Partners In Health Articles

Cholera Vaccine Succeeds in Haiti

This month Dr. Louise C. Ivers and colleagues publish a paper that shows exactly how much the vaccine Shanchol slowed the spread of cholera in villages north of St. Marc, Haiti, in 2012.

Writing in The Lancet Global Health online, the senior health and policy adviser at Partners In Health finds that Shanchol was widely effective when administered to thousands of adults and children in the region. “We found that there were about 65 percent fewer cholera cases among people that were vaccinated than there were in those that were unvaccinated,” she says.

It’s fantastic news, and not just for the obvious reason that fewer cholera cases means fewer cholera fatalities. ”Effectiveness of reactive oral cholera vaccination in rural Haiti: a case-control study and bias-indicator analysis” also reminds us of the importance of a vaccination campaign that almost never happened. And it paves the way for even stronger efforts to end the epidemic that has killed 8,800 Haitians and infected 20,000 last year alone. “It’s a huge victory,” says Dr. Ralph Ternier, director of community care and support at Partners In Health's (PIH) sister organization Zanmi Lasante (ZL).

As many remember, cholera didn’t even exist in Haiti before 2010. But then the United Nations flew in a group of peacekeepers from Nepal, whose capital had recently suffered a cholera outbreak, and it installed them in a camp with bad plumbing. Leaky sewage pipes and overflowing holding tanks sat on the banks of a tributary of the longest river in the country, the 200-mile Artibonite.

What happened next prompted many stories—stories based on factual evidence or circumstantial evidence or, most commonly, a mixture of both. But the sad conclusion to all is the same. Days later, a young man known to bathe just downstream of the camp suffered bouts of violent diarrhea and promptly became the first Haitian to die of Vibrio cholerae. A month later, cholera had spread to each district in the country, everywhere from the Northern Plain to the Tiburon. A cholera epidemic had exploded less than a year after January’s devastating earthquake. (For more on the U.N.’s role in the epidemic, see Dr. Ivers’s op-ed in The New York Times.)

The staffs at ZL and PIH responded. They mobilized thousands of community health workers, opened cholera treatment wards, ran sanitation and hygiene initiatives, and more. A proposal to administer the new, World Health Organization-approved vaccine Shanchol was also floated.

Exhausted aid agencies, politicized global public health organizations, and some leaders within Haiti were not excited by the idea. Delivering the $1.85-per-dose vaccine didn’t offer enough bang for the buck, they said. Also, Shanchol might have proven useful in countries like India, where cholera has been long-simmering, but it had never been deployed in the confusing midst of an outbreak, so wouldn’t it be better to focus on, say, teaching people to wash their hands properly? “Cholera Vaccine Isn’t The Answer For Haiti,” an NPR blog post declared.

Locals disagreed. PIH/ZL’s community meetings and focus groups made it clear that anyone at risk of dying from cholera preferred using the vaccine. “The community definitely wanted the vaccine,” says Dr. Ternier. And Dr. Ivers, who was PIH’s chief of mission in Haiti at the time, had little interest in parsing critiques—critiques that sounded an awful lot like arguments for the “basic minimum package,” an old public health paradigm that offers only limited care to people in poor countries. (For more on the basic minimum package, see Dr. Paul Farmer’s recent piece in the London Review of Books.)

Like any of her PIH/colleagues, Dr. Ivers wanted to offer the best care. To her mind, that included preventative measures such as handwashing, treatments like rehydration, and using the vaccine. “When you see people dying, you want to do everything you can,” she says.

With the blessing of the Haitian Ministry of Health, PIH/ZL pushed ahead, and after overcoming all sorts of obstacles in distributing the tiny vials—training legions of staff, fighting the axle-gripping mud of rainy season, working around a simultaneous polio vaccination campaign, ensuring 45,417 patients swallowed two doses of the drug two weeks apart—the campaign finished in June 2012.

The critics couldn’t have been more wrong. As an earlier study in The American Journal of Tropical Medicine and Hygiene shows, virtually everyone got the vaccine. An impressive 90 percent of patients in the rice-growing regions of Grand Saline and Bocozel completed the full two doses—hardly a waste of money. And as detailed in the latest study, the vaccine proved just as effective as it has been in, say, India. Fully 63 percent of patients were protected against cholera infection.

“Our study contributes to mounting evidence that oral cholera vaccines have an important role to play as a component of comprehensive, integrated cholera control efforts in Haiti,” the study concludes.

As Dr. Ivers hints, the results of the study aren’t as earth-shattering as might be expected, but rather put a fine point on a cholera-fighting strategy that has become, well, standard. Since the vaccination campaign, the Haitian Ministry of Health, with the support of their partners, administered the vaccine to 300,000 citizens, and the World Health Organization has begun stockpiling the drug for use in future outbreaks.

“We are really happy with the results of this study as it demonstrates that the vaccination campaign really saved lives and reduced suffering,” says Dr. Ivers. “We undertook the campaign as a public health emergency, but having data to demonstrate how effective it really was helps to solidify the case for using vaccines in this kind of setting—and that helps transfer lessons from Haiti to other places where cholera occurs or may appear for the first time. The Haiti cholera epidemic has really reinvigorated the public health community’s efforts to address the problem of cholera, and it’s exciting to be part of the progress that’s being made.”

Pediatric Development Clinic Helps High-Risk Babies in Rwanda

Infant survival has steadily improved in Rwanda over the past decades. But mere survival isn’t enough for Rwanda’s Ministry of Health and Partners In Health’s sister organization, Inshuti Mu Buzima. They aim to ensure that high-risk babies have every opportunity to thrive.

To work toward this goal, the Ministry of Health and PIH/IMB have created the Pediatric Development Clinic with support from UNICEF and specialists from Boston Children’s Hospital. The interdisciplinary program is intended to improve health outcomes for babies at risk of death or developmental delays. It’s the first program of its kind in Rwanda.

The clinic started in April 2014 in Rwinkwavu District Hospital and has since expanded to Kabarondo and Ndego health centers. Staff have enrolled 123 infants who were born prematurely or with low birth weight, perinatal asphyxia, or other complications such as suspected genetic syndromes and developmental delays. The babies’ families receive services that include group education, peer support, and social worker assessments.

“Some mothers are always on the verge of giving up, thinking their children are about to die,” said Olivier Bigirumwami, nurse in charge of the clinic at Rwinkwavu District Hospital. “But through the counseling services we offer, we manage to educate them about the conditions of their children, how they can play their part while we also play our medical part. There has been massive improvement in the lives of the children under 5.”

The Ministry of Health and PIH/IMB conducted an early assessment of the program, collecting feedback from the mothers and caregivers who participated with their children.

“When I came here, I talked with the social worker and clinician, and they made me feel comfortable,” one mother said. “Before, I thought that the child would not be alive. I thought the child would die at any time. Now I feel comfortable, and I love my child.”

The Pediatric Development Clinic is one of many PIH/IMB efforts focused on child health. PIH/IMB identified the need for the clinic while improving overall care for preterm and low-birth-weight babies at health facilities, PIH/IMB Director of Pediatrics Dr. Hema Magge said. Complications from prematurity are the No. 1 cause of death for children 5 and younger globally, she said.

“Currently, there’s no systematic way to know what happens with [high-risk infants] after hospital discharge,” she said. “Yet, we know that they are at increased biologic risk of medical, nutritional, and developmental issues, and that early detection and early intervention can optimize their quality of life and prevent long-term complications.”

The clinic allows health care providers to follow these babies after they go home, through regular clinic appointments and community-based support.

The program features a weekly nurse-led clinic at health facilities, social supports such as food and transportation money for vulnerable families, and training for staff members in caring for high-risk infants through simple interventions. High-risk families are identified by social workers and receive home visits and community-based support as well. The program also is linked with electronic medical records systems to improve care and tracking of patients.

But beyond the clinic’s medical benefits, Magge sees the program as a step toward improving the lives of rural Rwandans.

“It’s really about breaking cycles of poverty,” she said. “You’re using this target population of medically vulnerable infants to shift the entire early childhood development agenda forward. … We want a generation of healthy, active children, going to school, getting educations, and getting out of poverty. That’s what this is all about.”

PIH/IMB hopes to add Pediatric Development Clinic programming at two more clinics in 2015 and is exploring the possibility of working with the Ministry of Health to replicate it on a national scale. Dr. Fulgence Nkikabahizi, Rwinkwavu District Hospital’s medical director, said one challenge has been making sure the model is affordable.

“Plans are under way to conduct a costing study and see how sustainable this program is,” Nkikabahizi said. “We want to assess the real cost, own it as Rwandans, and scale it up at national level in the near future.”

Scaling up the clinic would expand access to a unique program.

“We don’t know of any other models for long-term follow-up and intervention support for high-risk infants in resource-limited settings in rural, non-referral settings without specialists,” Magge said.

The Pediatric Development Clinic includes training for nurses, social workers, and doctors who might encounter high-risk babies. After infants are enrolled, they will continue to participate in the clinic for varying amounts of time, depending on their condition. Magge expects babies and families to receive clinic services until the children reach at least age 2 and up to age 5. Children who need specialized care after age 5 will be referred to other PIH/IMB-supported chronic care programs.

The clinic’s goal for most infants is to intervene during a key developmental stage and help them catch up to their peers.

When babies and their caregivers visit the clinic, Magge said, the caregivers learn how to interact and play with the children to promote development. One caregiver reported using those lessons at home:

Before, I thought my child couldn’t learn anything, but now after visiting PDC clinic, I try to teach my child things like, “This is a cup.” I repeat the word to the child over and over again, then after a few days I can say, “Look at the cup,” and the child sees it and shows that he understands. Now I sit with my child to teach him. This is a big difference. Before coming here I did not know I should do this. I knew the child has a very big disability and thought he could not learn. Now I see that he can still learn.

The early program assessment suggests caregivers and staff members are enthusiastic about the clinic. It also found that caregivers of high-risk babies face barriers, such as transportation challenges, lack of family support, and the stigma of being seen as unable to care for a child.

To address these concerns, PIH/IMB and the MOH plan to add weekend support groups and to increase the number of home visits, engaging fathers and other family members in the care of these children.

Malawi Maternity Ward Welcomes First Babies

When Alinafe* went into labor Jan. 28 in rural Malawi, she traveled about 3 miles from her home to Neno District Hospital. Her labor went smoothly, and she welcomed her son that day.

Had she given birth a week earlier, Alinafe’s experience would have been a bit different. She still would have received high-quality care from Partners In Health’s sister organization, Abwenzi Pa Za Umoyo, but she wouldn’t have delivered her baby in a private room at a brand-new maternity ward.

Alinafe’s son was the first child born in the new ward, built by PIH/APZU in partnership with the Malawian Ministry of Health. Alinafe named him Jonas in honor of former PIH/APZU Country Director Dr. Jonas Rigodon, who commissioned the building along with MOH colleagues.

PIH/APZU organized a “Celebration of the Mothers of Neno” this week to mark the start of operations in the new wing. The ward won’t officially open, however, until Malawian government officials visit later this year.

Alinafe said she was pleased with the care she received and happy that the new ward meant she and Jonas could stay at the hospital longer after his birth. Ample space in the 10,200-square-foot wing allows women to stay the recommended 24 to 48 hours after they give birth.

In the old facility, women were discharged from the labor ward soon after giving birth, admitted in the postnatal ward for a minimum of 12 hours, and then discharged with the aim of giving room for other patients to use the services, Ministry of Health Nursing Officer Gladys Ntonya said at the celebration Feb. 11.

Ntonya spoke alongside PIH leaders from Boston who traveled to Malawi for the celebration. Co-founder and Executive Director Ophelia Dahl, co-founder and board member Todd McCormack, and incoming CEO Gary Gottlieb were on hand. They joined local colleagues including PIH/APZU Executive Director Dr. Luckson Dullie and District Health Officer Lawrence Nazimera.

Dullie stressed the need for continued collaboration between PIH/APZU and the Ministry of Health.

“We would like to think that motherhood is something we look forward to,” he said. “It should not be a cause for anxiety. It should not be a cause for apprehension. Our mothers should look forward to being mothers. We realize that to achieve this, we will need partnership at all levels.”

The new ward will enhance care for every woman who gives birth at Neno District Hospital. It includes four private delivery rooms, replacing a facility that had a single two-bed delivery room.

The addition also includes a 9,400-square-foot gynecology ward. Together, the two freestanding wards provide nearly 80 beds. PIH/APZU expects the maternity and gynecology wards to serve a population of about 35,000 women.

Encouraging facility-based births

Thousands of women in Malawi give birth at home each year. PIH/APZU hopes the new maternity ward reduces that number, drawing women to have their babies at the hospital because of the quality of care they’ll receive. The hospital already averages 114 deliveries per month. If every pregnant woman in the catchment area gave birth at the hospital, that would increase to about 160 deliveries per month.

In addition to providing plenty of space for care, the new ward could save lives.

“We expect to have reduced numbers of neonatal deaths since we now have the nursery ward with the required equipment as well as the kangaroo mother care ward,” Ntonya said, referring to care for small or preterm infants that involves skin-to-skin contact. The “maternal death rate is also expected to reduce because the patients are now receiving the required care.”

The new maternity and gynecology wards will provide basic gynecological care, antenatal care, basic and emergency obstetric care, neonatal care, and prevention of mother-to-child transmission of HIV. Women who are at risk of pregnancy complications also will be able to await delivery at the new ward.

“To have seen what there was before, and to see what there is now, it’s difficult to put into words,” Dahl said at the Feb. 11 celebration. “Last time we were here, the maternity ward had two women in each bed, some of the women who had just given birth to their babies on the floor, and people here remember what it was like. And now to see that entire structure laid out, supported by the ministry, and all of the partnership, it’s a very, very heartening thing."

A safe C-section

The improved care made a world of difference for Edina*. She gave birth to twin boys by cesarean section on Feb. 3. The C-section was necessary because the twins were in breech position, meaning they were positioned to leave the uterus buttocks, pelvis, or feet first. Babies typically are born headfirst, which is safest. For cases such as Edina’s, the maternity ward works in concert with Neno District Hospital’s operating theater, which opened in November 2013.

One baby received specialized care because he was small, weighing only 3.5 pounds. The facilities at Neno District Hospital have allowed Edina and her babies to remain as long as necessary, and PIH/APZU staff members are optimistic that the small baby will do well.

Edina had arrived by ambulance with her mother, Chikondi*, whose own delivery experiences differed significantly from her daughter’s. Chikondi gave birth to Edina, the eighth of 11 children, 18 years ago at home. No one was present to help deliver the child, and Chikondi managed alone. Had Edina given birth at home like her mother, she and her boys would have faced serious health risks.

Chikondi welcomed her twin grandsons, calling them a gift from God, and said she was thankful they received good care at Neno District Hospital.

*Names have been changed to protect privacy.

In Their Own Words: Ebola Clinicians Share Stories

“What was a high point? What was a low point?” Those are the questions we recently asked a half-dozen doctors and nurses working in Ebola Treatment Units (ETUs) in Sierra Leone.

Their answers were surprisingly candid. And they remind us that beneath the flurry of news headlines, plenty of real people are battling a very real virus.

Amanda Coyle, assistant professor of nursing, Rochester, NY

My last week, I was working in the community, but Tim and I decided that the last day we were going back to the ETU, because we missed it, as weird as that sounds. We donned and entered and Tim was the Pied Piper, with the children really loving him, while I was just kind of in the background. We had fallen into these roles where he was the fun parent and I was the serious parent.

Anyway, one of the children was Foday, 14 years old. The night he had turned the corner for the better was also the night it was clear his father was going to die. When his father did, I had gone in, held his hand, put a hand on his knee, and said, “I’m so sorry, so sorry.” He had been very stoic.

So anyway, Tim is doing his clowning thing and I went to Foday, “How are you?” And he just said, “I love you.”

Kim Spray, paramedic and nurse, Santa Fe, NM

Say you need to find some supplies. You go from room to room, looking for water or a piece of tape and you can’t find it. And as each little frustration builds, then a patient you’re close to dies. And then it turns out your clinician friends are leaving. All in one day. Whammie. It’s a bad day.

Luanne Freer, emergency medicine physician, Bozeman, MT

I’ll never forget just giving this man a drink. He was so parched. Just taking the time to kneel down beside him and put the water to his lips—if you’re a hospice nurse, maybe you do things like this all the time, but not me.

Dana Clutter, infectious diseases fellow, Redwood City, CA

We had this girl, Kadiatu. Ridiculously cute. Big bright eyes. Three years old. Even when her tests came back positive for Ebola, she had enough energy to attempt mischievous little “escapes” from the ETU.

When she cleared her Ebola, she was left with ongoing seizures, and had developed blindness and paralysis on the left side of her body. But a pediatric neurologist arrived with the next cohort of PIHers; her grandmother, who was always there, proved to be a talented physical therapist; and Dr. Farmer secured us a stash of phenobarbital, an anti-seizure medicine. The stars aligned for her.

And she got better. She stopped seizing, began walking, and her sight returned. By the time I left, her only deficit was weakness in her left arm.

Before she got really sick, during one of her “escapes,” she had ended up running through wet cement, in a doffing area they were making. Now all of us love to doff in Lane One because you can see her little footprints there.

Musa Sillah, psychiatric nurse, Willow Grove, PA

We’d just started the psycho-social community outreach and were visiting this village. I think it was our first venture out there. It had had 60-something people with Ebola. And 18 survived. And 12 or 13 of the survivors came from our treatment center. So people in the village knew about PIH before we showed up. But still, when we got to the outskirts, the whole town was there. The chief. Everyone. And survivors started talking and talking about our center, and they knew the names of the nurses that cared for them. It was a good meeting.

Dana Clutter, infectious diseases fellow, Redwood City, CA

There’s this one guy I felt particularly bad about, maybe because he was young, probably my age, 32.

He looked healthy at first glance, it seemed like he should do well. But as we’re interviewing him, he just started vomiting so much blood. Tons. He just kept vomiting and vomiting. He looked uncomfortable but what was most noticeable was that he looked scared. His eyes were so wide, and he was looking at the blood in the bucket and trying to read our faces. I told him, “Don’t worry, we’re going to give you medications and fluids and help you survive. You’re gonna get better. We’ll help you beat this.” He died the next night.

I think I had mixed feelings. I felt good that I gave him all the care I could, and that I gave him hope—made him hope. But on the other hand, I felt bad that I couldn’t keep my promise.

Charles Callahan, professor of pediatrics, Alexandria, VA

The highlight was Aminata. She came in on the evening of December 23rd. It was late, we were working late, and we could not get an IV in her. I fully expected that on Christmas eve morning she would not be alive. But I came in early that day, so I could get there ahead of everyone else, and she was still alive. I got her to drink a tiny bit. A day later, we decided to put in an intraosseous line in—a special IV placed directly into the bone. We put that in on Christmas day, according to my diary. And eventually she was Ebola negative and discharged. It was like a Christmas miracle.

Kim Spray, paramedic and nurse, Santa Fe, NM

We try to have dance parties once a week. They often start laughing when I dance. Seeing the patients smile at the funny white woman trying to dance is one of the highpoints.

Amanda Coyle, professor of nursing, Rochester, NY

A colleague and me walked into the ward during the last night shift. And there was a man laying on the floor, all curled up in urine and vomit and stool and blood. And he was just out of it. We knew we had to clean him up, put him on a mattress. You want to run screaming from the building but you’ve done it so much, you know what to do.

Paul and I started to clean him up and Paul’s glove broke. He had on three gloves, but it was a big enough break in the outer one that we were worried. And we had some new arrivals, new clinicians, with us, and they were overwhelmed. And you have to be very sensitive to their safety and PPE. So we had to make this incredibly difficult choice--that it was not safe for the healthcare team to be in there at that moment.

We left the man in that state.

While I waited for them to doff, I had time to round in the confirmed ward. That’s when I discovered a corpse, a woman that had been circling the drain. And the awareness that it was 10 at night and she was going to be there until the corpse team arrived in the morning…. And the awareness that next to her was a father with boys and he was probably going to die, too…. As a nurse, to have to leave those people….

Musa Sillah, psychiatric nurse, Willow Grove, PA

It was devastating for us. Most of us had fallen in love with this kid. We put an IV in her. We continued to hydrate. We didn’t give up. One day we’re doing rounds, and one of my coworkers is kneeling down to change her diaper. And I look over and she isn’t breathing. And I have to say, “I don’t think she’s breathing.” And my coworker is stunned. I say, “She’s dead.” But it doesn't register. “No, I have to change her diaper,” he says.

Charles Callahan, professor of pediatrics, Alexandria, VA

Every time a child died, I’d write down the name. I just thought these kids need to be remembered. I need to carry their names with me. There were a lot. During my time, almost two dozen kids passed away.

Luanne Freer, emergency medicine physician, Bozeman, MT

I was sitting with two Sierra Leonean nurses and we started talking about the war in Sierra Leone. I asked, “How did it affect you?” One pulled his foot out and showed me the toe that had been chopped off in front of his mother when he was five. He said, “This is nothing,” and asked if I’d seen the short sleeve people and the long sleeve people. I had, but I didn’t know that’s what they were called. During the war, rebels would ask if you want short sleeves or long sleeves and then either chop off your hand or chop off your arm.

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.

*names have been changed to respect patient privacy

Haiti: Radiology Improves Hospital Care

Dieuseul Saint-Ange left his native Haiti in 2006. His destination: the United States. His goal: obtain skills that would help him serve people back home.

Nearly a decade later, he has been integral to the success of the radiology department at University Hospital in Mirebalais, in Haiti’s Central Plateau. Saint-Ange is the administrator for a computerized picture archiving and communication system—called PACS—that electronically stores medical images such as X-rays, CT scans, and ultrasounds and allows clinicians or radiologists to view them anywhere they have access to a computer. Although this technology is common in U.S. hospitals (as many as 91 percent use it, according to one survey), it is far more difficult to implement in resource-poor settings.

“[PACS] allows doctors and nurses to view radiology images very quickly wherever they are in the hospital,” Saint-Ange said. “They can make diagnoses based on what they are able to see in the images, and when a case is difficult for them to understand, they can ask for interpretation from a radiologist.”

University Hospital’s radiology department has been operational since the hospital opened in March 2013. Built by Haiti’s Ministry of Health and Partners In Health’s Haitian sister organization, Zanmi Lasante, the hospital houses the only CT scanner in a public facility in the country. Haitians who need a CT scan would otherwise have to pay about $300 U.S. in a private facility. This is out of reach for most people in Haiti, where the World Bank puts per capita income at about $800 a year.

The hospital also has X-ray machines, ultrasound machines, and dental X-ray capabilities, among other radiology equipment.

Clinicians use the hospital’s electronic medical records system to order a variety of scans. Once the scans are in PACS, they’ve entered Saint-Ange’s realm.

Saint-Ange began studying management and information systems in 2006 at Liberty University in Virginia. When he returned to Haiti six years later, PIH/ZL hired him as operations coordinator and then as PACS administrator. He attended PACS training at McKesson in Canada and has held the position for nearly two years. The PACS at Mirebalais has an unusual configuration; it’s synchronized with a PACS system in Boston.

No radiologists are available in Haiti to staff University Hospital, so U.S.-based volunteer radiologists read studies instead. They access the Boston-based PACS from their home or office via a secured online portal. The volunteers interpret the studies and create reports, which are transmitted to University Hospital and are saved in patients’ electronic medical records for easy access.

In 2014, volunteers interpreted more than 4,000 CT scans, double what they read in 2013, Radiology Coordinator Alexis Bowder said.

“We greatly rely on [radiologists who live abroad] to help us with the increasing amount of reads that we’re having every day,” Saint-Ange said. “We’re available to communicate with them via email or calls.”

These open lines of communication can result in odd working hours or long days. Saint-Ange has received queries while in church or on holidays. Once, he had gone home to Hinche to work on his farm when he learned that system glitches were resulting in lost X-rays 35 miles away in Mirebalais.

“I left everyone at work in the farm. I caught a tap-tap and headed to the hospital,” he said. “When I got there, I was able to find the images they thought were lost, pushed them to PACS, and, at the end of the day, I caught another tap-tap to head back home in Hinche. Everything happened in my farm behind my back that day.”

Radiology Technician Johnson Severe prepares a patient sent by the Emergency Department for a head CT scan at University Hospital in Mirebalais, Haiti. (Photo: Rebecca E. Rollins/Partners In Health)

Volunteers lend expertise

University Hospital initially built its volunteer network through the efforts of radiologist Dr. Jeffrey Mendel, PIH’s senior health and policy adviser for radiology. About 40 radiologists at sites across the country—including the Mayo Clinic, Massachusetts General Hospital, and the University of California, San Francisco—sign up for two shifts per month.

PIH/ZL hopes to expand these ranks. Mendel would like to have 100 volunteers on board by the end of 2015. Bowder is part of these recruitment efforts; she asks surgeons and physicians who visit PIH/ZL to see whether their home hospitals’ radiologists want to help.

PIH/ZL asks volunteers to interpret a minimum of four to six scans per shift, Bowder said. She also asks volunteers to be available to read urgent scans that must be interpreted within a day or two. Timely and accurate reading of scans can be crucial for patients.

“Rapid turn-around for readings is both important for patients with acute illness … and a challenge for a volunteer network,” Mendel said. “Often I am reading urgent studies late in the evening. However, for many patients with an acute illness or injury, a CT scan may be critical. It allows physicians to make treatment decisions and to assess the extent of injury that may not be apparent on physical examination.”

This rapid interpretation is particularly important for patients with conditions such as trauma, acute abdominal pain, a change in mental status, or chest pain, Mendel said. A CT scan for a patient who had been having seizures and arrived in a coma in December required urgent reading, for instance.

Mendel would like to have 100 volunteers on board by the end of 2015.

A 2013 case provides another vivid example. When 17-year-old Roseline Bernard fell from an avocado tree, X-rays and CT scans helped identify broken bones, internal injuries, and a traumatic brain injury. Without the radiology department, surgery, emergency care, and rehabilitation, Roseline’s diagnosis and treatment would have been far more difficult. Read more about her recovery here.

In addition to reading scans, volunteer radiologists have shared their expertise with medical residents and other clinicians in Haiti, Bowder said. University Hospital staff members have participated in teleradiology conferences with the volunteers.

“They’ll pick five scans a month where they weren’t sure how to interpret it or needed more imaging,” she said. “The residents will present it to the radiologist in the States, the radiologist will go over it with them … and they can ask questions and have discussions.”

The main challenge for the radiology department is a backlog of images. As of late December, 170 non-urgent scans awaited interpretation, Bowder said. She and others are seeking more volunteers to help bring that number down.

Radiologists or fourth-year radiology residents who want to volunteer can apply here.

Ophelia Dahl on the Vaccination Debate

Ophelia Dahl, co-founder and executive director of Partners In Health, discussed with broadcaster Katie Couric this week a letter Dahl’s father wrote 27 years ago about the importance of vaccinations. Roald Dahl penned the letter a quarter-century after his 7-year-old daughter, Olivia, died of measles.

“Some people are willing to walk hours and hours barefoot to get their children vaccinated. And then, in other places, people need to be persuaded to vaccinate,” said Ophelia Dahl. “I’ve seen it played out in places like Haiti, where I’ve known kids who have died for lack of vaccinations and from preventable illnesses …. [If] you don’t get vaccinated, you’re much more vulnerable to these childhood illnesses.”

She continued. “If you’re acquainted with some of the figures ... that involve hundreds and thousands of children dying of an illness like measles … then you have to see this as a trend that needs to be stopped.”

Watch the full interview.

PIH Continues Mobile Clinic amid Malawi Flooding

Heavy rainfall continues to cause flooding in Malawi, affecting 1.15 million people and displacing 336,000, according to United Nations estimates. The nonstop rains that pummeled the country in early January have slowed into patterns more typical of Malawi’s wet season. Still, flash floods and downpours are exacerbating flood-related issues.

Partners In Health’s Malawian sister organization, Abwenzi Pa Za Umoyo, has worked with the Ministry of Health in Neno District since 2007. Although Neno, in southwestern Malawi, is not among the country’s worst-affected districts, flooding has displaced thousands. PIH/APZU has responded with a weekly mobile clinic in the low-lying Matope community.

A 20-person team of local health officials, doctors, nurses, and support staff members led the first clinic, on Jan. 24. Responders assessed the community’s needs and provided free medical care to 662 people, nearly 10 percent of whom were children younger than 5. The second clinic was Feb. 5 and served 250 patients.

As of late January, 461 households in the Matope community had been damaged, and 2,000 people—including 1,300 children—had been displaced. Nearly 400 acres of crops have washed away, creating concerns about people going hungry. Most people in Matope are subsistence farmers, meaning their crops must yield enough food to last until the next harvest. Many families lost their stores of maize along with their crops in the floods, leaving them with no food source for the immediate or long-term future.

Malawians hoping to cross a bridge in Neno District wait for water to recede. Flooding this rainy season has raised health-related concerns and destroyed crops. (Photo: Margot Prendergast/Partners In Health)

The flood-related health issues are only part of the picture in Neno District, however. Many patients seeking care at the mobile clinics have conditions that are linked to lifelong poverty. The most common complaints at the Jan. 24 clinic were of musculoskeletal pains. Twenty-one percent of patients had respiratory tract infections, 9 percent had malaria, and 6 percent had diarrhea. In children 5 years and younger, respiratory tract infections, malaria, and diarrhea were the most common conditions.

The second mobile clinic incorporated a multidisciplinary team that provided malnutrition screening and examined sanitation concerns in Matope. Of the 250 patients seen Feb. 5, 80 percent were children. The most common diagnoses mirrored those of the Jan. 24 clinic: malaria, respiratory infections, and diarrhea.

In addition to treating these diseases, PIH/APZU provided water-purification tablets to help protect people from water-borne diseases such as cholera.

Flooding remains a concern as Malawi’s rainy season continues, and the nutrition and agriculture emergency is likely to persist for months. PIH/APZU is committed to providing relief and to helping rebuild the Matope community.

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I learned to better understand the importance of giving each individual patient health care with compassion, dignity, and respect.

What’s the most important thing you learned in the residency program?

During my residency at University Hospital, one of the most important thing I learned was to approach each patient as a whole person, not just an illness, and to integrate the patients’ daily life challenges into the planning of their health care. I learned to better understand the importance of giving each individual patient health care with compassion, dignity, and respect.

What are the most challenging aspects of your job? What gives you inspiration and hope?

For me the most difficult part of my job is giving many patients care, and making sure that each patient receives high-quality care according to their illness. It’s hard to get patients to understand their health, and to educate them about illnesses because they often have alternative beliefs. My inspiration is when every patient leaves the hospital on two feet after having come in with little hope. This makes me know what I am doing is important and that I am where I am supposed to be. I am working with those who need help the most.

Post-Earthquake Haiti: ‘Always there is Opportunity’

Dr. Ralph Ternier is director of community care and support at Zanmi Lasante, Partners In Health’s sister organization in Haiti. Here he reflects on his experiences during the country’s earthquake in 2010—and the five years since.

A few days ago we celebrated the 211th anniversary of the famous Haitian Independence Day. This tiny land of contradiction has witnessed stunning and unfortunate events over the last two centuries. Some people keep saying the nation is damned; others who are attached to the country speak of hope, solidarity, and compassion, especially after having faced one of history’s most destructive and deadly earthquakes.

In a few days we will remind ourselves how fragile and precious life can be. For many years into the future we will tell our grandchildren about that day of sorrow. Some might refuse to believe such a narrative. Even I was incredulous toward what the Dominican taxi driver told me that Tuesday evening five years ago.

I had left Haiti to go to the Dominican Republic at 4:30 p.m. on January 12—20 minutes before my people plunged into the deepest desperation. I returned to Haiti two days later in a small airplane with two Partners In Health colleagues. From the sky I could watch the chaos on the ground—people with their belongings running away from death, an abyss of curse.

From that day on, we spent the whole year rescuing, saving, and relieving as many as possible, guided by one label: TNTC (too numerous to count). Then the first cholera epidemic in the country’s history hit, stressing and weakening the health system further.

But always there is opportunity.

We have learned particularly in this last decade that all these unfortunate events and disasters must be a platform to revitalize the health system. Five years after the terrible earthquake, it is important for us to reflect on our major achievements, impediments, and perspectives.

In addition to the roughly 1 million people that received emergency and general health care, we pride ourselves on the legacy of the teaching hospital in Mirebalais that came from all the international support. During 2010, Zanmi Lasante (ZL) understood that this massive contribution to the public health sector wouldn’t be productive without sustaining the community health structure. Therefore we formalized all ZL community activities through the new department of community care and support.

Very often we ask ourselves how we would adequately fight cholera without these tireless workers who still go door to door to raise awareness of the epidemic and ensure that community members are safe and protected. In many narratives we’ll frequently link cholera and the earthquake: they happened the same year, they created panic and chaos, and they took away so many lives.

But we have become stronger in the wake of these disasters. Our network of community health workers has grown to 350 members, and we now have several thousand accompagnateurs—compared to fewer than 100 before 2010.

Challenges, however, persist. The earthquake destroyed most of the important public health facilities in several departments, especially in West, where the needs of the surrounding population dramatically increased. To respond to these needs, the community network stepped up to expand services, such as rehab and mental health care in the communities.

A few days ago, I drove into the so-called downtown of Port-au-Prince. At points I felt as if I was living in 2010 as rubble is still piled on many avenues. One of my friends in the car from the diaspora asked me how I kept morale and stayed in the country. With a beaming smile I responded with what someone had told me the day I came back: “This country cannot be worse; it can only be better.”

After five years, everything that we are doing for the health system, for the patients, must be better, better than what it was before 2010, better than what it was during the cholera outbreak—better for the sake of our beloved lost during these tragedies.

Haiti: Rehab Helps Patients Regain Independence

When the dust settled after the 2010 earthquake in Haiti, Shelove Julmiste was alive. But something was very wrong.

Julmiste was on the third floor of a six-story building in Port-au-Prince when the earthquake occurred, on Jan. 12, 2010. The building collapsed, crushing her left leg—an injury that later required amputation below the knee. Five years later, she still doesn’t know how she escaped.

Julmiste, now 29, received a prosthetic leg and recovered through Partners In Health/Zanmi Lasante’s rehabilitation services, offered then at Cange in Haiti’s central plateau. She now works as a rehabilitation coordinator for patients requiring prosthetics/orthotics at University Hospital in Mirebalais.

“If rehab didn’t come to Haiti, I could have lost both my legs, because my other foot was also crushed in the earthquake,” she said. “It’s after lots of exercise that my foot started to get better. I don’t know for everyone, but rehab is good for Haiti. One hundred percent of the people who have done rehab think it’s great for Haiti.”

PIH/ZL’s rehab program has expanded significantly since 2010, said Dr. Andree LeRoy, who directs the program at University Hospital. LeRoy is a Haitian-American physiatrist, or rehab physician, who spends part of her time at Boston’s Spaulding Rehabilitation Hospital. She returned to Haiti a month after the earthquake to help assess the country’s need for rehabilitation care. When PIH/ZL decided to create a comprehensive rehab program in 2010, LeRoy served as an adviser.

The program initially consisted of community rehab educators, who identified people in need of rehabilitation services and helped get them into treatment, she said. Now, a nine-bed inpatient rehab ward is part of University Hospital, which PIH/ZL built with the Haitian Ministry of Health. The ward opened in May 2014. A 10-bed Center of Excellence in Rehab and Education was completed in June and is expected to open in late February at University Hospital.

“We’re really excited that this is coming into fruition after all this time,” LeRoy said.

She remembers the pre-earthquake days in Haiti, when people who needed amputations had to see a surgeon, wait for the wound to heal, try to get fitted for a prosthetic and then—most likely—encounter complications because they hadn’t received rehab services to strengthen the existing limb and prepare it for use with a prosthetic.

“Without any therapy then you’re going to put a prosthetic on the person, and they can’t really use it properly,” LeRoy said. “They walk with a limp, they have other issues—a lot of skin breakdown can occur because they haven’t been prepared with the proper therapy.”

Before the earthquake, Haitians who could afford to do so could travel to Port-au-Prince and pay $25 to $50 U.S. for a prosthetic. Additional costs would include transportation, overnight accommodations, and return trips for outpatient services and therapy.

Now, those patients can come to University Hospital and immediately be referred to a sizable rehab team of eight educators, six technicians, two physical therapists, two doctors, and two nurses. LeRoy estimates the rehab program has served more than 1,000 patients since 2010.

And the care continues after people are discharged. Because of the rough Haitian terrain, a prosthetic limb lasts two to three years, says physical therapist Jonah Feldman. The rehab program provides new fittings and helps with replacement prosthetics. PIH/ZL doesn’t make the prosthetics, but pays for patients to receive those services at Hospital Albert Schweitzer in Deschapelles. It’s “a lifelong follow-up,” Feldman said.

Rehab services also have improved at other sites in Haiti. PIH/ZL runs a small rehab program in Saint-Marc and collaborates with the rehab program at St. Boniface Hospital. The University of the Aristide Foundation has partnered with the State University of New York at Stony Brook to train physical therapists in Haiti. This five-year master’s program is the first physical therapy program in Haiti, which will be an asset to the country.

“Over time, [rehab programming] has just grown exponentially,” LeRoy said.

Renoit Joseph, a rehab technician, works with 21-year-old Jean Sauveur Sodeline at University Hospital in Mirebalais, Haiti. Joseph has been working with her since Oct. 23. She couldn't walk when she was admitted. (Photo: Cecille Joan Avila/Partners In Health)

Dramatic change

Julmiste has watched the rehab program evolve—and experienced an evolution of her own.

“When I came [in January 2010], I had nothing,” Julmiste said. “I started to work, I started to get better, do little things, do little activities. … It changed my life a lot. When I started working, I had money in my hands. Before I started working I used to have bad headaches, and I would cry so much.”

Part of her job now is to stabilize patients and help them understand what it means to experience amputation. She also explains the rehabilitation process and what to expect when receiving a prosthetic.

She and LeRoy offer one success story after another. Julmiste describes a woman whose leg was crushed in a mudslide. The woman, afraid of being unable to care for her child, refused amputation. When she developed a dangerous fever, doctors sent Julmiste to try to change her mind.

“I told her that in January I lost my leg, because of the earthquake, just like you lost your leg. … Then I asked her, ‘Do you want me to show you?’ And then I lifted up my pant leg, and she was shocked. She said, ‘OK, I accept it.’”

The woman underwent surgery and was walking with a prosthetic three months later, Julmiste said.

One patient who is a paraplegic and uses a wheelchair plans to go to nursing school so she can work in Haiti, LeRoy said. Another patient suffered from a spinal cord injury and now competes in wheelchair racing. The rehab program also helps patients with neurological diagnoses, such as strokes and brain injuries, and has helped numerous patients with these diagnoses recover and return to work.

The rehab program intentionally hires people like Julmiste who have participated in rehabilitation. Among her colleagues is Quesnel Cirena, who is mentioned late in Mountains Beyond Mountains, Tracy Kidder’s book about PIH co-founder Dr. Paul Farmer. An injury with a sugar cane grinder resulted in Cirena’s above-the-elbow amputation.

Cirena, referred to in the book as Kenol, has worked for PIH/ZL for four years, LeRoy said.

“His injury was not earthquake-related, but I think as a result of the work we did after the earthquake … we have more awareness around what people with disabilities are capable of doing and can do, and there’s less stigma related to it,” LeRoy said, adding that Cirena now attends university at a diplomacy school in Port-au-Prince.

In a richer country, these success stories would be less remarkable. But in Haiti, stigma and the limited availability of treatment compound difficulties for people with physical disabilities. People who cannot contribute to the household often are viewed as burdensome. University Hospital’s rehab program aims to help patients return to a productive, more independent life, decreasing the burden of care on their families.

Physical therapist Jonah Feldman sorts through donated equipment inside a storage closet in the rehabilitation ward at University Hospital in Mirebalais, Haiti. (Photo: Cecille Joan Avila/Partners In Health)

A cultural shift

Although much work remains, LeRoy said, PIH/ZL is combating the idea that life ends after a severe injury or amputation. Even some clinicians at University Hospital had to see the benefits for themselves, she said.

“People didn’t have this concept that once you are injured, you get out of bed and you move, and it helps you get better,” LeRoy said. “It was more so the mentality—which is still changing and growing and evolving—that, ‘oh, you stay in bed or you stay on bed rest until you’re better.’ So it’s a big shift that’s happened in both the hospitals and in the homes.”

Feldman said educating family members of people receiving rehabilitation care is a key part of the program. When community members see neighbors returning to church or work after experiencing rehab, it can alter their perspective.

“We’re all-inclusive of people with all levels of ability,” he said, “and we feel that with rehab growing in Haiti and being more visible, this will hopefully change the tide, culturally speaking.”

There’s no shortage of need for rehab services in Haiti. About 10 percent of Haiti’s 10.2 million residents are thought to have a disability, LeRoy said. And those people are increasingly speaking up and serving as their own advocates, she said.

“A lot has changed,” she said. "It's seemed so subtle because it's been almost five years, but a lot of amazing things have happened. A lot of patients have made remarkable recoveries that we didn't even think were possible."

Shelove Julmiste, a rehab coordinator at University Hospital, sits in the recently completed Center of Excellence in Rehab and Education. The center is scheduled to open in the first months of 2015. (Photo: Cecille Joan Avila/Partners In Health)

Looking ahead

What’s next? LeRoy offers an ambitious list.

She hopes to see PIH/ZL’s community program grow to cover more of the region. Also part of her vision: increased services in Saint-Marc and the expansion of the new Center of Excellence in Rehab and Education to include a state-of-the-art gym and more bed space.

Environmental changes also are necessary to accommodate people with disabilities in Haiti, LeRoy said. She hopes to see new construction in Haiti designed to be accessible, employing principles of universal design.

Another piece of LeRoy’s vision is helping to build a cadre of trained rehab professionals. Ideally, that would include a rehabilitation residency program at University Hospital, specialty training for nurses, and training for psychologists and community health workers.

Her vision reaches beyond Haiti, however, to other countries where PIH works.

“The team down here is so strong that we could be offering assistance to maybe Rwanda, maybe Malawi, maybe other places that are emerging markets or in the developing world that need help and support in building the infrastructure we have,” LeRoy said.

As far as Julmiste is concerned, plenty of work remains to be done at the new Center of Excellence in Rehab and Education in Mirebalais.

“When I look at it, I think it’s still too small,” she said. “We have a proverb that says: Piti piti zwazo fè nich li (little by little the bird makes its nest). … We need a really big building for the amount of people there are that want to do rehab. We will fight for this: to get more room in order to care for more patients to rehabilitate.”

PIH Welcomes Dr. Gary Gottlieb

This week Partners In Health Co-founders Dr. Paul Farmer and Ophelia Dahl penned an opinion piece in The Boston Globe about the recent announcement that Dr. Gary Gottlieb will be taking the helm of PIH later this year. Farmer and Dahl, who say Dr. Gottlieb's transition "has to be seen as one of the great boons to global health in these frightening times," note that Gottlieb will be tasked with leading PIH's Ebola response in West Africa and will bring his decades of experience building health systems to PIH sites around the world.

Farmer and Dahl write:

A clinician, a designer and organizer of care, a teacher and mentor of students and trainees, a funder of some of the world’s leading medical research—that’s been Gottlieb’s job description since he became CEO of Partners HealthCare in 2010.

At some level, running a complex system of sites and providers in eastern Massachusetts isn’t so different from doing it in remote, impoverished places like Liberia or much of Haiti. How do you balance the right investment in a series of smaller centers connected to larger ones, distribute the care, sustain the infrastructure, maintain the supply chain, and deepen the finding pot? How can a system become, in Gottlieb’s words, “an economic driver for a region, creating vendors of every nature, a place where you can grow food?” The work of public health leaders everywhere is to try to move from our “illness system” to a genuine “health care system,” which is hard to keep sight of during an emergency like Ebola. But a key lesson from Ebola is the need for well-designed, well-resourced medical and nursing schools, plus labs able to conduct surveillance and to guide early and effective responses.

While Boston-level infrastructure in West Africa might seem a crazy ambition, this actually will be Gottlieb’s mission. But we can learn lessons from Africa, too. As we’ve discovered in Rwanda, we must deliver care closer to where people live. We also need to recruit, train, equip, and retain an army of community health workers.

Please visit The Boston Globe to read the article in full.

Updates from West Africa

Ebola emerged in West Africa in late 2013 and has spread across borders, killing thousands and leaving behind survivors and shattered families. Partners In Health has helped respond to the epidemic, aiming to address not only Ebola but also the "staff, stuff, systems, and space" challenges that hamper containment efforts. PIH has recruited and trained American volunteers, many of whom are now working to curb Ebola alongside West African partners in Liberia and Sierra Leone. Several share their reflections below. (Patient names have been changed for privacy. Posts have been edited for space.)

Abass' Smile (or, Then the Lights Went Out)

March 2, 2015—I arrived for my evening shift at Maforki on Monday anxious to hear how my patients had fared since I’d last seen them 24 hours before. I expected (and part of me hoped) to hear that Foday had passed away and was no longer suffering. No one I worked with could remember seeing a patient recover after progressing to the bleeding stage, so it had begun to feel like we were simply torturing him. I dreaded the thought that Abass might have died.

I immediately scoured the whiteboard with patients’ names and breathed a deep sigh of relief to see that Abass was still on it. When day shift reported that he had seemed a little better to them, I told myself it was because he was on the upswing; that the worst hadn’t killed him, so he would survive.

Monday night taught me that you can’t make predictions about Ebola. Another patient in Abass’s room, a 36-year-old woman named Mariatu, had been looking comparatively well when I met her on Saturday. She was sitting up in bed, eating and drinking and completely lucid, unlike her roommates Foday and Abass. Although she had diarrhea and vomiting the last time I’d seen her on Sunday, she still seemed to be in better shape than the others. When we reached her bedside during our first round in the Red Zone, she was moaning with pain and laboring heavily to breathe. Since we hadn’t anticipated Mariatu being in so much discomfort, we hadn’t brought any pain medicine into the Red Zone for her. We had used our last dose on a patient in the previous ward. She would have to wait until our next round in a couple of hours before we could get her some. Promising her that we would be back to take care of her, we left Mariatu in bed moaning in pain.

When we returned for our second round at 9:45 pm, it felt eerie in the dim fluorescent light of the Red Zone. We found Mariatu lying on the ground just outside the door of her ward. I suddenly remembered another nurse checking under the beds while he was giving us a tour of the Red Zone, and telling me about this “weird Ebola thing” – that patients often crawl out of bed near the end and die on the floor.

But Mariatu was still alive, breathing hard and looking at us with wide, terrified eyes. I helped my coworkers sit her up against the wall, then stepped into the ward to check on Foday and Abass. When I turned back to the door a minute or two later to ask if they needed help getting Mariatu back into bed, they told me she was already dead.

I couldn’t believe I’d heard right. I started to take a moment to process it, then looked around at the rest of my team who were moving forward with the job at hand. With only 90 minutes in the Red Zone, we don’t have any time to waste. Mariatu’s body was left where we found her and covered with a lapa. Ebola is extremely contagious in the bodies of the deceased, and it wasn’t our job to care for her any longer. The corpse team would be called after we left the Red Zone, and they would come the next day to move her to the morgue so the specially-trained burial teams could come to pick up her body. Nowadays every death in Sierra Leone (whether Ebola-related or not) is handled by the burial teams in full PPE, just to be safe.

With nothing left that I could do for Mariatu, I walked back to check on 10-year-old Abass. He and his 25-year-old neighbor Foday were now both lying on mattresses on the floor; they’d been moved out of bed when they were agitated and the clinicians worried they might fall. Abass had pulled his IV out since we’d last seen him, and another team member felt he would die overnight if we didn’t get another one in him. In the poor light, no one felt excited about attempting it: An accidental needle stick injury to one of us is statistically a death sentence. One of the national nurses stepped up without missing a beat, and had a beautiful IV in Abass’s arm before the rest of us could even tell her to be careful. We hooked him up to a bag of IV fluid and were feeling pretty good.

Then the lights went out.

I won’t pretend it isn’t scary to be the the Red Zone of an ETU at night with no lights. You become extremely aware of all the infectious material around you that you suddenly can’t see. I hate to be dramatic, but it does feel a little like a horror movie. Unfortunately power outages aren’t an unusual occurence, so our more experienced coworkers had warned us beforehand that if we found ourselves in total darkness in the Red Zone, we would have to stop whatever we were doing and leave. I knew we had to go for our own safety, but I wanted to scream out of frustration, since we’d just arrived and had barely started caring for our patients. I was fortunately still holding the battery-powered LED light I’d shined on Abass to help the national nurse get more direct light to start his IV. We all agreed we could take a moment to unhook his IV fluids, otherwise he would tear his IV out again as soon as we walked away.

As soon as we had unhooked Abass’s line and resolved ourselves to leave, the ceiling lights sputtered and flickered back to life. The Red Zone is not a comfortable place to be, but I silently cheered that we wouldn’t have to leave. We restarted Abass’s fluids and decided to try to feed him since he was awake and calm. Fortunately some formula had been left in the Red Zone, so I drew up a few mililiters in a small syringe, squatted on the floor next to his mattress, and held it to his lips. I knew he had painful mouth sores and I worried that he’d refuse it, but he silently swallowed the tiny amount that I squirted into his mouth. I flicked away an ant that skittered across his mattress. Another nurse sat above him, stroking his head. We both encouraged him to eat and cheered him on every time he swallowed a few drops. His eyes met mine while I told him how well he was doing, and I felt sure he was lucid. I tried a silly little dance and suddenly he was smiling. His grin was weak but wide, and his eyes were bright, and all of a sudden I could clearly see the little boy he was before he was sick. I laughed and smiled back at him as hard as I’ve ever smiled, certain that he would see it in my eyes if I could just smile hard enough, even though my mask and hood covered every other part of my face. He babbled at me in a language I couldn’t understand, then called out “Auntie, auntie!”

I don’t know how long my friend and I sat there, entreating him to swallow drops of formula, rubbing his head and his bare chest, dancing and singing in our suits, hoping to elicit another smile. We were rewarded with a few more beautiful grins before Abass shut his mouth and refused to eat any more.

Our time was up anyway. I knelt beside him and told him he was strong. I promised we would be back for him soon. Maybe he didn’t understand, but I think some things don’t need to be translated. I reluctantly stood up and walked away, leaving him alone with his neighbor Foday struggling to breath, and the body of Mariatu just outside the door. As we were leaving the ETU later that night, one of the other nurses told me she thought he had a shot.

Abass died the next day.

I don’t know if he was afraid, or in pain, or even if anyone was there with him. I hope someone was. I hope I made his last night a little less frightening. I think I brought him joy and I have to believe that matters.

I wish I could find the right thing to say to make his death meaningful, but I don’t think there’s any meaning in a 10-year-old dying alone on the floor. I could rant about how he might have been saved if he’d had access to the best medical care in the world, but I’d rather just let him be a sweet little boy than an example of all the injustice in the world. Even though it was only for a fraction of the time I spent with him, I’ll always think of him as Abass with the big contagious grin and the bright eyes, not as one of thousands of children who have died of Ebola. I didn’t know him very well, but now you all know a little piece of him too, and I think that counts for something.

Emily Scott

Numbers Become People

March 2, 2015—The only word I have been able to find to describe this experience so far is surreal. Today it became real. Today Ebola ceased to be a faceless mass of African suffering and became two individual human beings.

I’ll give you all the lay of the land at Maforki before we get much further. Maforki ETU belongs to the Sierra Leonean government, and is built out around what used to be a school. The patient wards are the old classrooms, large concrete buildings painted red on the outside, with several beds in each. When it was turned into an ETU, additional basic structures were added at the periphery: a triage area, nurses’ station, meeting room, areas for donning and doffing PPE. Nailed together out of mismatched wood and blue tarps, the whole thing looks a bit ramshackle, but the center is known in the area for giving excellent care. Port Loko residents who fear they have Ebola ask to be brought to Maforki because they have heard they’ll be treated well.

To enter, you must dip the bottoms of your shoes in a bucket of chlorine, wash your hands in chlorine, and have your temperature taken at the gate. The whole center is divided into two main areas: the Green Zone and the Red Zone. The clinicians’ areas are in the Green Zone, so we can have meetings, draw up medications, eat meals, etc. in an area that is not contaminated with the virus. The patient wards are in the Red Zone. No one steps one foot into the Red Zone for any reason unless they are in full PPE, and nothing you take into the Red Zone is allowed to come out.

At the beginning of each shift, the staff gathers in front of the large white board that shows the names and medical information of each of our patients. Today there were ten (five confirmed Ebola, and five suspect). We discuss how each one fared overnight, and divide them up between the nurses. My group of nurses was assigned to the confirmed Ebola patients, so we huddled at the nurses’ station to make a plan.

Because we are limited to 90 minutes in our PPE, we need to decide everything we’re going to do before we enter the Red Zone. We also need to be deliberate about gathering any supplies we might need, since there’s no way to step back out of the Red Zone to grab something once you’re inside. The Suspect Ward does have a wooden slide from the window of the supply room in the Green Zone going over the fence into the Red Zone, so if we need something we can ring the bell on the Red Zone side and someone will slide whatever we need down to us. But again, that just wastes time in your suit.

So my team drew up all of the medications we thought we’d need--IV start supplies, plenty of bags of IV fluid, rags, and lapas (beautiful African fabrics used for just about everything, but in this case as sheets). I found myself giving doctors tips on how to draw up meds, since at home they are normally the ones writing orders, while nurses carry them out. Here in Maforki, it’s all hands on deck and the doctors gladly do nursing care with the rest of us. One of our patients had just been confirmed Ebola positive this morning, so we would need to move him from Suspect to the Confirmed Ward. We had been told he was too sick to walk, so we brought a body bag to put him on so we could carry him.

Then it was time to don our PPE. I hunted for two pairs of gloves in my size, as well as a pair of black rubber boots that fit me, out of the many drying on a rack in the sun outside the nurses’ station (exposure to sunlight kills the virus, too). Then I joined the rest of my team in the donning room, the last stop before you enter the Red Zone. A few Sierra Leonean staff double-checked us as we donned our suits. We were ready to go in.

As we walked through the doorway into the Red Zone, I took up the “Ebola pose” that we had been taught in training – interlocking my fingers in front of me at about the height of my navel, to discourage me from reaching up to touch my face or anything else around me. One of the Maforki nurses told me that when he’s in the Red Zone he pretends he’s playing a giant game of Operation, trying not to touch anything around him that he doesn’t have to. He assumes that every surface is contaminated with Ebola.

The Red Zone is designed to flow from lowest to highest risk, so the first ward we came to was Suspect. The Suspect patients (who have Ebola symptoms but have not yet had a positive test) are divided between those who have dry symptoms (fever, headache, hiccups, weakness, etc) and those who have wet symptoms (vomiting, diarrhea, and bleeding). The idea is to decrease the likelihood that one patient will infect another with Ebola. “Wet” patients produce a huge amount of highly infectious diarrhea and are often too weak to make it to the toilets. Many wards have old cholera beds, which have a large hole at the center that patients can position themselves over, with a bucket on the floor underneath to catch their waste.

Unfortunately Maforki does not have its own lab, so we send our blood samples to another nonprofit which runs our lab tests and emails us the results. The process can take 12-36 hours. In the meantime, all suspect patients must be housed within the Red Zone in case they do turn out to be Ebola positive. We don’t get many patients who return after they’ve been discharged negative, which is reassuring.

One of our patients today was not so lucky. Foday was brought to Maforki yesterday already very ill, and his test came back positive this morning. We needed to move him from Suspect to the Confirmed ward. When my team of four entered the Suspect Wet ward, Foday lay curled up in bed in his own waste. We carefully cleaned him up with the help of a sprayer who followed us with a tank of chlorine on his back, rinsing our outer layer of gloves whenever they were visibly soiled. Once Foday was as clean as we could get him, we rolled him onto the body bag we had brought with us and lifted him out of bed. Communicating with each other the entire time, we made our way out of the Suspect ward, through the gate into the Confirmed area, and lay him down on a bed in a room with the other Confirmed patients.

In the bed next to Foday lay 10-year-old Abass. When we visited him yesterday he had barely responded, and we worried over the bleeding we saw at his gums – a late sign, and not a reassuring one. Today he was reaching out for something with both hands, probably a family member whose presence he was hallucinating. The team before us had given him his meds, but I couldn’t help walking over to him to try to give him some comfort. When I entered his field of vision he recoiled. Between the language barrier and his delirium, I couldn’t explain to him why his family wasn’t there to wipe his face and hold his hand, and he was instead being cared for by a stranger dressed like an alien.

Having used up a lot of our allotted time already, we went to work giving Foday his medications. At Maforki we are aggressive with IV fluids, although it’s difficult because we can only give them while we are inside the unit with the patients. Experience has shown that if we hook up an IV line and leave it hanging, we will return a couple of hours later to find that the patient has accidentally ripped it out and bled everywhere. So we did the best we could with the time we had left, giving Foday IV fluids, antibiotics to prevent secondary infections, artusenate for malaria, and paracetamol for his fever. Although we had cleaned him up after he’d soiled himself again, by the time we had to leave he was already lying in his own diarrhea for the third time since we’d arrived about an hour before. With no time left, we had to leave it for the next round of clinicians.

Although we technically can spend 90 minutes in the PPE, a good chunk of that is taken up by the doffing process. As I’ve mentioned before, removing our PPE is the point at which we’re most likely to contaminate ourselves. We have infectious body fluids all over us, and we have to get out of our suits without getting a speck of it on ourselves. Once we do, it’s almost noon, and we head to the nurses station to re-hydrate and have a snack before our second round in the Red Zone. I’m feeling fine physically. I seem to be one of the lucky ones who is surprised when our time is up, and I come out of my PPE almost as dry as I went in while others return with their whole scrubs a shade darker from the sweat. Emotionally, it’s harder.

By our second round in the afternoon, Foday was looking worse. He was having pretty much constant diarrhea, rolling over to vomit into a bucket next to his bed, and dripping blood from his nose. His fever had risen and he was tachycardic. Dried blood was caked all over his nose and mouth. We started a second IV and rushed fluids into him, and tried to clean him up from head to toe. At some point he decided he was done putting up with all of these white-suited monsters poking at him, so he rolled over and tried to stand up, clearly agitated. With two IVs hooked up and blood running down his face, any quick movement on his part would mean spraying infectious blood all over the place. As a nurse, everything in my heart wanted me to go rub his back, help him back into bed, and calm him down enough that we could continue to care for him – while everything in my brain was shouting, “Get away from him!” Suddenly my PPE seemed so fragile. He eventually calmed himself down and crawled back into bed, and I was left feeling surprised and ashamed at how afraid I’d been.

Most of the clinicians who have been here a while think he’s too far gone to recover, and I hope if they’re right that he passes away soon. I’m heading back to Maforki shortly for an evening shift, and I know we’ll do everything we can to make him comfortable. Even if he is going to die, he doesn’t have to die in pain and covered in his own mess.

Night shift tells us little Abass is looking better today, and I’m looking forward to seeing him for myself.

I hope that telling Abass and Foday’s stories stories has put faces to the outbreak. The numbers we hear on the news are PEOPLE, every one of them just as important as us and our families.

Emily Scott

You Can Get Blood Out of a Stone

February 27, 2015—Those of you who know me know that I’m always freezing, so maybe I have the ideal constitution for working in an ETU. On Thursday and Friday we donned full PPE and trained in the mock Ebola Treatment Unit. In an effort to prepare us, our instructors had described in great detail the science behind what we all know already: That it is really dang hot in there. Inside the PPE is a micro-climate of 40-50 degrees Celsius and 100% humidity. This is, as our trainers put it, an “un-compensable” environment – meaning that our normal heat dissipation mechanisms (i.e., sweating) won’t work. We were repeatedly admonished that there is NO HURRY in the ETU. If we over-exert ourselves, core temperatures can reach critical levels in under an hour. They key is to pace ourselves.

A couple of members of our group did overheat during our training in the mock ETU. Although it’s awful to watch someone you’ve grown close to as they struggle against the limits of what our bodies are capable of, it was nice to see our little family rally to help each other out. If someone starts to feel unwell in their PPE, the most important thing is to admit it and get out of the red zone asap. If someone faints and goes down in their PPE in a real Ebola unit, we’ll have a whole new set of problems. Fortunately my friends headed straight to the doffing stations, and with a little fluid and electrolytes, ice packs under the armpits, rest, and kind words, they were right as rain.

While the heat turned out to be the least of my problems, I was struck by just how restricting the PPE is once I tried to do my job from inside it. Between a hood, face mask, and face shield, my field of vision is pretty restricted. And if I don’t get my mask on just right, my breath fogs up my face shield and suddenly everything is a blurry mess. The first time I donned the full getup, I pulled my hair up in a tight bun, thinking it would be best to get it out of the way altogether. I discovered quickly that with the big lump of hair at the back of my head, if I tilt my chin to look downward, my hood pulls back from my face mask, leaving a strip of completely exposed skin on my forehead. One of the lovely Sierra Leonean nurses, who probably knows more about working in an ETU than I ever will, told me that a braid down the back works best and I was happy to follow her advice.

Another restriction to adjust to is wearing two sets of gloves on top of each other. This is great from an infection control standpoint, but garbage when you want to start an IV. Most nurses I work with in the States will throw on a tourniquet and run their bare fingers over a patient’s arm to feel for the best vein – it’s usually a better bet for finding a good one than just looking. Here, we will be hunting for shriveled veins in severely dehydrated patients, with two layers of gloves between our fingers and their skin. I’m told that this is one of the areas that the Sierra Leonean nurses excel in. While we try over and over to get an IV in, another PIH-er told me that the national staff “could get blood out of a stone.” So I’ll be keeping an eye on how they do it!

As we acclimated ourselves to the PPE, we split up into teams to do rounds in the mock ETU that is set up at the training center. Ebola survivors were stationed in each ward to act like patients, and we were expected to manage their care as we will in the real world. I know I just missed the Oscars, but in my opinion every survivor we worked with should get one. As we approached one man who seemed to be unconscious, he suddenly leapt up and lurched towards us, ripping out his fake IV and trying to escape. Even though I knew there was no real danger, no actual Ebola blood spurting all over the room, it definitely got my heart pounding.

While the mock ETU was invaluable in preparing us for the real thing, I was a bit disappointed to see the national nurses take a backseat role. Our doctors made decisions and called out orders, while the nurses carried them out obediently. One of the things I’m most excited about doing here is helping to strengthen the national nurses’ confidence and critical thinking. The impression I get is that nursing education here is very task-oriented, and they are encouraged to follow protocols without necessarily understanding the reasons behind them. Although many of the nurses we trained with were very intelligent and experts at their job, one of them told me, “The doctor is always right.” In any scenario, that can be a dangerous way of thinking, since nurses should be the doctor’s eyes and ears, their final check before care is administered, and strong advocates for their patients. But in a country ravaged by Ebola where there were hardly any doctors to begin, it will be even more essential for nurses to step up and take a leading role. I do hope that once this outbreak is over, what remains are some newly trained, skilled nurses who are motivated to build their country’s health system back from the ground up.

One perfect example is a young woman I’ll call J., a beautiful Sierra Leonean nurse I met during training. She volunteered to work at a government ETU last September, without asking her family’s permission since she knew they would not approve. At that time, nurses only received two days of emergency Ebola training before being tossed in to work at an ETU. J. has been treating Ebola patients ever since, and only gets to see her husband and child when she travels back home to visit them on her days off. I asked her if she wanted more children, and she told me she does not “because it doesn’t leave time for my work, and I love my work.”

It has been such a joy getting to know the national nurses at training. All of these wonderful men and women showed up to our last day of class on Friday dressed in a gorgeous array of African fabrics. Apparently Friday is “African dress day” which made the Americans look pretty shabby in our old scrubs. Nonetheless, it was graduation day and a festive atmosphere as we all rushed around posing for photos and saying goodbye to our new friends.

Directly from training our group left for Port Loko, a district hard-hit with the virus, where PIH’s Ebola Treatment Unit is located. Here we are being housed at a tent city run by a Danish emergency management organization, which looks a lot like MASH and feels like arriving at a colony on Mars. Several large tents are each separated into six rooms, with a cot, mosquito net, and a light in each. Though it looks sparse, it’s actually quite fancy, with air conditioning, wifi, hot showers, and electricity by generator. Plus the food is fantastic, and apparently there is a clothing-optional tanning area (I’m not kidding). Although I greatly appreciate the hospitality and the amount of organization and effort that it must take to keep a camp like this running so that health workers can do their jobs, I can’t help but feel ashamed at the stark contrast between one side of our fence and the other. It is jarring to sit under a nice tent under bright lights, listening to music and going back for seconds at the buffet, while Sierra Leonean kids walk past the fence in threadbare clothes and stare.

After months of waiting, hoping, reading the news itching to be here, tomorrow is the big day. We’ll go to the ETU in the morning, where we will don our PPE and treat Ebola patients for the first time. Maybe I should feel nervous, but I don’t. I’m just glad the wait is over and I can finally have a hand in the important work that needs to be done.

Emily Scott

Catch 22s and Surprises

February 26, 2015—I am currently taking up residence on the stairway landing between the third and fourth floors of our guest house, where the wifi has been most reliable today. It's a nice way to meet all the PIH-ers I don't know yet, as they pass me on the way to their rooms and laugh knowingly at the lengths it sometimes takes to get a good signal. One of the long-term staffers jokingly calls us "stairway trolls."

It's late and I'm still a bit jet-lagged so I know I should go to sleep, but I am bursting at the seams with new information and experiences and I'm afraid that if I don't write it all down, little details will start slipping away. The past two days of training have been fascinating.

We spent most of Tuesday learning the case definition of Ebola, which sounds boring but turns out to be the bedrock of everything we do here. Patients will show up to triage at an ETU with a variety of symptoms, and it's our job to decide who should be admitted to be treated for Ebola, and who should be sent to another healthcare facility or home. Sounds easy, right? From what the news tells us, it seems like turning up at an ETU with a fever would be an automatic admission.

The trouble is that there are several tropical diseases here that have similar symptoms to Ebola (Lassa Fever, for example, looks very much the same with the exception that Ebola patients commonly have hiccups). So why not just admit them to be safe, and then figure out what they have for sure once you have them quarantined in the ETU? Because of the nightmare scenario of admitting a person with suspected Ebola who turns out to only have malaria, but then they catch Ebola from having some contact with another patient while they waited to be diagnosed.

Patients who are admitted to an ETU through triage join the other non-confirmed patients in the "suspect" ward. This means they automatically live in the Red Zone, the high-risk area that we healthcare workers can't set foot in without being completely suited up. As much as we will try to keep suspected Ebola patients separated from each other before they are confirmed, it's not possible to guarantee that one won't infect another. One of our case studies described a patient in the suspected ward (who turned out to be Ebola positive) who was delirious, ripped out his IV, and wandered into other suspected patients' rooms, spreading his blood everywhere. If any of those other patients had turned out to be negative, now they were at serious risk. Essentially, it would be horrible if patients came to the ETU Ebola-negative, and then caught it there.

We don't want to admit non-Ebola patients to the suspect ward if at all possible, but we also don't want to send someone home who turns out to have Ebola after all. Here's another nightmare: You triage a patient and wrongly decide that her symptoms don't meet the case definition for Ebola, and she goes home and infects her entire family.

If Ebola tests were instantaneous and 100% accurate, we wouldn't face scanarios like this. Unfortunately, they aren't. The amount of time it takes to get results on a PCR (the blood test for Ebola) has decreased during this outbreak in many cases from days to hours, but many places don't have a lab that is sophisticated enough to handle blood samples as hazardous as these. And even if your patient's Ebola test comes back negative, they don't get an automatic ticket home. In the first few days of the illness the viral load may not be high enough to be detected by the test, so they'll have to remain in the ETU for a few more days and re-test, to make certain that the initial PCR wasn't a false negative. One of the national nurses told me today that she felt their most egregious mistake at the start of the epidemic was that they sent patients home after one initial negative test. She was clearly upset as she recalled that they had sent home one of their health workers despite his symptoms because his Ebola test was negative, only to have him return a few days later and die shortly thereafter.

Now I'll complicate things even more. It would be easier to adhere to the case definitions that guide us to admit a patient if we were certain that every patient was being perfectly honest. But people who don't want to be admitted to an ETU often hide their symptoms, denying that they've had diarrhea or vomiting and insisting that they feel fine. You may also triage someone who has no fever, which lowers your suspicion, until you ask the right question and find out they've been taking Tylenol in order to bring their fever down.

Many of the examples I'm using have come from real case studies that we discussed in small groups in class, which for me has been the most valuable part of training so far. You think you're somewhat prepared, until you find your group split down the middle trying to decide what to do with the case you're discussing, which is an actual situation that clinicians faced in an ETU.

We were faced with another sobering reality today, as Ebola survivors had been invited to our training to share their experiences with us. They sat in a row at the front of the class, bravely recounting the hell they had somehow managed to survive. While one survivor took his turn to speak, others stared blankly at the floor as if re-living their experiences. Another leaned back and covered his face with his hands, seemingly willing himself not to remember what he'd seen.

Most of the survivors we heard from contracted Ebola while caring for their ill family members early in the outbreak. In one case, a patient was sick in a government hospital but the nurses refused to care for her because they feared Ebola. When her family came to the hospital to do what the nurses wouldn't, they all became infected. In another case, an ill woman refused to go to the hospital, so her family members who were health workers cared for her at home. They started IVs on her with their bare hands, and of course infected themselves.

One man told us that when he went to an ETU his family had no hope for his survival, and that "with every tick of the clock, they called me to ask, 'Are you ok?'" Their experiences in holding centers, which screen patients for Ebola and transfer them to ETUs if necessary, were horrific. One man recalled sharing a toilet with 10-15 people, diarrhea and vomit covering the floor, leaving anyone who didn't already have Ebola to almost certainly be infected. The medics were so terrified of their patients that they handed them medicine through a barbed wire fence. "Nobody helps anybody," he said. "It's like the day of judgment."

Once they were transferred to an official ETU, many described how grateful they were for the competent care they began to receive. One survivor explained that healthcare workers in the ETU were confident in their PPE, and therefore not afraid to enter the ward and care for their patients. They repeatedly thanked their Sierra Leonean caregivers, insisting that "the staff are making so many sacrifices."

When they were asked what the worst and best moments of their experience had been, I was certain they would all say that their best day was when they were pronounced Ebola negative and discharged. But most of them described that moment as conflicted; although overjoyed to have survived, they knew they had to return to lives in which many of their family members, including spouses and children, had died. One man's wife died of Ebola on the same day that he was discharged home cured.

Surprisingly to me, most of them described their "best" moment as an experience with a healthcare worker. It put faces to the constant message we are hearing that providing quality, humane care in the ETUs is essential. At the beginning of the outbreak, the care in ETUs was horrible and degrading (how many photos did you see in the news of patients dying alone on a cement floor?). Many people chose to keep quiet if they were sick, terrified of what would happen to them if they turned themselves in. Our trainer told us of one case in which a patient's mother was told that he had died in an ETU, only to have him return to his village cured a week later. His neighbors ran from him, believing he was a ghost. After thinking that her son had gone to an ETU and died, the mother refused to seek treatment when she fell ill, and she died of Ebola at home a few days after her son returned.

Although ETU care has greatly improved (and it is now criminal to remain at home if you have Ebola), some people still resist seeking treatment. Confirmed Ebola patients are interviewed to determine who they have been in contact with since showing symptoms, and those contacts are actively monitored for 21 days. Community health workers visit them at their homes to check their temperatures and ask about symptoms, but it can be difficult to get the true story. Our trainer encouraged asking the families to step outside of their houses to take their temperatures, using the example of an old woman who told the health workers she felt fine, but was unable to stand up when they asked. In other cases, people aware of what time the health workers are coming have removed their sick family members from the home to hide them. There has been a big push to involve local leaders in the process of monitoring. As our trainers pointed out, the villagers will never trust us as much as they trust an authority figure they already have faith in.

There is also an intense focus here on safe burial practices. Since an Ebola patient's viral load increases the longer they are sick, corpses are extremely infectious. Studies have shown that the virus can live on dead bodies for 6 days. In a culture where washing the body of the deceased is a common and important ritual, that spells disaster. We were told that some burial practices include mourners washing their faces with the water used to clean the body, or in extreme cases even drinking it. While that may seem abhorrent to us, try to imagine if a stranger from another country wanted to take the body of your child from you without a funeral or a coffin. It's easy to understand why many Sierra Leoneans refuse. Unfortunately, this can mean that a single funeral can set off a chain reaction in which everyone who attended contracts the virus.

I could go on and on, but I should follow the health workers' cardinal rule (to take care of myself first) and go to bed! It has been a fascinating few days. I take notes furiously and hope that it's all sticking in my brain somewhere, ready to be called forth when I need it in the coming weeks. I'm excited to get into the mock ETU tomorrow and start practicing getting my hands dirty (or rather, my outer layer of gloves. Never, never my hands).

Emily Scott

"That 'Good Morning' has Ebola!"

February 23, 2015—We made it to Sierra Leone! Something like 30 hours after we left Boston, we finally landed in Sierra Leone on Sunday night. The same smells I know from East Africa made me feel at home from the moment I stepped off the plane. Even after so many hours of travel and sleeplessness, I knew I was exactly where I was supposed to be.

The reality of the Ebola outbreak hit us as soon as we walked across the tarmac and reached the door to enter the airport. Chlorine hand washing stations awaited us outside, and everyone was made to wash their hands before being allowed to enter. After reading so many news stories about it over the past several months, it was surreal to be actually washing my hands with chlorine to prevent spreading Ebola for the first time.

Once inside, it was probably the most fun I've ever had in customs. We were surrounded by other humanitarian responders from MSF, World Health Organization, Direct Relief, you name it. It was lovely to chat with them all as we waited. After clearing customs, I waited in line to have my temperature checked. It's an odd moment, if you let your imagination run away with you and start to wonder what might happen if your temperature comes out high.... Fortunately, I was a normal 36.3 C and was waved right on.

A short bus ride, ferry trip, and another bus took us to the Partners In Health guest house, which is lovely. We are sharing an apartment with electricity by generator, running water (though not hot), and wifi that comes and goes. We even have a washing machine! My coworkers are laughing at me right now as I sit on the couch, blogging beneath a line of drying scrubs and underwear.

Our first day of World Health Organization training was today. It was clearly well-run and fascinating since I was able to stay awake for 8 hours of class despite some serious jet lag! We PIH-ers are just about the only non-Sierra Leoneans there, which is lovely because we get to interact with national staff, some of whom have been fighting Ebola much longer than us. Many haven't received adequate education, so they are just now attending this training with WHO. Of course we all took advantage of the hand washing station before entering the building, and had our temperatures checked and recorded by the staff.

Our first lecturer wished us a good morning, and chided our lackluster response with, "That 'good morning' has Ebola!" We were reminded of the huge importance of infection control and prevention among healthcare providers, not only to keep ourselves safe, but because of the role it plays in public perception here. We were told that, "You have not come here to die," which is always reassuring! At the beginning of the outbreak, hundreds of Sierra Leonean healthcare workers contracted Ebola due to poor infection control measures. 221 have died to date. To the public it seemed like the situation was hopeless. Why would you come to an Ebola Treatment Unit for care when those who are caring for you are dying themselves? To put it simply, dying sends a bad message. Fortunately this perception has shifted as infection control measures and patient care have improved, but we healthcare workers play an important role in continuing that momentum. Ebola survivors are also pivotal in instilling hope and proving that admission to an ETU is not an automatic death sentence. Because they are immune to the virus for an unknown period of time, many survivors have also been helping to provide care in ETUs.

It has quickly become clear that habits I live with in the US will need to be broken ASAP. One of our trainers stepped into class this morning to let us all know that they had been watching us for 15 minutes, and we each touched our faces an average of 3.4 times per minute. Considering Ebola enters the body through our mucous membranes (eyes, nose and mouth), I'll just have to learn to put up with the itch on my nose. We also don't shake hands when we meet someone new. Instead, we offer to touch elbows. It's hard not to feel rude at first, but the stakes are too high to care really.

The basics are essential here: We all re-learned how to wash our hands, the Ebola way. I'm certain I have never paid such close attention to a person washing his hands as I did at that moment. It takes a full minute, with maneuvers to make certain that we clean every centimeter of our hands. We practiced in a group, everyone nit-picking each other's technique because it will likely be the thing that keeps us Ebola-free.

Next we tested our ability to remove dirty gloves without contaminating ourselves. After dipping our hands in mud, we each SLOWLY removed our gloves, careful not to snap them and fling infectious material, and making certain that no part of the outside of the glove touched our skin. Our trainers inspected our hands and declared, "Quarantine!" to anyone with a speck of mud on their skin. It's excellent practice for when our gloves will be covered with bodily fluids, and it's no longer a game.

And finally, it was time for the infamous suits. We refer to them as Personal Protective Equipment (PPE), and we'll need to know exactly how to don and doff them in order to keep ourselves safe in the hot zone. Today was just a test run, with trainers walking us through the correct procedure for putting on each item - rubber boots, suit, fist pair of gloves, hair cover, mask, face shield, hood, apron, and second pair of gloves. Another surreal moment, to be completely encased in the suits I've been seeing on TV for months. Between the mask, face shield, and hood, my visibility was incredibly limited and I struggled to hear what the nurse next to me was saying. We then took a lap around the building, getting a feel for how we would react to the PPE. My lovely African teacher acted as my buddy (everything in the hot zone is done in pairs), and kept asking me, "How are you doing, buddy?" every few minutes. It's hot in there, for sure, but I didn't feel faint or claustophobic. We'll see in the coming days if that changes when it's an hour and a half, rather than five minutes, that I have to work inside the suit.

The moment you remove your PPE is the highest risk time for contaminating yourself, so this skill is crucial. My buddy walked me through each step, as the support staff will do in the ETU. The motto is "There is no emergency in Ebola," meaning that we do everything at a snail's pace to ensure we are doing it safely. We remove each part of the PPE carefully, with a minute-long hand wash in between each piece. It's a long process. I'm actually looking forward to getting more practice tomorrow. I'd like it to be muscle memory by the time I'm doing it in real life.

Of course we wrapped up the day with a temperature check.

Emily Scott

Ready to Depart, Thinking About Coming Home

February 20, 2015—Our stateside training is complete, our passports have arrived complete with our visas just in the nick of time, and tomorrow morning we begin our long trek to Sierra Leone! We'll have a week of World Health Organization training complete with a mock Ebola Treatment Unit and survivors acting as patients, then real hot zone training in an ETU before we are sent to our respective assignments. It has been an absolute pleasure spending time with the rest of my group; there's nothing like hanging out with a bunch of like-minded people who "get" why you do what you do, to really light you up. I think we are all itching to get started.

Partners in Health has taken great care of us and treated us like part of the family, which makes it easy to entrust ourselves to them. Yesterday we had a session with PIH's occupational health doctor to discuss the protocol if we become ill in the field. PIH has not had any clinicians contract Ebola (knock on wood!), but it's common to experience diarrhea or other illnesses that could mimic some of the symptoms. We'll be checking our temperatures twice a day, reporting any issues, and isolating ourselves if necessary. Which I explain only because I think it's interesting, not because I expect it to happen!

Of course, we have also spent plenty of time discussing the surveillance process that we will experience when we get home. I'll explain a bit now, just to soften the ground for when it's my turn!

Regulations for returning Ebola responders are set by the COUNTY in which they live. The CDC has guidelines, but states are not required to follow them, so it's up to each county to decide how they want to do it - which is why some of our clinicians are being told they can't leave their homes for 21 days (the incubation period for Ebola), while others have much more reasonable restrictions.

Unfortunately, some counties are basing their requirements on public perception, rather than actual science. I understand that people are terrified of catching Ebola, but acting on irrational fear rather than proven facts simply doesn't do anyone any good. The fact is that Ebola CANNOT be transmitted by someone who is not showing symptoms. It is NOT like the flu, for example, which someone could spread to others before they even knew they were sick (by the way, thousands more Americans will die of the flu this year than Ebola, so if you're freaking out about Ebola, get your darn flu shot). This is the exact reason that returning clinicians check their temperatures at least twice a day and monitor themselves closely for any symptoms. Even if we had somehow been exposed and contracted Ebola, we can't give it to anyone else until we show symptoms.

Secondly, Ebola is only passed through direct contact with the bodily fluids of someone who is ill - it is NOT airborne. "Direct contact" includes physical touch but also contact with infectious droplets. The common confusion that I have heard is that Ebola could, in certain cases, be transmitted through a cough - so doesn't that make it airborne? Not in an infectious disease sense. To clarify, for this specific example to happen you would have to be in close proximity to someone who is already sick with Ebola, and they would have to cough in a way that their saliva or blood landed in your mucous membranes (eyes, nose, mouth). The difference with airborne viruses (like a cold) is that the virus can hang in the air in a lingering cloud. So if I have a cold and I cough, you could walk through the room a few minutes or even hours later, after I'm long gone, and still catch my cold. That is not possible with Ebola. I know it seems like a fine distinction, but it's an important one. I mean, you usually notice when someone coughs their bodily fluids onto you, and it's easy to prevent, whereas you don't have any idea when a virus in hanging in the air that you walk through.

Still don't believe me? Let's get real, and imagine how many more infections there would be, not just in West Africa, but everywhere, if Ebola was airborne. There's a reason Ebola has been referred to as "a disease of caregivers": most people who have contracted it have done so while taking care of someone who was ill. They don't catch it walking down the street, or hugging their healthy friends. Family members and healthcare workers catch it while caring for someone who is very ill and losing a lot of highly infectious bodily fluids through huge amounts of vomit and diarrhea. Remember Thomas Duncan, the Liberian man who died of Ebola in Dallas? He was misdiagnosed and sent home with Ebola for DAYS. He lived with his family members while he was actively ill, and NONE of them caught it. If Ebola truly was airborne, how did they come out unscathed?

Another HUGE factor in the spread of Ebola which must be mentioned is the sanitary conditions in West Africa. Imagine caring for a family member who is losing liters of fluid through diarrhea and vomiting, in a hut with no running water or flush toilet or washing machine. Now compare that to the United States. Though of course I don't know for sure, I would guess that Mr. Duncan's family avoided close contact with him and washed their hands a lot, as any of us would do if our family was sick with anything. There's a reason Ebola spread like wildfire in West Africa and was stopped in its tracks in America.

So please excuse the long rant, but that brings me to me. My plan is to live in my house with my husband for 21 days, see my friends and family, and (just to be extra safe) to refrain from swapping bodily fluids with anyone. It shouldn't be terribly hard - I rarely lick strangers or uncontrollably release bodily fluids at the grocery store :) So let's say, in theory, I'm at home with my family a week after I get home from Sierra Leone, and I develop a fever. I'll immediately self-isolate, alert public health, and if I meet the criteria, I'll be taken to a designated hospital for treatment before I am a risk to anyone. And fortunately I will have been keeping my bodily fluids to myself in the meantime anyway, so there's no way for anyone to get sick. This is, by the way, all in line with the regulations that King County Public Health has set for me.

Questions about this? Ask me! It is hugely important to me to make this clear so that the public isn't living in fear for no reason, and returning clinicians aren't stigmatized.

Please feel free to impart this information on anyone and everyone! I know plenty of Ebola responders who are doing this work in semi-secret, for fear of how their friends and neighbors will treat them if they find out. I believe that is truly a shame, and they deserve better. If all of the scientific data doesn't convince you, take a moment and really ask yourself: Do you honestly believe that humanitarian responders would put their lives at risk to save strangers on the other side of the world, and then come home and knowingly put their friends and family in danger?

There's so much more to say about what we're expecting to see on the ground, but I'll report back to you when I've begun to see it for myself.

Emily Scott

A Valentine's Day Explainer

February 14, 2015—Happy Valentine’s Day, everyone. I have the morning off, as today I am scheduled for my first evening shift. It is HOT – getting up to 100 today – and Port Loko is not, needless to say, entertainment central. I’m planning to read and write and maybe snooze till I have to go in.

It occurs to me that I should give you a clearer description of what exactly we’re doing. So: I am working in an Ebola Treatment Unit (ETU) called Maforki, which is currently the busiest one in the country. The purpose of the unit is to isolate and treat people who either are confirmed to have, or suspected of having, Ebola.

It works like this: People come to the ETU who have symptoms of some kind and/or have an established contact with an Ebola victim – they lived in the same house; they shared a long taxi ride; they took part in the person’s funeral. Occasionally, we have “walk-ins” – people who have decided they might have Ebola. Mostly, though, the patients come in ambulances, and mostly they are sent by contact-tracing teams. These teams are out in the community looking for, and then following the health of, anyone who might have come into contact with Ebola. They are really the front line soldiers in the struggle – the ones getting on top of what could otherwise be an exponential rise in cases, getting any possibly sick person into isolation before he or she can affect anyone else.

Once the person arrives at the ETU, they are screened – by someone from here, who speaks the language, needless to say. We need to see if they “rule in” or “meet criteria” – that is, if they have enough signs and symptoms to make us conclude they might have Ebola. Currently, the screening is “high sensitivity/low specificity” – in other words, we cast a wide net. The thinking is that it would be much worse to fail to identify an Ebola case (who could then go on to infect 20 or 30 other people) than it would be to keep someone in isolation unnecessarily who does not have the disease. But we can’t pretend this is 100% benign – it is completely possible that someone who does NOT have Ebola but whom we bring into the isolation unit will then CATCH Ebola from another patient while they are there. As you can see, we are deciding that risking one additional (and isolated) case is better than risking 20 (un-isolated) cases. But it might not feel that way to the person involved.

When you're admitted, we try to place an IV and give you some basic medications (including malaria treatment for everyone, since it is so widespread). We also take your blood for laboratory analysis. We then move you to the “suspect” ward – where people stay who do not have confirmed Ebola.

The suspect ward is, as much as possible, divided into two parts – “dry” and “wet.” Which means what you might imagine – if you are vomiting, have diarrhea, or are bleeding, you go into “wet;” if your symptoms are limited to things like fever, weakness, and headache, you go into “dry.” This is because wet people are more contagious (the disease is spread via bodily fluids, after all), and also probably more likely to actually have Ebola. Separating wet and dry is a way of trying to avoid, as much as we can, any spread from infected to uninfected people in the suspect ward. (For the most part, people are all together in big rooms with metal beds and not much else in them – we are isolating cases from the community but, except in some special cases, we can’t completely isolate patients from each other.)

Meanwhile, the blood we drew is going to a lab, where a little miracle of modern bioengineering called a polymerase chain reaction (PCR) test takes place. The test increases the quantity of DNA in a sample to the point that different DNAs can be detected by different tracer molecules. If you have DNA from the Ebola virus in your blood, the test will find it. In that case, you are “positive” for Ebola, and moved from the suspect to the confirmed ward. If, however, you are “negative” – and, critically, if the blood was drawn at least three days after your symptoms started (three days being the generally understood time it takes for the virus to multiply enough to become detectable) – you are considered Ebola-free and can be discharged. (If It’s been less than three days, you have to stay in the unit a little longer so the test can be run again at the appropriate time.) Some “negative” people are still clearly sick – with TB, malaria, HIV, malnutrition – sometimes we have a pretty good sense of what it is, sometimes we don’t. These people are discharged to Government Hospital for further care. People who are otherwise well get to go home. But, of course, everyone who has been in the unit must be followed for 21 days after leaving, because – see above – they might have picked up Ebola while in the ETU. So the contact-tracing teams I’ve already referred to will add these patients to their list and keep tracking them.

Things are, in many ways, simpler once you go to the confirmed ward. Obviously, we try to maintain basic hygiene as much as possible, but it is less critical to separate wet and dry, since everyone is already infected. Similarly, while we have to be obsessive about hand-washing etc. in the suspect ward – the last thing any of us wants to do is to bring Ebola from an infected person to someone who is not infected – we can be thorough but more efficient in the confirmed unit since, again, everyone is already infected. (For now, there is no evidence that there are multiple “kinds” of Ebola virus – one person’s virus is the same as another’s. So even if one patient receives some virus from another it shouldn’t make any difference, since everyone is full of the same virus anyway.)

As I’ve said many times before, there isn’t a whole lot we can do to specifically fight Ebola. Either your body fights it off or it doesn’t. What we try to do is to give your body the best chance possible of doing this, by keeping you from getting other infections (antibiotics), by keeping you strong (food, if you can eat; vitamins; IV glucose if you can’t eat), by keeping enough water in your body (IVs, oral rehydration solution), and by keeping you comfortable (anti-nausea medications, pain relievers, Tylenol for fever, anti-anxiety drugs, sleep aids). These are the treatments you get in the confirmed ward (and in the suspect ward, too, if you are already clearly ill). There is certainly some debate about the BEST treatment – one ETU has published data indicating a survival rate of over 70%, and, needless to say, everyone is interested in adopting their protocol – but that is more or less the range of things we use.

With luck, after 5 or 10 days, you start to get better! At this point, we scale back your medications and tailor them to what you need – we can take out your IVs if you’re drinking well; stop antibiotics if you’ve received a full course; make sure you have lots to eat. And, once you are without symptoms for three days, we can re-test your blood. If at that point the PCR is negative, it means you have fought off the virus and can go home! You bathe to remove any remaining virus from your skin and go, quite literally, naked into the world – anything that came with you to the unit, clothes, money, cell phone, has to be burned. On the other side of the isolation fence, you are met by people who give you clothes, some money, some basic food, some basic household equipment, and a new phone. If you are a man, you are given condoms and told to use them for 3 months or abstain altogether, since the virus appears to live on in semen for that long. And everyone is given an official certificate establishing that they have survived Ebola, which they can show to people in their community who might still be afraid of them. It doesn’t guarantee you won’t be stigmatized, but hopefully it helps. (These days, you are also met at the gate by other survivors, who can talk to you about what it’s like, how to go back to your community, how you may be feeling if many people in your family have died, etc. It’s a wonderful program.)

That is the flow in the unit, and what I am specifically occupying myself with every day – triage, admission, treatment, discharge. I hope that makes things a little clearer!

Wesley Clark

Leadership Lessons from an Ebola Treatment Unit

January 17, 2015—I did not arrive to work in Sierra Leone in any kind of leadership capacity.

Prompted by the news and the conviction of faith, in October I signed up with USAID and then with Partners In Health to serve as a clinician caring for patients with Ebola. I was initially scheduled to go to Liberia but with the growing need in Sierra Leone I was rerouted a week or so before my travel date.

We arrived in Sierra Leone on Wednesday, December 3, trained aggressively and began working in the Ebola Treatment Unit (ETU) in the Maforki Chiefdom of Port Loko by that weekend. Providing care to these wonderful people in partnership with the courageous Sierra Leonean nationals and a cohort of exceptional international professionals was one of the true honors of my life.

Although I was not formally in a leadership role until I became ETU clinical lead the last week or so of my time there, I was aware of the challenges and I was very impressed with the leadership team assembled. Applying the critical dyad of “attention and intention,” I discovered that in the ETU, as is usually the case, leadership lessons abound: “If the spirit of the student is in you, the lessons will be there” (Sir William Osler). Here are several of my observations.

Master narratives and names. New expatriate staff arrived at Maforki regularly. It would have been very easy for the “long-timers” (those who had already been there a week or two) to develop the kind of exclusivism that could disrupt team development and undermine the “changing class picture.” One solution was to aggressively learn the new peoples’ names and stories and take the initiative to reinforce that knowledge by introducing them by name and “narrative” to the folks who were already there.

People won’t readily surrender personal identity to take on group or team identity until the former is at least acknowledged. The same practice was an important part of getting to know the local national staff and to build the team with them.

We need to practice “intentional inclusivity.” This follows by purposefully including newcomers into existing rituals. For us at Maforki this meant eating meals together and inviting new colleagues on the morning walk to the ETU through the town of Port Loko. It was a tremendous opportunity to get to know one another and to reinforce our new, shar La Colombe Coffee and Arcade Fire Announce RaRa Coffee

In Haiti, the sunshine, soil, and rolling mountains could mean real potential for coffee farming—and an infusion of much-needed jobs to the hemisphere’s poorest nation.

So Win Butler, lead singer for the band Arcade Fire, approached La Colombe Coffee with an idea: Create a new coffee, from Haiti, for Haiti—and funnel the profits right back to those who need it most.

They came up with RaRa Coffee, specially grown in Haiti, with the proceeds going straight to PIH and the Haiti Coffee Academy.

You're invited to the official release for RaRa Coffee:

DATE: Saturday, February 14, 2015

TIME: 5 to 6:30 p.m.

PLACE: La Colombe Hudson Square Cafe

75 Vandam Street

New York City, N.Y.

If you can't join us in person this Saturday, follow along with our live-tweet from 5-6 PM EST: www.twitter.com/PIH

Join PIH staff, including Dr. Louise Ivers, PIH Senior Health and Policy Advisor, supporters, and Win Butler at La Colombe’s Hudson Square shop to sample this specialty coffee.

It’s a chance to mingle with PIH staff and supporters around the city. You might even find your new morning brew—and a new way to support our lifesaving work in Haiti.

Support PIH by purchasing coffee at LaColombe.com.

2014: Our Top 20 Photos

To mark the end of 2014, we wanted to share 20 images that capture the dedication of our clinicians, the ambitions of our founders, and the lives of our patients. Please visit the accompanying links for more information.

20. Paul Mainardi, left, began hearing voices and hallucinating when he was 20 years old. He was treated with psychotherapy and medication by the mental health team at Zanmi Lasante, Partners In Health’s Haitian sister organization. Mainardi walks in his neighborhood with Dr. Reginald Fils-Aime, University Hospital’s director of mental health services.

Photo: Rebecca E. Rollins/Partners In Health

19. Driver Sergey Goryunov and Nurse Yulia Safronova trek through the snow to a patient’s home in Tomsk, Russia. Goryunov and Safronova work with Partners In Health/Russia’s Sputnik Initiative, a model of patient-centered accompaniment that provides daily support to tuberculosis and drug-resistant tuberculosis patients who are at the greatest risk of defaulting from treatment.

Photo: Elena Devyashina for Partners In Health

18. Driver Sergey Goryunov works with PIH/Russia to deliver medication to tuberculosis patients in Tomsk, Russia. As part of the Sputnik Initiative, PIH/Russia staff members meet patients wherever they are, no matter how low the temperature or how challenging the path. Check out charts explaining multidrug-resistant TB in Russia.

Photo: Elena Devyashina for Partners In Health

17. Dr. Eduardo Peters, left, speaks with colleague Dr. Dan Palazuelos and a patient in Chiapas, Mexico. Peters is spending his social service year working with Compañeros En Salud, PIH’s sister organization in Mexico.

Photo: Rebecca E. Rollins/Partners In Health

16. Dr. Dan Palazuelos (reflected in mirror) visits the home of 71-year-old Belisario Cifuentes Gonzalez, who has prostate cancer. Gonzalez had surgery but remains uncomfortable and depressed. “I used to be active, I used to be able to work, but now the evil has consumed me,” he said. Palazuelos works with Compañeros En Salud, PIH’s sister organization in Chiapas, Mexico.

Photo: Rebecca E. Rollins/Partners In Health

15. Benitha Germain, who has worked at Belladère Hospital in Haiti since 1989, examines a patient. The patient, a 24-year-old woman pregnant for the second time, is attending her fourth prenatal visit. Her previous child did not survive. Read more about PIH's women's health work here.

Photo: Rebecca E. Rollins/Partners In Health

14. Community Health Worker Inela Espinoza Cadenas explains child-development activities to Samantha Huarcaya Tamani in Peru’s Carabayllo District. Cadenas works for Socios En Salud, PIH’s Peruvian sister organization, to help mothers improve their children’s language, psychomotor skills, coordination, and social ability.

Photo: Raúl Silverio Carbajal/Socios En Salud\

13. Community Health Representative Rebecca Tsosie drives a pickup hundreds of miles every week to visit patients in her home community in the Navajo Nation. Tsosie works with PIH’s sister organization, Community Outreach and Patient Empowerment, or COPE.

Photo: Rebecca E. Rollins/Partners In Health

12. Community Health Representative Rebecca Tsosie visits a patient at home in the Navajo Nation to ensure that she has been taking her diabetes and hypertension medications. Tsosie also checks the patient’s vital signs and blood sugar levels. View more photos from the COPE program here.

Photo: Rebecca E. Rollins/Partners In Health

11. Residents of the Nyamicucu community listen to the governor speak at the inauguration of the Nyamicucu Health Post in the Burera District of Rwanda. Inshuti Mu Buzima, PIH’s Rwandan sister organization, teamed up with the Rwandan Ministry of Health to open the post. It serves a community of more than 7,000. Read more about PIH/IMB's work in Rwanda here.

Photo: Maria Kaitesi/Partners In Health

10. Traditional Basotho huts line the mountainous landscape along the road between Nkau, where PIH/Lesotho runs a small clinic, and Maseru, Lesotho’s capital.

Photo: Jeff Marvin/Partners In Health

9. Partners In Health Chief Medical Officer Joia Mukherjee speaks to global health equity residents attending boot camp during a visit to the PIH/Zanmi Lasante women’s clinic in Lascahobas, Haiti.

Photo: Cecille Joan Avila/Partners In Health

8. Partners In Health co-founder Dr. Paul Farmer speaks to NPR about the Ebola outbreak in West Africa while waiting to board a U.N. flight at Spriggs Air Strip in Monrovia, Liberia. PIH is working to combat Ebola in Liberia and Sierra Leone. Read more from Farmer about Ebola here and here.

Photo: Rebecca E. Rollins/Partners In Health

7. The Partners In Health advance Ebola response team visits the Martha Tubman Hospital in Zwedru, Liberia.

Photo: Rebecca E. Rollins/Partners In Health

6. Wellbody Alliance members and Partners In Health co-founders Dr. Paul Farmer and Ophelia Dahl met with Sierra Leone’s president during a trip to Freetown, Sierra Leone. PIH and Wellbody Alliance are working together to treat people who have Ebola and to halt the spread of the virus.

Photo: Rebecca E. Rollins / Partners In Health

5. Partners In Health leaders and Wellbody Alliance members walk to the homes of Ebola survivors in Freetown, Sierra Leone.

Photo: Rebecca E. Rollins/Partners In Health

4. Yabom Koroma, 38, is an Ebola survivor. She lost her two sons (ages 5 and 7) as well as her husband, father, and father-in-law to the virus.

Photo: Rebecca E. Rollins/Partners In Health

3. Partners In Health began treating patients at this Ebola Treatment Unit in Port Loko Town, Sierra Leone, in early November.

Photo: Jon Lascher/Partners In Health

2. Dr. Jean Jacques Alain, a member of the first OB-GYN class at University Hospital in Mirebalais, Haiti, listens to a patient while presenting during morning rounds. Partners In Health/Zanmi Lasante and Haiti’s Ministry of Health built the hospital, which treats patients and serves as a training ground for future clinicians.

Photo: Cecille Joan Avila/Partners In Health

1. Dyson Seven, a village health worker with Partners In Health/Abwenzi Pa Za Umoyo, receives a call on the border of Malawi and Mozambique. In nearby Chawe, PIH/APZU operates a mobile clinic that provides free health care, including maternal care and immunizations for children.

2014: The Year in Quotes

From South America to West Africa to Siberia, Partners In Health and its sister organizations are marking another year spent providing a preferential health care option for the poor. Here's a glimpse into our efforts during 2014, represented by quotes from patients and staff members across our sites.

10. “Our work is very dynamic. Today you help a patient cope with side effects; tomorrow another patient may need assistance obtaining his pension while another needs to go to the hospital because he was in a drunken fight. Our work is a continuous process of solving patient problems, which involve many actors.”

Sergey Goryunov, a driver for the Sputnik Initiative in Tomsk, Russia. Sputnik is a model of patient-centered accompaniment that provides daily support to tuberculosis and drug-resistant tuberculosis patients who are at the greatest risk of defaulting from treatment.

9. “I so believed in the mission: whatever it takes to provide a preferential option for the poor. It’s a very definitive statement. It’s a mission that propels us to do more, that goes beyond the blame so many place on poor people.”

Samson Njolomole, community program and external relations manager for Abwenzi Pa Za Umoyo, PIH’s Malawian sister organization.

8. “As days went by, I came to accept my illness. The doctors told us there was a cure; I only needed to follow a long treatment. I couldn’t abandon the treatment if I wanted to live.”

Melissa Sanchez (name changed), a teenager being treated for extensively drug-resistant tuberculosis by Socios En Salud, PIH’s sister organization in Lima, Peru.

7. “The vision of this hospital is to work with the Ministry of Health to change the practice of health care in Haiti. How could I not want to be part of something that would outlive me?”

Marc Julmisse, chief nursing officer at Hôpital Universitaire de Mirebalais in Mirebalais, Haiti. PIH operates the hospital in partnership with the Haitian Ministry of Health.

6. “We strive to empower the community by working directly with community members, whether through outreach events, health screenings, or similar programs. Because many of the team’s nurses have been in Tuba City for years, we have a strong connection to the people and know the pulse of the community.”

Charlene Blindman, a nurse and public health manager at the Tuba City Regional Health Care Corporation in Tuba City, AZ. She has delivered care in the Navajo Nation for seven years.

5. “When I’m not working on the big picture of NCD care in Rwanda, I love interacting with and listening to patients. Seeing our patients, especially the elderly and children, improve the quality of their lives gives me satisfaction.”

Gedeon Ngoga, a nurse and noncommunicable diseases (NCDs) program manager at Partners In Health/Inshuti Mu Buzima in Rwanda.

4. “We improved infrastructure, we treated patients with dignity, we addressed transportation challenges, and we made sure expectant mothers were accompanied to the clinics before their due date. Focusing on these issues and properly training staff made a significant difference. Addressing maternal mortality is a gate for us to address all aspects of women’s health—empowering women, which impacts their children’s and families’ health.”

PIH/Lesotho Director Dr. Hind Satti, discussing Lesotho’s Maternal Mortality Reduction Program. The Lesotho Ministry of Health and PIH/L are collaborating to scale up the program nationwide over five years.

3. “Nothing is unchangeable. If you think you can't improve systems, the environment, or people, then you are living in a false realistic world. In this moment, while we’re talking, new doctors under our mentorship are converting idealism and clear-eyed optimism into a better reality.”

Dr. Enrique Valdespino Serrato, who is supervising a class of young Mexican doctors with Compañeros En Salud, Partners In Health’s sister organization in Chiapas, Mexico.

2. “After I had an explanation of what was happening to me, I started to understand that when I heard a voice, I didn’t have to do what the voice told me. Before, if the voice told me to run away, I would run away, but then I learned that the problem is that I’m hearing this voice. When I see something, when I hear a voice, now I understand that it is not about the devil. I’m not afraid anymore. I don’t have to obey them anymore. I sleep well. I can say there have been many changes.”

Paul Mainardi describing the results of mental health treatment and care he received from Partners In Health/Zanmi Lasante in Haiti.

1. “An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care—including fluid resuscitation, electrolyte replacement and blood products—the great majority, as many as 90 percent, should survive.”

Partners In Health co-founder Dr. Paul Farmer. PIH launched Ebola response efforts this fall in Liberia and Sierra Leone.

‘PIH Healed My Disease—and My Hunger’

Daphroza Nyiranzoga, 59, is a single mother of five who lives in Rwanda’s Butaro District. Below is an edited transcript of an interview in which she reflects on her experience with Partners In Health and discusses the importance of community health workers.

I found that I had HIV when I was already pregnant with one of my children. I was so sad when I found out that I was infected, and I was miserable because I thought that my daughter would be born with it, too. But PIH/Rwanda enrolled me into a program that performed miracles. My baby was born without any trace of HIV. To me, this was a miracle.

Before PIH/Rwanda had started in Butaro District, it was almost impossible to get ARVs [antiretroviral therapy, medication used to treat people living with HIV and AIDS]. When PIH began working with me, the group not only provided for my ARVs, but they assigned me a community health worker who follows up to make sure I take my medication as prescribed and checks my health regularly. Even though I didn’t go to school, my community health worker has taught me a lot about basic health and what I can do to keep my family and I healthy.

PIH/Rwanda didn’t only help manage my HIV, they also healed my hunger. Thanks to PIH donors, I was given two cows, which provide milk and manure that I can sell.

More recently I was enrolled into the Food Security Program, which taught me about the importance of having a kitchen garden and how vital it is to have a healthy, nutritious diet. They gave me various types of vegetable seeds and now we feed on lots of vegetables with my family. My children will never suffer from malnutrition again.

Now that I know the causes of malnutrition, and how to prevent it, I will make sure the people in my community learn from me as well. I won’t let them suffer from malnutrition as I plan on passing on these lessons and sharing my vegetables with people in my village.

I was too weak and had even failed to fend for my family before meeting PIH. If I was only given medication, I would be fine but not healthy and confident. What was very key was the community health worker that PIH assigned me. She follows up on me and my children. She advises us about different health issues, and we are no longer ignorant about how to live healthy. I take my medication as prescribed, eat healthy, and live a stress-free life. I am now living positively and no longer feel sad and hopeless about the future.

Life has never been better.

Dr. Michelle Morse: A New Mindset for Global Health Training

This article originally appeared on Devex.

This November, Haiti’s first ever emergency medicine residents began training at University Hospital, a 300-bed teaching facility born out of the destruction of the 2010 earthquake.

They joined dozens of other residents who are advancing their skills in family medicine, pediatrics, internal medicine, general surgery, obstetrics and gynecology, and nurse anesthesia. In the years and decades to come, the residency program at the hospital, located in the country’s rural central plateau, will allow a consistent stream of young doctors to work shoulder-to-shoulder with experienced Haitian and U.S. doctors, gaining expertise that is sorely needed.

When we consider how to expand access to high-quality medical care, not only in Haiti but around the world, we must also consider access to high-quality education and how to best draw upon the resources of academic institutions in the United States, where a growing number of students are seeking out opportunities to study global health.

This is a relatively recent phenomenon in academia. Consider that the number of global health programs at universities ballooned from just a handful in 1999 to more than 200 today. In fact, global health initiatives on U.S. campuses have roughly tripled every five years since 2000, according to a recent study from the Center for Strategic and International Studies. As a result, colleges, universities and teaching hospitals are developing global health majors and minors for undergraduates, building institutes for interdisciplinary research and teaching, and establishing overseas rotations for medical students and residents.

But too many of these programs verge on neocolonialism, re-creating the dynamics that have historically exploited low-income countries and undermined their capacity to build health systems that provide care for all people.

As a doctor working in Haiti, I’ve talked with several U.S. universities interested in partnerships that offer trainees safe field experiences, or opportunities to provide direct service. Their focus on student experiences results in medical “mission-style” trips, where trainees with inadequate skills visit a developing country for a few weeks and usurp resources such as transportation and human resources for supervision. While these service trips may help students broaden their horizons, they do little to strengthen health systems that provide reliable, high-quality care to patients in need.

Instead of advancing research agendas and creating opportunities for U.S. medical students, universities should contribute to bilateral faculty-led initiatives to strengthen the health system through medical education, improve hospital operations, and work with local clinicians on relevant research questions.

Surgeons-to-be must not be allowed to exploit the surplus of patients in poor countries to fulfill their training quotas.

One of the chief barriers to accessing high-quality care in poor countries is a lack of trained health professionals, a gap U.S. universities can help fill by supporting training programs. Universities are uniquely positioned to leverage the energy and idealism of talented, motivated trainees as a piece of the puzzle in developing structured global health programs. With the right intentions, they can build partnerships led by U.S. faculty that are designed to strengthen medical education and health systems in poor countries that desperately need partners with their expertise.

One such example is the Human Resources for Health program recently launched by the Rwandan Ministry of Health. This program leverages the expertise of U.S.-based academics to build, over the next eight years, the cadre of health professionals Rwanda needs to serve its population. Meanwhile, the Brigham and Women’s Hospital has long collaborated with the nonprofit Partners In Health in Haiti to support and collaborate with local health professionals. We call this approach “accompaniment” to convey long-term, open-ended support that follows the lead of local communities who can best determine where foreign partners and their expertise can add value.

University Hospital is now a training ground offering several residency programs and continuing education opportunities for rotating health professionals to raise the standard of care across Haiti. Building such infrastructure — and leveraging it for teaching and training — wouldn’t have been possible without the support of key partners, including Harvard Medical School and the Haitian government.

Before focusing on their own institutional needs, U.S. academic institutions that wish to offer global health education to their students have a responsibility to focus on building equitable partnerships in developing countries that advance the right to health. Poor countries cannot continue to serve as training grounds for students from rich countries without having the opportunity to strengthen their own health systems. Surgeons-to-be must not be allowed to exploit the surplus of patients in poor countries to fulfill their training quotas. This is what’s at risk when universities create global health programs to meet the needs of their trainees rather than the needs of their partners on the ground.

We stand at a juncture for global health. We can shape the field to do more than repeat the medical missions of colonial days. The good intentions of young people who want to build a more equitable world are a driving force behind the proliferation of global health programs. But to fulfill the promise of global health and truly expand access to modern medicine for all people, U.S. academic institutions and their faculty must provide greater leadership to ensure responsible global health engagement.

Dr. Michelle Morse is deputy chief medical officer for Haiti at Partners In Health. She supports clinical services and medical education systems strengthening at University Hospital in Mirebalais, Haiti.

World AIDS Day: Lessons from HIV

Last December, The New England Journal of Medicine published the 2013 Shattuck Lecture by Partners In Health co-founder Dr. Paul Farmer, which describes the work of PIH and its partners to deliver HIV care. His reflections remain relevant as we commemorate World AIDS Day, Dec. 1. Farmer’s lecture also focuses on key tenets of PIH’s work with local, national, and international partners to strengthen health systems. These efforts remain central as we join with partners and survivors to combat Ebola in West Africa. You can read the lecture and watch a slideshow narrated by Farmer here.

It was 1998, and Dr. Fernet Léandre knew who would be first.

More than a decade earlier, Partners In Health clinicians had seen the first case of HIV in Cange, a rural squatter settlement in central Haiti.

For years, Léandre and PIH co-founder Dr. Paul Farmer worked side-by-side, helping AIDS patients as best they could. Léandre and a team of doctors, nurses, social workers, and community health workers treated patients’ opportunistic infections, which arose as HIV destroyed their immune systems. The team also introduced AIDS prevention activities in rural Haiti and had used the antiretroviral drugs AZT and nevirapine to prevent the transmission of HIV from mother to unborn child.

The most common infection, tuberculosis, fanned an epidemic and afflicted HIV-negative family members, other patients, and staff. Although Léandre knew how to treat TB, it became increasingly difficult to prevent its spread and to manage the rising caseload. And some patients with HIV-associated TB fell ill a second time—often, he believed, because of re-infection.

Antiretroviral therapy for HIV turned a death sentence into a manageable, chronic disease.

As HIV infection progressed to AIDS in his patients, Léandre knew there was only one option for recovery—antiretroviral therapy with at least three drugs. But who would be first to receive ART, a lifelong commitment?

“It was easy to choose. We knew the sickest already. We had their medical records, and we knew when they first tested positive,” Léandre said. “So we saved ART for the sickest. By the time we started ART, they were moribund.”

In the mid-1990s, combination antiretroviral therapy had become the standard of care in the United States. A “cocktail” of virus-killing medicines worked together to prevent HIV from developing resistance to any single drug. It turned a death sentence into a manageable, chronic disease.

“Many of us who were treating HIV disease in the United States saw people literally get off their deathbeds, go back to school, go back to work, take care of their families,” said Dr. Joia Mukherjee, an infectious disease doctor who went to dozens of funerals of AIDS patients in Uganda before joining PIH. “I thought, ‘certainly we’ll start giving this medicine out in Africa.’”

But by 1998, while 95 percent of people with HIV were living in poor countries, almost none had access to antiretroviral therapy, which then cost $12,000 to $16,000 a year per patient.

The first patient

Adeline Merçon, a mother of two, was diagnosed with HIV in 1991, one of the first in the Central Plateau. By the mid-1990s, when her health took a turn for the worse, her life had already been a struggle for survival.

She grew up in a village not far from Cange, and lost three of her eight siblings. Merçon left her hometown when she was 18 to continue her schooling in Port-au-Prince, but, unable to pay school fees, she dropped out to study at a vocational school where she learned to embroider. Living with her sister in Cité Soleil, a slum near the bay of Port-au-Prince, she struggled to get enough to eat.

Merçon started a relationship with a man named Joel, but he fell ill shortly after their son was born and died a year later. After her own diagnosis, she assumed he’d died of AIDS. She met another man and had another child, but her second partner abandoned her after she became sick.

A decade after her diagnosis, Merçon’s health rapidly worsened. By October 1999, she weighed 79 pounds. Farmer and Ophelia Dahl, PIH’s executive director, hiked to her home and found her bedridden. Her father had collected materials to build her coffin.

As a New York Times reporter later wrote, “Farmer promised to return with medicines to save her. Back in Boston, he scavenged drugs from AIDS patients, doctors, and clinics. Partners In Health bought more with money donated by Thomas J. White, a retired Boston businessman, and raised yet more cash by selling its headquarters in Cambridge.”

What can I say? The medicines are eloquent enough. What they have done for me is amazing.

A month later, Merçon started ART. In two weeks, her diarrhea disappeared. After five weeks of ART, she gained 26 pounds. Her photo a year later, which appeared in The Lancet, showed her smiling at a celebration for patients at the T.J. White Pavilion in Cange.

“What can I say? The medicines are eloquent enough,” Merçon said. “What they have done for me is amazing. Everyone was shocked when I went home for Christmas. I was so sick before I started treatment. I was skinny, and the medicines made me big again. I was so weak I could not walk, and now look at me.”

Closing the gap

Adeline was one of about 60 patients in rural Haiti who started ART, free of charge to them, in the late 1990s. With an eye toward expanding treatment in African countries with high HIV rates, the project was called the HIV Equity Initiative. It sought to bring a medical innovation—ART—to people who needed it but who didn’t constitute a market for the drugs because they couldn’t afford them.

“Only a decade after the region’s first documented case, the [Cange] facility was full of patients with AIDS,” Farmer wrote in the 2013 Shattuck Lecture. “At times, Harvard and Haiti seemed to be in two different worlds. But HIV and other communicable pathogens remind us that we live in one world.”

The price tag was expensive, between $12,000 and $16,000 per patient per year, and said by some to be difficult to deliver.

Knowing that it would be used as a model for care in places with scarce equipment, Léandre insisted that PIH’s criteria for starting patients on ART not require a series of laboratory tests unavailable in Haiti. Often, the team used what they termed the “CIOS” test—“carried in on stretcher.” These AIDS patients were so sick that ART was the only thing that could save their lives.

At the time, ART was otherwise out of reach for these people. The price tag was expensive, between $12,000 and $16,000 per patient per year, and said by some to be difficult to deliver. The medicines had to be taken reliably to prevent drug resistance and relapse, which posed a threat to the patient’s survival and might endanger others who might be infected with a harder-to-treat strain. Even more common, the problem of hunger, according to many patients in rural Haiti, inhibited patients’ ability to take the medicines. And the drugs had to be taken for life.

PIH developed community-based care that helped patients overcome these barriers to health. The foundation of the delivery system was community health workers, themselves poor and many of them also living with HIV.

Community health workers delivered drugs and observed patients taking them each day. They also provided psychological and social support; the HIV Equity Initiative helped not only with diagnosis and therapy, but also with food and housing assistance. The model was based on PIH’s approach for caring for patients with tuberculosis, including multidrug-resistant TB, another disease that required strict adherence to a lengthy regimen. Treatment costs, which were falling, were not borne by the patients.

One by one, PIH’s AIDS patients began ART, and one by one, they rose from their deathbeds, a transformation termed “the Lazarus effect,” first in Haiti and later worldwide.

Adeline Merçon rapidly recovered after beginning antiretroviral therapy for HIV in 1999, a transformation termed the "Lazarus effect."

Such resurrections also allowed many people living with HIV to engage in activism. The patients voiced their solidarity for others who didn’t have access to the lifesaving drugs in a message called the Cange Declaration. Nerlande Lahens read the statement on behalf of her fellow patients.

“We, the patients of Partners In Health, are fortunate to receive medication and health care even if we do not have money. Many of our health problems have been resolved with the medications. Given how bad off we used to be, we have greatly benefited. But while we feel fortunate to receive the medications, we feel sad for others who don’t receive the same treatment we do.”

“We have a message for the people who are here and for those who are able to hear our plea. We are seeking your solidarity. The battle we are engaged in—to find adequate care for those with AIDS, tuberculosis, and other illnesses—is the same as the combat that has been waged by other victimized people over time so everyone can live as a human being.”

In the late 1990s, PIH was among a handful of non-governmental organizations to provide antiretroviral therapy to the poor at no cost to them. Dr. Jean William Pape and GHESKIO in Port-au-Prince also provided treatment of opportunistic infections, after they described Haiti’s first cases of AIDS in 1982. They were also hoping to begin ART for these critically ill patients.

A little paper, a big meeting

PIH published the results of its project in a 2001 Lancet article, innocuously titled “Community-based approaches to HIV treatment in resource-poor settings.”

The authors wrote, “We believe that if [community-based HIV treatment] can be implemented in the devastated Central Plateau of Haiti it can be implemented anywhere.”

It was with the most affected continent in mind that the piece continued: “In settings of affluence, it seems as if no expense is too great in order to prolong life, even when patients are elderly and have irreversible conditions. In sub-Saharan Africa and Haiti, where HIV is the reason for plummeting life expectancies and for increasing numbers of orphans, we discern fairly overt obstructionism to the use of [antiretrovirals].”

Inspired by the HIV Equity Initiative, Mukherjee had joined PIH in 1999 to help enroll patients on treatment. After seeing the HIV epidemic destroy lives in Uganda, she was frustrated that year after year went by and the world still didn’t bring ART to poor people in Africa, which had more than 90 percent of the world’s cases.

As she tells it, “We wrote a little paper. We said we treated a handful of patients in Haiti, they all gained weight, they did better. None died, even though they’d all been dying. It was published in a prestigious academic journal. This paper is probably the most cited paper our group has ever written, and this paper was roundly critiqued.”

The World Health Organization Bulletin invited PIH to submit the work to its “Roundtable,” in which public health experts responded to the HIV Equity Initiative—or, in Mukherjee’s words, took “potshots at it.” It was too expensive, some said. Not sustainable. Unfeasible. Lacking data.

Bulletin editor Dr. Richard Feachem wrote in response, “I wish that the world was different. I wish that poor countries were not so poor. I wish that the health systems of poor countries were not so dysfunctional. I wish that rich countries were far more generous in their support for health sector activities in poor countries. Regrettably, none of this is the case in the real world in which we live. Farmer and his colleagues do not give us a clear idea of how to overcome these major constraints.”

Farmer concedes this was true: “We hadn’t given a clear idea of how to overcome constraints. They were largely economic and thus related to funding. The obstacles were not that the therapy itself was too complex to deliver. We needed new funding mechanisms.”

From small to scale

But the sea change had already started.

While the HIV Equity Initiative hadn’t convinced all public health experts, AIDS activists in the United States, South Africa, and elsewhere used it to fuel their arguments for equity in treatment.

The HIV Equity Initiative gave people hope that it was possible to treat HIV in rural and urban settings of great poverty.

“Activists took our paper and started calling it the Haiti model,” Mukherjee said. “They said, if they can do it in rural Haiti, we can do it in Bangkok. If they can do it in rural Haiti, we can do it in Soweto. If they can do it in Haiti, we can do it in Kampala. It became a rallying point for activists all over the world. I think it gave people hope that it was possible to treat HIV in rural and urban settings of great poverty.”

The same year PIH published the results of the HIV Equity Initiative in The Lancet, Jeffrey Sachs and more than 100 other Harvard University faculty members wrote the Harvard Consensus Statement. People joked that the name was a contradiction in terms, because consensus was so rare at Harvard.

But the signatories argued that it was feasible to scale up access to ART, and presented a plan to do it. They included cost estimates based on PIH’s program in Haiti, which was described as an example of how ART might be successfully delivered to people living with both AIDS and dire poverty. The statement recommended the creation of a new source of funding: wealthy countries would make financial contributions to a multilateral fund, which would then dole out grants to support developing countries’ public health systems as they began to offer treatment for AIDS as a public good for public health.

According to the Harvard statement, “The disparity in access to effective treatment between wealthy countries and developing countries is neither scientifically nor ethically justified at this time.” It concluded, “There should be no further delay in launching a major international effort to save the lives of millions of HIV-infected persons.”

HIV became our battle horse in the fight to break the cycle of poverty and disease.

A year later, the Global Fund to Fight AIDS, Tuberculosis and Malaria was born.

Feachem, one of those who thought it infeasible to scale up the HIV Equity Initiative in settings of rural poverty, became the founding executive director of the new fund. The first meeting of Haiti’s country coordinating mechanism, the in-country group that decides where to allocate funds, wasn’t held in Port-au-Prince but in Cange, attended by Haiti’s then first lady, Mildred Aristide. Haitian partners received one of its first grants, which allowed scale-up of the HIV Equity Initiative to clinics across the Central Plateau and also major initiatives in Port-au-Prince and other urban centers.

“Quickly, HIV became our battle horse in the fight to break the cycle of poverty and disease,” Léandre said. “We leveraged the HIV money to improve primary health care in those settings, where there was no lab, no X-ray, no drugs, nothing to take care of the sickest patients. We used this as an opportunity to not only expand the HIV Equity Initiative but also to provide primary health care in those facilities. This was key to the approach.”

PIH published the early results of the approach, called health systems strengthening, in 2004.

One of the patients who started ART after the expansion, Joseph Jeune of Lascahobas, became—quite literally—the poster boy for the effectiveness of ART in Africa. With PIH co-founder Jim Yong Kim at the World Health Organization leading a charge to enroll 3 million people on ART by 2005, Joseph’s before-and-after photos appeared on posters in Kenya promoting ART. When Farmer and Dahl visited the rural reaches of the country to advise on HIV programs, they told the surprised Kenyan doctors and nurses that the patient in a poster seen in clinics around the country was Haitian, not Kenyan.

Lessons for the world: The Shattuck Lecture

Today, the prevalence of HIV in Haiti has shrunk from 6.2 percent in 1993 to 2.2 percent in 2012, according to Farmer’s Shattuck Lecture. Haiti has achieved universal ART coverage according to WHO 2010 guidelines, defined as 80 percent of those who most need it, according to the national Monitoring, Evaluation, and Surveillance Interface, a collaboration between the Haitian Ministry of Health and the U.S. Centers for Disease Control and Prevention.

In Rwanda, where public health officials also used AIDS funding to improve health systems, especially in rural areas, the results have been stunning, Farmer says. Of the first patients enrolled in community-based HIV treatment in rural southeastern Rwanda, more than 92 percent were still in care two years later. Health has also improved for other conditions: death during childbirth has dropped more than 60 percent in the past decade, and deaths of children under 5 years old have fallen even more rapidly. Life expectancy has doubled since the early 1990s, when a genocide killed close to 1 million people and left health services in shambles.

And Haiti and Rwanda were not the only poor countries to scale up HIV care with the new funds. Across Africa, more than 7.1 million people are now receiving antiretroviral therapy.

The global AIDS debate … was really about funding.

Looking back at what exactly was at issue in the debate about delivering ART to poor people in Haiti, Farmer concludes that implementation itself was not the primary challenge. With the help of community health workers, patients could take the medicines; treatment could prevent new infections; resistance to drugs could be managed; HIV care could strengthen other health services; and costs would come down.

“The global AIDS debate … was really about funding; claims that treating a chronic infection with a multidrug regimen was impossible in poor settings were invalid,” Farmer writes. “Above all, we fail to bring new deliverables to people who need them most because demand is constructed largely around the notion of markets. There are too few equity plans to link demand to burden of disease. When treatments are easily administered, convenient, and likely to result in cure or excellent clinical response, there will be great demand for them. But when such need is seen as demand only if there is an established market for these innovations, it is fair to talk about market failures.”

In other words, lifesaving medical treatments will never reach the poor who need them if they are only sold on the market as commodities. They must be delivered as public goods and through robust delivery systems.

And when they are, lives can be saved, whether the illness in question is AIDS or diabetes, mental illness or cancer, and whether the location is rural Haiti or Rwanda or the United States.

Farmer concludes, “Only by building health systems that provide high-quality care for all, especially the most vulnerable, can we catch up with the preventive, diagnostic, and therapeutic revolution. What we need now are revolutionary improvements in the delivery of prevention, diagnosis, and care.”

Read the Shattuck Lecture and watch a slideshow narrated by Farmer here.

Ebola Stems Economic Growth in Liberia and Sierra Leone

A new report warns that years of economic progress and social development in Sierra Leone are eroding as the Ebola outbreak continues to spread across the West African nation. The report is from Sierra Leone’s Ministry of Finance and Economic Development and the United Nations Development Programme (UNDP), among other partners.

After having emerged from a decade-long civil war, Sierra Leone was home to one of the world’s fastest-growing economies with a gross domestic product (GDP) that expanded 20 percent annually in recent years. The new report predicts a sharp decline in economic growth, down to 5 percent, and warns that academic setbacks from ongoing school closings will have long-term effects on the country’s workforce.

The news is no different in Liberia, where the price of some crops has soared 150 percent in recent months, businesses have shut down, and many social services have been interrupted.

Unfortunately this is not unexpected news. But it is a stark reminder of why Partners In Health has made long-term commitments to Sierra Leone and Liberia that will stretch long after the Ebola outbreak is stopped.

“Our Ebola response is an entry point to work closely with the governments of Liberia and Sierra Leone on a long-term plan to strengthen the health systems,” PIH Chief Medical Officer Dr. Joia Mukherjee says. “This will be done by training the workforce, by improving the supply chain, by building needed infrastructure, and by hiring community health workers.”

The strain imposed by Ebola on the countries’ already-weak health systems has caused untold suffering and severely interrupted access to primary care. Eighty percent of people in Sierra Leone living with HIV have not been able to access their treatments, and “expectant mothers are dying at alarming rates in childbirth,” according to the UNDP.

Investments in health care create jobs, alleviate food insecurity, and help prevent against future epidemics that can crash an economy.

In Sierra Leone, we have already hired dozens of Ebola survivors to join us as community health workers. They are engaging their communities, educating their neighbors, and helping expand access to care. We know that investing in health care works.

“Never has it been clearer that health is integral to development,” Mukherjee says. “More money is needed to build strong public sector health systems. Investments in health care create jobs, alleviate food insecurity, and help prevent against future epidemics that can crash an economy.”

At the heart of our strategy are our longtime partners, the grassroots organizations Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone. We’re working closely with these organizations to strengthen the delivery of primary care, whether it’s supporting a vaccination campaign or accompanying an expectant mother for prenatal care. We will seek out opportunities to deliver social support and look to create programs that address food security, job development, and education.

“We need to link a public health agenda with a social protection agenda,” Mukherjee says.

We know that building health systems is not only good for health, but it’s good for the economy. When we opened University Hospital in Haiti in 2013, a flurry of economic opportunities followed. Economists recently determined that for every $1 invested into University Hospital, $1.86 was pushed into Haiti’s broader economy, from health care workers buying egg sandwiches at local stands to taxi drivers picking up more fares.

University Hospital was a long-term vision that came to fruition through long-term partnerships. Our ambitions and commitments are no less great in Liberia and Sierra Leone.

In Liberia, Rapid Response Teams Look to Get Ahead of Ebola

On Wednesday, five Partners In Health nurses, a doctor, and a logistician arrived in Rivercess, Liberia, a predominantly rural county located in the southern portion of the country. These five frontline health workers are part of a multiorganization “rapid response” team. The team will assess epidemiological reports suggesting there is a cluster of Ebola cases in this remote county. They will meet with county health officials and community leaders to understand the immediate needs, and they will begin training local staff in infection control and prevention.

Many of Liberia’s Ebola cases have been confined to three counties—Monteserrado, Margibi, and Bong. However, the epidemic seems to have now turned away from Monrovia. “Even though the overall daily case number now appears to be falling in Liberia, we don’t have the luxury of having nearly all those cases confined to three counties,” said John Welch, chief clinical officer for PIH’s Ebola response. “There are now confirmed Ebola cases in every county of the country. We are at a very dangerous stage epidemiologically.”

Rapid response teams will play a vital role in evaluating reports of Ebola clusters in remote areas, and when needed, deliver timely care to patients in need.

When PIH first committed to fighting the Ebola outbreak in Liberia and Sierra Leone, one of our main objectives was to decentralize care away from capital cities and overwhelmed Ebola Treatment Units and expand services in rural areas. The rapid response teams are a major step toward achieving this, and they should improve contact tracing—a critically important step in containing the outbreak—in hard-to-reach areas.

The rapid response teams work in two phases. The first phase is a thorough and swift assessment. The team will meet with county and community leaders, seek to better understand the epidemiology and determine how severe the outbreak is, and evaluate what type of existing infrastructure can be leveraged in mounting an immediate response. One of the most important considerations is nearby access to a clean water source that can support UNICEF’s WASH (water, sanitation, and hygiene) efforts.

“The second phase depends on the community’s needs. Every mobile response will be different and we will adapt to the specific needs,” Welch explains. “They will all, however, have the same foundation—isolation, triage, and compassionate, dignified care.”

The nearest Ebola Treatment Unit is an eight-hour drive from the part of Rivercess that the team is working in, potentially longer depending on weather and road conditions. Welch says that one option may be to establish small treatment units within the county by either repurposing existing facilities or setting up a small treatment unit.

We are all doing our part to provide as much dignity for what is really an undignified disease.

PIH has extensive experience dispatching small teams to provide high-quality care and support to hard-to-reach patients. In Malawi and Haiti, our mobile clinics regularly travel to remote regions where the need is substantial and resources are severely limited. In Russia, our Sputnik team makes daily home visits to deliver medicine and food to marginalized drug-resistant tuberculosis patients.

While the highly infectious nature of Ebola presents unique challenges, we are drawing on our past experiences to ensure that rapid response teams address the acute need of patients while contributing to long-term efforts that strengthen Liberia’s health system.

In addition to the rapid response team in Rivercess, a PIH nurse recently traveled with two Ministry of Health doctors and a hygienist to Grande Cape Mount, Liberia, where at least 30 deaths have been reported since September. Welch says while the challenges remain immense, it is uplifting to see nongovernmental organizations, the Ministry of Health, and communities work in concert to get ahead of the outbreak. One organization has committed itself to facilitating the safe burials of Ebola victims. UNICEF has consistently delivered WASH support.

“This is a true coalition, and we are all doing our part to provide as much dignity for what is really an undignified disease,” Welch says.

Working in Global Health: Dr. Mercedes Aguerrebere

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

That’s why we ask seasoned colleagues to share advice for those interested in forging a career in global health. This month we asked Dr. Mercedes Aguerrebere, mental health coordinator for Compañeros en Salud, PIH’s sister organization in Mexico, to discuss how she became involved in the movement for global health.

When I was in high school, before I had field experience, before I had been trained as a doctor, I thought that education was all we needed to reduce inequity. So I committed myself to the task by attending medical school and vowing to share the knowledge with the most vulnerable people in my country.

During my second year of medical school, I met a group of students with similar concerns and similar goals. So we got together and started organizing activities and events to promote health. But it wasn’t until we visited a marginalized region in the state of Querétaro that I realized the complex challenges to delivering medical care. Due to the lack of access to quality primary care in the region, we, a bunch of medical students with some donated over-the-counter painkillers, were giving medical attention to more than 100 people. These people often could not go to their primary care clinic because the health professionals were almost never there. It was also common for these clinics to be out of medication and supplies, which rendered the clinics ineffective.

Witnessing these challenges firsthand allowed me to understand that the lack of medical attention could not be overcome by mere education and knowledge-sharing. Instead, I realized that we needed committed doctors in the field, along with political, economic, and operational commitment from the Ministry of Health.

As my interest in health equity grew, I had the opportunity to go to a congress organized by one of the elite medical schools in the country. The congress was named “Global Health 2010.” I had never heard that term before, "Global Health." But the curriculum seemed interesting. Lucky for me, Dr. Daniel Palazuelos, chief strategist of Compañeros En Salud, PIH’s Mexican sister organization, was one of the speakers. He discussed what they were doing in the Sierra Madre mountains of Chiapas, and the stories he told us were heartbreaking. I was being pulled toward the movement for global health.

In Mexico, all medical students are required to do a social service year at the end of medical school. These social service year physicians are called pasantes. Sometimes the pasantes work with a team of physicians and nurses, sometimes with a team of just nurses, and sometimes they find themselves working alone in challenging environments with few resources or support.

It is estimated that 82 percent of rural primary care clinics under the purview of the Ministry of Health are operated by pasantes. The pasantes have a fuzzy status; they are not students, nor employees, and they are often forgotten by the medical school and overlooked by the MOH because they are only “passing by.” Pasantes usually do not receive any kind of continuing medical education, training, or support. They are left facing many challenges—medication stock outs, or the expectation to provide care without any functional team for patients who are suffering from complicated illnesses.

I didn’t think twice when presented with the opportunity to do my social service year with Compañeros en Salud, which was launching a model that included supportive supervision and ongoing medical education. I was part of the third generation of pasantes who would spend the year working with Compañeros en Salud. And I am now among the 90 percent of them who have decided to stay working with the team after the end of the social service year.

I learned to see disease as a social illness as well as a biological disturbance.

That year exposed me to a transformative education: I learned to see disease as a social illness as well as a biological disturbance. The lack of access to quality care makes rural farming families, like in many other countries, vulnerable to charlatan doctors. A family can spend more than its monthly income in search of care. Many families encounter catastrophic expenses for illnesses that could be easily treated in their primary care clinics, if their primary clinic were properly staffed and stocked. Mental illnesses like schizophrenia and depression are perfect examples of how patients and families suffer.

In the three years PIH/CES has been working in the region, we have accompanied many patients with schizophrenia or psychosis. Before we were able to link some of these patients with proper medication and care, their families and communities were frequently forced to chain the patients’ ankles or lock them in sheds to protect both the person and themselves from harm. All of these patients had visited several private and public doctors, including specialized mental health facilities. They bought expensive medications and paid for follow-up consultations in the capital city, which is six hours away, but they didn’t find a solution to their illness. PIH/CES has also seen more than 150 patients across six communities who were diagnosed with depression. They, too, faced similar histories in their quest to find health care.

Many pasantes have little to no training in mental health and struggle to meet the needs of these patients. Still, it has been proven by PIH and others that mental health care can be provided in marginalized rural areas when primary care doctors and community health workers are trained and have the tools they need.

To achieve equity, we all have to work from our different fronts, paying special attention to the most vulnerable among us.

And that is my job now: to make it possible for pasantes to deliver care for patients with mental health needs by finding and providing the tools they need, and by arranging ongoing medical education and training in mental health and psycho-education. At the same time, my job is to make sure that those patients receive not only clinical care but the social support they and their familes need, which can be done through a psycho-education strategy and by working with community health workers who visit patients’ homes to encourage them to adhere to their medications. This strategy makes it possible for our patients to receive quality care in their communities, through primary care and low-cost interventions, liberating patients from their physical and mental chains.

Working with the CES team, I have learned that people who make a difference are ordinary people with broad insight into the complexity of social issues and a vast capacity to continue working in spite of constant frustrations and disappointments. I now know that we all have the ability to act in a way that facilitates the integral development of fellow human beings. To achieve equity, we all have to work from our different fronts, paying special attention to the most vulnerable among us.

A Small Girl with a Big Challenge

Dr. Odunayo Johnson Alakaye stood in the hallway of Botsabelo MDR-TB Hospital in Maseru, Lesotho, cradling a toddler in his arms. Mamahele,* the 14-month-old girl, fussed for her mother, who stood beside Dr. Johnson wearing a blue respirator that concealed her nose and mouth. After a few tired pouts, the child let out a raspy cough.

Mamahele and her mother arrived at the Partners In Health-supported hospital six weeks prior. Before arriving, clinicians at a health center near her village unsuccessfully treated her for pneumonia three separate times. “She showed no response to the pneumonia treatments. She was still coughing. She was still losing weight. She wasn’t developing properly—she couldn’t stand on her own, she wasn’t walking,” Dr. Johnson says.

Such delays in proper diagnosis and treatment can be deadly. An X-ray of the child’s chest revealed to the team at Botsabelo a damaged section of lung. To confirm TB was the culprit, they needed a sample of sputum—mucus from the lungs that is examined to diagnose TB and identify drug resistance.

Pediatric TB cases present unique challenges at every step. Producing sputum can be difficult for adults, let alone a child Mamahele’s age. This leaves two options: Staff can perform gastric aspiration, a process that involves routing a tube through the infant’s nose and into the stomach in order to extract stomach fluid; or they can induce a sputum sample using a catheter fitted to a syringe. In the case of Mamahele, the team opted to induce a sputum sample. Within a day of obtaining the sputum sample, they were able to determine that Mamahele had a strain of TB resistant to rifampicin and isoniazid, two first-line TB drugs that have been in use since the 1950s.

While Dr. Johnson and his team began putting together a treatment strategy, health workers visited Mamahele’s home to screen family members and anyone else who had been in close contact with the child. This process, known as “contact tracing,” is used to approximate how a patient was infected and ensure that nobody else is sick. After the initial contact screenings, the team found that no immediate family members had TB. How then had the child become infected?

An estimated 30,000 children become sick every year with MDR-TB.

The global burden of TB is staggering. Annually, more than 8 million people become sick with TB and approximately 1.5 million people die from it. Pediatric TB has been neglected for decades; until a few months ago there weren’t even reliable estimates on how many children were sick. Earlier this year, Dr. Mercedes Becerra, senior TB specialist at PIH, published a study that estimated 1 million children become sick with TB every year—double the number previously thought—and 30,000 children become sick every year with multidrug-resistant TB (MDR-TB).

It was a pediatric patient that led Dr. Johnson to focus his efforts on TB and HIV. One day during his medical residency in Nigeria, Dr. Johnson was talking with a 13-year-old TB patient. The boy began violently coughing up large amounts of blood and died within a matter of minutes. It stunned the young doctor. “I knew then that I wanted to specialize in TB,” Dr. Johnson says.

Over the years, he has worked with many pediatric patients, including Mamahele. One of the persistent challenges is that there are no pediatric formulations of MDR-TB drugs, which means that clinicians must work closely with pharmacists to monitor the patient’s weight and adjust the dosages. “We work together to calculate their dosages and then break up the adult medications, or cut them or grind them, to be precisely the dosage the child needs,” Dr. Johnson says. “It’s not easy.”

Nothing about MDR-TB is easy. It takes two years to treat. An average adult patient will consume more than 14,000 pills and endure eight months of daily injections. Current treatment regimens are highly toxic and can lead to hearing loss, psychiatric illnesses, and liver damage, among many other side effects. Because children Mamahele’s age can’t communicate how treatment is affecting them or whether particular issues are surfacing, it’s imperative they’re closely monitored and followed up with regularly.

She is doing very well and responding to the medications.

After six weeks the team at Botsabelo began making plans for Mamahele and her mother to return home. “She is doing very well and responding to the medications,” Dr. Johnson says. “She gained more than 3 kilograms and the cough is no more.”

Mamahele and her mother live in a village near the town of Mokhotlong, which is seven hours from the Botsabelo MDR-TB Hospital. To ensure the child has steady access to quality care, PIH/Lesotho has made arrangements to rent a house for the family that’s only a few minutes walk to Mokhotlong Hospital. When the family moves, a village health worker from the community will visit the child at her home daily to administer the medications and monitor for side effects, providing a critical link between the patient and the health care system.

Still, it’s unclear what the future holds for the young girl. The global cure rate for MDR-TB is only 48 percent, and 80 percent of patients who fail treatment die within three years. This is why PIH insists on accompanying patients, delivering food and providing social and moral support in addition to clinical care.

Mamahele and her family have a long and daunting road ahead. Dr. Johnson and everyone at PIH/Lesotho will be with them each step of the way.

*The patient’s name has been changed.

Dr. Paul Farmer: 'An Ebola Diagnosis Need Not be a Death Sentence'

This week the London Review of Books published an essay by PIH Co-founder Dr. Paul Farmer in which he reflects on a recent trip to Liberia and assesses the severity of the Ebola outbreak in West Africa.

Dr. Farmer writes:

Weak health systems are also to blame for the high case-fatality rates in the current pandemic, which is caused by the Zaire strain of the virus. The obverse of this fact—and it is a fact—is the welcome news that the spread of the disease can be stopped by linking better infection control (to protect the uninfected) to improved clinical care (to save the afflicted). An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care—including fluid resuscitation, electrolyte replacement and blood products—the great majority, as many as 90 percent, should survive.

We encourage you to read this important article in full.

Learn more about PIH’s Ebola response.

Global Hand Washing Day: A Reflection on Water, Soap, and Infrastructure

October 15 marks Global Hand Washing Day. Below, Elizabeth Campa, director of WASH and Protection programming at Zanmi Lasante, our sister organization in Haiti, reflects on the importance of water, soap, and infrastructure in low-resource settings.

Wash your hands with soap! Stop the spread of germs! Lather up for a cause! I can say all these messages in six languages. Sound trivial? It isn't.

Hand washing with soap is one of the most effective and inexpensive ways to prevent diarrheal diseases and acute respiratory infections. Millions of children in developing countries die each year from these preventable diseases. Even though we know this, and even though we fully grasp how hand washing with soap can save lives, promoting hand washing with soap is often difficult—and impossible if services aren’t even available. Why?

In Haiti, many of the communities we work in do not have access to potable water—wells, natural springs, and other sources—and they do not have adequate sanitation in their homes, which leads to open defecation and the spread of disease into water sources and the environment. Exactly four years ago this week, the first cases of cholera came to the clinics of Zanmi Lasante in the Central Plateau. More than 8,000 people have since died from cholera and nearly 1 million have been affected by it.

Meanwhile, children encounter a whole host of unique challenges as they attend classes in schools with no access to water, sanitation, or soap for hand washing. Imagine having to relieve yourself in an open field or along a river bed. This is the reality for hundreds of thousands of children in Haiti and millions of children around the world.

If more individuals have the resources and tools to build hand washing with soap into their daily habits, countless lives can be saved.

Zanmi Lasante is promoting hand washing with soap before eating and after using a toilet as part of its WASH (water, sanitation, and hygiene) programs in the Central Plateau. With the support of UNICEF, we are working toward improving access to WASH facilities in homes and schools so that thousands of children can lead healthier lives. If more individuals have the resources and tools to build hand washing with soap into their daily habits, countless lives can be saved.

By increasing the number of schools and communities with access to safe toilets, potable water, and soap, and by promoting good hygiene, we are making a difference and saving lives.

On this Global Hand Washing Day, it is encouraging to know that we have forged partnerships with the government of Haiti and the communities we serve to help amplify this important message. One hand washing station, one toilet, and one hygiene lesson at a time, we will continue to improve access to these lifesaving resources that so many of us take for granted.

It is not easy, and we have a long way to go. But we are confident that one day soon the people of Haiti may also live in a world free from death by preventable diseases.

Training for Ebola: An Interview with PIH's Dr. Sara Stulac

As the Ebola outbreak continues to unfold in West Africa, frontline health care workers are facing enormous challenges. More than 400 health care workers had been infected with the virus as of Oct. 5, and more than 230 had died from it, according to the World Health Organization. As PIH and its partners respond to the outbreak, we are acutely aware of the personal risk our clinicians are taking and are seeking to implement robust trainings and systems to minimize the risk and ensure that we deliver the highest-quality care possible to patients.

Last month Sara Stulac, Partners In Health’s deputy chief medical officer, and several colleagues, including Joia Mukherjee, Anany Gretchko, Pierre Paul, Sheila Davis, and Corrado Canceda, attended a Centers for Disease Control and Prevention training in Anniston, Alabama, designed for clinicians who will be responding to the Ebola outbreak in West Africa. We asked Dr. Stulac to share her impressions of the training and discuss PIH’s evolving response to this historic health crisis.

Can you tell us a bit about the CDC training?

It was a three-day training, focused on preparing clinical providers to deliver care in the safest possible manner. The group was mostly clinicians, and was taught by CDC staff as well as clinicians who had recently returned from West Africa: a nurse from Médecins Sans Frontières and a doctor who works in infection control at Boston University who had on-the-ground experience with the current outbreak.

What did the average day look like?

We spent a few hours each morning in a classroom, discussing everything from logistics to new treatments in the pipeline to how communities are carrying out contact tracing. The afternoons were spent working in mock Ebola Treatment Units. We spent several hours going through the process of donning and doffing the personal protective equipment (PPE) and doing exercises with mannequins. We would run through mock scenarios: For instance, there’s a patient lying under a tree in the courtyard who just came in and collapsed and is vomiting and is now unconscious. What do you do? And how do you do it safely?

What aspects of the training surprised you?

This is such an infectious virus that we need to be extremely vigilant, following every protocol.

Doffing, or taking off, the PPE was a sobering experience. This is one of the highest-risk activities, because that’s when your protective equipment almost certainly has fluids on it from patients who are infected. If you don’t take off each protective item in a very specific order, following a very specific procedure, you are putting yourself and others at risk. And keep in mind that this happens after a clinician just finished working a shift in an intense environment. They are tired and they’re hot and they need to get out of this equipment, yet it has to be done methodically and carefully. In many ways you need to commit the process to muscle memory.

While this was certainly sobering, we weren’t at any risk. We weren’t doing real work; we were doing pretend work with mannequins. So we had this tiny, tiny taste of the challenges and risks practitioners will encounter in the field, and that gave us a huge appreciation for how serious this type of preparation and training is. This is such an infectious virus that we need to be extremely vigilant, following every protocol.

Are there challenges in terms of getting and securing enough PPE?

Yes, there are supply chain issues and procurement issues that need to be addressed. I’d like to emphasize, though, that PPE is not the full answer. PPE is one very important tool that is needed to provide safe and effective care for patients. But we still need to have medicine, we still need to have transport, we still need to have the “staff, stuff, and systems.” But PPE is just one specific thing that is in obvious shortage right now.

Also, keep in mind that the supply chain for very basic medical supplies in the countries and areas where we are working were never perfect to begin with, and this outbreak has put an enormous strain on every aspect of very fragile health systems, including the supply chain. But we are starting to see the large, global mobilization of resources with significant financial commitments from the U.S. government and others. This is very important, and we need more such commitments.

There is a severe stigma around Ebola. Are there lessons PIH can draw on to reduce stigma and provide dignified care?

And with the right supportive care, the cure rate can be so, so, so much higher than it is now.

PIH has learned a lot of lessons in a lot of other places that we can apply to addressing the kind of stigma and the need for dignified and high-quality care with Ebola. We need to remain humble, knowing that we haven’t worked in Liberia or Sierra Leone, so it’s a new disease for us, and it’s a new situation and cultural context, which is so important to understand. This is why we’re grateful to be working with organizations that have been working in these countries at the community level for many years.

As a clinician, however, I understand the tension between needing to protect yourself and wanting to have that personal connection with patients. When you’re dressed in a space suit, how can you possibly feel close to a patient or let them know that you care for them and that you’re trying to provide them good care? You may not be able to touch patients directly or talk to patients without a piece of plastic and PPE between you, but you can provide for their needs. You can provide food—providing food goes a really long way. There’s not an antibiotic or treatment for Ebola; it’s all supportive care. And with the right supportive care, the cure rate can be so, so, so much higher than it is now.

And we are working on ways to work closely with the communities PIH and our partners are serving. Getting community members involved, getting people who have recovered from Ebola to speak with neighbors, is one if the best strategies I can think of. This same strategy has helped us reduce stigma around HIV in other countries.

JAMA: 'The Ebola Outbreak, Fragile Health Systems, and Quality as a Cure'

Staff. Stuff. Systems. In recent media appearances, lectures, and op-eds, PIH Co-founder Dr. Paul Farmer has been arguing that to contain the current Ebola outbreak in West Africa and take meaningful steps toward mitigating future outbreaks, we need trained medical staff, a steady supply of resources (or stuff), and a strategic approach that focuses on long-term development of health systems.

Today, Dr. Farmer, along with Dr. Andrew Boozary and Dr. Ashish Jha of the Harvard School of Public Health, published an article in The Journal of the American Medical Association elaborating on the need for quality care, and why the needs for staff, resources, and systems persist in low-resource settings.

In making the argument for staff, the authors write:

The scarcity of health care workers in western Africa poses a serious challenge. Even before the outbreak, Liberia’s 4.3 million people were served by just 51 physicians—fewer than many clinical units in a typical major U.S. teaching hospital. Many more physicians are needed, but focusing on physicians will not be enough. Successful integration of prevention and treatment efforts requires a comprehensive strategy, including community health workers, who can encourage sick patients to come to health care institutions, and nurses, who provide lifesaving supportive care, such as intravenous rehydration and electrolyte management, in an environment that is safe for both practitioners and patients.

In explaining the need for health care resources, the authors write:

While experimental therapeutics have garnered significant attention, vaccines or monoclonal antibodies that have yet to enter clinical trials are no panacea for the current outbreak. However, appropriate supportive care can help reduce many unnecessary deaths. Currently, the lack of basic health care resources—such as protective gloves and gowns, intravenous fluids, and straightforward protocols and guidelines—has limited front-line health workers who risk their lives to care for those affected with Ebola. The health systems of high- and middle-income countries are awash in basic health care materials and guidelines, and there is no good reason these fundamental health care resources cannot be provided to front-line workers in West Africa to save lives.

Lastly, in discussing the need to build and strengthen health systems, they write:

The problems of inadequate systems reach far beyond West Africa. Despite a recent global movement to expand access to health care, the Ebola outbreak is a cogent reminder to carefully consider 2 simple questions: What kind of care are people going to access? Is that care worth having, and can it be made better? A focus on accountability, especially for quality, is critical. Over the past decade, many countries have committed to spend more money on health care, but spending more is not enough. There has been little effort to understand the quality of care that such spending buys and how that care might be made better.

The authors conclude with a sobering sentiment. “The outcomes of the next several months will reveal the capacity to forge effective partnerships across borders and disciplines, and the extent of the commitment to value all human lives equally.”

Read the full article here.

Learn how to support PIH's Ebola response.

Ebola: Countries Need 'Staff, Stuff, and Systems'

Last week PIH Co-founder Dr. Paul Farmer, PIH Chief Medical Officer Dr. Joia Mukherjee, and a small team of clinicians traveled to Liberia to assess the Ebola outbreak and determine how PIH can best respond to this historic challenge. Upon returning, Drs. Farmer and Mukherjee penned the following opinion piece for The Boston Globe.

As doctors with long experience in fighting epidemic diseases, we have just returned from the front lines of the Ebola crisis in Liberia and are dismayed over the scale of the outbreak. But we are also optimistic. After months in which Ebola seemed to be winning a battle against the citizens and health care providers in Liberia, Sierra Leone, and Guinea, the world’s leaders are unleashing the first ambitious efforts to fight back.

Last week, the United Nations declared an all-out war against Ebola, saying that “we cannot afford delays; the penalty for inaction is high.” It passed a resolution calling for every member state to accelerate its response to the outbreak and to lift travel restrictions on the most affected countries; with 134 votes, the resolution garnered more support than any previous one. Meanwhile, the United States is dispatching 3,000 soldiers as well as medical and public health troops to Liberia with an unprecedented mission: Wage war on Ebola by helping the battered Liberian public-health and medical community, including setting up treatment units in each of Liberia’s 15 counties. President Obama called for a “campaign for community care.”

Community care could, when coupled with infection control, stop the epidemic. Of course, the region needs more treatment units for the sort of care that can only be provided in an in-patient setting. And hospital care can be improved long-term only by training and equipping Sierra Leoneans and Liberians: the staff and the “stuff” required to save lives. But it also needs to provide the tools that smaller clinics and front line health workers need to fight the virus in their neighborhoods and villages.

The health systems in West Africa, which were already weak before the outbreak, are now decimated by it. A group of physicians from Partners in Health, a Boston-based medical nonprofit affiliated with Harvard Medical School and its teaching hospitals, along with Last Mile Health and the Wellbody Alliance, two community-based health care delivery organizations in rural Liberia and Sierra Leone, saw these weakened systems first-hand in both countries. It is clear that the region lacks the “staff, stuff, space, and systems” required to stop Ebola.

Meanwhile, the outbreak is spreading. More than half of the reported 5,843 cases were logged in the past three weeks alone. In addition, many other cases are either not diagnosed or reported. On Tuesday, the Centers for Disease Control and Prevention reported that Liberia and Sierra Leone could register up to 550,000 cases by Jan. 20 unless there are significant and immediate efforts to accelerate the delivery of services across the region. These services include efforts to stop the transmission of Ebola within households, clinics, and hospitals.

The irony of Ebola is that it is those who provide care who are most at risk of falling ill.

The irony of Ebola is that it is those who provide care who are most at risk of falling ill: not only nurses and doctors, but mothers and sisters and caregivers in general. It’s no accident that up to 75 percent of those afflicted with Ebola are women.

This is why strict levels of infection control need to include what’s called PPE — personal protective equipment, which includes clothing, gloves, and goggles. PPE and other protective tools have been largely absent from not only homes and villages but also public clinics and hospitals. This is one of the reasons why so many facilities were shuttered; they became sites of transmission and death rather than of care that might have stopped an epidemic. Some hospitals have already lost a majority of their nurses and doctors to Ebola — in a region with far too few of them to begin with. This means that patients who are sick with more common afflictions, including malaria, typhoid, and pneumonia, are dying in greater numbers than prior to the explosion of Ebola. More women are dying in childbirth. Ebola worsens old problems as it causes new ones, including a burgeoning epidemic of fear.

So is this tension between prevention and care unresolvable? Must all patients thought to have Ebola be shut up in their homes or removed to isolation units without the requisite staff, stuff, space, and systems? Absolutely not.

Years ago, when Partners in Health first engaged in fighting another deadly epidemic — drug-resistant tuberculosis — our colleague Jim Yong Kim (now president of the World Bank) and others referred to it as “Ebola with wings.” We learned then, in settings from the slums of Lima to the mountains of Lesotho, that community-based care, delivered in large part by community health workers, was not only safer than facility-based care, it was also more effective. This was true when caregivers had the staff, stuff, space, and systems required to prevent, diagnose, and treat tuberculosis with the tools of the trade. “Community-based care” does not mean “community-based no care”: that, we’re providing already, and at large scale.

The countries fighting Ebola need to have the tools to treat patients closer to their homes and communities. They also need more Ebola treatment units, and we were encouraged last week to see our Liberian colleagues put the finishing touches on a large and well-laid out unit in Monrovia. On Sunday, there was a large crowd in front of the visitors’ entrance; a Liberian priest was about to bless the building, as a Ugandan doctor working with the World Health Organization looked out over the crowd. “They’re volunteers from across the country,” she explained to us. “They’re being trained to help.”

Some were nurses, but most were not medical professionals. They will be before this war on Ebola is over. They are at the front line of building stronger community-based health systems to stop this epidemic.

Ebola: A Call to Action from PIH's Dr. Joia Mukherjee

This week PIH Chief Medical Officer Dr. Joia Mukherjee, PIH Co-founder Dr. Paul Farmer, and a small team of specialists traveled to Liberia to assess the Ebola outbreak. PIH is working in close partnership with Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone to respond to the outbreak in a way that addresses the immediate needs of patients while focusing on long-term systems building so that the right to health is realized in these countries.

Ebola.

The very word strikes fear. Those paying attention to this outbreak have undoubtedly seen the gruesome media images from West Africa and the shocking number of deaths—more than 2,600 and climbing every day—from a scourge progressing unchecked. But the outbreak presents us with a critical—and lifesaving—opportunity: to globalize the notions of solidarity and of health care as a basic right.

Globalization has been the watchword for several decades—air travel, the Internet, trade policy, and flows of capital have brought humans into a proximity previously unknown. To be sure, the effects of globalization have a checkered impact on development, bringing opportunity to some and misery to others. If there is one thing the Ebola outbreak makes clear, it’s that access to modern medical care—the right to health care—has not been globalized.

Liberia, Sierra Leone, and Guinea, the three countries most affected by Ebola, are among the poorest and least developed on the planet. Because the virus spreads through direct contact with the bodily fluids of a person who is infected or has died from Ebola, it’s easy to understand how quickly it can spread in places without running water and adequate sanitation—places where people live in utter poverty.

It is within this egregious breach of basic services that Ebola has flourished.

These countries also have an appalling lack of health infrastructure and insufficient numbers of trained and equipped health care providers. It is within this egregious breach of basic services that Ebola has flourished.

This is why Partners In Health has decided to work shoulder-to-shoulder with two of our longtime partners, the grassroots organizations Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone. Building and strengthening health systems and the capacity to respond to Ebola in rural Liberia and Sierra Leone will help ensure that people don’t have to travel hours to get help. This approach will help frontline health workers do proper contact tracing—a critical practice to contain the outbreak—because the patients will be from nearby towns. It is important that our response helps reinforce the primary care efforts of our partners. It’s still more common for children in any of these countries to die of malaria or pneumonia, and if the health system entirely collapses under the weight of this outbreak, the death toll will be far bigger than just Ebola alone. Linking Ebola diagnosis, treatment, care, and education with the ongoing provision of primary health care is key to saving lives.

In poor countries, health workers often work without soap and water and most certainly lack other necessary protections. More specialized protective equipment—gowns, gloves, and face shields—is routinely available in the U.S. and European facilities. In fact, much of the protection against Ebola for health care workers falls under the egis of “universal precautions,” the standard practices adopted in the U.S. in the late 1980s as a response to the HIV epidemic. Such precautions are considered an immutable standard of care in the U.S. and Europe. Yet these items aren’t available to health care workers in poor settings who try daily to stem the spread of highly transmissible diseases, whether Ebola or drug-resistant tuberculosis.

Without adequate protection, those charged with caring for the sick are at risk of contracting Ebola and often choose not to risk their lives by working in unsafe conditions. Health facilities attending to Ebola victims do not have the tools to diagnose, isolate, or treat people with the virus. As such, victims who make it to health centers die at unacceptably high rates.

It’s imperative that we now demonstrate a different facet of globalization, the globalization of solidarity.

This is why it’s imperative that we now demonstrate a different facet of globalization, the globalization of solidarity, of the right to health, of justice and basic dignity. Can we use the globalization of transportation, communication, knowledge, skills, and resources to respond to this crisis?

As a medical organization that provides health care for the poorest in many challenging environments, we stand in solidarity with those trying to respond and pledge to leverage our expertise to directly support the prevention, control, and treatment of Ebola. We see this as a chance to strengthen health systems so that frontline health workers have steady access to basic safety equipment, proper diagnostic tools, and necessary medications—not just during the Ebola outbreak, but whenever they need.

But this crisis needs more: more global financing, more global medical staff to treat the sick, and more global advocacy for health care and Ebola treatment.

We must demonstrate our solidarity pragmatically, in the form of financial and human resources. We have put out a call for this solidarity, and so have others.

We seek trained clinical staff who are willing to fight for justice through care of the destitute sick. We seek partners who are willing to support this effort.

And we seek to spur a new face of globalization—one that prioritizes social justice and guarantees the right to health.

Experienced clinical and non-clinical health sector workers interested in volunteering to help people affected by the Ebola outbreak are welcome to register here. At this time, PIH can only accept applications from U.S. citizens in accordance with evacuation guidelines set forth by the U.S. government. We are hiring long-term positions (ideally 12 months), and we are also recruiting short-term clinical and non-clinical volunteers (eight-week minimum).

Dr. Fils-Aime: 'Working in Mental Health Gives Me Hope'

Dr. Reginald Fils-Aime is a Haitian physician who from 2010-2012 directed the Multidrug-Resistant Tuberculosis program in Haiti at Partners In Health and Zanmi Lasante, our sister organization in Haiti. He began his career in mental health after being inspired by the change he saw in patients through treatment with psychotherapy, medication, and social support following the country’s 2010 earthquake.

Dr. Fils-Aime has led efforts to bring mental health care into the community-based health system supported by PIH and ZL, in partnership with the Haitian Ministry of Health. He entered the Masters in Medical Science in Global Health Delivery program at Harvard Medical School in 2014, with the goal of returning to Haiti to build teams and improve systems to address health needs in the community. Here, he reflects on his work.

Mental disorders cause the same disasters in Haiti that they do in other parts of the world. When people think they have or a relative has a mental illness, they look for solutions for it. They turn to religion and to traditional healers, which are often more familiar and trusted to them than the health system, but they usually come to the hospital after, in my experience.

Most people in Haiti tend to attribute mental illness to supernatural causes, and some believe that mental disorders can be transmitted to other people. For our work, this means that staff in hospitals may be more reluctant to approach a mentally ill person. For example, some people believe that if a moun fou, a psychotic person, hits you, you should hit him or her back or you might become “crazy” too.

But working in mental health gives me hope that things will get better. One reason is because of the values of the Haitian people, the sense of community cultivated in the rural areas. We are all family in the rural area. Although rural poor people are overwhelmed by all kinds of problems, they still want to help their relatives, their neighbors, and others.

Working in mental health gives me hope that things will get better.

At Zanmi Lasante, we are treating mental disorders at the primary health care level and in the community, rather than through institutionalizing mental health patients in inadequate, locked facilities far from their families. To make mental health part of the primary health care system, we train all types of health providers to identify people and help them receive care for their problem. We train and employ community health workers as key participants to educate, screen, assess, refer, follow up, and support people in their own communities. We train and employ psychologists as central providers, as mental health leaders and advocates in our health facilities. (Learn about one tool we use in Need to Know: Screening for Depression in Haiti.)

We have also trained all the social workers at Zanmi Lasante’s clinics, and we collaborate with general practitioners, other doctors, and nurses to ensure comprehensive care for our patients. We try to organize each provider’s competency around the patient, for the patient.

With this system, we are receiving patients and treating them humanely and efficiently for mental disorders ranging from mild to severe. At University Hospital in Mirebalais, besides the community and outpatient services provided by our team, we have hospitalized several patients who were severely ill and risked harming themselves or others. We were able to hospitalize these patients in collaboration with physicians, nurses, and other staff from the emergency and internal medicine wards.

I believe what we are doing now is something that will work well in other parts of Haiti, both in the communities and in the departmental hospitals. Knowing that gives me a lot of hope for mental illnesses in Haiti.

We started this type of mental health care in Cange and we’re systematizing it now, and it’s an innovation in Haiti. As with most innovations, there is resistance to it. The biggest challenges are lack of structures and systems to treat mental illnesses, a lack of trained human resources, the need for political commitment and financial means, and the social perceptions of mental illness, including stigma.

Some relatives of mental health patients want to leave the hospital because of the disdainful, stigmatizing looks of the other patients and their families, or because they feel stigma even from some members of the staff. We handle these situations by talking to people and explaining our understanding of the disease. We try to help them with their own anxiety and fear of the disease. The University Hospital team believes that when we are treating a patient in the wards, we also have to treat the anxiety surrounding mental illness, including the fear of the staff and of the patient’s relatives who are overwhelmed by the disease.

We are trying to understand and appreciate the community and individual understandings and approaches to mental illness in the context of all their other problems. We listen to them, and we engage in productive dialogue with them. This is how we are striving to build an adaptive and sustainable system to humanely care for mental disorders.

We have to act on several fronts at the same time, but there is a lot of hope because we are finding more people very enthusiastic to help mentally ill people. Each patient we treat lessens the skepticism in the minds of some staff who didn’t help only because they didn’t know they could.

Need to Know: Screening for Depression in Haiti

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

What is it?

The Zanmi Lasante Depression Symptom Inventory is a screening tool that helps clinicians identify depression in Haiti. The inventory lists the symptoms of depression using both universal and local descriptions of the illness. For example, symptoms such as trouble sleeping, loss of appetite, and feelings of sadness are signs of depression in developed countries and in Haiti. But the screening tool also includes three Haitian idioms for the symptoms of depression, such as de la la (low energy), kè sere (constricted heart), and kalkile twòp (thinking too much).

Why is it important?

Depression is sometimes thought of as an affliction that only affects people in developed countries. But in reality, the burden of disease is great in developing countries. The World Health Organization predicts that by 2030, depression will become the number one cause of disability globally. Eighty-five percent of people living with a significant mental health problem in poor countries don’t receive the treatment they need.

Mental health issues such as depression were in the spotlight after the 2010 earthquake in Haiti, but the truth is that many Haitians have struggled with depression long before the earthquake—and likely will long after. Depression is associated with the poverty that many people live in, and it also worsens patients’ ability to take care of their families and their own health—such as taking medicines for HIV.

Where does it come from?

Partners In Health clinicians, along with partners at Fordham University, New York University School of Medicine, Emory University, and Harvard Medical School and School of Public Health, conducted research to identify key descriptors of depression among rural Haitians. They used rigorous analysis to develop an inventory of symptoms that were most closely linked to depression in the Haitian context. The results were published in the July 30, 2014, online issue of Transcultural Psychiatry (see “recommended reading” at left/link).

How is it used?

PIH has worked with Zanmi Lasante, our sister organization in Haiti, to train a range of health professionals to screen patients for depression, following up with a thorough clinical evaluation. Haiti has less than 10 psychiatrists for the entire country of 10 million people, and nowhere near enough psychologists to meet the needs of Haitians. Without these specialists, it’s critical to train all health providers—nurses, physicians, community health workers, and social workers—to be able to identify depression and help patients access treatment. PIH/ZL has conducted trainings and established a system of clinical supervision for health professionals in the community, at clinics, and at hospitals to be able to use the tool to identify depression.

What happens after patients are screened?

Let’s take a community health worker as an example. Community health workers are local people trained to identify people in need and provide follow-up care, helping to ensure the health care system is accessible to everyone, no matter how poor or how far from health facilities they live.

A community health worker visits a person in their home who they suspect may be depressed. They use the screening tool to evaluate the person’s mental health. If the patient scores high on the inventory, indicating they are likely to suffer from depression, the community health worker will refer the person to a local clinic for further evaluation by a specialist. There, a PIH clinician will do a second evaluation to determine the patient’s condition. They may be treated with interpersonal therapy or medication, depending on the severity of the case.

For people scoring lower on the inventory, the community health worker will provide basic psychoeducation and psychosocial interventions, in addition to following up with the patient at home at a later date to provide additional focused support tailored to their needs.

Who else besides PIH/ZL is using this tool?

The Haitian Ministry of Health has been enthusiastic to expand access to mental health care at public facilities throughout the country. PIH/ZL has trained them on use of the tool so they can use it to identify depression around the country, not just in the Central Plateau and Artibonite regions where PIH/ZL works.

I couldn’t abandon the treatment if I wanted to live.

As days went by, I came to accept my illness. The doctors told us there was a cure; I only needed to follow a long treatment. I couldn’t abandon the treatment if I wanted to live.

Today, I am almost finished with a year of treatment for XDR-TB, receiving fifth-line drugs through a central line they’ve implanted in my chest beneath the skin. Despite the difficult situation my family is living in, they haven’t abandoned me. They always give me the strength to go on.

As my disease has responded well to the treatment, my doctors decided I could receive treatment at home. This helped my mom in her work, because every day she leaves to work so we can eat. My sister, with her little son, takes care of me. I know that I should take care of myself to avoid infecting them, and I know that they love me and they would never leave me.

The central line in my chest and the pills I take every day are a cross I have to bear. I have side effects daily, including frequent diarrhea and gastritis from the quantity of pills I have to take. But I have to tolerate this, with a huge effort, and my family gives me strength to do so.

Now I only have to complete the treatment, and I don’t have much left. I always repeat this to myself.

Even though my family is humble and our economic situation is terrible, I have the hope that when I finish with this nightmare I will finish high school. I want to be someone; I want to study. I think that through studying I can get my mother and my sister out of this, and they’ll never have to experience this situation.

Encouraging facility-based births

A safe C-section

Volunteers lend expertise

Mendel would like to have 100 volunteers on board by the end of 2015.

I learned to better understand the importance of giving each individual patient health care with compassion, dignity, and respect.

Dramatic change

A cultural shift

Looking ahead

Abass' Smile (or, Then the Lights Went Out)

Numbers Become People

You Can Get Blood Out of a Stone

Catch 22s and Surprises

"That 'Good Morning' has Ebola!"

Ready to Depart, Thinking About Coming Home

A Valentine's Day Explainer

Leadership Lessons from an Ebola Treatment Unit

You're invited to the official release for RaRa Coffee:

DATE: Saturday, February 14, 2015

TIME: 5 to 6:30 p.m.

PLACE: La Colombe Hudson Square Cafe

75 Vandam Street

New York City, N.Y.

If you can't join us in person this Saturday, follow along with our live-tweet from 5-6 PM EST: www.twitter.com/PIH

Support PIH by purchasing coffee at LaColombe.com.

Surgeons-to-be must not be allowed to exploit the surplus of patients in poor countries to fulfill their training quotas.

Antiretroviral therapy for HIV turned a death sentence into a manageable, chronic disease.

The first patient

What can I say? The medicines are eloquent enough. What they have done for me is amazing.

Closing the gap

The price tag was expensive, between $12,000 and $16,000 per patient per year, and said by some to be difficult to deliver.

A little paper, a big meeting

From small to scale

The HIV Equity Initiative gave people hope that it was possible to treat HIV in rural and urban settings of great poverty.

HIV became our battle horse in the fight to break the cycle of poverty and disease.

Lessons for the world: The Shattuck Lecture

The global AIDS debate … was really about funding.

Investments in health care create jobs, alleviate food insecurity, and help prevent against future epidemics that can crash an economy.

We are all doing our part to provide as much dignity for what is really an undignified disease.

I learned to see disease as a social illness as well as a biological disturbance.

To achieve equity, we all have to work from our different fronts, paying special attention to the most vulnerable among us.

An estimated 30,000 children become sick every year with MDR-TB.

She is doing very well and responding to the medications.

If more individuals have the resources and tools to build hand washing with soap into their daily habits, countless lives can be saved.

Can you tell us a bit about the CDC training?

What did the average day look like?

What aspects of the training surprised you?

This is such an infectious virus that we need to be extremely vigilant, following every protocol.

Are there challenges in terms of getting and securing enough PPE?

There is a severe stigma around Ebola. Are there lessons PIH can draw on to reduce stigma and provide dignified care?

And with the right supportive care, the cure rate can be so, so, so much higher than it is now.

The irony of Ebola is that it is those who provide care who are most at risk of falling ill.

It is within this egregious breach of basic services that Ebola has flourished.

It’s imperative that we now demonstrate a different facet of globalization, the globalization of solidarity.

Working in mental health gives me hope that things will get better.

What is it?

Why is it important?

Where does it come from?

How is it used?

What happens after patients are screened?

Who else besides PIH/ZL is using this tool?

I couldn’t abandon the treatment if I wanted to live.

Paul's Promise

Bending the Arc

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