewards me for it. PIH is a family to me now.

Cyprien Safari
Medical stock coordinator     

Having worked with IMB since 2005, I am celebrating my own 10 years with IMB alongside IMB’s 10th anniversary. I started as a nurse, but today I am the medical stock coordinator.

I came from a poverty-stricken village that was full of despair. My father died right after I joined IMB, but I found hope at IMB and have never looked back since.

When I joined IMB, Rwinkwavu was a deserted place. There were many sick people who had given up seeking medical care since there were no health facilities in the vicinity. Many of them were only waiting to die—although they looked like they were already dead. Rwinkwavu was a mess.

IMB came and restored hope and health in Rwinkwavu. IMB health workers would go find the sick people in their homes, take them to the health facility, and offer them treatment. People thought they would never heal, but they regained their health.

Many in Rwinkwavu and the neighboring areas now have proper health care, the likes of which they never had before.

I have also had a chance to benefit from different trainings under IMB. They have enhanced my career with trainings in pharmacy management, supply chain, quality improvement, human resource management, and health services management, among others.

The leadership team at IMB served passionately while reaching out to the sick people and meeting their needs. My motto is “whatever it takes.” I have learned from IMB to do whatever it takes in order to save lives and restore health. This is the spirit one sees at IMB. Leadership and staff serve passionately, playing a role to improve people’s lives.

Seeing how IMB has transformed many lives—not only through offering treatment but also through improving their general socio-economic wellbeing—has kept me going. This has kept me glued to IMB since its inception. It isn’t about the money. It’s about the changing of lives that are on the verge of death.

Jean Claude Gatoto Rutayisire
Head supervisor of community health

I was one of the very first employees and patients of IMB, when it was established 10 years ago in Rwinkwavu. I was already a resident of Rwinkwavu so IMB found me there. I was working with HIV associations then.

When IMB started in Rwinkwavu, I joined as a volunteer, and also as a patient, since I was living with HIV.

There was only one health center and no hospital in the area. There were no doctors and fewer than five nurses. IMB focused a lot on HIV. Many people were living with HIV, but were ignorant; they thought it was witchcraft.

As a volunteer, I helped create awareness of HIV and show IMB where the sick people were. I worked with the sick and encouraged them to seek medical care, as the majority didn’t know it was important. Rwinkwavu was one of the poorest and most rural areas in the country. Most people were ignorant about diseases and how vital medical care is. As time went on, more people were enrolled as community health workers. They would travel within the community under the supervision of IMB, monitoring patients’ health and following-up on patients who were on daily medication. Later on, three doctors joined the team and more people began seeking medical care from the health facility.

IMB gave more than medication, providing food and transport and building houses for the sick and poor patients. The organization also started getting community health insurance for patients.

Personally, IMB helped me overcome stigma. Many of the people I used to work with rejected me and stigmatized me because I was HIV-positive. IMB helped me to start living positively. Most people used to say I would never have children of my own because I was infected, but now I have five children.

I wasn’t doing well then but IMB helped improve my livelihood and employed me. My salary has increased. I used to live in a one-room house with my family, but today I am a proud owner of a big family house.

My biggest dream is to complete high school and even pursue further studies. I hope that IMB can help me fulfill this wish. I also hope to visit Haiti and Boston to share work experience with colleagues at those sites.

After 10 years, the biggest thing to celebrate is that IMB improved the livelihoods of many people in many communities.

Peter Niyigena
Community health director

Known as “Nurse Peter” throughout the IMB community, I am celebrating a decade with IMB this July. Currently finishing my master’s degree in environmental health, I joined IMB during its inception, working as a ward nurse at the health center, which was the only health facility in Rwinkwavu.

Rwinkwavu was a total mess in terms of health facilities. The only health center available had about three nurses and offered very few medical services, but the need was high. People had given up on seeking health care despite being sick; this is because they knew that there were no medics or treatment available. However, the story changed when IMB was established in Rwinkwavu.

IMB expanded health services, bringing treatment and more trained medics. We then went to the communities to inform people about the services the health center was providing. People started seeking treatment. Health services were expanded, including maternity services, HIV care, internal medicine, and a bigger laboratory.

IMB was different from the other nongovernmental organizations (NGO) in the district. Only IMB staff remained in the area to stay close to the vulnerable people it reached out to. IMB went where the sick people were and stayed there, while other NGO leaders and staff would return to the city.

So many people were dying from HIV/AIDS and tuberculosis. Most of those with HIV/AIDS had a very low CD4 count and were very ill as they had no access to antiretrovirals. IMB freely provided ARVs to the HIV-infected poor people, and even followed up to make sure they took the medication as prescribed. I was touched by this kindness and dedication to the poor and vulnerable. They provided food, transport, and lots of other social-justice measures alongside treatment.

These gestures tremendously improved peoples’ health and lives. This one of the reasons that I have stayed with IMB for the last 10 years: being a witness to lives transformed every day.

Through working with community health workers, thousands of people in the community are reached every day, offered treatment, invited to learn about health, and encouraged to visit health facilities.

Overall, if IMB hadn’t been established in Rwinkwavu, many people would have lost their lives. I have seen many people who were in a critical condition 10 years ago; IMB came to their rescue and today they are still alive, happy and healthy!
 

Ndifanji Melia Namacha, 22, is completing her final year of medical school in the College of Medicine at the University of Malawi. Last fall she finished a family medicine rotation in Neno, a remote rural district where Partners In Health works. Here she shares her thoughts and experiences—the beginning, she says, of a medical career devoted to global health.

For my family medicine rotation I decided to go to Neno, where I had never been before. Everyone I asked about it said, “It’s in the middle of nowhere.” Although it required some bravery to go, for me, this is what medicine is about—providing care where nobody else does. My time in Neno was a major stepping-stone. It led to a global health course in the Netherlands, which opened my eyes to global health.

My parents have always encouraged me to make challenging decisions, and I think that has made me a risk-taker. When the day came to travel to Neno, Partners In Health collected four classmates and me from my home city, Blantyre. Travelling up the hills to Neno was a beautiful experience. I admire doctors who leave their comfort zones to work in Africa; I felt the same coming from the city. This was me living the dream. I felt like a doctor with no border.

I was in Neno for four weeks, and I did not leave the district the entire time. It was enough time to adjust to the heat and a new working environment. On arriving, I was encouraged to hear from classmates who completed the last family medicine rotation that we would perform procedures we had only seen in books, never in public hospitals. We learned about everything from pediatrics to geriatrics. And PIH’s role at the district hospital allowed us full access to rapid diagnostic tests—something you don’t usually experience in a government public hospital.

PIH’s work in Neno is a great example of family medicine. They have an excellent home-based care system run by village health workers. And they provide social assistance through financial aid and by helping patients start their own small businesses. I was also impressed by how many HIV patients are receiving antiretroviral therapy (ART).

It was in Neno when I realized that the causes of major global health challenges are beyond a medical degree and include economic development, climate change, public policy, business, and management. Global health is for the critical mind—for those doctors who always want to know, “WHY?”

And that was me in November 2014, when I sat in the HIV Testing and Counseling clinic in Neno. A 35-year-old mother of three walked in with her 3-year-old son, David*, whom she wanted to get retested. David had been on ART since he was 2, but she was still not convinced he was positive because she, his father, and David’s siblings were negative. But after retesting, his results were still positive.

I sat quietly in the corner of the room. The mother was told to continue David on ART. She left the room hopeless, just as she came in, carrying the child on her back.

I felt the mother had not been fully managed. What about her psychological and social needs? I want to be that doctor who looks beyond the disease at each and every determinant of health—be it social, economic, or political—and apply them in my clinical practice.

I brought it up in the morning handover the next day. To my surprise, PIH Medical Officer Dr. Noel Kalanga asked me to make further enquiries about the case and write it up. This experience led me to look holistically at medicine. Are we providing the highest standard of care? And what happens when we don’t? Global health brought out the activist in me. 

My time in Neno influenced me to apply for a summer school program in global health at the University of Groningen in the Netherlands. I was successful and joined 30 medical students from other countries. I was one of two students representing Africa.

The summer school was an amazing opportunity and what I call my baptism into a career in global health. I learned that, although it is of great importance that each nation develop solutions that are localized to address most of its health problems, some health issues are best resolved using a global approach.

Global health suits me perfectly and allows me to look at the major challenges beyond clinical medicine. I learned to look critically at health systems and not just to move inside them. I saw ethics and legal frameworks in medicine, cultural diversity, global epidemiology, and socioeconomic and environmental determinants surrounding 3-year-old David and his mother.

Looking back at my time in Neno at the district hospital, I believe there is so much that other district hospitals can learn. Serving in a remote place is challenging. It was encouraging to see PIH health workers and Ministry of Health staff working tirelessly to provide care to patients.

I believe I am being trained to serve Malawi and Africa. I feel I better understand what it takes to treat patients in poor countries. After my time in the Netherlands, I know I have more to learn from other health systems around the world, and I’d like to get exposed to them and bring experiences home. My goal in life is to work for an international organization as a global health specialist, to be involved in clinical research, and to work across borders.

*The patient’s name has been changed.

Farming isn’t an easy way to make a living, regardless of location, but growing coffee has been particularly frustrating for the past two years in the Sierra Madre mountains of rural Chiapas, Mexico. A fungus known in Spanish as la roya has spread rapidly among coffee plants throughout Central America and significantly hampered their productivity. Families typically gather 30 bushels of coffee beans during the two-month harvest; now they’re pulling in less than five.

Whatever profit families make depends on fickle global coffee prices. Lately, that annual lump sum just hasn’t been enough.

“They have to live the entire year on the money they used to earn in one or two months,” says Dr. Héctor Carrasco, community programs coordinator for Compaňeros En Salud (CES), Partners In Health’s sister organization in Mexico. “It’s really diminishing their capacity to live and buy food.”

Protein-rich and fatty foods such as meat and dairy products are hard to come by and expensive in rural Chiapas, partly because refrigeration is scarce to non-existent. Small neighborhood shops are more prone to stock items with long shelf lives, such as prepackaged cookies and soda, than fruits and vegetables. And Coca-Cola is cheaper than bottled water in most communities.

In an average year, rural Chiapanecan families grow a good portion of what they eat. Corn for tortillas and beans are staple crops and, when prepared in combination, provide a good source of protein. But there’s little variety beyond that. What families don’t grow, they buy with profits from the coffee harvest.

“This year was a one-two punch because bad weather decreased food crop harvests and the roya decreased coffee income,” says PIH Mexico Program Officer Lindsay Palazuelos. “When people have less food and less income, they buy the food that is cheapest per calorie, such as pasta or cornmeal mix for tortillas.”  

Cultural practices do not always align with good nutrition either. When children are weaned, they are often given caldo de frijol, or bean broth, which has the flavor of beans, but none of their nutritional benefits. 

Children’s health reflects this nutritional deficit in rural Chiapas, where CES operates in 10 communities. Mexico’s 2012 National Health Survey found that 44 percent of children in the region suffer from chronic malnutrition—six times the national average. It’s a grave concern for CES doctors, nurses, and community health workers. They know, and see firsthand, that chronically malnourished children are at an immediate disadvantage. Not only is their growth stunted, but their brains fail to develop at a proper pace, making it more difficult for them to learn and concentrate. They’re also more likely to get sick than well-nourished children.

Health equity through nutrition

Dr. Héctor Carrasco (right), CES community programs coordinator, says children in rural Chiapas are six times more likely to be chronically malnourished than those living in the rest of Mexico.

When he began working in Chiapas three and a half years ago, Carrasco wasn’t fully aware of the difficulties his patients faced growing and purchasing nutritious food. He thought families merely lacked proper nutrition information, so he launched educational workshops and sat down with families to discuss how they could change their diets. But the workshops failed to spark change at home, and doctors continued to see stunted children in their clinics. It was only after he’d spent more time in the communities that he figured out the importance of having reliable, high-quality sources of food.

That’s when Carrasco looked for outside help and found Heifer International, an Arkansas-based nonprofit focused on ending hunger and poverty through sustainable agriculture and commerce. He, CES volunteer and Argentine dietician Clara Perdomo, and César Durantes, Heifer’s program coordinator in Mexico, started talking in 2013 about a two-year pilot program that could improve Chiapanecan families’ access to nutritious food, reverse childhood malnutrition, and spark the local economy. Their plan? Provide 14 hens and one rooster to each family with a chronically malnourished child under 5.

Over the short term, they thought, the Heifer chickens would provide families with a daily source of protein through the eggs they produced and, on special occasions, a meat dinner. Whatever the families didn’t eat, they could sell for extra income. The long-term goal was to improve local diets and the economy by “Passing on the Gift” originally given by Heifer, Durantes says. Should all go well, the families’ chickens would reproduce to the point of doubling their flocks. Those extra chickens would then be passed along to family, friends, or neighbors in surrounding CES communities who could use the extra source of food or income.

“All this goes hand-in-hand with equity,” Carrasco says. “We can’t talk about health equity when half of our children are malnourished.”

A pilot packs on pounds

Their plan swung into action last August. Carrasco and his colleagues identified 68 children in two CES communities, Soledad and Matasano, who would be their first participants. While raising chickens is common locally, not all Chiapanecan families have the resources to have tried it in the past. So Durantes and his staff invited the family of each child to attend small-group trainings that covered a variety of topics, from the chickens’ proper shelter and nutrition to vaccinations and locally sourced cures for common avian ailments. Once Heifer staff deemed families ready to receive their chickens, they were invited to the clinic to pick up their “package” of 15 birds.

The past year was one of constant collaboration. Durantes and his crew made monthly home visits to follow up on the families’ progress and troubleshoot. And families occasionally reached out to Heifer so staff could admire their latest hatchlings or assess why their chickens lowered their heads to their chest and “were sad.” (Turns out, the chickens were sick.) Meanwhile, CES nutrition community health workers visited the families once or twice a week to talk about diet, hygiene, disease prevention, and how to know when a doctor’s visit was necessary.

The ultimate test, though, came each month during check-ups with the children. CES doctors and nurses measured and weighed them, carefully charting whether a change in diet was having a positive effect.

Halfway into the pilot, Carrasco is proud of the results. At least 14 of the 68 children have grown enough to rise out of chronic malnourishment. There’s been a 15 percent reduction in the number of families who experience moderate-to-severe food shortages. And during especially lean months of the year, families at least have eggs to eat for protein, and they can sell a chicken or eggs to buy other essential goods. These are small victories, but they may be what’s needed to prove the pilot’s worth and garner additional funding.  He would like to extend the program to all 10 CES communities, where he could reach as many as 600 children over a three-year period.

Selena Herrera has firsthand knowledge of the pilot’s success. Her family was among those to receive a package of chickens from Heifer last summer after a CES doctor diagnosed her children with chronic malnutrition. She prepares eggs every day now. Whatever her family doesn’t eat, she sells for extra cash to buy milk and other items formerly considered a luxury.

“This one,” Herrera says, pointing to her daughter standing nearby, “has already gained weight.”

We’re an organization passionately committed to bringing high-quality health care to people around the world. The task is great, time is precious, and the urgency is often palpable. The consensus among staff is that reading a good book is a great way to recharge, especially with longer summer days to enjoy.

Take a look at what books PIH staff are reading this summer. You’ll find Dr. Seuss among global health works, and the Middle-earth book Dr. Paul Farmer has enjoyed since fifth grade.

Add your picks or send us your thoughts! We’d love to hear them.

Rachael Weisz, director of human resources

I love reading books that give me glimpses into other people’s lives. The novel I’m reading now, Preparation for the Next Life, by Atticus Lish, is a love story between an illegal Uighur immigrant and a wounded Iraqi veteran, told in a style like no other book I’ve read. It’s simultaneously heartbreaking and uplifting, and I’m immersed in the lives of characters I have come to care about.

Dr. Askar Yedilbayev, Russia program director

I don’t seem to have time to read for myself this summer, but I do for my kids! I am reading them The Cat in the Hat, by Dr. Seuss. Normally, it’s a different book every day, but The Cat in the Hat is one we have read multiple times.

At work I am reading clinical guidelines on multidrug-resistant tuberculosis. For clinicians in the field, I would recommend having an electronic or hard copy of The PIH Guide to the Medical Management of Multidrug-Resistant Tuberculosis, 2nd Edition.

Leah Nordman, multimedia intern

This summer I am reading The Cruel Radiance: Photography and Political Violence, by Susie Linfield, which my supervisor recommended. While some critics deplore images of political violence and human suffering, Linfield argues they instead connect the viewer to the subject, bear witness to the events pictured, and are key to addressing and alleviating political violence.

It’s a jarring and thought-provoking read for anyone questioning what makes an image morally “right,” and how we can capture human suffering in an appropriate and equitable way.

Dr. Luckson Dullie, executive director in Malawi

My daughter and I are rereading Who Moved My Cheese, a parable by Spencer Johnson about two mice and two men and how they cope with change. As Partners In Health has upcoming discussions with the Ministry of Health in Malawi about expanding our work across the country, I thought now more than ever seemed like a great time to read this book again and gather insight on areas of our work that are in need of change and enhancement.

Oscar Alfredo Ramirez Koctong, program officer in Peru

I’m rereading Dying for Growth: Global Inequality and the Health of the Poor, by PIH Co-founder Jim Yong Kim and others. I first read it three years ago when I found it, a book without an owner, in a box in PIH’s Peru office. It made me more attentive to wider global forces that keep the poor marginalized from economic growth and development. Today I opened the book again and found a fitting surprise: a photo (pictured above) of a group of patients whom we trained on entrepreneurship through one of our projects. I believe most have their own small businesses now.

Jon Shaffer, senior strategist for grassroots organizing

I’d call the book that I’m reading not recommended but required reading for people interested in advancing a right to health. In The Good Project: Humanitarian Relief NGOs and the Fragmentation of Reason, Monika Krause digs into how international nongovernmental organizations consider who, how, and when to serve in communities around the world. She is critical of a financing environment that puts pressure on organizations to produce and sell “good” projects—short-term, time-bound, cost-effective, efficient, and inexpensive projects—that are chosen and implemented without consulting governments, communities, and individuals affected by them. Though Krause doesn’t give concrete solutions, her analysis poses significant philosophical and strategic questions for organizations working to deliver high-quality health care to people around the world.

Erin Gathers, monitoring, evaluation, and quality coordinator

This summer I’m reading Ta-Nehisi Coates’ new book, Between the World and Me. It’s intense. Coates reaches beyond the concepts of race/racism, and forces the reader to confront the lived experience of black people in America.

Here is a quote that stayed with me: “… all our phrasing—race relations, racial chasm, racial justice, racial profiling, white supremacy—serves to obscure that racism is a visceral experience, that it dislodges brains, blocks airways, rips muscle, extracts organs, cracks bones, breaks teeth. You must always remember that the sociology, the history, the economics, the graphs, the charts, the regressions all land, with great violence, upon the body.”

Cecille Joan Avila, multimedia coordinator

Donna Tartt’s The Secret History is a satisfyingly disturbing novel that opens with a murder at a small college in Vermont. Tartt draws the reader into the dark, cult-like world of a group of Classics students, whose decisions and actions reveal the cause of the murder. She manages to make this world seem both surreal and plausible in beautiful prose. Totally fascinating; it’s a book that makes you ask, “Where did five hours of my life just go?” which makes it perfect for long-haul flights.

Dr. Paul Farmer, chief strategist and co-founder

I recommend two great books by great colleagues, Adia Benton's HIV Exceptionalism: Development through Disease in Sierra Leone and Salmaan Keshavjee’s Blind Spot: How Neoliberalism Infiltrated Global Health. For uplift and a bit of a break, everyone should read chapter 70 of Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, “Pleural Effusion and Empyema.” I would also strongly recommend anthropologist James Ferguson’s work in general, and just finished his 2006 book, Global Shadows: Africa in the Neoliberal World Order.

And I’ve read The Lord of the Rings too many times since fifth grade to get much out of it, and so I am enjoying, as a mental palate cleanser, El Señor de los Anillos.

Editor's note: As Paul didn't boast about another book we know he definitely read this summer, we're including it on his behalf. Check out Paul's chapter, "Health-Care Financing and Social Justice," in To Save Humanity: What Matters Most for a Healthy Future, by Julio Frenk and Steven Hoffman.

At 10 a.m. on May 14, in a small Navajo town called Shonto that sits at the bottom of a narrow red-rock canyon, Betty J. John is preparing to set off on her daily rounds.

The 58-year-old tosses a shoulder bag in an off-road pickup, climbs into the cab, and steers her rig for the canyon rim. She splashes across a stream formed by the town’s eponymous spring, past a couple leafy cottonwoods that her grandfather planted, and powers up Indian Route 221, a gravel road cut into the face of a cliff. As she ascends toward 6,600 feet, the clear blue sky unfurls overhead with all its epic, Western promise.

“I was raised down there,” she says. “I didn’t want to be stuck in a canyon.”

She chose the right job. As a community health representative for Navajo Nation, John’s “office” is roughly 1,000 square miles of crinkled brown land just south of the Arizona-Utah border and east of the Grand Canyon. It’s a swath of geologic wonders, thirsty brush, and scattered homes where many people suffer health problems and few have an easy time getting to clinics, never mind hospitals in faraway places like Tucson.

John, who is a certified nursing assistant, plays a crucial role. Like her 98 colleagues in the Navajo Community Health Representative Program, she visits well over 30 patients a month, many of them fellow members of the Bitterwater clan. In their homes, she takes blood pressures, monitors medications, and talks nutrition.

But these tasks add up to much more. By checking in with her patients once every couple weeks, often over years, she develops a deep understanding of their lives and some of the challenges they face. And she plays a key role in maintaining their attenuated link to the standard health care found on paved roads.

“Clinics are always advertising, but I like working in the field,” John says.

Today her plan is to meet with three patients—Linda, Ned, and Marie*—before lunch.

She rattles along, the shiny truck winding through sage and piñon pine, up muscular buttes, down unnamed, unmarked dirt tracks. Ominous, dark clouds walk across the horizon. Not a half-hour after departing Shonto, the fickle high-desert weather is already changing.

John couldn’t be less worried.

“The roads are terrible, but the views are amazing.”

-Betty J. John

John grew up in Shonto, which translates loosely to “sunshine springs” or “water shining on a cliff.” When she was young, her parents’ relationship ended and her maternal grandparents took care of her, raising her in Shonto. John still lives nearby, but on the mesa. When not working, she tends to her fruit and vegetable garden and spends a lot of time with her daughter, two sons, and grandkids. While driving between patients, she opts not to listen to the radio, preferring to sing gospel songs to herself. Her tidy hair bun and pastel-colored nurse’s scrubs belie her ability to break a wild horse.

John became interested in health care at a young age. When she was 6 years old, her grandfather suffered a stroke, and a pastor’s wife made regular visits to look after him.

“After she left, I would pretend that I was taking his blood pressure,” says John.

She worked in several different fields for a couple decades—chef, building maintenance, construction—until angling from senior care into community health in 2003.

“I really, really like it,” she says.

Her patients, ranging from 40 to 98 years old, suffer a variety of ailments that aren’t hard to imagine. Alcoholism is widespread, with some experts estimating that 40 percent of men drink too much. Cancer looms, in part due to late diagnosis. (Smoking rates among Navajo are lower than among virtually all other ethnic groups in America.) Diabetes is also widespread, which reflects the difficulty many have in accessing healthy foods. With a third of Navajo living below the poverty line, many people rely on the affordable, calorie-dense, nutrient-free foods that heighten blood-sugar levels and spur diabetes. Average life expectancy notches just 74 years, which is lower than in any U.S. state.

What caused this horrible situation? That’s a big, messy question. Suffice it to say that the U.S. federal government has not always acted in the tribe’s best interest—beginning in 1864, when the U.S. Army imprisoned or killed all the Navajo it could find, and continuing up to the present, when, for example, the Environmental Protection Agency’s Superfund Program makes slow progress on detoxifying the hundreds of uranium mines it is responsible for on Navajo Nation.

In the last couple decades, however, the Navajo people have begun making increasingly strong pushes for self-determination. John can be counted among them. Though she would never say it herself, she and her CHR colleagues are fierce, frontline defenders of tribal health.

Six bumpy miles and 40 minutes after departing Shonto, John descends from a plateau and turns onto a road no wider than her truck, juniper branches scraping the side panels. A cluster of three houses and a horse paddock appear. It’s the home of Linda, the first patient of the morning.

John raps on the door. A woman’s head appears and says Linda had an appointment that she forgot about until this morning.

John returns to the truck. She knows it can be difficult to find clients at home, especially because the community doesn’t have good cellphone service. 

“You never know when they’re just going to be gone,” she says. “They don’t tell you.”

John drives for another 20 minutes, rounding a point above a green meadow and passing an oversized puddle called Little Lamb Pond, where she and her 3-year-old granddaughter water their horses when they ride together. Easing onto a slick rock bulge, heading toward the scalloped edge of a dark mesa, John notes the wind picking up, blowing dust off the trees.

“It snowed here two weeks ago,” she says.

She sometimes doesn’t head out when the weather threatens to turn nasty like today. A place such as Piute Mesa, near Glen Canyon, can cause problems. Two hours from the nearest paved road, with no cellphone service, it’s just sand—a fine, chalky sand the color of rust. After a rain, it becomes peanut butter. When her truck sunk up to the axles two years ago, she slipped out, grabbed the shovel she keeps stashed in the truck bed, and began digging, mud splattering her scrubs.

“Eventually I got out,” she says, a wry twinkle in her eye.

Ten minutes later, Ned is also not home, it turns out. But a half-hour later John arrives at house three, which is occupied.

Inside the one-bedroom, Marie, 81, and her husband, who appears to be about her age, are lying on twin beds in the living room, adjacent to a soot-blackened coal stove. Marie is one of John’s “high risk” patients—she has diabetes, high blood pressure, arthritis, asthma, migraines, and low platelet count.

“Yá’át’ééh,” says Marie, greeting her in Navajo.

“Yá’át’ééh,” says John.

John has been visiting Marie for five years. Before 2010, Marie was a frequent visitor to the emergency room of the Kayenta Health Center, a small clinic about an hour east. Then a provider recommended she meet with a community health representative, knowing Marie could benefit from working closely with someone in her community. John served Marie’s area, so she asked Marie if it was OK to come by and visit. Marie said yes, and they’ve met roughly twice a month ever since. These days, Marie occasionally receives health care in the ER, but less often than before.

Thanks to improvements like that, the Navajo Community Health Representative Program, which the Navajo Department of Health has run for 47 years, has lately become something of a showpiece. Studies such as this suggest that community health representatives improve patients’ health, lessen the burden on busy hospitals, and keep overall health care costs down.

The Affordable Care Act has bought into them in a big way. The Act allows Medicaid to reimburse for services provided by a community health worker that are referred by a licensed physician, and it sets aside money for so-called State Innovation Models, which are any new initiatives that improve health and drive down costs. Community health representatives—or community health workers, as they are more commonly called—neatly fit the bill. In just the two years since the Act became fully operational, some half a dozen states have launched programs like the Navajo’s, including Texas. Other states, such as New Mexico, have passed legislation to formally certify CHWs. With the Supreme Court’s recent defense of the Act, their popularity seems poised to grow.

PIH sister organization Community Outreach Patient Empowerment (COPE) works closely with Navajo Nation to ensure that the CHR program is as good as it can be. Though the Obama administration has increased federal funding for Indian Health Services for the first time in decades, the funding allocated for CHR programs remains far from flush. (Indian Health Services spends roughly $3,000 dollars per user per year, which is “significantly short of what is required to bring health parity to Native Americans” and roughly one-quarter of what Medicare spends per beneficiary, finds The National Tribal Budget Formulation Workgroup’s “Recommendations on the Indian Health Service Fiscal Year 2015 Budget.”) COPE, based in Gallup, New Mexico, operates on a shoestring budget but shares ample expertise.

COPE staff members, the majority of whom are Navajo, have years of experience working in community health. In Navajo Nation, they collaborate with local partners to create training materials, work with CHRs to teach health promotion skills, help with professional development through leadership and quality improvement workshops, and partner with health facilities to integrate CHRs into care teams.

Currently, they’re experimenting with how iPads might allow CHRs to update patient records in real time, further tightening the link between doctors and patients. Staff also work with a food coalition to spearhead initiatives to improve access to healthy foods in the community.

John and Marie have a good rapport. When someone jokes that Marie has an appointment at a hair salon, Marie doesn’t miss a beat. “Well, if I’m going to be done up, then we better find me a husband,” she says, of the man who has slept right through their chat.

John removes her stethoscope from her shoulder bag. She takes Marie’s temperature, measures her blood oxygen level, and inspects her feet—which have good blood flow and nerve sensitivity for a diabetic but could be elevated more. They decipher the labels on the new generic versions of her longtime medications. And John reminds Marie that she could stand to lose a few pounds. John notes all of this on a clipboard, to be transcribed later into an electronic health record system.

But the most important conversation, health-wise, turns out to be about challenges Marie is having in her home.

Marie moved from her hogan—a traditional Navajo home made of stacked sandstone blocks, the chinks packed with insulating mud—into her current house in the ’70s. At that time, the local Navajo government helped community members attain more modern housing. They dug a well so it had running water, but they weren’t able to connect running water to the house. Years later, they plumbed the mudroom as a bathroom, but the cramped space isn’t handicap friendly—nor was it up to code, as Marie recently discovered when an officer from Arizona’s social services paid a visit.

Since there is no electricity in this area, Marie relies on solar power. However, the solar panel array out front stopped working. A nonprofit had installed it but failed to set up a system for maintenance. It broke recently and now no longer powers the refrigerator or hot water heater.

The coal-burning stove also appears to be leaking. Marie and her husband had family members move their beds into the living room to be nearer the warm stove, but they worried that the fumes might exacerbate her asthma. So the couple stopped using the stove altogether, which finally tipped the scales, causing her recent visit to the hospital where she was diagnosed with pneumonia.

Although the provider likely prescribed the best antibiotic for the pneumonia, it is John’s attentiveness that shines. In the days following the visit, she will see about coordinating other help, and will contact a solar panel repairman in Page, Arizona, who will agree to come out and take a look at the inverter.

“I’m there. I’ll clean house, chop wood, haul coal, if I have to,” she says.

After leaving, John turns back to Shonto. She has a busy day, not to mention week, ahead of her. First off, she needs to catch up on some patient paperwork, in addition to logging every mile she has driven and minute she has worked. Then, of course, there are her visits to many other community members, including Linda and Ned.

A half-hour and seven miles from Marie’s house, the puffy, black-bottomed clouds that have been casting shadows on the ground finally open up. Hail pelts the windshield.

But getting stuck won’t be a problem today. John timed it right. She is already descending into Shonto, on Indian Route 221, right beside the water-slicked canyon wall, which shines like a mirror.

*Patient names have been changed for privacy.
 

Cholera is a centuries-old disease, but it’s a relatively young scourge in Haiti. It entered the country in October 2010 when contaminated sewage from a United Nations peacekeepers’ camp leaked into one of the largest water sources, the 200-mile Artibonite. There have since been more than 745,500 cases of cholera and nearly 9,000 deaths, according to Haiti’s Ministry of Public Health and Population.

The disease is a day-to-day battle for health care professionals working with Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti.

There’s an immediate side to eliminating cholera, which requires identifying and treating patients for a potent diarrheal disease that could kill within 24 hours. And then there’s the long-term side, which requires infrastructural and behavioral change.

In 2012, Haiti government officials crafted a 10-year national plan to eliminate cholera by responding to both sides of the epidemic—curing those who are ill and preventing further infections by improving water, sanitation, and hygiene (WASH) in rural and urban areas. To support those efforts, ZL formally began a WASH program in January 2014, applying its nearly three decades of expertise in programs related to health; water, sanitation, and hygiene; and disease control. The WASH team promotes behavioral change and supports the construction and rehabilitation of water and sanitation infrastructure at ZL- and government-supported clinics, hospitals, and schools.

“At the end of the day, if people are dying from preventable water-borne diseases, no amount of medicine or health care access will make a difference,” says Elizabeth Campa, ZL’s senior health advisor and advisor to the WASH program. “Without WASH, we do not have health.”

WASH staff face an uphill climb. Haiti is the most underserved country in the Western Hemisphere in terms of water and sanitation infrastructure, according to a 2012 report by the World Health Organization and UNICEF. Only 69 percent of the population has access to a clean water source and 17 percent had access to improved sanitation facilities in 2010.  The latter is comparable to some countries in sub-Saharan Africa and far below the regional average of 80 percent for Latin America and the Caribbean.

The work of the WASH team was critical during the most recent waves of the cholera epidemic, and for the past two years, its rapid response team helped chlorinate water, disinfect homes, provide hand soap, and offer referrals to mobile cholera treatment centers.

WASH is also focused on long-term, community-based programs, such as Communautes Assainies (Healthy Communities). Its goal is to reduce the prevalence of diarrheal diseases by 25 percent in 20 communities in and around Mirebalais and Cerca-La-Source within a 16-month period.

Since October 2014, the WASH team has supervised and provided technical support for community members who have built nearly 700 household toilets. The goal is to expand that number to 2,000 by January 2016. The team will also oversee the construction of water and sanitation facilities in 20 schools and five health centers over that same period.

A resident of Trianon in Mirebalais built this low-cost household toilet under the supervision of the ZL WASH team.

A major, yet less visible, part of WASH's work involves improving social norms regarding hygiene and sanitation. The WASH team meets regularly with local leaders to understand common practices. Together they decide when to gather the larger community to inform residents on cholera’s reach in Haiti, its transmission through contaminated water, and its broader economic and social impacts. During those meetings, a volunteer committee is selected and asked to develop a plan for the community’s eventual certification as “open defecation free” (ODF). A local resident is chosen as the WASH community agent, tasked with smoothing neighbors’ transition to a new way of life.

Once activities are in full swing, WASH staff provide advice to community members on the proper location and maintenance of household toilets. Government officials and local representatives assess the community after several months' work and award ODF status once that goal is reached. They also continue to monitor the community to ensure residents remain faithful to their plan.

WASH can already point to success stories. Jeremy, a town in Cerca-La-Source, was certified this month an ODF community, and other towns have built dozens of household toilets and are working to change behavior regarding sanitation and hygiene—arguably the more difficult of the two steps.

Other WASH community projects under way in the Central Plateau include improving water, sanitation, and hygiene facilities in the Belladere hospital and Lacolline School in Lascahobas. And next year, WASH will begin improving facilities at 25 ZL- and government-supported schools.

“All our kids in the ZL network of schools will have a safe place to relieve themselves and access to water points for drinking and washing their hands,” Campa says. “My hope is that this project will plant a seed in our kids’ lives on the importance of sanitation, clean water, and good hygiene behavior.

“Adolescent girls will likely not miss so much school because they'll have a safe place to wash during their menstruation,” she adds. “And our team is striving to target the parents of these kids too in constructing their own household sanitation. The possibilities are endless.”

Mónica Córdoba isn’t the type to brag about the work she does. Since she was little, she’s wanted to take care of people. That desire translated into a nursing degree 17 years ago. She’s worked nearly ever since out of a clinic in her home community of Capitán, a rural village in the mountains of Chiapas.

But Córdoba is anything but typical. She has traveled up to 12 miles in a single day—by foot or donkey —up and down mountainous terrain and across rivers to visit patients in their homes. She’s vaccinated children. She’s checked on pregnant women. And she’s identified patients with tuberculosis and gotten them on treatment plans. It should be the work of an entire health care team, but she’s done it mostly by herself, with only occasional help from doctors who spent several weeks in the community before asking to be transferred to a less remote location.

In honor of her steadfast service, Córdoba was awarded the Lucia Salcido national nursing prize by Mexico’s President Enrique Peňa Nieto and Minister of Health Dr. Mercedes Juan at a ceremony on April 7 in Mexico City. The 40-year-old nurse was among 12 recipients nationwide who got a medal and cash prize in recognition of their efforts. Her picture even appeared in an article in the national newspaper La Jornada.

Córdoba says she couldn’t believe she won the award, claiming that other nominees had more education, specialization, and worldly experience.

But Dr. Nadia Sanchez could. “She deserves the prize,” says Sanchez, a social service doctor working with Compaňeros En Salud (CES)—Partners In Health’s sister organization in Mexico. She and Córdoba’s supervisor at the Ministry of Health nominated the nurse. “It doesn’t take into account where you study, if you are a professional, or are very specialized. It’s more a recognition of your work and effort.

“There had never been a (full-time) doctor in the community of Capitán until I arrived” in August, adds Sanchez, who is among 10 CES pasantes, or social service doctors, working alongside community nurses throughout Chiapas. “Monica always had done the work of a doctor and a nurse.”

Shortly after completing her exams in Tapachula, Córdoba married and moved to Capitán, where she has served for the past 15 years. Sanchez describes her colleague as responsible, energetic, and dedicated to service. The nurse checks vital signs at the clinic, conducts vaccination campaigns, helps her with consultations, treks along on home visits to five surrounding communities, and completes all patient paperwork.

Córdoba has taught the doctor how to properly care for patients far away from big, urban hospitals and to be always open to provide care—regardless of the time of day.  

“It doesn’t matter if it’s late at night or 3 in the morning,” Sanchez says. “She is always available.”

At the Liberian national nursing exam, a stressful two-day affair at a dilapidated hospital in the capital of Monrovia, 10 students stood out even before the first pencil was raised. They were in their early 30s, unmarried, and sharply dressed. They looked just like their dozens of contemporaries from private universities in the north, but word quickly spread that these 10 were from a public school, called Tubman University, 20 hours’ drive south.

“The other students could not believe that people from a rural part of Liberia were going to sit the exam,” recalls Malcom Smith, a Tubman student in the exam.

Smith and his schoolmates didn’t just sit it, they aced it. A couple weeks later, the Tubman students found out they had all passed, becoming the first graduates from a public university to earn a nursing license in Liberia in decades. “I am so happy,” says nurse and Tubman graduate Joe Davies.

So are others, including friends at Partners In Health, who had a chance to help the class along. The nurses triumphed over huge challenges. And if Liberia is going to rebuild its civil-war-battered, Ebola-splintered health system, then it needs pioneers like Tubman’s new nurses to prove that great things can be achieved in the face of long odds.

“We are so proud of these nurses and so incredibly happy for Tubman University,” says Heather Bedlion, PIH’s director of nursing in Liberia.

The nurses entered primary school during the beginning of the Liberian civil war, a bloody struggle that lasted, with brief respites, from 1989 to 2003 and killed some 250,000 people. They studied through the crossfire, the drugs, the rival warlords’ ritual killings.

Peace didn’t make things easy. After graduating from high school, they had the choice of attending roughly a dozen expensive private schools, mostly far away in the cosmopolitan north, or nearby Tubman University, which offered a nursing program starting only in 2009. They all enrolled in that inaugural class, became friends, and studied hard, some using textbooks for the first time.

“People can’t even imagine the work these students had to do to get where they are,” says Iona Thomas-Connor, chair of Tubman’s department of nursing.

Ellen Johnson Sirleaf, the president of Liberia, spoke at their graduation in June 2014; sadly, she was also the one to share a fresh batch of bad news just weeks later. With the Ebola epidemic looking like it might spiral out of control in Liberia, Sirleaf clamped down on non-essential travel and the annual nursing exams were postponed indefinitely.

The students did not sit idle. They worked as aides at a nearby hospital, sanitized the Harper Ebola treatment unit that PIH helped operate, checked temperatures at road blocks, and more. According to The Lancet, nearly 10 percent of the doctors, nurses, and midwives in Liberia, some 83 health care professionals in total, died from Ebola, many during that fall. The students survived in part thanks to their vigilance, in part thanks to arguably their first bit of good luck. Compared to the rest of the country, their corner of Liberia got off easy with just a few dozen cases.

After the Ebola epidemic began to come under control in Liberia in December 2014, the make-up exam was scheduled for June 4 and 5, and the students started the hard task of refreshing their memories. PIH clinicians, assisting the Ministry of Health in rebuilding the health system, jumped at the opportunity to work with professors at Tubman University to organize formal review classes. Nurse and short-term clinician Cristina Congdon led all-day tutorings each Saturday for three weeks and then a three-day cram, complete with practice tests.

The group finally arrived in Monrovia in June. Day one of the exams covered general medicine, surgery, obstetrics and gynecology, and communicable diseases. Day two, pediatrics and psychiatry.

They breezed through each test in less than the two hours allotted. “We were the first to finish every time,” recalls nurse Davies. “The test was like a study session, like a mirror before us.”

Joe Davies, Godfred Dossen, Webster Forkpah, Morris Jarka, Mark Quitee, Esther Scere, Malcolm Smith, Quayee Toe, Rufus Wilson, and George Wlateh all passed.

Perhaps even better, fully nine of the 10 have returned home to apply for jobs in the slowly growing number of clinics in the rural south. Rather than seek bigger salaries at hospitals in northern cities, they will consult with thousands of patients who have never had the chance to talk with an expert in scrubs.

“Rural nurses are a foundation of a health system,” says Dr. Anany Gretchko Prosper, PIH's executive director in Liberia.

“We call ourselves the 'agents of change,'” says nurse Davies.

Cecilia Kanjadza, 19, scanned the local newspaper in Neno, Malawi, for her name while standing in Partners In Health’s office. It was a moment she wanted to share with PIH staff. Earlier that day she had received a phone call letting her know she had been accepted to college. The newspaper, containing university admissions, would confirm this.

Edwin Kambanga, a PIH officer, laughed, recalling her delight when she found her name listed under Mzuzu University’s degree program: “As soon as she saw her name in the newspaper, she screamed, clapping her hands. She said, ‘This is wonderful!’”

The chance to pursue a bachelor’s degree is truly something to celebrate for Kanjadza and PIH. She is the first girl to be accepted to university from a public high school in Neno, a remote and poor district in the south of the country with a population of 150,000. Families struggle to help their children reach high school let alone university—a pipe dream for most, and certainly for girls without private schooling. Kanjadza is exceptional, both because she worked hard despite significant challenges, and because through a PIH program she was able to pay for her schooling.

Kanjadza’s victory is preceded by many difficult years for her and her family. Her father passed away when she was four and all his possessions went to his relatives. Kanjadza and her brothers and sisters—she is the fifth of six children—were left with nothing. Her mother decided to leave the country’s second largest city, Blantyre, population 1 million, and move the family to Neno, where they live in a small village called Kambale. For six months the family survives on maize they grow in their garden. The rest of the year, her mother must try to find work on nearby farms.
 
To have the financial stability to look after her mother was Kanjadza’s greatest wish. Although she doubted she would go to college, she let herself dream about it. She excelled in math and science classes. Her favorite teacher, Emmanuel Soko, spotted her talent and encouraged her to continue her education.

Doing this would require resilience as well as brains. Schools don’t always have enough teaching materials; libraries and laboratories are a luxury; and for most students, studying ends when the sun sets (95 percent of the population does not have electricity, according to the 2010 Malawi Demographic Health Survey).

Facing these difficulties and financial problems, parents are forced to withdraw their children from school. In PIH’s view, this is a devastating outcome for poor families who, without education, face worsening job prospects and have little hope of improving their situation. Without the money to live safely and comfortably with adequate housing and nutrition, their health will inevitably suffer.

This is why PIH began POSER, the Program on Social and Economic Rights, which addresses social problems that impact an individual’s health. Kanjadza and her siblings receive support from POSER, which she says was the reason she was able to stay in school. POSER supported 2004 students last school term, including 948 girls. With uniforms, exercise books, and school fees paid for by PIH, Kanjadza excelled in high school.

Kambanga, who works closely with Kanjadza and other families through POSER, knows what this means for Kanjadza’s future. “What we like to see when we support students is that their lives change,” he said. "Once they go to university, they get a good job and are able to sustain themselves and their families."

It’s a shared victory for PIH and Kanjadza. After that initial phone call about her university admission and a dance of joy in her house, Kanjadza was quick to come to PIH’s office. “If there were no PIH, I could not have got into university,” she said. “I wanted to let POSER staff know.”

Amidst the excitement, there is the hope that Kanjadza’s story will become more common. Members of her community, intimately aware of the challenges she has faced, are now hopeful for other students. “I would like to encourage more girls to follow her example,” said Reuben Menyere, the district education manager. Younger girls have already approached her for advice on reaching college. Proud to be a role model for her community, she beams and advises them to work hard and believe in their goals.

In late June, Partners In Health staff and colleagues published a study on a groundbreaking medical device. Appearing in The Lancet, the study shows that a portable, fast-working Ebola test called ReEBOV was widely effective.

The trial took place in Sierra Leone in February. A clinician pricked the finger of a patient suspected of having Ebola, placed a drop of blood on what looks like a plastic spoon, and less than a half hour later, a small strip of paper indicated whether the patient had Ebola or not. After 106 such tests, the authors found that ReEBOV was just as accurate as lab-based tests.

It’s great news. Getting results from a lab-based test can take days and of course requires a full-blown lab. ReEBOV, on the other hand, is speedy, easy to transport to wherever it’s needed, and presumably more affordable. While maybe not a “game changer”—as CBS News claimed, parroting a press release from the ReEBOV manufacturer—it’s a terrific new tool. Along with topnotch hospitals and clinics, well-trained doctors and nurses, ample stocks of medicines and supplies, ReEBOV could help snuff out future Ebola outbreaks before they become epidemics.

Partners In Health is launching a new initiative in Rwanda—the University of Global Health Equity (UGHE). A different kind of university, UGHE will harness the best ideas in higher education and integrate cutting-edge technology platforms with immersion in complex health care delivery systems.

Owned and operated by PIH, UGHE is a private institution that will leverage expertise and resources from the government of Rwanda, Harvard Medical School, and key partners to create a forum for delivery-focused teaching, research, clinical care, and implementation. Classes will be taught by local and international experts including Harvard Medical School faculty. Students will learn from a broad network of global policymakers, leading research scientists, community health workers, and social entrepreneurs. UGHE’s academic programs aim to cultivate global health leaders with the vision to tackle consequential challenges and the pragmatic leadership skills to effect transformational change.

“UGHE will train the next generation of Rwandan and global leaders in health care delivery, making Rwanda an international hub for delivery science,” said UGHE Executive Director Dr. Peter Drobac. Drobac will teach an innovative course this September that explores key principles of global health.

PIH has focused on delivering high-quality health care and social services in some of the world’s poorest communities for nearly 30 years. For the past decade, PIH has worked in close partnership with the government of Rwanda, helping to strengthen a health care system that has achieved record improvements in health. This new university is an exciting next step for PIH in Rwanda.

UGHE is actively recruiting students to participate in the inaugural Master of Science in Global Health Delivery (MGHD) degree, which begins in September 2015. The MGHD will be the university’s flagship program, providing a one-of-a-kind learning experience rooted in the principles of global health delivery and One Health, and incorporating policy, management, finance, and leadership. Students with professional experience in health care management and administration, veterinary science, policy, and research will have opportunities to connect and collaborate with global health colleagues and peers throughout the program. Over the coming years, UGHE will add programs in undergraduate medicine, nursing, and dentistry, and graduate programs in veterinary medicine and health management.

Rwanda’s Honorable Minister of Health, Dr. Agnes Binagwaho, a Harvard Medical School senior lecturer and UGHE professor, is passionate about the university’s launch. She looks forward to teaching biological and social determinants of health.

“I have always dreamed that putting academic rigor into health sector management at all levels—local, national, regional, and beyond—would greatly improve the health of the population,” said Binagwaho. “This is exactly what UGHE will do for Rwanda and for the world. I am so excited to be part of this outstanding initiative.”

The two-year, part-time program is designed to complement students’ full-time jobs and scheduled so that students can remain employed. Beginning with a week in residence in Rwinkwavu, the course will meet one night per week in Kigali and one weekend a month in Rwinkwavu, while the first of two state-of-the-art permanent UGHE campuses is under development in Butaro.

Those who wish to apply can visit www.ughe.org.

Rwanda has long been a front-runner in the race to achieve the Millennium Development Goals, those eight benchmarks in health, education, and other areas that United Nations member states aim to hit before the end of 2015. A report out this month shows that the country might be even farther along than expected.

Rwanda’s Demographic and Health Survey—which includes information on everything from HIV prevalence to infant mortality, assembled from a survey of thousands of homes—shows big gains since the last such study, released in 2010. Highlights? The number of women dying from complications due to pregnancy or childbirth dropped by half, to roughly 1 in every 475 births. The chances that a child will die before age 5 decreased to 1 in 20—still high, but a 35 percent reduction nonetheless. And virtually every young boy and girl is still vaccinated against basic diseases such as polio. Looking back at the state of health care in 1990, as the Goals do, Rwanda’s advances appear flat-out terrific.

"In the 30 years that I've been involved in the provision of health care services to the poor and marginalised, I can think of no more dramatic example of a turnaround than that achieved in Rwanda," PIH Co-founder Dr. Paul Farmer told The Guardian.

Credit goes to the Rwandan Ministry of Health, which considers providing equal access to high-quality health care an imperative, and to PIH sister organization Inshuti Mu Buzima. Since 2005, PIH/IMB has partnered with the Ministry of Health to build hospitals, train nurses, accompany patients through treatments, and make sure that even the most rural farmer has easy access to a well-equipped expert in scrubs.

What does this mean for Rwanda’s shot at becoming a Millennium Development Goals champion? The government promises a thorough analysis of the data soon. And a U.N. spokesperson says they will publish a progress report on the Goals on July 6. But when staff, officials, supporters, and community health workers gather for IMB’s decennial in Kigali on July 7, the party will certainly celebrate big achievements—and maybe even Millennial milestones.

More reading:

Farmer Paul E, Nutt Cameron T, Wagner Claire M, Sekabaraga Claude, Nuthulaganti Tej, Weigel Jonathan L et al. Reduced premature mortality in Rwanda: lessons from success BMJ 2013; 346 :f65

http://www.bmj.com/content/346/bmj.f65

Binagwaho, Agnes et al. Rwanda 20 years on: investing in life The Lancet 2014; Volume 384 , Issue 9940 , 371 - 375

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext

Whenever he wasn’t at school or helping his family in the coffee fields, Meynor Perez loved playing basketball. For the last couple of years though, he wasn’t up to it. He felt feverish. He was tired constantly. And he preferred staying inside his home in rural Chiapas to going out to shoot hoops.

There was something else that worried his family—their little boy with a wide, toothy grin had a mass in his neck that had been slowly growing and was now the size of a baseball.

“People made fun of me, saying that I was going to die,” Perez says. Some would even chant, “’Tú al hoyo, y los vivos al pollo.’” A childish rhyme that, loosely translated, meant he was going to the grave and they, the living, were going to carry on without him. His classmates even started to hit him. “I didn’t defend myself because I don’t like to hit,” says the 12-year-old. “Maybe they thought I was a coward or stupid.”

For two years, Perez’s family tried herbs and olive oil treatments thinking they would help. They even took him to a traditional healer who brushed him with a small branch and tied a handkerchief around his neck. For that, the family paid 1,000 pesos—more than one month’s salary. Nothing helped. Until he visited Azucena Espinosa, a social service doctor, or pasante, working in Laguna del Cofre with Compaňeros En Salud (CES)—Partners In Health’s sister organization in Chiapas.

Espinosa examined Perez in March 2014 and his symptoms immediately sent up red flags. With the help of CES clinical director Patrick Elliott, she presented Perez’s case to her fellow pasantes, who meet monthly at CES headquarters in Jaltenango for global health seminars. The young doctors strongly suspected the boy had a malignant form of Hodgkin lymphoma and that he needed immediate care.

Although the incidence of lymphoma has not been widely studied in Mexico, a 2015 article in Cancer Causes & Control provides a glimpse of the cancer’s reach in the capital, Mexico City. The overall incidence of lymphomas between 1996 and 2010 was 11.8 per one million children per year. For Hodgkin lymphoma specifically, it was 4.4 per one million children. While this is significantly lower than rates found in the U.S. and Europe, it is similar to rates found in African countries.

Getting Perez to care was easier said than done. He lived an hour’s walk from the Laguna del Cofre clinic. His parents, coffee farmers like most of their neighbors, were barely making ends meet for their family of 12. Finding additional resources to pay for transportation, food, and lodging throughout their son’s treatment was daunting.

“Laguna del Cofre is a place with a lot of poverty, but this boy was an extreme,” Espinosa says.

Thankfully, CES’s Right to Health Care team stepped in. Elliott, Espinosa, and Valeria Macías—the team's coordinator at the time—organized every detail of Perez’s treatment, from paying for medical bills and arranging transportation to doctors’ appointments to finding food and lodging for the boy and his family when he had to travel to distant hospitals for specialized care.

Perez’s first appointment was six hours away in Chiapas’s capital of Tuxla Gutiérrez, where doctors performed a biopsy and conducted tests on the growth in his neck. Espinosa’s diagnosis was accurate; her patient had Type 3B Hodgkin lymphoma, one of the cancer’s most aggressive forms.

Perez was immediately put on chemotherapy. He traveled to Tuxla Gutiérrez for his treatments for eight months, and every month the Right to Health Care team provided him and his family with the logistical and emotional support he needed to make it through. When he returned home after each session, Espinosa monitored his progress and gave him injections meant to stimulate the production of white blood cells.

“One of the side effects of chemotherapy is that it causes immunosuppression,” Elliott says. “Azucena had to be an observant clinician and take him through some really risky points in his care when he was outside of tertiary care centers and at home at risk of developing severe infections.

“That’s a lot for one young clinician to manage,” Elliott adds, considering such care is otherwise managed by an oncologist and a team of specialists.

The treatment was a lot for Perez to bear too. He didn’t eat, vomited, always felt dizzy, and was often in pain. Despite the side effects, he made the hourslong, monthly trek to visit Espinosa for his shots, sometimes with his younger siblings in tow, and sometimes alone—his mother’s arthritis was often so severe she couldn’t move for days.

Once he finished chemotherapy, Perez needed radiation three times a week for nearly two months. But no hospital in Chiapas was equipped for that level of care. The closest such facility was in Campeche, a city at least 12 hours away that bordered the Gulf of Mexico. Again, the Right to Health Care team accompanied him and his mother so that they could stay close to the hospital during his treatment.

Perez had plenty of reasons to feel down—the chemo, the radiation, and the distance from nearly everyone and everything he knew. Instead, he was excited about going to Campeche. After all, he’d never seen the ocean, and he could visit the beach there every day. “The people were very kind,” he says. “They told me that whenever I wanted to return, I was welcome.”

Espinosa was shocked when she saw Perez again. He’d gained a lot of weight. Even more surprising, he’d completed his treatments without any complications and showed no symptoms of Hodgkin lymphoma.

Several weeks ago, Espinosa—now CES’s Right to Health Care coordinator—went with Perez to his oncologist for follow-up tests. The results? She’s happy to report that he is officially in remission. The whole experience confirmed her desire to work in pediatrics. Only now, she wants an additional specialty in oncology.

Had Espinosa not been there, she and Elliott agree that Perez’s story wouldn’t have had such a happy ending. But the young doctor hesitates to say she saved his life: “I only did what I had to do—fight as much as I could for the life of a child.”

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

In this series, we ask a seasoned colleague to share professional experiences with those interested in forging a career in global health. For this edition we asked Shin Daimyo, clinical program officer and program manager for mental health.

As an undergraduate at the University of Southern California in 2005, I was fortunate enough to take a service trip to the Navajo Nation, a large tribal area in the Southwest. At a traditional ceremony one day, a Navajo leader introduced himself with the standard greeting Ya’at’eeh and spoke of some of the hardships that the Navajo faced. While we talked, he stressed how important it was to care for your own and to care for those who were the most vulnerable.

I’m the first generation of my family to grow up in the United States. My mother is from Vietnam and my father is from Japan, and I spent a good deal of time with the Vietnamese boat-person refugee community in Los Angeles, CA. Many of them fled political persecution during the Vietnam War and braved treacherous journeys across the Pacific Ocean in small boats. Growing up, I admired their strength and resolve to build better lives for their families, but was also struck by how difficult it was for them. They sacrificed so much to escape persecution, but found themselves suffering new hardships. Something about the Navajo leader’s call for empathy resonated with me that day. Actually, it did more. It set me off on the long, hard, and deeply rewarding career path I’ve been pursuing ever since.

Back at USC, I changed my major from business to psychology, and over the next couple of years, I researched depression and phobia treatments for Asian Americans and systems-based interventions for at-risk Latino populations. My time in Cyprus, learning about the long-running tensions between Turkish and Greek Cypriots, and the complex psychological consequences that accompany the Cyprus problem, shifted my passions globally.

I decided to pursue a master’s degree in public health at Boston University. While there, I won a fellowship through Duke University to work at the World Health Organization to develop global mental health policies. The work was incredible, but I still felt I was missing a key piece of the puzzle. Policies tended to be general and broad; it was unclear how to translate them into culturally sound and locally driven global health services.

Wanting to see how things actually happened on the ground, I took a job as a health systems and quality improvement advisor for four hospitals in the Kingdom of Lesotho. While it only paid a stipend and housing expenses (and I shouldered significant debt), I learned the invaluable lesson of how to integrate specialized health services (HIV, tuberculosis, and mental health) into the primary care system in a low-resource setting. It also revealed how supply chains, finance, management, monitoring and evaluation, and supervision are as critically important as high-quality clinical expertise. Overall, it helped me connect big-picture policy and systems thinking with practical strategies for how to get services to those who needed them most.

I felt like I was finally carving out my niche in global health, but after returning to the United States from Lesotho, finding a job in that niche proved hard. Despite emailing professors, applying for openings, and working connections for months, I couldn’t find a position in global health, let alone one in global mental health. Still strapped for cash and deep in debt, I almost gave up. But I was lucky enough to get a health-policy job that taught me about how to improve health care quality (and make it more equitable for all people, not just those who can afford it). Soon after, I got a job working in global mental health, managing programs for victims of torture and natural disasters.

I ended up at PIH because friends and colleagues vouched for my passion for the work and for my ability to make that passion a reality. If there has been anything I’ve learned in this work, it’s to surround yourself with people who challenge you and share your passion for social justice, and whom you genuinely like. Not only did that help me get my job at PIH, but it has made my journey a much more fulfilling and enjoyable one.

It has been an incredible three years at PIH. But as I write this, I am actually about to do something I never thought I would do: leave PIH. Supported by the community of the Paul and Daisy Soros Fellowship, I’m going to Yale School of Nursing to become a psychiatric nurse practitioner.

Why I’m doing this takes a bit of explaining. At PIH, I’ve had the privilege to work with colleagues to build sustainable, high-quality mental health systems for the poorest and most vulnerable people in the world. When I visit our most rural clinics, the majority have very few staff doing everything they can to serve those in need. But no matter what, there is always a nurse.

Our nurses, along with our community health workers, are often tasked with providing care to the most marginalized patients. I believe that integrating advanced levels of psychiatric and psychological care in general nurses (and raising the profession of advanced-practice nursing) will be key in ensuring that the mental health burden is addressed in a sustainable and impactful way.

What have I learned in my career so far? Do what you know is right, even if it is the hard thing to do. Do it even though all those around you doubt you. Do it even if all those around you berate you. The suffering of others should never be taken as the status quo, and you should refuse to ever believe anything else. The journey is long and hard, but I cannot think of a more deserving cause to devote your heart to than those who suffer without a voice.

Haiti is still grappling with a pernicious cholera epidemic nearly five years after the disease’s first appearance in the country. Cases spiked from 1,000 per month last summer to 1,000 per week in the fall, according to Haiti’s Ministry of Public Health and Population. There were nearly 8,400 cases in January and February alone and 82 deaths—twice as many cases and three and a half times as many deaths over the same period last year.

Beyond Port-au-Prince and its suburbs, the Artibonite and Centre regions—the hub of operations for Zanmi Lasante (ZL), Partners In Health’s (PIH) sister organization in Haiti—have been among the hardest hit, especially the communities of St. Marc, Mirebalais, Hinche, and Lascahobas. There were 5,179 cases across all PIH/ZL sites in 2014. The worst spike was over the last four months of the year, peaking at 808 cases in November alone. That monthly tally slowly declined and then bumped back up to 540 cases in March this year. So far, PIH/ZL staff are seeing two or three times as many patients in 2015 as they did over the same period last year. 

This wave of cases is like a recurring nightmare for Dr. Ralph Ternier. A big part of his job as ZL’s director of community care and support is to prevent the disease’s spread, which can be as simple a task as reminding patients to wash their hands with soap and water. But patient follow-through is the tricky part. They often ask him, “’Where am I going to find soap and water?’”

That’s the reality for many Haitians. About 40 percent lack access to clean water, and only one in four have access to a sanitary toilet, according to the World Bank. Even if they do have safe water and proper sanitation, “many Haitians are so poor that they're literally choosing between buying soap one day or buying food for their family or for their children,” Dr. Louise Ivers, PIH’s senior health and policy advisor, told NPR in a recent interview. The World Bank reports that more than half of Haitians live under the national poverty line of less than $2.50 per day.

Cholera spreads when people come in contact with contaminated sewage, usually through consuming unclean food or water. This happens with relative ease in communities without proper latrines, and where torrential downpours during Haiti’s rainy seasons in the spring and fall cause daily flash floods. People who contract cholera suffer excessive vomiting and diarrhea and can die of severe dehydration within 24 hours.

Haiti never knew cholera until 2010. That’s when the United Nations flew in a group of peacekeepers from Nepal, whose capital had recently suffered an outbreak of the disease, and set them up in a camp with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in the country, the 200-mile Artibonite. Since the first person was diagnosed in October 2010, there have been more than 739,000 cases of cholera and 8,900 deaths, according to Haiti’s Ministry of Public Health and Population.

So why does cholera continue to plague Haiti, and PIH/ZL sites, five years after the initial outbreak?

“We haven’t gotten rid of the reasons for the transmission of the bacteria, and that’s because there’s such poor water and sanitation,” Ivers says. Since the outbreak began, “there have been no transformative water and sanitation activities, and so the underlying problem is still there. I think that’s why the number of cases has started to go up again.”

Ivers also says numbers may be higher where PIH/ZL operates because the Centre region is one of the poorest in the country and, therefore, has limited water and sanitation infrastructure. Plus, staff actively record cholera cases, something that is not true everywhere in the country because human resources are lacking. A full count of the disease could be much higher nationwide.

In response to the epidemic, the governments of Haiti and the Dominican Republic proposed a 10-year, $2.2 billion plan to eliminate cholera, including investments in new water and sanitation systems. But that plan, announced in 2012 and supported by an international community of donors, is only 13 percent funded.

Some advocates believe the U.N. should shoulder more of the burden for cholera in Haiti. Brian Concannon and the non-profit he co-founded, the Institute of Justice and Democracy in Haiti (IJDH), has requested the U.N. accept responsibility for the initial outbreak. (For more on the international body’s role in the epidemic, see Ivers’s op-ed in The New York Times.) The IJDH filed a lawsuit against the U.N. in U.S. federal court in 2013, but a judge dismissed the case in January 2015. The organization is now appealing that ruling.

Meanwhile, Ternier and his staff do what they can to halt the most recent spike in cases, as they’ve done with others in the past. They mobilize a network of community health workers to find patients, open rehydration posts in remote locations, educate people about proper hygiene and sanitation, and diligently work to bring reliable water and sanitation systems to the region.

More comprehensive work needs to be done. In a 2010 article published in The Lancet (“Five complementary interventions to slow cholera: Haiti"), Ivers and Dr. Paul Farmer, a PIH co-founder and chief strategist, laid out a detailed roadmap to break the cycle of cholera. They wrote that health care professionals have to aggressively find and treat cholera cases and administer vaccines such as Shanchol, which Ivers and her colleagues found reduced the number of cholera cases by 63 percent among those vaccinated in villages north of St. Marc. Water and sanitation systems need to be improved. Public health care systems have to be strengthened. And global health policy must be crafted to give cholera the level of attention it deserves.

All this takes time, something that isn’t always on the side of Ternier’s patients. Regardless, he keeps treating them for cholera and reminding everyone of the message he’s repeated for years. He knows “this is not something that we’re going to solve in five years.”

But it is something PIH/ZL knows how to tackle, and will, for as long as it takes. 

The Wall Street Journal takes a look at the challenges facing Liberia and Sierra Leone’s Ebola-wracked health care systems, and Partners In Health’s efforts to help in each country:

HARPER, Liberia—J.J. Dossen Memorial Hospital, on the southeastern tip of this nation recently declared free of Ebola, has three doctors and spotty electricity. Sixteen of its 46 nurses left during the Ebola crisis. When two motorcycle accident victims needed X-rays, the hospital dispatched them in its only ambulance on a bumpy eight-hour ride to the nearest facility with a machine.

The deadly disease may have receded, but it is still exacting a heavy toll. Run-down, poorly staffed and equipped health facilities allowed Ebola to explode. Since it was identified in early 2014, the epidemic has claimed the lives of 507 health-care workers in three West African countries, all of which already were short of medical professionals. The health-care system was so overwhelmed with Ebola victims that many other patients couldn’t receive care for malaria, heart disease or pregnancy complications. That bill is coming due.

“There are more people who are going to die from Ebola, but not have Ebola,” says Paul Farmer, a Harvard professor and co-founder of the Boston-based charity Partners In Health.

Read the full article.

Adama Nylenkeh began her professional life as a volunteer ambulance nurse in Sierra Leone in late 2014. The 24-year-old Sierra Leonean quickly developed a reputation for grit, humility, and creativity and in February, Partners In Health (PIH) hired her as a program coordinator. Then in May, just four months later, she became a program officer. The promotion made her career trajectory one of the steepest at PIH, and it was hardly a fluke.

“She stands out in every single way you could imagine,” says former short-term clinician Martha Phillips, who worked with Nylenkeh.

Nylenkeh’s career didn’t start out so promising. She graduated from Njala University, in the southern Moyamba District, with a bachelor’s degree in public health in 2014, just as the Ebola epidemic erupted in West Africa and the economy, which had been racing, ground to a halt.

On a lark, she applied to be a volunteer ambulance nurse in Port Loko District, some 60 miles north of Moyamba.

“There was nothing else to do,” she explains.

She wasn’t trained as a nurse, but the job didn’t actually require it. Was she willing to spend days in a hot metal truck, separated from patients by just a thin wall of glass? When she said she was, the National Ebola Response Center promptly enlisted her.

Up to three times a day, she and a driver transported up to a half-dozen patients at a time down rutted and potholed roads to a handful of treatment units, including Port Loko's PIH-supported Maforki Ebola Treatment Unit. Nylenkeh didn’t just slip the receiving clinicians a piece of paper with a couple patient names, as was customary. She described symptoms, gathered info to report back to families, and asked how she could help. If need be, she detoured to collect lab results so diagnosis could be made more quickly. And when triage units were overwhelmed, she donned Tyvek suits to help admit patients.

“I don’t know why I was doing these things,” she says. “They were just things I wanted to do.”

Short-term clinician Amanda Coyle, who worked with Nylenkeh, remembers it differently: “You could tell she genuinely cared for her patients. She went above and beyond.”

Her humble dedication continued. Partly at the urging of so many short-term clinicians, Cora Nally, a PIH community health manager, asked Nylenkeh to join PIH as a psycho-social support program coordinator in February. At the time, Ebola treatment units often offered counseling to Ebola survivors but rarely to families, who could be just as traumatized. Nylenkeh and Nally quickly created programs to support families who had lost loved ones or whose members were being treated for Ebola, offering everything from free counselling to baby food.

Nally promoted her the first week in May. As a program officer, Nylenkeh now directs a team of 150 psycho-social workers in Port Loko District. They go door to door in three chiefdoms, spreading the messages of national or local governments, such as, “It’s now safe for children to return to school.” Nylenkeh keeps things running smoothly.

Nally remembers an incident where a soldier was trying to foist his work onto Nylenkeh’s staff. “She very courteously and directly told him to stop pushing his responsibilities onto others,” Nally says. “She always stands up straight, always holds herself with this quiet confidence.”

The last year hasn’t been easy. Seeing sick children saddens Nylenkeh, especially if they are 2 or 5 years old, like her children. And her husband, an HIV program supervisor for the Moyamba District, was not particularly excited about the ambulance nurse job. “You are joking,” he said after hearing that she had applied. An Ebola ambulance driver friend of his had died not long before. But neither he nor Nylenkeh have any regrets.

“Working as an ambulance nurse is the best thing that ever happened to me, in terms of my career,” she says.

Of the dozens of cancer symposia held around the world in April, none resembled The Navajo Cancer Survivorship Conference, a gathering of some 70 doctors, patients, traditional healers, nurses, community health workers, and residents at the Navajo Nation Museum in Window Rock, NM, on April 16. The goal of the conference wasn’t to tout cutting-edge advances or experimental drugs, as so many do. It was to figure out how existing cancer care can better serve patients in and around the Navajo Nation, a 27,000-square-mile tribal area in the Southwest. 

The Dana-Farber Cancer Institute and Chevron Corporation, among others, helped cover expenses. The Navajo Nation Department of Health, cancer patients, health-care providers, and non-profits, including the Gallup, NM-based Partners In Health sister organization Community Outreach and Patient Empowerment (COPE), set the agenda. Former Navajo Nation Vice President Rex Lee Jim sat in, as did Partners In Health CEO Dr. Gary Gottlieb.

At issue were two galling facts: First, there is no cancer care available within the Navajo Nation, the largest tribal area in the U.S. And second, American Indians have the lowest cancer survival rates of any racial group in the U.S. Overall, 52 out of 100 American Indians survive for five years after being diagnosed with cancer, compared to 58 out of 100 non-Hispanic whites, according to the National Cancer Institute. The conference aimed to tease out some of the reasons for that disparity, and brainstorm how cooperation and collaboration could improve care.

It was a busy day. The director of the Navajo Nation Epidemiology Center shared what’s known about cancer prevalence and inequitable cancer deaths in Navajo. (Deaths from lung and breast cancer are extremely low compared to whites; the opposite holds true for stomach cancer.) A traditional healer talked about how Navajo medicine, such as local herbs and ceremonies, have long cared for and treated patients. Survivors and their loved ones shared personal stories, in part to support each other, in part to illuminate the challenges to providing top-notch care. To reach the nearest clinic offering chemotherapy treatments, one attendee explained that she had to drive for four hours. And it wasn’t like a road trip from New York to Boston. Traveling out of the Navajo Nation is often a huge challenge; transportation and lodging expenses fall to patients and 44 percent of the Navajo Nation's population lives below the poverty line.

Attendees highlighted the need for better access to hospice care and oncology units, improved clinician-patient communication, and patient advisory committees. But maybe best of all, another small step was taken toward self-determination. Navajo people, not outside researchers, led the discussions about improving cancer care in the Navajo Nation.

Doctors and nurses from across Rwanda gathered at Rwinkwavu District Hospital this spring, aiming to walk away with an understanding of the country’s new neonatal care package.

One nurse and one doctor from each of Rwanda’s 43 district hospitals and three referral hospitals participated in the training. Rwanda’s Ministry of Health and Inshuti Mu Buzima, Partners In Health’s Rwandan sister organization, organized the training. Boston Children’s Hospital and the Rwanda Family Health Project also partnered on the project.

“This is part of a broader national effort to improve the health and survival of small and sick newborns,” said Dr. Hema Magge, director of pediatrics at PIH/IMB.

The training is a product of the ongoing partnership between Rwanda’s Ministry of Health and PIH/IMB. Ministry officials asked PIH/IMB to help develop national clinical guidelines and protocols for caring for sick newborns in 2010. Clinicians created evidence-based guidelines and field-tested them in Rwinkwavu, a PIH/IMB-supported Ministry of Health hospital, Magge said. The Ministry of Health adopted the initial guidelines in 2011.

“The quality of care being provided is variable across the country, so the goal is to standardize and harmonize the care,” Magge said.

In 2014, PIH/IMB began leading the process to update the protocol and create a more harmonized approach to newborn health by broadening the package to include training materials, medical records, and quality indicators, based on years of field testing.

The curriculum and training team at PIH/IMB helped develop the materials using a “training of trainers” format, in which participants learn both technical skills and teaching skills so they can return to their home districts and train others. The five-day interactive program includes sessions on teaching methodology and clinical protocols, as well as practical, hands-on experience.

Rwinkwavu District Hospital leaders welcomed the participants into their new neonatal unit, which opened in September 2014, for practical bedside teaching.

PIH/IMB surveyed participants daily and at the end of the training. The feedback was largely positive, Curriculum and Training Specialist Suzannah Ellis Johnston said.

“The training went very well,” one clinician wrote. “Please continue this initiative as it will help us to save lives and prevent neonatal death.”

Another pledged to share the information back home: “We thank you for this training and we promise you that we will bring the knowledge we learned to others.”

One challenge is making the training relevant across settings. Some clinicians at the training come from hospitals that don’t have a neonatal unit at all, Magge said, and must refer all sick or underweight infants elsewhere. Others work at hospitals with established units and have more experience with these babies. For those with little experience, key components of the training have been stabilizing and resuscitating newborns, thermal regulation, infection control and prevention, and respiratory support.

But the training moved beyond a purely medical focus. Sessions also focused on problem solving, critical thinking, and task prioritization, as well as interpersonal skills such as how to break bad news to families. Clinicians were eager to develop their skills, Magge said, noting that many stayed late of their own accord to continue learning. That passion is encouraging, she said.

“The goal is that these trainers will continue to be champions of newborn health,” Magge said.

The Ministry of Health and PIH/IMB will follow up on the training by encouraging participants to organize district-level trainings on the neonatal care package. They’ll also monitor whether health facilities create quality improvement initiatives.