Cory McMahon, chief nursing officer at Partners In Health, writes below about her daughter with Down syndrome and the many global inequities surrounding the care and treatment of children with developmental disabilities.

I often reflect on Paul Farmer’s words: “The idea that some lives matter less is the root of all that is wrong in the world.” As chief nursing officer at Partners In Health, this call to action drives our nursing efforts in some of the world’s most resource-limited countries. As the mother of a child with disabilities, Paul’s radical sentiment on worldwide humanity hits close to home. My daughter, Mali, now 9 years old, has Down syndrome. She faces a lifetime of navigating an exclusionary society full of barriers for people with Down syndrome and other developmental disabilities.

I was working for the Human Resources for Health initiative in Rwanda prior to Mali’s birth. My partner and I came back to the United States for her delivery, always planning to return to Rwanda. But when we learned that our daughter was born with Down syndrome and grasped the full extent of Mali’s needs, we decided to remain in the U.S., where we had full access to medical specialists and social support networks, including our own family and friends and a strong Down syndrome community. The decision to stay was complex and wrought with mixed emotions.

The privilege we were afforded simply by being born in the U.S. became abundantly clear; because of that simple fact we knew Mali could get top-quality care from a team of practitioners and specialists throughout her life.

A Whirlwind of Care

And care she got: from her earliest days there would be a whirlwind of tests and appointments, medical and child development experts. We were connected to a Down syndrome clinic, ensuring that Mali was getting the medical care she needed from a multidisciplinary team. We received services in our home from the time Mali was four weeks old that supported her growth and development and now those services continue in school. We had an entire community and resources to support us – we were not alone.

But even with this top-notch care, the message we got was often about what Mali couldn’t do—communicating a constant reminder that she will not develop the same way, or at the same pace, as other children. Soon, though, Mali became my biggest teacher, evolving my own beliefs of what’s possible for her day by day. Each milestone, while not on the same timescale as most children, was another step toward a fulfilling, happy life.

Few Services, High Stigma

I often wonder what our experience would have been like in Rwanda. In 2012, when Mali was born, there were few—if any—medical, therapeutic, and supportive services we needed. The stigma associated with Down syndrome in many parts of the world remains a reality that further prevents parents from accessing care. This stigma inhibits more than just access to medical care, it also limits access to community and resources that would help families navigate this often difficult terrain.  This lack of resources and support also conveys a strong message: some lives matter less.

Rwanda has made tremendous progress. Today, there is a pediatric development center that has enrolled over 2,500 children and families. This center, the first of which opened at Rwinkwavu District Hospital in 2014, provides comprehensive services including physiotherapy, occupational therapy, nutrition services, screenings for vision and hearing impairments, and caregiver groups to teach parents ways to play and interact with their children that promote early childhood development. The center focuses on engaging fathers who were often abandoning their families, leaving mothers alone to care for their children with complex needs. In recent years, the center has served as a model that has since expanded to 18 public health centers in PIH-supported facilities across Kirehe and Rwinkwavu Districts and into Malawi. 

The Work Ahead

Globally, there is still much more work to be done to meet the needs of this unique population and others with developmental delays and disabilities. Accessing diagnostic testing and a lack of country-wide birth registries remains an enormous challenge. As a result, we don’t track or know how many people are born or live with Down syndrome around the world.

Without a diagnosis, many families are unable to obtain necessary medical, psychosocial, and caregiver supports needed. Approximately half of all babies born with Down syndrome have congenital heart conditions, requiring access to specialized services like cardiac surgery and neonatal intensive care units. Gastrointestinal abnormalities, thyroid conditions, immune disorders, respiratory complications, hearing and vision impairments, and childhood leukemia are other complex medical conditions associated with Down syndrome requiring specialized care. Children born with Down syndrome have low muscle tone and experience difficulty latching on during breastfeeding; they, therefore, run a higher risk of malnutrition. These mothers and infants require additional support, and, when necessary, nutritional supplementation, which is often inaccessible.

Most of these conditions are treatable, allowing people with Down syndrome to lead healthy, productive lives. Without these interventions there is a higher mortality rate and lower quality of life, preventing individuals from meeting their full potential and the community from benefiting from the unique contributions of this population.

No Child Matters Less

We can and must do better. In the U.S., the life expectancy for people with Down syndrome has increased from just 9 years in the 1920s to now close to 60 years. Access to comprehensive health care and increased community acceptance have all contributed to improved life expectancy and quality of life. People with Down syndrome are business owners, teachers, models, actors, marathon runners, daughters, sisters, and a loving, irreplaceable, integral life force in a family. And the list goes on. It is our moral and social imperative to include people with Down syndrome and other disabilities in the global discourse and ensure the right to health care, autonomy, community integration, financial security, and opportunity.

No child matters less because they are born with a disability.

Paul’s call to challenge conventional beliefs, and to disrupt the status quo, forges a healthy and dignified path forward for children with Down syndrome like Mali. Heeding his words would give all children, no matter what their special needs might be, the opportunity to live healthy and fulfilling lives.

Marí Romero Sánchez first felt the lump while she was changing clothes. It was in her right breast—not painful, but hard and growing.

Sánchez, 50, had already faced a string of health scares over the past year, including COVID-19 and a motorcycle accident. She dreaded the thought of another. But, she and her daughter reasoned, it was better safe than sorry.

Reluctantly, she went to the Villa Clorinda Medical Center, about 15 minutes from her home in Cómas, in February.

There, an OB-GYN examined the lump and delivered some unsettling news: it could be a sign of breast cancer; she would need a mammogram.

Breast cancer is the most common cancer worldwide and in Peru, where more than 6,800 cases were detected in 2020. But 75% of cancer cases in Peru aren’t diagnosed until the advanced stage, resulting in deaths that could have been prevented with wider access to screening.

Mammograms—critical tools for early detection of breast cancer—are not available in impoverished communities like Cómas, a district in northern Lima. To access this service, patients must get a referral to a hospital—typically, hours away and fraught with complex referral procedures and long waitlists.

Socios En Salud, as Partners In Health is known in Peru, is determined to help as many patients as possible beat the odds—accessing screening, diagnoses, and lifesaving care.

Early Detection

Socios En Salud has worked in Peru for more than 25 years, ever since it responded to a deadly outbreak of multidrug-resistant tuberculosis in Carabayllo. In the years since, Socios En Salud has expanded its medical care and social support programs and strengthened the health system in partnership with the Ministry of Health.

Breast cancer care has been part of that work for years. Through the Aceleración de descarte de Lesiones de Mama (ALMA) program, which began in August 2020, Socios En Salud dispatches its team of community health workers—locals hired and trained in basic health services—to proactively find women over 40 years old in Cómas and Carabayllo, two impoverished districts in northern Lima, and educate them about breast cancer and health services available to them. This outreach is conducted in markets, soup kitchens, neighborhoods, and clinics.

The impact is immense.

Last year, Socios En Salud provided breast cancer screenings to more than 1,886 women in northern Lima.

Sánchez was one of hundreds of women connected with a mammogram this year. The result was what she feared: breast cancer.

She would need several rounds of chemotherapy to treat the cancer, which was in stage two. Each session would be five hours long and in a city hours from her home, taking her away from her daughter and grandchildren.

“I suffered from depression during the first several months,” she says. “But life goes on.”

‘A Long Road Ahead’

The chemotherapy began in May. During her first appointment, she was so nervous that her blood pressure dropped. Fortunately, she was not alone.

María Rosas, a community health worker with Socios En Salud, was there to support her, helping her navigate the hospital and referral process and staying by her side for the five-hour session.

"She accompanied me and was with me during the first chemotherapy, giving me strength and encouragement,” says Sánchez.

After she completed the first round, Rosas continued to accompany her, checking in regularly. Socios En Salud also connected Sánchez with a therapist—care that its mental health team routinely provides for patients with chronic conditions, which can contribute to anxiety, depression, and other mental health conditions.

“Marí is a very strong woman,” says Rosas. “From the first day of treatment, she knew that it would be a long road ahead and that the medical team of Socios En Salud would be with her at all times.”

That support proved crucial for Sánchez, as the treatment took a toll on her physical and mental health.

“After the first round of chemotherapy, my hair started to fall out,” she recalls.

She began wearing a turban. She noticed a drop in her energy, too. In the morning, she felt dizzy and nauseous, leading her to take a pill to cope with the side effects.

It was a process that would more or less repeat itself every 21 days, when Sánchez was due for her next round of chemotherapy—a moment she dreaded, not just for the discomfort, but also for how it took her away from family.

But she knew she had support.

“Socios En Salud has been by my side, from the time I was diagnosed until today,” she says. “I feel accompanied.”

And the treatment was working. Month by month, she felt her strength returning to her. After four rounds of chemotherapy, the lump in her breast had shrunk from three centimeters to one.

For the first time in months, she felt relief—and hope.

“Many people think that cancer is synonymous with death, but science has come a long way,” she says. “I am confident that I will be cured.”

Aline Niyizurugero, then 16, was heading home from school with her friend.

They had brought mangoes for her father and brother, who were at home cooking lunch. But when she was half a mile from her home in Kabarondo, a village bordering a busy road to a national park, a speeding motorcycle hit her from behind.

She was knocked unconscious.

Within minutes, the news got to her father Benjamin Shumbusho, from the neighbors. He rushed to the roadside to see her, fearing that he would lose his only daughter. The family of three had already suffered the loss of Niyizurugero’s mother, when she was just a baby. Another death would be devastating.

When he arrived and found his daughter, laying on the side of the road, he thought she was dead.

“I didn’t think she was still breathing,” said Shumbusho.

Desperate, he called an ambulance, knowing that emergency services could take an hour or more to arrive. The next several hours were a blur.

Niyizurugero was rushed by ambulance to the emergency room at Rwinkwavu Hospital, one of several hospitals in Rwanda supported by Partners In Health.

Advanced Care

Inshuti Mu Buzima, as Partners In Health is known locally, has worked in Rwanda since 2005, supporting the Ministry of Health to strengthen the health system. Rwinkwavu District Hospital was the first fruit of that collaboration. In 2005, PIH transformed the broken-down facility in Rwinkwavu into a functional district hospital.

There, in the emergency room, Niyizurugero received lifesaving care, stabilizing her, though she was in a coma. But she had suffered injuries to her head and legs that would require advanced care—and a trip to a referral hospital in Kigali, some hours away.

Many families in Rwinkwavu live on less than 3 dollars a day and survive on subsistence farming, barely making enough to make ends meet, much less afford medical bills. Niyizurugero would need multiple surgeries for her head and leg and intubation to help her breathe. Such procedures are typically costly—far out of reach for most families in rural Rwanda.

Still, Shumbusho would stop at nothing to save his daughter.

“I was willing to do anything to see my daughter alive again,” he said. “I had no health insurance nor money. I was going to sell everything for the treatment of my daughter.”

It was a desperate measure that, fortunately, he never had to take. Just two days later, as his daughter remained in the hospital, staff with Inshuti Mu Buzima reached out with life-changing news.

“A lady I hadn’t met before approached me,” he recalled. “Her words at that time gave me the hope I needed. She worked with Partners In Health. She said they will be covering my bills 100% percent.”

Right to Health Care

Inshuti Mu Buzima works with several referral hospitals, which are mainly in cities like Kigali and far away from the rural areas where PIH works. Even though health care is generally accessible in Rwanda, such care comes with many hidden expenses, such as transportation, lodging, and meals. These costs are only amplified when it comes to advanced care, which often requires hours of travel and accommodation in a major city, for extended periods of time—putting this care financially out of reach for many patients and families.

To address this issue, PIH established the Right to Health Care program in the countries where it works. The program supports patients with coverage of medical bills, essentials like food and clothes, follow up care, and funeral arrangements in case of death.

“Our role is to support patients who require treatment outside the district hospitals,” said Dorcas Sifa, who manages the Right to Health Care program in Rwanda. “In a month, we support over 100 outpatients and between 30-40 inpatients.”

In Rwanda, the Right to Health Care program has served more than 4,000 patients.

That support is crucial for patients like Niyizurugero.

After nearly a month of surgeries, including multiple procedures at different hospitals, Shumbusho saw his daughter’s eyes open. She couldn’t move, speak, or eat. But she was conscious, again.

“I felt like I was tied to the bed,” she later recalled. “I didn’t know what was going on. I just wanted to go home.”

It would take two more months for her to return home. Support from the Right to Health Care program didn’t end there. Inshuti Mu Buzima staff regularly checked in with her, helped her get medications and schedule appointments, and provided financial assistance.

Inshuti Mu Buzima is also working in partnership with the Ministry of Health to strengthen the surgery ward at Rwinkwavu District Hospital by expanding the space, hiring new staff, and buying new equipment.

More than a year later, Niyizurugero reached another milestone: she started walking and speaking again.

She began dreaming again, too. As school approaches, she hopes to return to class and finish her primary education.

“I feel ready to sit in the classroom with my friends,” she said.

This information was updated on October 17.

A recent cholera outbreak in Haiti, announced by the Haitian Ministry of Public Health and Population earlier this month, is adding turmoil to the country’s escalating troubles, where gang violence, damaged communications systems, and dire fuel shortages have increased over the past 15 months. 

The medical team at Zanmi Lasante, as Partners in Health is known in Haiti, reports there are seven suspected cholera cases being treated at Hôpital Universitaire de Mirebalais as of October 17, five adults and two children. 

Anticipating more cases to come, the team has converted one of its COVID centers into a cholera treatment center, with an 18-bed capacity. 

Children Most Affected 

As of October 12, the Haitian Ministry of Health reported 384 suspected cases of cholera; 43 laboratory-confirmed cases; 197 people hospitalized and 22 deaths. Of the total reported cases, 53% are male and 46% are female. The most affected age group is 1 to 4-year-olds.

ZL has been distributing food and hygiene supplies to staff and trying to procure fuel to keep medical sites running. The team is also working with international partners to rapidly distribute essential supplies to respond to cholera. To date, not one ZL facility has closed or been forced to stop caring for patients throughout the region. Indeed, 1.3 million people, or 1 in 10 Haitians, rely on ZL-supported facilities for care, treatment, and accompaniment.      

Previous Outbreaks 

Haitians never experienced cholera before 2010. Then, just after the devastating earthquake that year, UN peacekeepers arrived in the country from Nepal, which had recently suffered a cholera outbreak, and set up operations in a camp near Mirebalais with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in Haiti, the 200-mile Artibonite river, which is a water source for countless Haitians.  

This led to a massive cholera outbreak: more than 9,700 people died and at least another 815,000 were sickened from the disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours. Many victims are children. 

Mass Vaccination Efforts 

PIH was among the first responders to the 2010 outbreak in Haiti. Within several months, staff set up 11 cholera treatment facilities throughout the Central Plateau and lower-Artibonite and immediately began treating the sick. More than 3,300 community health workers were trained to identify symptoms and triage neighbors to nearby health centers. Ultimately, PIH treated more than 180,000 people.  

Doctors, nurses, and community health workers also worked to prevent cholera infections by teaching about proper water and sanitation practices and vaccinating as many patients as possible, which boosts immunity for up to five years. In 2012, PIH vaccinated 50,000 people in communities north of St. Marc. And following Hurricane Matthew in 2016, leaders traveled to the south to help the government vaccinate 800,000 residents. 

That campaign was followed by another effort in 2017: ZL, in collaboration with the national Ministry of Health and Massachusetts General Hospital's Center for Global Health, launched a vaccination campaign that aimed to cover the entire commune of Mirebalais, or roughly 100,000 people. Each resident received two doses of the vaccine over the course of a month, along with interventions to help treat drinking water at home and educational messages about good hygiene and sanitation. 

Read More About Cholera

The University of Global Health Equity (UGHE) in Rwanda has earned regional accreditation for its medical school, furthering its mission to radically transform global health education and care delivery.

The university was accredited following an inspection by the East African Community (EAC), an intergovernmental organization comprised of seven states: Rwanda, Uganda, Tanzania, Kenya, the Democratic Republic of the Congo, Burundi, and South Sudan.

The EAC’s Council of Higher Education inspected UGHE’s campus in Butaro, Rwanda in September, along with its teaching hospital, Butaro District Hospital.

The accreditation paves the way for UGHE to deepen its collaboration with regional and international institutions and affirms its standing as a leader in global health education.

“UGHE is proud to be among the universities in Rwanda with the EAC regional accreditation and this will go a long way in extending our unique educational pedagogy,” said UGHE Vice Chancellor Dr. Agnes Binagwaho.

UGHE was founded by Partners In Health in 2015, in collaboration with the Rwandan Ministry of Health. The School of Medicine opened in 2019, offering a bachelor’s level medical degree coupled with a master’s level global health degree.

With comprehensive classes, intensive clinical internships, and hands-on practicums, the school trains the next generation of doctors, nurses, and global health leaders to deliver medical care rooted in social justice.

And that education isn’t limited to a classroom—the campus extends to Butaro District Hospital, where students put their skills into practice, and to the rural communities in Butaro, where Partners In Health, known locally as Inshuti Mu Buzima, has provided medical care and social support for more than 15 years.

After graduating, students serve six to nine years with the ministries of health in their home countries—service commitments that place them in underserved communities ranging from rural areas to refugee camps.

This is all part of the university’s strategy to upend inequities in global health, a field that has historically excluded doctors, nurses, scholars, and other leaders from the Global South. With each graduating class, UGHE seeks to shift the center of gravity from where it has traditionally been, within higher-income countries, to lower-income countries—specifically, within Africa.

The continent bears 27% of the global burden of disease but has just 1.7% of the world’s doctors. UGHE students come from all over Africa, with the most recent cohort representing more than 23 countries.

UGHE’s mission—to level the playing field in global health—has earned it international recognition. In February, the university was highlighted by the United Nations’ education agency as a model for global health education.

The accreditation comes as the latest evidence of the university’s far-reaching impact.

“UGHE continues to create a cradle of unique solutions that drive systemic change, in a way that others have not,” said Binagwaho, “based on our principle that equity in quality health services delivery starts with equity in access to quality education.”

There were few, if any, mental health care options for the 64-year-old woman in Chiapas, Mexico, who suffered from depression, anxiety, and social isolation. That’s because for every 100,000 residents in the country, there is barely a single psychiatrist, and most work in major urban cities. People who live in rural regions with mental health conditions must travel as much as six to nine hours for such care, according to a report in the journal Intervention. 

Enter Problem Management Plus, or PM+, a novel psychological support intervention developed by the World Health Organization and adapted in different countries and contexts by the cross-site mental health team at Partners In Health. Through PM+, the woman* from Chiapas was able to receive help that not only improved her symptoms, but also her outlook on life.  

“She was very content when we finished PM+ sessions,” reported Carolina Guzmán Roblero, her community mental health worker  with Compañeros En Salud, as PIH is known in Mexico.  “I would continue visiting her every once in a while…because we are also part of the community and our patients will always be regarded as our patients, so we will never abandon them. Whenever I found her listening to the radio, I would feel very joyful.” 

Problem Management Plus 

Over 5 billion people worldwide suffering from mental health conditions cannot access appropriate care, contributing to already-high disease burdens for nations around the world. According to the World Health Organization: “The failure to deliver effective mental health care to over 80% of people who need it represents the single most significant challenge for global mental health.” 

To bridge this gap, the WHO developed the PM+ intervention, which can be provided by lay practitioners and licensed mental health clinicians alike, to support adults living in poverty and afflicted with emotional, psychological, or daily life problems. Its goals are straightforward: to alleviate disabling symptoms and assist patients to develop new coping skills, such as stress management, general problem solving, behavioral change, and a stronger social support system. 

The five-session program “gives the space for people to narrate their stories for the very first time,” said Dr. Fátima Rodriguez, mental health coordinator for Compañeros En Salud. “Some arrive saying they haven’t told this story before, like telling about their abuse as a child…also knowing that other people have been through the same situation, have the same symptoms, it brings hope to know these symptoms can be treated.”  

Mental Health Care Across Sites 

Mental health care is embedded within primary care and at every PIH site, said Sarah Singer, PIH’s associate director of program & partnerships for mental health.  “The cross-site mental health program is an innovative and unique example of clinical integration and knowledge across sites.”  

Since 2016, working closely with local practitioners and community mental health experts, PIH has adapted the PM+ model in Peru, Rwanda, Mexico, and Malawi—with other sites exploring future adaptation of the intervention. Analyzing the cross-site development of these programs in a 2021 article published as well in Intervention, PIH authors concluded: “Our experience demonstrates PM+ is translatable across cultures and feasible for use in real-world public sector primary care and community contexts.” 

Every aspect of the program is refined to meet the needs of each site. In Mexico, for example, providers undergo three weeks of mental health training, including modules on basic mental health topics and accompaniment, specific PM+ skills, trauma-informed care and also suicide risk assessment. Other sites offer variations of this training, including ongoing clinical supervision.  

Symptoms are ‘Culture Bound’ 

Mental health is, of course, cultural, so listening and adapting to each region's customs, language, and beliefs is critical, said Dr. Ksakrad Kelly, PIH’s cross-site senior psychotherapy technical advisor.  

“There’s a recognition that symptoms are culture bound,” Kelly said. “Depression, anxiety, and trauma can be very different, even within one household.” It’s this degree of specificity that is explored and developed in PIH’s adaptation process, she said, adding, “there’s not a specific standard approach; we let the sites take the lead.” 

For example, Kelly said, one standard question on a widely used depression screening tool is, “How often do you feel angry?” In Liberia, where the team implements other types of psychotherapy, the word “angry” is not used, so instead a word closer to “vexxed” replaced it in the questionnaire.   

In Mexico, for instance, one measure used to evaluate a person’s clinical functioning is whether they look disheveled or haven’t taken the time to arrange themselves. But “being disheveled doesn’t reflect if you’re depressed or not,” said Rodriguez, also the lead author on a paper detailing the adaptation of PM+ in Chiapas. 

The disheveled question is gone, Rodriguez said. Now, there are four questions that remain as the most relevant when assessing daily life functioning. Patients are asked whether they are having trouble sleeping, eating, with interpersonal relationships, or dealing with routine domestic tasks.  

Care delivery focuses on each individual patient’s needs and can include a combination of cognitive behavioral therapy, a kind of intentional reframing of problems, as well as relaxation techniques and “behavior activation,” which involves the deliberate practice of certain healthy behaviors to jump-start a more positive emotional state.  

In Malawi, for instance, the team adapted PM+ materials for group settings and trained lay mental health counselors to screen mothers for depression at routine prenatal visits in an effort to treat depression in pregnant and postpartum women. Like all of PIH’s mental health work, care delivery sites determine the priority needs of their communities and tailor the relevant interventions to fit those needs. 

Establishing a Connection 

Rodriguez cited another example in Mexico that involved flipping a script with patients to work through barriers. This, of course, could only be done by establishing strong relationships, she said. 

Initially, patient evaluations began with a checklist of clinical signs and symptoms, followed by a discussion that delved deeper into personal and psychological challenges, Rodriguez said. Health workers noticed that people were somewhat hesitant when the visit launched straight into a just-the-facts medical questionnaire, so they decided to begin each visit with conversation to try to establish rapport with patients who may have been hesitant to reveal personal information. Now, the health workers spend “a considerable amount of time,” around 20 minutes, conversing, before they ask about symptoms.   

“We inverted that order, because the patients told us they would feel the conversation was very abrupt” when workers launched right into the clinical checklist, Rodriguez said. “That’s how Mexico works. We are a lot about conversation, being warm.” 

Clear Mental Health Impact 

Data on the program in Chiapas shows the program’s success: 

About 70% of people who have been through PM+ reported a reduction in clinical symptoms, Rodriguez said. Currently 280 patients have enrolled in the program, and its managers have now widened the criteria for eligibility to include people experiencing gender or sexual violence, which impacts more than 68% of women in the community.   

“Through COVID, there weren’t any other providers addressing any of this, so we opened up criteria [for participation],” Rodriguez said.  

To date, almost 7,000 people have received PM+ across PIH’s four sites implementing the intervention, administrators said. 

And the approach continues to spread. PIH’s mental health adaptations around the world are now extending to the U.S., Singer said. Currently, PIH is working with a Massachusetts-based foundation and the nonprofit, The Family Van—through its Healthy Roads Program—to provide technical assistance on how to adapt PM+ for community-based organizations looking to provide mental health support across the Commonwealth of Massachusetts.

“Here’s a genuine opportunity for bi-directional knowledge exchange,” Singer added. “This is core to PIH’s mission and here’s a true example of making it work.”  

*Name has been withheld to protect the patient’s privacy 

Content warning: This story relates to suicide.

Ángel Morales is 32 years old and originally from Laguna del Cofre, Chiapas. For most of his life, Morales, like many farmers in his community, dedicated himself to growing coffee and corn—crops that provide income for him and his wife and children.

Chiapas is one of the poorest states in Mexico; many are forced to migrate to higher income countries such as the United States to seek better opportunities for their families. In 2021, Morales migrated to work "up north." That’s when the health problems started.

While Morales was working in the U.S., he was diagnosed with the stomach flu. Fortunately, he was able to access medical care and antibiotics and recovered. But the memory of that experience still haunted him. Negative thoughts began to snowball in his mind. What if he had experienced some serious and complicated illness? What if this illness had led to his death? What would happen to his wife and children if he was missing?

He started to isolate himself and stopped sleeping, eating, and working. He was no longer the man he had been months before. Everywhere he went, guilt, shame, and sadness seemed to follow.

He decided to return to Mexico and live with his family again. But the thoughts only grew worse.

"I couldn't control my nerves," he recalls. "I had panic attacks [and] headaches. My whole body ached and I couldn't sleep."

He began to lose hope that he would ever recover. Slowly, the impulse to take his own life became stronger and stronger.

It was at a local clinic, just steps away from his home in Laguna del Cofre, that he found help.

Morales had come to the clinic seeking treatment for the panic attacks and other physical symptoms. During his appointment, he also received a mental health screening, which led to a diagnosis: anxiety and acute depression. Within days, he began treatment, including medication and psychotherapy, working with one of the nine community mental health workers hired and trained by Partners In Health.

Comprehensive Care

Partners In Health, known locally as Compañeros En Salud, has worked in Mexico since 2011, partnering with the Ministry of Health to provide medical care and social support in the rural communities of the Sierra Madre region of Chiapas. Since 2014, Compañeros En Salud has provided mental health care at local clinics and through house calls from community health workers—care that, before the program, would have been at least five hours away.

In the years since, hundreds of patients have been able to access mental health care in an area once underserved. Between July 2018 and June 2021, Compañeros En Salud helped more than 1,200 patients access treatment for mental health conditions like depression, anxiety, and schizophrenia.

Mental health conditions have been on the rise globally, as people grapple with challenges such as the pandemic, climate change, and global inequities. Many factors put people at risk of suicide, including mental health conditions, substance use, lack of a strong support network, and physical, sexual or psychological violence.

More than 700,000 people die of suicide each year; 77% of global suicides occur in low- and middle-income countries. In Mexico, 7,896 people died by suicide in 2020.

The mental health team at Compañeros En Salud is determined to provide care that saves lives.

The team includes mental health workers hired from the communities, trained on how to support patients with depression and anxiety, and dispatched to make home visits to patients with these conditions.

It was a community mental health worker, Zoemia Morales, who helped Ángel Morales understand his condition and develop a safety plan, which consists of healthy, effective coping strategies and sources of support in times of crisis—a tool used in combination with psychotherapy and medication.

“I like to learn about mental health because it is very different from physical pain,” she says. “Sometimes people do not realize that what is hurting them are their feelings and that is what I am here for—to give them a safe place where they can talk about it.”

Now, with Compañeros En Salud’s support, Morales is receiving mental health care and regaining his sense of freedom, fulfillment, and purpose.

"I thank Compañeros En Salud for supporting me," he says. "They have always supported me. Even when I stopped taking my medications, they were looking out for me. That is how I have been able to get through this."

If you or a loved one are experiencing suicidal thoughts, help is available. In the U.S., call 988 for the Suicide & Crisis Lifeline. In Mexico, call 800-911-2000 for Línea de la Vida.

Current Situation 

Haiti has faced a steadily deteriorating security situation over the past 15 months, which has worsened dramatically in recent weeks. Gang violence, protests, roadblocks, damaged communications infrastructure, and fuel shortages pose grave operational and logistical challenges for the team at Zanmi Lasante, as PIH is known in Haiti.    

At the same time, the instability leaves people at increased risk of injury and illness, of unaccompanied births, malnourishment and cholera, even more in need of ZL’s “expert mercy,” as Paul Farmer said.  

And so, despite the instability, ZL persists with unwavering support from PIH’s care coordination site. Not one ZL facility has yet closed or been forced to stop caring for patients throughout the region. Indeed, 1.3 million people, or 1 in 10 Haitians, rely on ZL-supported facilities for care, treatment and accompaniment.    

Now More Than Ever 

To assist in these efforts, PIH is focused on doing what it can to mitigate the effects of fuel shortages, reducing consumption whenever possible (in part by upgrading our facility-powering solar arrays) and limiting staff movement. On October 1, the Ministry of Health confirmed a new case of cholera; since then there have been eight cholera deaths. Working with the Ministry of Health, ZL is also helping to assess the potential for a widespread cholera outbreak and set up treatment space for acute patients, relying on the organization’s deep experience with the disease. 

 As one ZL colleague said:  

 “Haitians need us now more than ever and it would be inhuman for those of us on the ground to turn our backs. Unlike some other organizations who come to Haiti for a project or emergency and leave, PIH/ZL stays long-term to help build the health infrastructure in the long term. We’re not going anywhere and we are 100% committed to our mission." 

Led and Run By Haitians  

PIH believes a solution to the current nationwide crisis must be led by Haitians, and likely with the support of the international community. But our focus remains on working with ministries of health, not politicians; looking at histories, not the news of the day; and engaging in accompaniment and strengthening of equitable, high-quality health systems. 

ZL is of course not just an organization capable of emergency response. It is a Haitian organization, led and run by Haitians. It works with and through the Ministry of Health, serving to bolster that institution’s capacity to deliver quality health care to Haitians. Since 1985, it has only grown bigger and better, despite all sorts of political and environmental challenges. Its residency programs now train tomorrow’s leaders. In short, it is a sterling example of how to aggressively chip away at a deep, deep problem—namely, a history of oppression that has resulted in a galling lack of modern medical care in the country—through solidarity, accompaniment, and providing a preferential option for the poor. 

With a four-decade history of Haitians providing high-quality health care for Haitians, the caregivers of ZL say they will continue their work on behalf of patients, notably:  

• In 2021, ZL nurses and doctors attended to 20,220 deliveries. 
• Each month, the emergency department at University Hospital cares for an average of 700 patients for just maternal health-related reasons. 
• In 2021, ZL provided care to 2,083 mental health patients. One in five were 18 years old or younger. 
• In 2021, ZL delivered treatment for malnutrition to over 2,600 children. 
• ZL has created 190 beds for COVID care, become one of the clinical groups in the country to save the lives of COVID patients, and been invited to advise other hospitals and the national response. 
• Between July 2020 and June 2021, ZL diagnosed and treated 623 women for breast cancer.  

Medical Education, And More  

Not only is ZL providing essential services in the midst of a crisis, it also continues to strengthen health systems overall through its medical training programs. Those programs include University Hospital’s internationally accredited, top-caliber residency programs in 11 specialties—family medicine, pediatrics, internal medicine, surgery, emergency medicine, OBGYN, nurse anesthetics, neurology, plastic surgery, emergency sonography and orthopedics. 

Moreover, ZL’s response to last summer’s earthquake has grown into a long-term partnership with care delivery institutions in the south of Haiti, and it works with other health institutions in Haiti to advocate for the rights of patients and health care workers by speaking with one voice.  

Despite past and current challenges, the ZL team said it will continue to do whatever it takes to strengthen the country's health infrastructure and accompany the Ministry of Health and patients to achieve more accessible and equitable health.  

In Malawi, where residents have endured cyclones and storms followed by a cholera outbreak over the past nine months, local health teams have completed a massive oral cholera vaccination campaign in the hard-hit Neno district.  

A total of 87,352 individuals, or 59% of the district’s target population were given both doses of the vaccine, meaning they are fully vaccinated, according to a report by health workers with Abwenzi Pa Za Umoyo (APZU), the sister organization of Partners In Health. More than 86% of the population received at least one dose of the oral cholera vaccine during the campaign. 

Jones Chimpukuso, the Community Health Director for APZU), which led the vaccination efforts in collaboration with the Ministry of Health and the Neno District Health Management Team, said the vaccines provide protection against the disease for three years.  

The large-scale vaccination campaign was launched following a cholera outbreak in April that killed two people and sickened more than 300 in the Neno District, the APZU report said.  

APZU, with support from local health workers and leaders, shepherded the effort throughout, from early detection and treatment of patients to community awareness and vaccine administration. 

But the campaign required the mobilization of many in the community. For example, the APZU report noted that all 169 village heads and religious leaders in the area were briefed on the campaign and helped strategize on how to organize residents for vaccination.  

Local leaders took the vaccine in public, which sent a positive message and helped increase vaccine uptake, APZU said. Using mobile vans in densely populated regions also helped, as well as teams of health workers going door-to-door to reach families. 

Dorothy Sinkhani, a resident of the Dembe district, said the messages from local health workers convinced her to get both doses of the vaccines for herself and her young daughter. 

Cholera is a deadly disease that can cause severe diarrhea and vomiting. Children are most often affected and can quickly become dehydrated, go into shock, and die within 24 hours if they are not treated. The disease can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between 2 hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae.    

Cholera spread through the region earlier this year, in the aftermath of Tropical Storm Ana and Cyclone Gombe. The pounding rain, wind, and subsequent flooding disrupted already weak structures, including water sources, officials said. Homes across the region collapsed and most people lost their household items for sanitation and hygiene. The result: Many residents had limited access to safe drinking water.  

The storms impacted over 221,000 households and 945,000 individuals nationwide, officials said; in Neno District, more than 7,500 homes were destroyed. 

Targeted vaccination campaigns are not new for PIH: successful cholera vaccination programs were launched previously in Sierra Leone and Haiti. Indeed, PIH's work in Haiti during a 2010 cholera outbreak, rapidly mobilizing to treat more than 145,000 Haitians and vaccinate another 45,000, was key to the development of a global stockpile of oral cholera vaccines by the World Health Organization and other partners in 2012.   

Anyone seeking evidence that the current system for funding global health and other vital initiatives is failing should consider the world’s response to COVID-19. To date, there have been more than 615 million cases reported, and 6.5 million deaths, while vaccination rates have been profoundly inequitable around the world.  In a series of reports published recently in The Lancet, authors characterized the pandemic and its response as both “a profound tragedy and a massive global failure at multiple levels.” 

Now, a growing international collaborative is reimagining public investment around the world.  A new Global Public Investment Network, launched September 19 during the United Nations General Assembly, aims to move away from “an old-fashioned aid mentality” toward a new common framework for financing the most critical social, economic, and environmental challenges in rich, poor, and middle-income countries alike. According to the network’s organizers: “GPI is a co-created movement with leadership from every region of the world. It is a movement for evolving beyond aid and leveraging significantly increased international public finance to meet the common needs we all care about through the principles of ‘all contribute, all benefit, and all decide.’” 

Alicia Ely Yamin, a lecturer on law at Harvard Law School as well as PIH’s senior advisor on human rights and health policy, and Joel Curtain, director of advocacy for PIH, have been centrally involved in the development of the GPI Network. We spoke with them to find out more about the bold ideas driving this movement, including a recent article in Open Global Rights they co-authored, laying out the moral underpinnings of the campaign. 

What is Global Public Investment? 

GPI is a simple concept: all countries pay in to a pool according to ability; all receive benefits; and all have a say in how the money is spent. Global Public Investment (GPI) is about spending on global and regional public goods—common needs that transcend borders. This model shifts away from the status quo, in which decision-making is concentrated among a handful of Global North countries, to one that takes democratic decision-making seriously.   

How does GPI align with PIH’s overall mission? 

Since PIH’s founding as a social justice organization, our work has involved direct service delivery in resource-limited settings while working hand-in-hand with governments to ensure access to high-quality health care for all. PIH has simultaneously engaged in policy advocacy efforts to fight the status quo around financing health care where policy makers and world leaders have become socialized to scarcity when imagining what it will take to ensure the human right to health.

In the early days of PIH, Co-founder Dr. Paul Farmer received a MacArthur Genius Award and created the Institute for Health and Social Justice within Harvard Medical School, where he and [fellow Co-founder] Dr. Jim Kim worked together with scholars from around the world to publish books, such as "Dying for Growth," which challenged the current health and development financing structures that had become the norm in the neocolonial development financing arena. In the midst of the COVID-19 pandemic, we’ve reinvigorated our organizational engagement and commitment to advocating more deeply for structural change and we believe that the Global Public Investment principles are on the right path toward a structure of global solidarity rather than charity.  

Why is there momentum on GPI now? 

The way aid is handled now is basically as crisis-based charity; it’s politicized and counterproductive and there are huge transaction costs. GPI started as an idea a few years ago and now there’s a huge amount of attention and a window of opportunity to move toward a new model of financing. 

The world is ripe for a paradigm shift in development finance and lessons from the COVID-19 pandemic underscore that building a movement to shift that paradigm is urgent in order to advance health and other social rights.   

How did the pandemic crystallize thinking about GPI? 

COVID-19 brought the world’s attention to how desperately underfunded health systems are in much of the world. All of the other social determinants of health that shape how diverse people can manage in a pandemic or normal times, from education to social protection to digital networks, also require sustained funding and long-term investments. 

We also saw that our system of multilateral cooperation is deeply broken, and talk of “international assistance and cooperation” without changing the rules of the game are radically inadequate. In the piece published recently in OGR, we noted that: "the G7 countries’ refusal to meaningfully regulate multinational pharmaceutical monopolies or to encourage sharing of know-how and decentralization of vaccine and therapeutics production is not just morally repugnant; it undermines the well-being of the whole planet.” Instead of incentivizing technology transfers and knowledge-sharing as global public goods, “COVAX was a poorly designed emergency facility for pooling donated vaccines, which failed to meet even its dismally low aspirations for low- and middle-income countries.” 

As we noted in our article, “preventing future pandemics and advancing global health equity is inextricably tied to food security and climate justice, which in turn is also related to conflict and gender inequality.”

None of these intersecting challenges can be met through crisis-driven aid and rituals of fund replenishment; all require statutory budget assignments for sustained global and/or regional public investment from pooled international sources. 

How is PIH involved in these efforts? 

For the last two years, Partners In Health, along with many other organizations, has contributed to co-creating the GPI model because we believe it is a crucial complement to the many other efforts to promote structural conditions that underpin health and other social rights, including tax justice, debt forgiveness, intellectual property reform, and principles of rights-based economies.  .   

Realizing health for all, and responding to our global crises, requires new forms of global cooperation. These new forms of cooperation must: 1) deliver global economic justice, i.e. stop illicit extraction and unjust drain of wealth from poor countries to rich countries and 2) mobilize and distribute public resources on a global basis, i.e. global public investment. 

Why have these goals been so difficult to achieve through the current system of aid? 

The dominant narrative of aid tells us that poor countries are poor due to some inherent failing and that rich countries benevolently provide assistance to them. Not only is this untrue, but it also serves to hide the brutal reality that it is actually poor countries that develop rich ones, through unjust and illegal resource flows. What is required is justice and solidarity, not charity.  

Mobilizing and distributing public resources on a global scale requires new levels of global solidarity and requires reimagining global cooperation and the very conception of international development. Currently, the global health architecture promotes narrowly defined programs that are in misalignment with local needs, are highly fragmented, and ultimately entrench low standards of care that are deemed “appropriate” in poor settings but would be unacceptable in rich ones. This reality, in which 13 million people die medical preventable deaths each year, is a consequence of an unjust global economy and a lack of global public investment to build health systems that deliver high quality care. 

Strengthening health systems is a central pillar of PIH’s strategic plan and necessary for realizing universal health care. The principles of GPI can help with such a transformation toward a more equitable and effective mode of multilateral cooperation fit for the 21st century. 

How do you build momentum for such a movement? 

The launch of the GPI Network this week is the first step in building a movement for GPI. GPI principles are already gaining traction in policy-making, advocacy, and scholarly communities, for example  the World Bank’s new fund for pandemic preparedness and response, as well as climate finance. But GPI cannot become another tool for technocrats to discuss and deploy behind closed doors. We need a GPI movement that intersects with other progressive movements, including human rights, which are aimed at changing the structure of our institutionalized social order.

Support the Movement

A new coalition in the U.S. House of Representatives today introduced a resolution honoring the life and work of Partners In Health Co-founder Dr. Paul Farmer with an ambitious roadmap to end medically avertable deaths and realize global health equity.

The resolution calls on the U.S. government to adopt a bold “21^st century global health solidarity strategy” to end poverty, ensure health care as a human right, and address structural, economic, environmental, and colonial harms that undermine the health and well-being of people around the world. At its core, the resolution enshrines Farmer’s vision for global health equity, serving as a “North Star” for global health politics into the future.

Sponsored by Rep. Jan Schakowsky, an Illinois Democrat, Rep. Barbara Lee, a California Democrat, Rep. Raul Ruiz, a California Democrat and physician, and about a dozen original co-sponsors, the Paul Farmer Memorial Resolution is aspirational, bold, and visionary, much like Farmer, who died in February in Rwanda. Specific legislation from each of the resolution's core pillars will emerge from this effort in the near future, supporters said.

“Dr. Paul Farmer is responsible for transforming the lives of millions and millions of poor and marginalized people around the world, bringing them health care, dignity, and justice," Rep. Schakowsky said. “A true visionary, Paul insisted that all people have a right to excellent health care, and he developed the systems to deliver it in places people had written off. Gleaming world class hospitals and locally trained doctors, nurses, and community workers now exist in places like Haiti and Rwanda."

She added: 

“We are the richest country in the world at the richest time in the world. Paul called on us to understand global health inequity as an injustice—a result of centuries of violence and exploitation inflicted on the global poor. We can make the choice to end global health inequity, and with Paul’s vision guiding us, we will.”

The idea for the resolution came immediately after Farmer’s death, when his long-term supporters and admirers in Congress began discussing how to honor him and carry his vision forward. Rep. Schakowsky led the construction of the text, with input from Farmer’s colleagues at Partners In Health and Harvard Medical School.

“Paul’s long-time collaborators and global health champions in Congress wanted to honor his legacy by taking action in solidarity with the global poor,” said Joel Curtain, director of advocacy for PIH.

The Paul Farmer Memorial Resolution

The resolution seeks to put an end to “the tragic and unnecessary deaths” of more than 13 million people each year, largely the global poor, by adopting new strategies to strengthen health systems, including:

• Increasing U.S. global health spending to $125 billion per year;
• Reforming global health aid to support national health systems and direct funding to align with local plans and priorities, not the development industry;
• Creating new medical technologies for diseases of poverty and ensuring their availability as global public goods; 
• Making the global economy more fair, just, and democratic by: 1) Democratizing the International Monetary Fund [IMF], World Bank, and World Trade Organization [WTO] so that impoverished countries have equal representation and a greater say over decisions that affect their economies and their ability to finance health systems; 2) Canceling global debt for all developing countries that need it, acknowledging these debts have often been unjustly imposed and maintained;  3) Ending harmful licit and illicit financial flows from poor countries, such as global tax evasion;
• Supporting global labor rights, such as a global minimum wage;
• Proposing reparations, including award, apology, and guarantee of non-repetition of harms for the institution of slavery, colonialism, imperialism, and ecological breakdown. 

Following Farmer's Vision

In his body of work, Farmer argued our world has more resources than at any point in history. Yet, tragically, over 100 million people die every decade because they lack access to basic medical care, what he often referred to as “stupid deaths.” There is no way, he said, that we stop this injustice without ensuring the poorest countries have more resources to build health systems. To do this, he argued in much of his writing—including the books “Fever, Feuds, and Diamonds” and “Pathologies of Power”—the global community must:

• Increase global health funding to close the financing gap for universal health care, at the same time ensure this funding is used to support local public health systems, train and pay doctors, nurses, community health workers, and ensure medicines are available to the global poor, and
• Stop the ongoing economic harms to poor countries that rob them of the resources they need to provide health care for their citizens, and redress past harms and legacies of the colonial and postcolonial eras.

As Farmer pointed out, poor countries have helped develop rich countries for hundreds of years, not the other way around. We must reverse this trend as a matter of justice, he said.

A fundamental problem in global health is the low aspirations of people in power, borne partly out of a misunderstanding of the causes of and solutions to global health inequity. Farmer termed these chronically low aspirations as being “socialized for scarcity on behalf of others.”

This resolution is the most serious effort Congress has made to address this problem, Curtain said.  

Paying for universal health care

The fundamental question addressed by the resolution is: why don’t poor countries have the resources to provide universal health care?

The resolution points out that the current global economic architecture siphons resources from poor countries to rich countries.

And that this is by design, from the colonial period to today’s governance structure of the WTO, IMF, and World Bank. The resolution states: “Many of the poorest developing countries presently lack the tax capacity to mobilize the necessary resources to close the universal health coverage financing gap, meaning unnecessary deaths will continue in these settings for the foreseeable future without external donor financing or dramatic increases in domestic tax capacity.” The spending gap to achieve essential universal health care in low- and lower-middle income countries,according to the Lancet Commission on Investing in Health, cited in the resolution, is around $350 billion per year (in 2016 U.S. dollars).

Experts estimate that conferring essential universal health care in these settings would end the vast majority of medically avoidable deaths globally, preventing approximately 100 million unnecessary deaths per decade. Ensuring universal health care and strong health systems would also further protect countries currently vulnerable to pandemics. While $350 billion seems like a large figure, it represents only 0.5% of the G20 GDP in 2021,and only 2.8% of the wealth possessed by billionaires in 2021. The problem, Curtain said, is not a lack of resources but a lack of ambition.

Contrary to popular belief, the U.S. has room to significantly increase development spending; the resolution proposes increasing global health spending from $11.4 to $125 billion annually, which could come through a number of different Congressional committees, proponents said. This spending would meet around 30% of the “essential universal health care” financing gap for low- and lower-middle income countries and allow the U.S. to meet the United Nations [UN] aid target of 0.7% gross national income for the first time.

Reimagining global health

The resolution argues we should reform global health delivery spending to make sure it funds public institutions in alignment with national health plans, not private contractors in the development industry.

The resolution also asserts that the government should fund areas seldom funded in global health, like the creation of hospitals and clinics, new medical and nursing schools, and the payment of existing clinicians. It also points out that medical technologies for diseases of poverty are rarely researched; and medical technologies are also priced out of reach for the global poor. One use of the $125 billion in spending, the resolution proposes, should also be to fund an ambitious research and development program that results in new technologies available as global public goods—not kept away from the global poor behind patents, trade secrets, and market forces.

As one undeniable case in point, the COVID-19 pandemic illustrated how high-income countries’ vaccine research and development policies failed to treat vaccines as a global public good, which led to an unnecessary scarcity of COVID-19 vaccine and left millions of people without access to lifesaving tools to prevent the virus’s spread.

Support the Resolution

Partners In Health established a $200 million scholarship fund that will support University of Global Health Equity (UGHE) students in Rwanda for more than two decades, launched by a transformative $50 million gift from the Bill & Melinda Gates Foundation that was announced on September 19 at the Clinton Global Initiative in New York.

During a recent visit to UGHE’s rural campus, Melinda French Gates, the foundation’s co-chair, was inspired by students, including Eden Gatesi, an aspiring cardiothoracic surgeon. Gatesi knows the importance of quality health care; she overcame malaria during her high school finals, and her mother was a nurse who worked long hours in an understaffed clinic in their community.

“UGHE has what [Eden] needs to learn to be a cardiothoracic surgeon,” French Gates said. “What I know and what I saw is that [Paul Farmer] and Partners In Health and UGHE are building a lasting legacy on the continent. It’s for a generation of doctors who will train a generation of doctors who will train a generation of doctors. That’s what global health equity looks like.”

The scholarship fund is dedicated entirely to students attending UGHE in Rwanda. The fund, structured as an annuity, will cover the tuition, room, board, and expenses of 3,000 medical students and global health delivery master’s degree candidates over the next 25 years. The Gates Foundation is joined by the Rockefeller Foundation, the Child Relief International Foundation, and other philanthropists as early investors in the fund.

Named after the late Dr. Paul Farmer, Partners In Health’s (PIH) co-founder and chief strategist, the scholarship is dedicated to an initiative he cherished. Farmer cared deeply about UGHE and what it meant for training the next generation of global health professionals. He knew high-quality health care can only exist in tandem with high-quality medical education. This advancement of Farmer’s dream will ensure UGHE can continue to provide a top-tier health sciences education for students, who will become clinical leaders in their own right and go on to serve the most vulnerable in their communities.

“Turning early dreams of UGHE into reality has been intense and remarkable and deeply satisfying,” said Dr. Agnes Binagwaho, UGHE’s vice chancellor, who later participated in a panel discussion with French Gates, moderated by former Secretary of State Hillary Clinton. “Seeing our seventh cohort of master students in caps and gowns this summer was very exciting and knowing that, thanks in part to this fund, the university will continue for decades to graduate passionate, principled, world-class health leaders the world needs is even more exciting.”

History of University of Global Health Equity

UGHE is a PIH-led initiative which launched in 2015 with the support of the Bill & Melinda Gates Foundation, the Cummings Foundation, and the Government of Rwanda. The university is located in rural Burera District, about 80 miles north of Kigali, the country’s capital. Two miles down the road and perched on the opposite hillside is PIH-supported Butaro District Hospital, where UGHE students perform their clinical rotations. 

UGHE’s goal is to educate future health care providers and leaders who will ensure the delivery of more equitable, quality health services for all. To achieve this, UGHE provides equity-based medical training with a multidisciplinary approach to prepare students to work in vulnerable communities. The highly competitive programs—which have a 6% acceptance rate—include two degrees: a master’s in global health delivery (MGHD) and the MGHD combined with a bachelor’s degree in medicine and surgery (MBBS). Degree candidates come from 23 countries in Africa and around the globe, all receive need- and merit-based grants, and a majority of graduates are female. In 2025, the inaugural class of MBBS/MGHD students will graduate from the 6 1/2-year program. 

The Paul E. Farmer Scholarship Fund will help prepare UGHE students for lifetime learning, innovation, leadership, and research without worrying about the burden of financial barriers. UGHE’s innovative and equitable approach to health education is radically changing the way health care is delivered–in Africa and beyond.  

Before announcement of the fund, Didi Bertrand Farmer, who leads the Women & Girls Initiative and is Farmer’s widow, shared gratitude to the Clinton Global Initiative for honoring her husband and noted that UGHE students are continuing his dream of delivering high-quality health care everywhere to everyone who needs it.

Over the course of their years together, Bertrand Farmer said, “he often made impossible promises but always, always delivered on them.”

Dr. Zulema García and Dr. Azucena Espinosa have been pediatricians with Partners In Health since April. But their history in Chiapas dates back many years.

Espinosa arrived in the rural, coffee-growing Sierra Madre region in 2014, as a first-year clinician with Partners In Health, known locally as Compañeros En Salud—a year she describes as "the best year of my life."

Each year, Compañeros En Salud hosts 10 first-year clinicians, called pasantes, who complete their mandatory year of social service in rural communities where the health system has historically lacked the staff and resources to deliver quality care. Compañeros En Salud has worked in Mexico since 2011, serving nine rural communities in the Sierra Madre region, in partnership with the Ministry of Health.

After completing her year of service, Espinosa stayed with Compañeros En Salud as a coordinator for the Right to Health program. As she helped patient after patient access advanced medical care, as well as connecting them with food, housing, and transportation, she noticed a troubling reality: there were no pediatricians in the region.

Children in need of advanced care had to travel to cities hours away—journeys that many patients in the rural communities couldn’t afford.

In Mexico, medical specialists like pediatricians are often based in large cities like Mexico City, Monterrey or Guadalajara, where more advanced infrastructure and health systems allow patients greater access to care. But in states like Chiapas, one of the poorest in the country, the reality is different.

Chiapas has the lowest rate of medical specialists in Mexico, with just 35.9 per 100,000 residents, compared to Mexico City’s 505.7. To make matters more complex, there is only one public hospital in the entire state for pediatric care, located in the capital, Tuxtla Gutiérrez. Anyone outside of Tuxtla Gutiérrez in need of these services would have to travel for hours or turn to the private health system—too expensive for most patients to afford.  

That reality compelled Espinosa to pursue a specialty in pediatrics. Now, three years later, she has returned to Chiapas with Compañeros En Salud. And she was not alone.

García also began her time in Chiapas as a pasante, assigned to serve the rural community of Capitán Luis A. Vidal. She, too, stayed after her year of service, becoming a coordinator for Compañeros En Salud’s community health worker program. Compañeros En Salud’s 106 community health workers, called accompañantes, conduct door-to-door outreach in the rural communities, visiting patients and their families at home and connecting them with care.

García saw first-hand the power of community in strengthening health systems from the ground up—and the unmet need. She decided to return to school to study pediatric care. The journey led her back to Chiapas.

"I was motivated to return by the fact that I could bring a specialized service closer to the population and that they would no longer have to travel for more than three hours to reach a specialist," she says.

Now, both Espinosa and García are developing a work plan in collaboration with the basic community hospital in Jaltenango and the Ministry of Health. That plan includes training nursing staff in pediatric care, since this team is a cornerstone of care for patients in the region. Another goal is to decentralize information among health personnel and reduce gaps in patient care.

The plan has been progressing, with 20 health workers trained so far. Still, providing pediatric care in a rural area comes with many challenges, from navigating an under-resourced hospital to considering how poverty can affect a child's recovery, such preventing families from attending follow-up appointments.

But the program is already having a massive impact, in a region where there were once no pediatricians.

"Parents come up to us and tell us that in other times and in other circumstances they would not have had any option to treat their children," says García.

For Espinosa, the reward is also the sense of community at Compañeros En Salud, from staff to patients.

"It's like a family that shares the same vision, the same passion as you, and doesn't abandon you,” she says. “This is a constant reminder of why I'm here."

Electricity is non-negotiable. Yet it is simply not a reality at health centers, clinics, and hospitals around the world for a variety of reasons, principally due to years of disinvestment in local health systems scarred by war, epidemics, colonial mismanagement, and unjust global policy and financing.  

Liberia knew this reality well. When Partners In Health was invited by the national government to help respond to the Ebola outbreak in 2014, electricity at health facilities, such as J.J. Dossen Memorial Hospital in southeastern Maryland County, was unreliable. 

“J.J. Dossen had a serious power problem because all the electrical grids were very old and could not really function. There were always power outages, fluctuations of power, lots of wires getting burnt, and [electrical] shocks,” explains Eugene Cheebo, PIH Liberia’s head of maintenance. “PIH saw the need to upgrade the electrical system and now we are not having any [of those] problems at the hospital.” 

Since work began, infrastructural upgrades made by PIH and the county health team have protected against fires from corroded wires and reduced the number of patient deaths. The facility’s improved electrical capacity is allowing for better care as lifesaving procedures continue without clinicians and staff being concerned about supply.   

“Those improvements, among others made over the last several years, have had a direct impact on patients. Most notably, the death rate at the hospital has improved, according to data from the District Health Information System at the Ministry of Health, from 138 in 2016 to 73 in 2021,” says Maryland County Health Officer Dr. Methodius George.  

A Look Back

The hospital has struggled to keep the power on since its inauguration in 1960. The national grid, responsible for powering the facility, was destroyed during the first Liberian Civil War in 1990, cutting off all electrical supply. The hospital relied on a 30 kilovolt (kV) generator donated by humanitarian agencies to power the facility; but it was not strong enough to meet demand and was a major strain on the hospital’s overstretched budget. 

As George explains: “We did not have room in the budget to run a generator, so the generator was run for about four hours during the day and turned back on during the night. It was on longer during the day in extreme cases when we had emergencies that needed to be treated with electricity, especially our cesarean sections.”  

Fortunately, in 2015, Maryland County was connected to the West Africa Power Pool, which provides electricity for the hospital and some local communities. Although the power from the West Africa Power Pool has improved the situation, it has been sporadic and unreliable. The supply comes from neighboring Ivory Coast; when there are disruptions in this neighboring country, there is no local supply to tap into.

PIH added a 45 kV generator in 2016 in response to this need. Yet power from the two generators combined could only provide electricity for critical sections of the hospital, such as the operating rooms and emergency ward.  

And there was another issue at hand. J. J. Dossen Memorial Hospital’s transformer was not powerful enough to regulate the increased electrical capacity, and it frequently malfunctioned. The two problems needed to be addressed simultaneously; the power supply had to be increased to meet demand, and the hospital required a transformer big enough to regulate that increased flow of electricity. 

"The team is prepared"

With support from the Ministry of Health, J.J. Dossen Hospital acquired a 165 kV generator in 2018, but lacked funding to operate and maintain it. After consulting with the county health team in 2021, PIH offered to take on the responsibility of operating the generator to provide consistent electricity for health care delivery and the hospital’s operations. This required replacement of the old transformer with a 250 kV transformer—one with enough capacity to handle the increased flow of electricity—and total re-wiring of the facility to extend electricity supply to a long list of locations throughout and around the hospital: the surgical theater, pharmacy, eye clinic, county tuberculosis unit, pediatric unit, obstetrics and medical wards, electrical control, X-ray room, and laboratory. 

“The new generator is expected to support the facility for a few years and will continue to greatly improve patient care,” says George. “If a problem arises, the team is prepared. All technicians were trained by PIH on how to quickly and efficiently troubleshoot electrical problems by going directly to the source rather than shutting down the entire compound.” 

In the future, PIH and the Ministry of Health plan to install a more powerful transformer to further improve and support the hospital’s electrical need. Ultimately, they’d like to invest in solar power, as it’s the most cost-effective and convenient option. 

Running facilities on solar power would ultimately be good for the environment, and good for the hospital’s hometown of Harper—known locally as “the land of sunshine and happiness.”   

Originally from California, Yesenia Cuello moved to North Carolina with her family when she was five years old. As a child, she and her sisters joined their mother in the tobacco fields, harvesting leaves for up to 12 hours a day in the summer heat. This experience inspired her to speak up about the realities of working in the field.

Yesenia began fighting for agricultural worker protections as a teen when she joined Poder Juvenil Campesino, a youth group that empowers young adults to advocate for immigration reform and fair labor laws. Her time as an organizer took her from the state capital to the nation's capital, and, in 2019, Yesenia became the executive director of NC Field, a community-based organization  that supports North Carolina’s farmworker community and a partner to PIH-US, the U.S. arm of Partners In Health focused on accompanying local leaders to build strong, community-led health systems. From directly providing services that educate, build power, and address immediate social determinants of health to empowering farmworkers to pursue educational and economic opportunities and raising awareness about the injustices behind the industrial agricultural system, NC FIELD is working to ensure that seasonal and migrant workers and their families are protected and have access to opportunities beyond the agricultural industry.

Under Yesenia’s leadership, NC FIELD has grown to seven employees, added workers from the farmworker community to support interpretation and outreach, and increased its foundational support. When COVID-19 hit, NC FIELD expanded its work, offering material support to agricultural communities and setting up testing and vaccination clinics where farmworkers live, buy food, and worship. Throughout the pandemic, PIH-US has supported NC FIELD through grant writing, professional development, and data management.

Below, we talk with Yesenia about NC Field’s COVID-19 response and the challenges farmworkers in North Carolina continue to face.

What inspired you to get involved in farmworker justice? 

I was first introduced to the agriculture industry through my mom. Growing up, she worked on hog farms and then tobacco farms. One summer my sisters and I begged my mom to join her in the fields. Considering we had never worked a day in our lives, it took some convincing. She thought we would want to quit after one day––but we worked in the fields every summer for four years.

My sisters and I have always looked up to our mom. She is a single parent, passionate about those around her, and extremely independent. In our eyes, our mom was who we aspired to be. Her activist nature and the experiences of my community led me to speak up about the issues that farmworkers face.

Can you share more about NC Field’s efforts to empower the farmworker community?

In Eastern North Carolina, where NC Field is based, there are many large tobacco farms and crops such as sweet potatoes, cucumbers, and watermelon. These farms run almost entirely on the labor of farmworkers. We consider seasonal farmworkers among the most vulnerable and poverty-stricken of all farmworkers. They are a priority population for NC FIELD. Farmworkers are often exploited and suffer from malnutrition and food scarcity due to poor wages, lack of work, transportation difficulties, and rural isolation.

Empowerment is only possible when basic needs are met. At NC Field we are addressing the social barriers that keep farmworkers and their families from thriving: access to food, clothing, and health care. Not only do we go into the community and listen to the needs of workers, but we also have agricultural workers coming to us asking to volunteer and attend trainings and connecting us to vulnerable farmworkers and families that they know of.

How has your work pivoted throughout COVID-19?

NC Field is a direct reflection of the community that we serve. We listen to what the community tells us they need and adapt our work from there. To address barriers that prevented agricultural workers from getting tested or vaccinated, we set up clinics outside of typical working hours. We also went door-to-door delivering education in vulnerable communities—often in the dark, rain, and cold. These one-on-one conversations were especially important to improve vaccination rates. We found that many communities were not using reliable sources of information about vaccines, so we had to do a lot of education around the benefits of vaccination. Stepping in to support the COVID-19 response sidelined NC Field’s capacity building plans, including occupational health training and English and cultural education for the agricultural workforce, as well as our youth programming. Despite this unexpected shift, we would not have been able to accomplish all that we did without the help of the seasonal and migrant workforce. They were invaluable in helping us locate spaces for testing and vaccines, as well as helping us identify trusted messengers for community outreach.

What are the biggest challenges facing NC Field and the farmworker community as we enter year three of the pandemic?

For NC Field, it is financial sustainability. We are now providing all types of services that farmworkers have come to rely on––from vaccines and health care, to access to food and clothing. It has been hard to look beyond COVID-19, beyond a temporary response team. We want to be able to establish long-term infrastructure and provide job security for our staff.

For the farmworker community, transportation and access to health care remain big issues. We are working with partners to expand the days and hours that health centers are open, as well as the services they provide. Having health education, news, and other critical information accessible in a variety of languages is also important. Many parents rely on their children to translate. It is unrealistic to expect children to accurately process and relay the type of information they are being called upon to support with. And honestly, it's just not fair.

How can we continue to build power in the agricultural worker community?

We need to keep the focus on vulnerable groups at the state and federal levels so that we don’t return to the period of anonymity and invisibility that farmworkers had before the pandemic.

Because of the partnerships we have built over the last few years, NC Field is sitting at tables where, historically, we've never been. In many of these conversations I am the only person who is a current or former farmworker. This isn’t enough. We need to push for adequate representation at these tables. Afterall, who better to share the realities of issues impacting the agricultural workers than the communities themselves?

My hope is that generations of child farmer workers and their families have the same opportunities that I had.

What makes you hopeful about the future?

Education, information, and advancement opportunities all give me hope. We’ve lost so much in my community. So many of us can’t legally drive to work, but we are harvesting this nation’s food supply; we struggle to access doctors and surgeries. Some of us are guest workers and live in housing that can’t be reached by first responders.  There is a lot wrong. Despite all of this, I see smiles and helping hands at every food distribution event, at every clinic, and as people are picked up and dropped off at appointments or the grocery store. I see hope. We are given hugs, and thanked for the medicine we delivered, the donated mattresses, and the driver’s license manuals we printed off in Spanish. We have learned to endure as resources arrive that teach us how to navigate languages, culture, and systems. I am hopeful because my community is strong, and we will persevere until we are truly equal—and then we will thrive. 

Oxygen is one of many critical building blocks of a functional and equitable health system—like running water and 24-hour power. Yet most medical facilities in low- and middle-income countries lack access to this crucial resource.

Effective treatment with medical oxygen requires the right amount at the right time, with close to zero margin for error—oxygen shortages lasting just 30 minutes can be catastrophic. Oxygen insecurity means that all it takes is a power outage, mechanical failure, or surge in patients for oxygen supplies to run out. 

Although this sounds complex and challenging, there is a solution: investing in the “five S’s”—the staff, stuff, space, systems, and social support needed for strong health systems. These investments save lives. For example, building and strengthening oxygen services for children under 5-years-old with pneumonia reduces the odds of disease-specific mortality by an estimated 46%. But the impact of improving oxygen systems extends beyond any single disease. It is also associated with a 40% decrease in the odds of death for all children in the hospital.

The global oxygen crisis must be addressed. While the COVID-19 pandemic highlighted regional disparities in oxygen access, it has been a longstanding issue. Before the pandemic, 9 in 10 hospitals in low- and middle-income countries lacked access to oxygen therapy.

To accelerate efforts to overcome oxygen-related barriers and in partnership with funder Unitaid, Partners In Health (PIH) launched BRINGO2, a yearlong oxygen systems strengthening initiative in Peru, Malawi, Lesotho, Rwanda, and Madagascar. BRINGO2 is helping fight the global oxygen crisis by supporting the repair and maintenance of piping systems and cylinders, training technical and clinical staff, and planning long-term oxygen distribution networks, among other efforts. So far, significant improvements have been made across countries: a high-tech remote monitoring system was installed at the Botsabelo pressure swing adsorption (PSA) plant in Lesotho, biomedical technicians repaired 76 oxygen concentrators in Malawi and are actively repairing 20 PSA plants in Peru, and a new PSA plant is being installed at Butaro District Hospital in Rwanda.

LEARN MORE

The comprehensive initiative involves every aspect of oxygen’s complex journey. In the infographic below, learn how oxygen makes its way–from production to bedside–to those who need it most.

Hugs and kisses weren’t always part of Carmen Dávalos' daily routine with her daughter. But now, the 35-year-old mother takes every opportunity she can to shower her daughter, Yeretzy, with affection.

No one had ever taught Dávalos, who had her first child at 18 years old, the importance of showing affection in a child’s development. It was a lesson she learned from Socios En Salud, as Partners In Heath is known in Peru, as part of the CASITA program.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the years since, it has expanded its work to provide medical care and social support to hundreds of thousands of patients in Lima and beyond.

Since 2013, Socios En Salud has supported children and caregivers through CASITA—a three-month program that identifies children ages 6 to 24 months who are at risk of developmental delays and helps them learn skills through play.

CASITA has enrolled 3,648 children and screened 6,795 since it began in Carabayllo, a district in northern Lima where high rates of poverty and domestic violence put children and their health at risk. Eighty-five percent of children showed improvement during the pilot program, which supported 180 families from 2013 to 2016.

Dávalos heard about CASITA last year, as she received follow-up care at La Flor clinic through Socios En Salud’s support. Staff had observed that Yeretzy, then a little over a year old, was very shy, fearful of others, and lacked the social, motor, and coordination skills of most children her age. They encouraged Dávalos to fill out a screening questionnaire for the CASITA program via chatbot.

Just a few days later, María Berrocal, one of 262 community health workers hired and trained by Socios En Salud, visited Dávalos and her daughter at home to carry out an evaluation, using games such as building a tower of cubes and playing with puppets to assess Yeretzy’s skills. Berrocal determined Yeretzy was eligible for the program and helped Dávalos join a WhatsApp group for caregivers.

Then the classes began.

Each week, Dávalos and other caregivers in the program received a recorded lesson to review and practice with their children at home. The classes covered a range of topics—motor skills, coordination, social skills—and incorporated games like hide-and-seek and toys made from household items. Dávalos completed the lessons with Yeretzy, often with the help of her husband and three other children.

With each lesson, Dávalos watched her daughter grow her skills and confidence. Yeretzy learned to tear sheets of paper. She built a tower of cubes and organized the pieces according to size. She imitated the sounds and actions of her mother.

Dávalos shared photos and videos with the WhatsApp group to document Yeretzy’s progress and receive feedback.

“Every week, we could see how she progressed,” says Berrocal.

Yeretzy wasn’t the only one learning.

“It has taught me a lot,” says Dávalos. “Hugs and kisses and caresses should never be missing. We must always show them without shame and attend to [our children's] needs.”

She began to sing for her daughter—something she had once been too embarrassed to do.

“Seeing the mothers in the WhatsApp group singing to their children…motivated me to do it,” she says. “I managed to sing in my house in front of my whole family, without problems or embarrassment.”

She hadn’t always felt so free.

Her pregnancy with Yeretzy began in December 2019, just months before COVID-19 sent the nation into four months of lockdown. She caught the virus in June, six months pregnant and unvaccinated, isolating her at home and sending her into a deep depression.

During that time, Socios En Salud continued to provide maternal health care, monitoring her pregnancy virtually, and connected her with mental health care, including therapy. That support came as a lifeline for Dávalos—and it continued after her daughter was born.

Early detection of developmental delays is crucial in helping children access the care and support they need to become healthy, independent adults. But the pandemic, marked by quarantine, social distancing and disruptions in care, complicated efforts to identify at-risk children, even as it hamstrung their development.

Only 28% of children under 36 months are up to date on their growth and development checks due to the pandemic, according to Peru’s Ministry of Health. More than half of children between 9 and 12 months old have not developed an adequate bond of trust, security, and emotional stability with their mothers.

Lesson by lesson, Dávalos was determined to defy those odds.

“Every week, with each game, I was able to connect with my daughter,” she says.

Now, Yeretzy is no longer scared. She smiles at strangers. She laughs and poses for the camera. In Berrocal’s words: “She is pure joy.”

Dávalos has only to look at her daughter’s face to see the difference.

“She is everything to me,” she says. “Seeing her now, as a happy and fulfilled child, is what fills my heart the most.”

The Inflation Reduction Act might not sound like legislation that has anything to do with health equity or addressing disparities in the United States. The name suggests that it will handle the costs of groceries and gasoline. But it goes much further by helping make health care more affordable for millions of people. This legislation, however, did not come to pass easily, and Partners In Health has been tracking it and supporting parts of the bill for nearly a year.  

In late 2021, the U.S. Senate failed to pass the Build Back Better Act (BBBA), the $1.75 trillion package that would have transformed health equity, green energy infrastructure, and U.S. health care, after the sweeping bill had passed the U.S. House of Representatives. This was a disappointing turn, as PIH supported the BBBA due to its inclusion of funding for maternal health, community health workers, and coverage for low-income families.  

Senators continued to negotiate a smaller version of the BBBA with the hopes of reaching an agreement on the pieces that could garner enough support to pass. In July, they announced an agreement on the newly dubbed Inflation Reduction Act.  The bill quickly passed the Senate on August 7 by a vote of 51-50 (with Vice President Kamala Harris breaking the tie) and the House on August 12 by a vote of 220-207, before being signed into law by President Jospeh Biden on Tuesday.  

Below, PIH-US Advocacy Manager Lucas Allen and PIH-US Advocacy Lead Justin Mendoza explain what there is to be excited about with the passage of the Inflation Reduction Act, who will benefit, and why it falls short in the battle for health care equity.  

What does the Inflation Reduction Act include? 

• Health insurance premium support: Through the American Rescue Plan Act of 2021, Congress enhanced the Affordable Care Act’s premium tax credits so that more people could obtain affordable coverage. Those tax credits lowered monthly costs for people who purchase their insurance from a private market place. Set to expire at the end of this year, it was critical to include the premium tax credits in the Inflation Reduction Act or millions would face increased health insurance costs and potentially lose coverage. The legislation extends these enhanced credits through 2025. 
• Lower-cost prescriptions: The Inflation Reduction Act will require Medicare to negotiate the prices of certain prescription drugs starting in 2026. It also caps out-of-pocket drug costs for people enrolled in Medicare and penalizes drug companies if they increase Medicare drug prices faster than the rate of inflation. For millions of people in the U.S., this policy will mean being able to afford their prescriptions, and for the U.S. itself it means working to rein in high and rising prescription drug costs. This is historic, since Medicare negotiation has been out of reach for the past 18 years.  
• Investments to address climate change: The Inflation Reduction Act includes $369 billion to reduce greenhouse gas emissions that contribute to climate change and related health impacts. This is the biggest investment in combatting climate change in U.S. history. 
• No anti-migrant amendments: PIH leaders have been advocating forcefully against Title 42, an unjustified and racist policy that uses public health and the COVID-19 pandemic as a pretext to block asylum-seekers from entering the U.S. Two amendments were proposed to the Inflation Reduction Act that would have further extended Title 42. Before the votes, PIH reached out to urge senators not to support such amendments, both were narrowly defeated, and the final bill did not include any anti-migrant policies. 

Who benefits most from passage of the bill? 

Right now, 14.5 million people in the U.S. get their health care from their state or federal health insurance marketplace. For millions of lower-to-middle income families or individuals, this policy will keep their current health insurance affordable. The health care credits also make insurance more accessible for Black and Latinx communities. Since these credits have been in effect, Black and Hispanic enrollment saw an increase in number of people willing to enroll in health insurance as compared to previous years. Maintaining these credits will be a big boost toward continuing to close the gap in health coverage and access to care. 

A senior citizen enrolled in Medicare will see relief in drug costs once Medicare has the ability to negotiate down the costs of high-priced drugs. A Medicare beneficiary who spent a significant portion of their income on prescription drugs will have their out-of-pocket costs capped at $2,000 per year. Today, more than half of seniors aged 65 or older take at least four prescription drugs, and nearly 1 in 4 of those seniors say it is difficult to afford their prescriptions. Particularly hard hit are low-income seniors and those who are in poorer health. This policy will save most of these seniors hundreds or thousands of dollars per year.  

The bill’s historic investments in addressing climate change will benefit the health and well-being of all who face risks from the climate crisis. By putting the U.S. on a path to reducing greenhouse gas emissions by 40% by 2030, this legislation is a step toward reducing the health impacts of climate change, which fall disproportionately on communities that have been historically marginalized.  

Where does the Inflation Reduction Act fall short?  

The Inflation Reduction Act is a compromise, and it does fall short in areas that PIH fully supports. We strongly encourage congressional leaders to take up these priorities as soon as possible to focus on health equity in the United States. 

• Closing the Medicaid coverage gap: The Inflation Reduction Act left out a provision that would have provided health coverage to low-income adults in states that have not expanded Medicaid,  a state and federal shared insurance program that provides health care coverage to low-income families. This would have provided health insurance to an estimated 2.2 million adults whose income is too low to be eligible for Affordable Care Act subsidies. 
• Maternal health: The Build Back Better Act also included policies to address the maternal health crisis, which disproportionately affects Black women. It would have required all states to extend Medicaid coverage to 12 months postpartum, which is currently optional, and it would have provided funding for Black maternal health across multiple agencies in the federal government. The bill did not include these provisions, leaving a gap in maternal health. 
• Child and family supports: Previous legislation, the American Rescue Plan Act, included a child tax credit that temporarily reduced child poverty by about half in the United States. In addition the BBBA included support and investments for child care. This bill did not include either of these provisions, leaving low-income children and families without essential evidence-based support. 
• Public health infrastructure: The Inflation Reduction Act also missed an opportunity to invest in the U.S.’s public health infrastructure and workforce to better address COVID-19, monkeypox, future outbreaks, and other health needs. Despite previous efforts in the American Rescue Plan Act and other COVID-19 relief legislation, public health resources for pandemic response are a far cry from what is needed to deliver an equitable public health system. 

While it is disappointing that these critical priorities were left out, the Inflation Reduction Act makes important investments in health and climate that will make a significant difference in people’s lives. Congress still has work to do to meet these critical needs for health equity, and PIH will continue to push for our health equity priorities. 

One year ago, a 7.2-magnitude earthquake struck 80 miles west of the capital of Port-au-Prince, Haiti, leaving more than 2,200 people dead, 1,800 injured, and hundreds of families displaced. Authorities reported that 97 health centers and 1,250 schools were damaged or destroyed in the powerful quake, which had an epicenter near the cities of Les Cayes and Jérémie.

Zanmi Lasante, Partners In Health’s sister organization in Haiti, does not work in the region, but partners in the Ministry of Public Health and Population and non-government organizations in the South reached out to ask for assistance in launching a comprehensive emergency response, knowing Zanmi Lasante's depth of experience in critical care and effective response to the 2010 earthquake. Together, they provided direct care and support in the region, triaged complicated cases to neighboring hospitals, and, in some cases, airlifted patients to Zanmi Lasante’s Hôpital Universitaire de Mirebalais (HUM).

Unlike the devastating earthquake of 2010, the vast majority of first responders and clinicians in the 2021 response were Haitian—including graduates of HUM.

Emergency Response

Over the past year, Zanmi Lasante has:

• triaged and treated 67,658 patients from the earthquake zone with severe conditions, including those requiring orthopedic surgery, at HUM
• served 36,825 patients through multiple mobile clinics staffed by physicians, nurses, medical residents, and psychologists
• provided 3,113 survivors with psychosocial assistance, including food, hygiene products, and school materials
• sent 209 medical items and equipment, including portable ultrasound machines, to support hospitals in the South

This was all done despite significant challenges: gang violence prevented regular travel along a major route between the capital and the southern peninsula, gas shortages forced rationing across the 16 public health facilities supported by Zanmi Lasante, and COVID-19’s spread remained a concern nationwide.

Building Health Systems

As weeks turned to months, Zanmi Lasante and partners shifted from emergency response to medium- and long-term planning that focused on reinforcing the public health system—both at facilities supported by Zanmi Lasante and in the South—so that the next disaster might have less of an impact.

Within that stream of work, Zanmi Lasante has been supporting the construction of a surveillance lab and emergency ward at Hôpital Saint-Nicolas in Saint-Marc and reinforcing emergency and trauma staffing to respond to growing need for these services in the lower Artibonite region. The team is also making targeted improvements to water, sanitation, and hygiene infrastructure within all 16 of its supported health facilities—key to preventing water-borne illnesses that often come in the wake of natural disasters, such as hurricanes and floods.

Meanwhile, in the South, Zanmi Lasante teams continue to provide essential medical supplies and equipment across the earthquake-impacted regions, while also supporting the construction of three permanent health centers.

Focus on Medical Education

Last August’s earthquake highlighted the need to develop more opportunities for specialized training in Haiti, especially orthopedic and emergency residency programs for clinical nurses. Zanmi Lasante leaders are now mapping out curricula for these programs, which they plan to launch in October at health facilities in Saint-Marc and Mirebalais.

Eventually, these residencies will add to a suite of options available at Zanmi Lasante-supported facilities, including HUM, which received international accreditation in January 2020 for meeting the highest global standards as a teaching institution.

Since 2012, HUM’s medical education program has trained 152 Haitian clinicians across specialties, including family medicine, pediatrics, internal medicine, nurse anesthesia, surgery, emergency medicine, and OBGYN. HUM also offers fellowships in neurology, plastic surgery, and emergency sonography.

Of those graduates, 98% currently work in Haiti, with 88% working in PIH-supported or other rural health facilities.

Dr. Marta Lado still remembers the early days of the Ebola outbreak in Sierra Leone—how patients needlessly died of the disease and suffered stigma, discrimination, and lack of access to lifesaving medical care. Now, the infectious disease specialist is watching some of those same patterns repeat with monkeypox.

While not usually fatal, monkeypox has led to more than 28,000 cases worldwide. Typically confined to West and Central Africa, the disease has since spread to 81 countries where it was not historically detected. Monkeypox is known for painful lesions and rashes and is usually spread through skin-to-skin contact.

PIH has responded to infectious diseases for decades, from HIV to Ebola to COVID-19. Lado is no stranger to outbreaks either.

Now PIH’s cross-site clinical advisor, Lado was formerly chief medical officer with PIH Sierra Leone, where she helped lead the response to Ebola in 2014 and was integral to caring for patients, fighting stigma, and building up the health system in the years that followed. Lado has also brought her expertise to the World Health Organization as a case management expert and in 2019 authored Ebola Virus Disease: A Manual for EVD Management.

Drawing on her years of experience fighting infectious diseases, Lado shares her insights on monkeypox—and what must be done.

Monkeypox isn't a new disease. It's been around since the 1970s. What’s so alarming to you about this current outbreak? What are we seeing that we haven't seen before?

There are two main points that we should be bringing up. One is we have had reports of monkeypox in several Central African and West African countries since the 1970s, and it was more localized in those regions. This is the first time that we are seeing very intense, rapid community transmission in countries that normally had never been affected by this.

This is exactly what global health implies: it's not like this disease is happening in one region and it's not going to affect me at any point. With Ebola, with COVID, and other things, we are seeing that this idea of creating regions to divide diseases is not valid anymore. We are living with globalization in terms of movement of people and this is also going to affect health.

The second point is that the clinical presentation that we are seeing right now is a different from what we historically saw in Central and West African countries. Normally, in these endemic countries there were symptoms like fever, weakness, headache, myalgia, and then one rash that started in the face and went to the trunk. [The virus] disseminated quite fast and in certain populations like children and the immunosuppressed.

This was the picture that we had of monkeypox until now. Now, in the outbreak that started in Europe and disseminated everywhere, what we are seeing are symptoms more localized in one region [of the body]. So that's why we are seeing a lot of infections that happen in the context of sexual contact or very close contact. We’re seeing lesions in the parts of the body that have been in close contact with the person who was infected.

PIH has responded to many pandemics and epidemics around the world, and monkeypox is just the latest virus to capture global attention. What are some of the lessons learned from our past responses that could be relevant and useful now?

There are two main outbreaks that we worked on—one was Ebola. What we can learn from our Ebola experience is that the work to prepare and respond to any kind of health emergency like this is based on comprehensive work between different teams. We need to be focusing our attention on surveillance—being able to identify potential cases and doing contact tracing and follow-up. We also need to focus on diagnosis. We have learned a lot [from Ebola] about how to do testing. Then there’s case management. We have learned quite a lot about how to manage diseases that develop complications and how to care for patients who develop shock, multiple-organ failure, superinfections, etc.

Then lastly, community engagement. We have been extremely good in our Ebola work at sending messages to the community and receiving feedback, as well as reducing the stigma against Ebola survivors. So these four main pillars are extremely important: contact tracing, testing and laboratory capacity, case management, and community engagement.

With COVID, our work [across these four pillars] has excelled even more. Paul was always repeating that we need to be able to deliver the same standard of care in low-income countries and high-income countries. If a patient is in a critical condition, we need to be able to strengthen the [health] systems to manage them. With monkeypox, a very small amount of patients get very sick. It's not as much as in COVID and even much, much less than Ebola. But it's still killing quite a lot of people in African countries.

Diseases like monkeypox have affected impoverished countries for years, even decades, with hardly any attention from the West. What do you make of this sudden urgency around monkeypox? How does global injustice factor in?

We are now living in a moment of great awareness of infectious diseases. We have information in real time about what is happening in different countries—like whenever you have a cluster of cases in this country, you are able to receive information about what is going on in neighboring countries or even very remote countries. I think it’s a positive thing, because it means that we are creating more surveillance and more detection.

But as a global health specialist, I strongly think that we also need to start involving more countries that have been suffering these diseases for longer periods, but didn't have strong scientific communities or health care systems to deal with them in the same way as high-income countries. Monkeypox has been not only a threat but a reality for many countries—people getting sick and dying and vaccination programs and treatments and everything being delayed. When it started happening in high-income countries, everything got triggered and now it's a big thing and everything is accelerated.

I tend to look at the positive side, which is: let's use this as an opportunity to advocate for the development of all these different elements, like surveillance and treatment and community engagement, so we can extend them to other countries that don't have as strong of health care systems. The more we improve our laboratory and surveillance capacity, the more we will start seeing more cases in low-income countries. We will need to have all these things ready to be able to help them deal with it.

With diseases that are spreading globally like this, we’ve often seen marginalized communities blamed and stigmatized. We saw this with HIV/AIDS, Ebola, and COVID-19. We’ve seen this same trend start to happen with monkeypox. How do we spread awareness about this disease while also fighting against stigma and discrimination?

One of the things we need to acknowledge is that the first cluster of cases started in one specific community—gay and bisexual men. This is quite tricky because it can lead to stigmatization and to associating the disease with this population. We have a bunch of cases in this community, but there is no clear evidence that it can only affect this population. The spread in this community has been very fast and the infection rate has been quite high in terms of number of contacts. But we don't have any evidence to think that this cannot go to other populations, like children, pregnant women, patients with chronic diseases, etc.

We need to be very careful with how we are communicating about this monkeypox outbreak, because it's very easy to repeat the mistakes that we made when HIV emerged in the ‘90s. Now, we all know that HIV can affect anyone; it's not related to your sexual preference. It’s more related to some kind of sexual contact. We know that monkeypox is transmitted by close contact. But it could also be transmitted by droplets—it could stay in the air and be inhaled. This is not only a sexually transmitted infection. It is an infection that is transmitted face-to-face and skin-to-skin and needs to be taken as that.

PIH has been calling for vaccine equity for decades for many different diseases and conditions. How is the issue of vaccine equity showing up with monkeypox?

The vaccines that are available for monkeypox were actually created for smallpox. After the eradication of smallpox in 1980, the quantities produced were quite small because the idea was that there could be some kind of bioterrorism threat. So those vaccines were produced, but with the idea of keeping them within the government. The thing is, smallpox and monkeypox are very similar. They belong to the same family, and the smallpox vaccine has around 85% efficacy against monkeypox.

Scaling up production of these vaccines may take time. It’s important to engage in advocacy. Vaccine production is not only about the current outbreak. There are several countries that have cases on an annual basis, and we need to produce more vaccines to be able to control the rate of infections.

In terms of equity, we’re in a moment where we have only a small amount. So we need to select which populations to prioritize. The populations that were prioritized historically were health care workers. But now, in the current outbreak, there is general concern and calls for advocacy to create more vaccines. Right now, we have one specific group with the infection, but the moment it starts spreading to other groups, we are going to need more vaccines. So our advocacy needs to go for increasing the production to be able to cover as many groups as possible.

Right now, the global conversation around monkeypox seems to be focused on vaccines or educating the public. How do you see the global response to this developing—what's the next chapter, and how do you see PIH being part of that?

Right now, the response is focused on specific countries and on a specific population. But we forecast that this may start affecting different populations and spreading more widely. It will be important to get clear guidance on who to vaccinate, who to treat, and what drugs to use for both, as well as to have these treatments accessible to all for free.

The way that I see PIH working is in advocating for equity and communicating that this is an infectious disease that could affect anyone. Right now, it's in a specific group, but it could extend to other groups very soon. So we need to increase awareness and continue advocating for surveillance, testing and laboratory capacity, case management, and community engagement. Also, as an organization that works mainly in low-income countries, we need to raise our voice even more to ensure that there is equitable access to medications and vaccines.

As PIH, we need to continue supporting the most vulnerable. And we need to think longer term about what happens if this starts becoming more global, and we start identifying more cases in the countries where we work.

When Dr. Afom Andom, chief medical officer at Partners In Health in Lesotho, noticed blank spaces and other discrepancies in several district tuberculosis (TB) registries in 2020, he was perplexed. 

As a former health reform technical advisor from 2016-2019, Andom quickly realized that local TB screening programs were not going well. He and several colleagues in Lesotho and globally sought to find out why.

In a new study, published in PLOS Global Public Health in March, Andom, who graduated from Harvard Medical School, Department of Global Health and Social Health in 2021 found that numerous barriers stood in the way of TB screening, with dire consequences.

“If we do not screen, we are not going to diagnose and thereafter treat TB,” said Andom, the study’s lead author, adding that, “Undiagnosed people live in the communities and continue to spread the disease.”

TB is one of the oldest infectious diseases, but these days it is far more prevalent in resource-poor countries and regions. Globally, around 30% of people with TB are neither diagnosed nor treated. Lesotho has the highest TB incidence globally with an estimated 654 cases per 100,000 for a population around 2 million. Due to the double burden of HIV, 62% of TB patients are co-infected with HIV. Timely detection through quality screening is need improve treatment rate, reduce mortality, and control transmission.

Patients Speak Up

For the study, Andom and his colleagues interviewed 24 patients at two facilities in the Berea district, Berea Hospital and Khubetsoana Health Center. The patients shared their experiences accessing TB services, noting numerous barriers. Many patients take public transportation; therefore, they need to wake up in the early morning to walk and catch the taxi. The taxi rides are long in distance and in time as the taxi will continuously stop and go, picking up passengers along the way. Finally, once the patients arrive at the clinic or hospital, they are greeted by long queues and can expect to wait half a day until they are seen by a clinician. One of the nurses interviewed stated, “once a patient has any TB symptoms, he/she is ordered to send the sputum to the TB clinic so this makes patients unwilling to give out all the answers when being screened.”

“We have a great problem. A person is already very sick, like I have told you that sometimes I even struggled to have food, I have already left home having not taken enough food. When you get to the facility, you get here at 8:00 am only to get consultations at 12 [noon],” a patient at Khubetsoana Health Center, who was quoted in the study, said.

Many patients shared that they hide their symptoms because they want to finish early and go back to their villages. Andom and his colleagues found that patients are sometimes screened twice in the same visit, prolonging the time they spend at a facility. Combined, these reasons indicated flaws in the screening process which leads to patients leaving the clinic or hospital undiagnosed with TB.

Health Workers’ Screening Burden

Makena Ratsiu, Berea District’s primary health care coordinator with Bo-mphato Litsebeletsong Tsa Bophelo—as PIH is known locally, said one aspect of the research, in particular, surprised her: health care workers find TB screening as one more task added on top of an already overwhelming scope of work, and so it does not receive adequate attention. Afom and his colleagues found that in the facilities nurses were not designated to carry out TB screening and that screening activities are shared among staff. Study authors discovered in their interviews with health care professionals that clinics and hospitals are frequently understaffed compared to patient demand; TB screeners lack adequate training; and multiple individuals are asked to screen, although it is not their primary role. “Ultimately, this means patients living with undiagnosed TB subsequently suffer,” said Ratsiu.

Ratsiu said this has been an eye opener for her and she can see where she needs to apply more effort when she visits various facilities for mentorship. To improve TB detection, all healthcare workers need TB education to properly screen for TB. TB screening education is a must. Additionally, Ratsiu mentioned that there should be follow-ups to see whether screening is done according to guidelines.

Low Screening Rates

Andom and colleagues found that of the 70,393 visitors from the two facilities studied, only 22% of hospital patients and 48% of health center patients were screened for TB. They discovered that out of those who were asked about TB symptoms, only 2% revealed their TB symptoms. This is a very low number in a country with the highest TB statistics.  The data reveals that there is a lot of work to be done to improve TB screening, researchers said, and the findings can help with the integration of better health services and also advocate for funding. “Sufficient and equitable staffing, adequate supply of essential commodities, and proper monitoring and evaluation of performance though effective data utilization is critical for eliminating TB,” Andom said.

Next Steps

As a result of the study, PIH has enhanced its support to the Ministry of Health by building capacity in TB screeners; which has resulted in identifying screening gaps and remedies to address screening needs. Additionally, PIH Lesotho has expanded TB screening and diagnostic services by equipping facilities with digital x-ray machines and teleradiology and new mini labs, along with the technical staff to manage and safeguard it.

Meanwhile, Andom is now studying the barriers of TB diagnosis and treatment and the impact of COVID-19 in TB in Lesotho. To improve TB treatment outcomes, he hopes to better understand challenges around drug adherence and other issues preventing patients from being cured.

As the world continues to battle COVID-19, another virus is making headlines.

Monkeypox, a viral disease known for rashes and lesions on the skin, has now infected more than 25,000 people worldwide, including in 76 countries where cases aren’t typically detected.

The current outbreak, which began in May, has since led the World Health Organization to declare a global health emergency.

Most patients recover on their own, after two to four weeks; but the disease has spread far beyond the 11 countries where it is typically found, sounding alarms worldwide and spurring calls for global vaccination.

Among the countries where PIH works, Peru is dealing with a major outbreak. Socios En Salud, as PIH is known in Peru, is working closely with the Ministry of Health and directly supporting people who have contracted monkeypox and their contacts in northern Lima.

Here are seven things to know about the disease:

1. What are the signs and symptoms of monkeypox?

Symptoms usually include a fever, severe headache, muscle aches, back pain, low energy, swollen lymph nodes, and skin rashes or lesions. The rash usually begins within one to three days of the fever.

The lesions may be flat or slightly raised and filled with clear or yellowish fluid. Eventually, the lesions dry, scab, and fall off. Rashes tend to occur on the face, palms of the hands, and soles of the feet, but may also be found on the mouth, genitals, and eyes.

Symptoms usually last two to four weeks.

2. How is monkeypox transmitted?

Human-to-human transmission can occur through contact with the skin lesions of an infected person, mucus or saliva, or contaminated objects. It typically requires skin-to-skin contact.

Animal-to-human transmission occurs through direct contact with the blood, body fluids, skin lesions, or mucous membranes of infected animals. The animals that host this virus are often rodents or primates.

3. Is monkeypox a new disease?

Monkeypox is not a new disease. The virus has been considered endemic in 12 countries on the African continent for decades. But it has also previously occurred in the United States—the first outbreak in the U.S. was reported in 2003, spreading from prairie dogs to humans and affecting six states.

The current outbreak is causing worldwide concern due to its fast and far-reaching spread. But monkeypox is not nearly as contagious or as deadly as COVID-19. Unlike the coronavirus, monkeypox typically requires close physical contact with someone who is infected.

4. Is monkeypox fatal? 

The current outbreak has led to 10 deaths, mostly in Africa—where not a single dose of the vaccine is available.

In most cases, symptoms often resolve within a few weeks on their own, without treatment.

In some people, the virus can lead to medical complications. These complications—such as pneumonia or infections in the brain or eyes—can be fatal.

Newborns, children, and immuno-compromised people are most at risk for severe symptoms.

5. Is there a cure?

In the U.S., patients with severe disease are currently being treated with tecovirimat. This drug is not available in countries where PIH works.   

The U.S. has two vaccines approved for use, as prevention measures, and recently announced plans to scale up distribution domestically. But at the moment, the U.S. has no plan to distribute vaccines to other countries.

6. Who is most at risk of catching monkeypox?

Globally, men who have sex with men are currently at the highest risk of infection from this outbreak and comprise the vast majority of new monkeypox cases. However, susceptibility to the disease is not limited to people who are sexually active or to men who have sex with men.

Anyone can catch monkeypox. In African countries where monkeypox is endemic, like Liberia and Sierra Leone, monkeypox often infects children. It is vital to fight not only the spread of the virus, but also the spread of misinformation and stigma, which only further endangers marginalized groups, including LGBTQ+ people and Black people.

7. How can I stay safe?

The World Health Organization currently recommends that men who have sex with men consider limiting their number of sexual partners to lower their risk of infection and reduce transmission.

The WHO also recommends avoiding skin-to-skin contact whenever possible, washing your hands regularly with soap or using hand sanitizer, and washing clothes, sheets, towels, and other items or surfaces that have been potentially exposed.

If you think you have symptoms, please isolate at home until you can be evaluated by a doctor.

Monkeypox testing is now widely available in the United States. If you have been in direct contact with someone infected, or have been at an event or location with a known monkeypox outbreak, please be on the lookout for symptoms, and consider getting vaccinated for monkeypox immediately.

For more information, visit the World Health Organization.

Ludentz Dorcelus clearly recalls the “complete chaos” that overwhelmed his hometown of Port-au-Prince after a 7.0 magnitude earthquake devastated Haiti in 2010, killing some 300,000 people. Dorcelus, 18 at the time, was one semester short of graduating high school when the quake, which leveled the capital city, hit.

In order to finish school, Dorcelus and his parents agreed that he would move to the U.S., to the home of an aunt and uncle, in Nanuet, NY—a small town about 30 miles north of Manhattan. There, he graduated, then returned home and passed the local exams to complete high school in Haiti and apply to college, settling on a career in medicine. Now, Dorcelus is in the final year of his residency: he plans to stay in Haiti and practice family medicine.

Education was a focus of his family, Dorcelus said, so it’s not surprising that when it came to structuring a research project as part of his medical school “social service” year, his hypothesis was that education was closely correlated with adherence to medication protocols. “A lot of that was based on my own experience,” he said.

However, the results of his research, which looked specifically at adherence to antiretroviral therapy (ART) at one hospital in Haiti and was published in the journal AIDS Research & Therapy last November, undermined that theory. For Dorcelus, the study’s lead author, that finding came as a “big surprise.”

Research Findings

The study included 411 patients at St. Therese Hospital in Hinche, a public facility in central Haiti, which is also supported by Zanmi Lasante, Partners In Health’s sister organization. Zanmi Lasante, founded in the early 1980s, now comprises a network of 15 clinics and hospitals in some of the country’s most impoverished regions and serves more than 1.3 million people.

Researchers, relying on self-reported patient data, found that age and the ability to meet basic needs were the only two factors that significantly correlated with adherence. “The odds of having poor adherence was significantly higher in patients under 40 years compared to those 40 years of age and older,” the study concluded. Additionally, it found: “Patients who could not meet their basic needs were more likely to have poor adherence.”

Earlier research has also found that younger patients can have more trouble following medical protocols in similar settings, Dorcelus said. That body of work suggested that older patients were more accustomed to the routine of medical regimens: “The survival instinct was also mentioned in these studies: the elderly patient, in decline, recognized that their life expectancy would be prolonged through good adherence.” At the younger end of the spectrum, “adolescents and young adults were at increased risk of treatment failure due to multiple social, psychological and adherence barriers,” the recent study had found.

Better Outcome and Survival

Adherence matters when it comes to all medications, but in particular, it’s associated with better outcomes and survival among people living with HIV, the study noted.

To be sure, most patients in the study —a full 82%— reported their adherence to ART was “excellent.”

Among those who reported poor adherence, the reasons varied, but many of them stemmed from general poverty: “Only 9% said they could always meet their basic needs compared with 27.9% who could never meet their needs. Not being able to meet their basic needs was associated with almost three times greater odds of poor adherence.”

The study noted that ART is free in Haiti. “Were treatment not free, it would likely pose an even greater barrier to treatment adherence,” the study said. “If they [patients] do not have enough resources for food, they are likely to be more focused on solving this immediate need, instead of achieving viral load suppression. It is also a common belief amongst Haitians that medication should not be taken on an empty stomach. Living in poverty, not having access to water/food may prevent them from taking their medication.”

More Studies Needed

And while other studies have shown a link between education and adherence, this one did not. The literacy rate in Haiti for those 15 and older is 61%, the study noted, and the Central Plateau region has the nation’s highest illiteracy rate. “Surprisingly,” the authors said, “we found no statistically significant difference between adherence among those that had been schooled compared with those who had received no schooling.” However, they theorized that given the high illiteracy rate and limited ability to meet basic needs, “it is likely that access to education could potentially improve adherence to ART in this area.”

Overall, Dorcelus said, more studies— at more hospitals— are needed to figure out all of the complex elements that drive adherence. “We need a nationwide study or a larger study to figure out the other barriers,” he said.

The Importance of Social Support 

Dorcelus’ driving curiosity in the research struck Mary Clisbee, provost for academic affairs and research at the University of Global Health Equity in Haiti. "What I find most amazing is that he recognized the problem, searched the literature, and developed the study on his own, and during his service year!" Clisbee said. "That is unheard of! His level of motivation and autonomy is remarkable."

Dr. Ornella Sainterant, director of medical education at HUM adds: "This study proves once again Dr Paul Farmer's teaching on social medicine [and] medical humanism: Our treatment won't work without social support."

For now, Dorcelus said he is working on another project looking at the factors linked to poor glycemic control in diabetic patients, while also finishing up his studies. Though his future career path is not clear at this point, one thing is certain.

“Even though the situation is bad, people are fleeing the country, and we are living in constant fear,” he said, “I grew up in Haiti. I want to stay here and serve my population.”

Some got it from needle injuries. Others got it from donating blood. Still others didn’t know the source of their infection. But for years in Rwanda, hepatitis C was a death sentence.

Then, in 2015, a medical breakthrough arrived: a pill that could cure the disease.

“For the first time, there was a bit of hope,” says Dr. Fredrick Kateera, chief medical officer of Inshuti Mu Buzima, as Partners In Health is known in Rwanda.

The pill came to Rwanda through years of advocacy and research by Partners In Health in collaboration with the Rwandan Ministry of Health, the Rwandan Military Hospital, and the Rwandan Biomedical Center—efforts that have since inspired a nationwide hepatitis elimination program and research published in The Lancet.

“During the COVID pandemic, it was easy to forget about the everyday pandemics that were going on in the world,” says Dr. Neil Gupta, former chief medical officer at Inshuti Mu Buzima and faculty at the Brigham and Women’s Hospital in Boston. “Hepatitis is a big one of those.”

Undetected, Undiagnosed

Hepatitis C is as prevalent in Rwanda as HIV, affecting some 3% of the population—but far less funding and resources are directed to the bloodborne virus, which attacks the liver and, in its most severe form, can cause liver damage, cancer, and death.

Most infections occur through unsterilized medical equipment, unscreened blood transfusions, and the sharing of needles among drug users. Often asymptomatic, the virus can go undetected for years, until serious complications arise.

There are no vaccines against hepatitis C, making prevention and early diagnosis and treatment especially crucial. But for years, patients in Rwanda and other impoverished countries had very little access to screening or treatment—even as these resources existed in the United States and other wealthy nations.

Inshuti Mu Buzima and the Rwandan government were determined to change that.

Since 2005, Inshuti Mu Buzima has worked in Rwanda, strengthening the health system and providing medical care in partnership with the Ministry of Health. In the years since, it has expanded its work to care for patients with chronic illnesses. But there was little that could be done for patients with hepatitis C, other than recommend an injection that was too expensive for most to afford and came with painful side effects.

Then, in 2014, a new hepatitis C drug was approved in the U.S., with cure rates approaching 100% for most patients. Kateera and his colleagues in Rwanda took note.

“Like most of our Partners In Health work, we are always interested in pushing the envelope of providing quality care services to people in developing settings,” says Kateera. “So we got wind of opportunities in the U.S. in terms of more modern medications for hepatitis C and we started off by doing some clinical studies.”

Finding A Cure

Those clinical studies began in 2015 and were led by Inshuti Mu Buzima in partnership with the Rwandan Ministry of Health, the Rwandan Military Hospital, and the Rwanda Biomedical Center. The researchers wanted to know if the new drugs were effective among patients with hepatitis C in Rwanda.

The first study, called Shared One, brought pills—taken once daily, for 12 weeks—to hundreds of patients from across the country. And the results were groundbreaking: out of the 300 patients who received treatment, 87% were cured.

“[It] was really like this long-awaited miracle for patients who had liver disease or were diagnosed with hepatitis C, after many years of searching for a diagnosis and having no possibility of a cure,” says Gupta, who co-led the study with Kateera.

Still, some 13% of patients were not cured. Kateera, Gupta, and their team set out to understand why, leading to two follow-up studies with other drugs, which determined for the first time how to best treat these patients, and amassing a body of evidence in support of making the new hepatitis C drugs free and accessible in Rwanda.

The results from all three studies were published in The Lancet, with the most recent featured in June. And the momentum didn’t stop there.

“We were able to take this information and say look, these drugs really need to be available,” says Gupta.

In December 2018, Inshuti Mu Buzima supported the Rwandan Ministry of Health in launching a nationwide hepatitis elimination program, providing free screening and treatment to over 50,000 patients, expanding the health workforce, and capturing data to monitor progress. Inshuti Mu Buzima also organized mass screening campaigns for at-risk populations, including more than 30,000 refugees from Burundi and the Democratic Republic of the Congo.

“This is very much part of the signature contribution of PIH everywhere we work,” says Kateera. “We think of innovative solutions around key major public health gaps and then we iterate and design a program that answers that.”

Showing The World What’s Possible

Dr. Jean D’Amour, director of infectious diseases at Inshuti Mu Buzima and a researcher on the study, still remembers a time when there were just four doctors nationwide following hepatitis C cases. Since the national program was launched, more than 1,000 doctors, nurses, and other health workers now monitor the disease and connect patients with care.

“All of this was designed to help the government and the population in Rwanda, but at the same time to help others in the world, showing them what was possible,” says D’Amour.

Despite the progress that has been made in Rwanda, hepatitis C remains a largely untreated epidemic across Africa, where 8 million people are estimated to be infected but less than 1% have been tested and treated.

In Rwanda, the national program has encountered hurdles, including the COVID-19 pandemic, which forced screenings for the general population to pause. But at-risk patients continue to receive treatment. And Kateera and his colleagues are hopeful that the program will rebuild its momentum. It’s already serving as a model for programs elsewhere.

The impact in health centers and hospitals is tangible, as patients once without treatment now have access to lifesaving pills.

“For the first time, we had an opportunity to access medications that not only could cure you, but could prevent chronic diseases,” says Kateera. “There was a lot more hope.”

In 1986, Partners In Health began caring for patients diagnosed with HIV/AIDS in Haiti. Clinicians with Zanmi Lasante, as PIH is known in Haiti, started with free testing, counseling, and inpatient care. Soon thereafter,  PIH leadership joined a growing global advocacy movement fighting for accessible, affordable, lifesaving antiretroviral treatment and the rights of all patients, despite nationality or economic status.

By the late 1990s, PIH was among few organizations providing free, comprehensive HIV/AIDS treatment to marginalized patients. Haitian men and women living with the virus rose from their deathbeds, in what became termed “the Lazarus effect,” as their conditions improved with community-based care and support.  

Word of PIH’s success in Haiti spread rapidly. Over time and at the invitation of national governments, PIH began collaborating with colleagues in Peru, Rwanda, Lesotho, Malawi, Liberia, and other countries to replicate its model of HIV/AIDS care globally. Though its reach broadened, PIH’s mission never waned: the work has always centered on accompanying patients throughout their medical journeys and beyond, with social support, compassion, and top-notch care. 

Explore the timeline below for more information about PIH’s global work in HIV/AIDS:

1991 

The First Patients

The first person living with AIDS walked through PIH's clinic doors in Haiti in 1986. Free testing, counseling, and inpatient care soon followed for hundreds of people living with AIDS.

Dr. Paul Farmer visits Adeline Merçon, who is among the first people living with AIDS to benefit from ART in Haiti. Photo courtesy of PIH

1992 

Paul Farmer's AIDS and Accusation

Farmer's book offers a systematic analysis of the racism driving theories that Haiti was the source of HIV in the western hemisphere.

1998 

HIV Equity Initiative

PIH launched one of the first programs to provide free, comprehensive HIV and AIDS treatment. Newly recruited and trained community health workers delivered medications and accompanied people living with AIDS through treatment.

Still healthy today, Adeline Merçon, St. Coeur François, and Monèse Gracia (left to right) began ART in 1999 and 2000 through the PIH-supported HIV Equity Initiative. Photo by Daniel Eisenson

1999

Paul Farmer's Infections and Inequalities

Farmer shows how entrenched beliefs about "cost-effective treatment" and patient "non-compliance" blame people living with AIDS for their illnesses, such as HIV, rather than call out systematic forces of oppression.

2001 

Cange Declaration

As Haitians living with HIV regained their health, some became activists, issuing the Cange Declaration and calling for increased access to lifesaving drugs.

2003 

Global Advocacy and Influence

PIH's success in Haiti was key to expanding ARTs globally, contributing to the development of the Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR.

2005 

National HIV and AIDS Program in Rwanda

PIH was invited to Rwanda to support the country's HIV and AIDS program by integrating HIV care and treatment in many primary health centers in Rwinkwavu District

2010 

CHWs Improve Outcomes in Peru

A study in Lima, Peru showed people living with HIV and accompanied by a CHW had better outcomes at 12 months, including higher viral suppresion.

2014 

Doubling Access in Rural Lesotho

PIH supported the government of Lesotho to revamp 72 inadequately resourced and understaffed clinics throughout four districts, increasing HIV treatment enrollment by 133%.

Matsebo Lerotholi learned she was living with HIV in 2009 and started on ART. She gave birth to her son, Nkuebe, in 2018 and is accompanied by her village health worker, Malerato Tsoelesa (in background). Photo by Cecille Joan Avila / PIH

2018

Post-Ebola Improvements in Liberia

A study of post-Ebola care in Liberia found that CHW support resulted in better ART coverage and retention of patients living with HIV.

2021

Leaving No One Behind in Malawi

PIH launched in Malawi the Tracing Retention and Care Enrollment (TRACE) program to welcome people living with HIV back into care. With CHW outreach, 86% re-engaged with HIV care.

At Neno District Hospital in Malawi, Nurse John Paul (left) and Dr. George Talama (right) examine a 27-year-old woman receiving HIV counseling and psychiatric help. Photo by Zack DeClerck / PIH

2022

HIV and AIDS Care Continues Amid COVID

As new threats emerged in the form of COVID-19, highlighting old challenges in care delivery, people living with HIV continued to receive lifesaving HIV treatment, offering hope.

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James Fatoma moved to Kono District, Sierra Leone, when he was in high school—and from his teens through his early 30s, had only been to the doctor once.

That checkup was five or six years ago, when, sick with a fever and headache, he opted to go to a private clinic in Kono, where they diagnosed and treated him for malaria. It was an expensive visit—but one Fatoma said he had much more faith in than going to Kono’s public hospital, Koidu Government Hospital (KGH).

“KGH was cheaper,” he said. “But the quality of services was poor, so people didn’t go.”

That changed in early 2019, on a day that quickly turned from typical to, in Fatoma’s words, “very scary.” At his job as a computer specialist, Fatoma fainted, and then that night at home began vomiting blood. Friends rushed him to KGH, where he was admitted to the emergency room—a department that had only recently opened thanks to Partners In Health’s (PIH) support of the hospital, five years after PIH began working in Sierra Leone.

It's also thanks to PIH’s investments in the hospital’s staff, stuff, and systems—from its team of nurses to its blood bank—that Fatoma survived through the night, even despite massive blood loss.

“There was a quick assessment [of Fatoma’s condition] and there was a very rapid response from the emergency team, the surgical team, and the blood bank,” said Dr. Marta Patiño, PIH’s internist at KGH who led Fatoma’s care. “We were dealing with life and death for two or three hours until he was stable.”

That stability didn’t last long—the next day, another bout of gastrointestinal bleeding necessitated that clinicians transfuse 18 units of blood. For three weeks, Fatoma remained in limbo in the emergency room, alternately stable and in critical condition, routinely saved by clinicians’ ingenuity.

“James was very, very close to dying on two occasions,” said Patiño. “He was lucky because we didn’t have an endoscopy, but we did multiple transfusions, kept his blood pressure stable through IV fluids, and did something that isn’t done anymore except in settings of poverty: we connected a nasogastric tube with the stomach and filled it with ice water, to stop the bleeding.”

“The information and the treatment”

“Let's assume this happened when a hospital like this was not around,” said Fatoma. “I would have been six feet below.”

Indeed, had Fatoma arrived at KGH five years earlier, when the hospital wasn’t resourced with clinicians trained in emergency medicine and supplies like IV lines, his chances of survival would have been slim. Still, as Patino notes, the hospital remained underequipped to provide truly proper care for Fatoma: Had he been a patient at a standard emergency department in the U.S. or Europe, clinicians would have immediately had the equipment and training to perform an endoscopy, a procedure that allows them to see inside a patient’s gastrointestinal tract to diagnose their illness and stop bleeding at the source.

“Endoscopy provides the information and the treatment,” Patiño explained. “If you ask any hospital in any wealthy country, nobody has any doubt that endoscopy saves lives.”

Without this essential procedure, clinicians were still able to diagnose Fatoma: Using ultrasound equipment and lab tests, they determined their patient was suffering from schistosomiasis, a parasitic infection commonly picked up in rivers in sub-Saharan Africa that, left untreated, can lead to liver cirrhosis. Growing up swimming in a nearby river with his friends, Fatoma likely had the infection for decades before it erupted in life-threateningly high blood pressure and subsequent bleeding.

Treatment was much more difficult to come by, contingent upon endoscopy services in capital city Freetown being up and running at the same time that Fatoma was stable enough to make the six-hour drive from Kono. In a testament to the volatility of health care services nationwide and the volatility of Fatoma’s health, the stars didn’t align for more than a year—during which Fatoma was in and out of the hospital with more episodes of intense bleeding.

With blood pressure medication, Fatoma had periods of stability—but daily life was a challenge.

“I was not able to eat much, I was weak and tired, I was not able to walk or even sit long, I had headaches,” Fatoma recalled, also noting that he sometimes had to miss months of work, an incredible stressor as the breadwinner for his fiancé, Dorcas, and two younger siblings.

Even so, Fatoma never lost hope. While he was still sick, Dorcas safely delivered their daughter at KGH. Fatoma named her Gifty—“because I got her during some amount of tragedy in my life.” And the care he continued to receive at the hospital kept him confident that one day his illness would subside.

“[The clinicians at KGH] applied a lot of effort,” he said. “They treated me with all possible care, as if I was a brother or sister to them. So I had 100% hope I would recover.”

Looking Ahead

That effort and optimism paid off when word arrived that a hospital in Freetown could perform an endoscopy for Fatoma, allowing clinicians to staunch all sources of bleeding as a complement to keeping his blood pressure down through medication. PIH provided transportation to and lodging in Freetown and paid for the $400 procedure.

Today, Fatoma is healthy—back at work and relishing returning home to his family each evening.

“When I get home, they are happy,” he said. “I play with Gifty, which brings such joy to my heart.”

Fatoma still goes to KGH regularly for checkups, and given the seriousness and permanence of liver cirrhosis, clinicians will continue to monitor his health closely for years to come. They say his case is emblematic of how far health care in Kono has come, but also the extent to which it still needs to be invested in and improved.

“James was lucky our treatment worked as we waited for months until we were able to find a facility [in Freetown] where we could send him,” Patiño said. “We have lost many patients in the emergency department to bleeding. Not all are able to survive, and some don’t even come in.”

Prevention—including education, screening, and early identification of schistosomiasis, as well as other conditions that cause liver problems, like hepatitis—is key, Patiño says. But so is providing timely, quality care to patients past the point of prevention.

“We need to be able to provide treatment,” Patiño continued. “We need to buy endoscopy equipment, train staff on it, maintain it. It is our responsibility to try and implement interventions that we think are going to make a change. And this is one of them.”

Longtime nurses Claudinette Favard and Nathalie Paul have seen a lot in their combined 27 years supporting patients and teaching nursing students in Haiti. But after nearly two weeks of training at Regis College outside of Boston, they realized something new. 

“Here things are different,” said Paul, who, since 2014, has served as a clinical nurse educator at Hôpital Universitaire de Mirebalais, the more than 300-bed facility run by Zanmi Lasante, Partners In Health’s sister organization in Haiti. “[In the U.S.], nursing students spend a lot of time in the simulation lab learning skills. In Haiti, they go to the lab once in the first and second year, and after that they only go to the hospital because they are needed to help care for the patients.” 

The two nurse educators, both affiliated with Zanmi Lasante’s Nursing Center of Excellence at Hôpital Universitaire de Mirebalais, say they will bring what they’ve learned from the Regis nursing faculty—on the importance of simulation lab skills and the practical application of such training—back home to “reinforce” and strengthen the curriculum at Haiti’s national nursing schools.  

Practicing on mannequins at the simulation labs, the nurses adopt techniques to help students and novices hone their skills. Each participant developed scenarios to present to the group. For instance, Favard, on the HUM nursing team since 2016, focused on dehydration in children; Paul presented on auto administration of insulin. 

“I think that we improve the skills of the students, and the patient will receive better care, and we will improve the quality of care in Haiti,” Paul said. 

A total of nine nursing faculty affiliated with government-run nursing schools and other teaching hospitals across Haiti are part of the “Regis in Haiti” program. The college had been working in Haiti, in partnership with the Ministry of Health, since 2007, but the current program was formalized in 2019 with a grant from the Wagner Foundation. Now, the focus, according to Regis administrators, is “advancing the nursing profession by training nurse educators, strengthening clinical skills among student and novice nurses, and fostering evidence-based research to bolster the country’s health care system.” Health Equity International, which operates St. Boniface Hospital in southern Haiti, was another partnering organization taking part in the training. 

Through the Regis program, the Haitian nurses “will learn how to incorporate the use of simulation labs into their personal teaching practice at their home institutions,” the college said in a press release. Currently, the nursing schools in Haiti do not rely on such skills lab training, which allows practical experience prior to working with actual patients.

Angeline Charles, a veteran nurse and Zanmi Lasante’s clinical systems education specialist, said Regis College has supported a number of efforts in Haiti designed to strengthen nursing across the country. When Favard and Paul return home, Charles said, they will help standardize lab simulation for all national nursing schools in Haiti in collaboration with the Ministry of Health, so nurses can learn skills “before they even touch patients.”  From there, Charles said, the team will develop research to determine the impact of the enhanced lab program.    

Raising the status of nurses, both as patient advocates and critical members of the health team, has been a central mission of Zanmi Lasante since its inception. The Nursing Center of Excellence offers standardized, specialized training programs, supervision, mentorship, and opportunities for nurses to become educators. Nursing leaders have also been appointed to serve as disease-specific specialists in each Zanmi Lasante-supported facility—connecting efforts to fight malnutrition and HIV and tuberculosis, for example, and serving as advocates for quality care in the institution and in the community.  

For PIH, the collaboration with Regis will have long-lasting impact. “Through the partnership between Partners In Health, Regis College, and [the Ministry of Health in Haiti], we have begun to move the needle on global health equity by elevating the standard of clinical practice and excellence,” said Cory McMahon, PIH’s chief nursing officer. She noted that in Haiti, as in other settings around the world, there’s a gap between classroom teaching and clinical reality. “As a collective, we have begun to bridge that gap by working closely with academic institutions in Haiti to strengthen preceptorship programs, clinical education, and simulation lab trainings to offer enhanced support during the transition to practice.

"The partnership will have a ripple effect across Haiti as we use this opportunity to model expert, dignified, and compassionate care for future generations of nurses.” 

She added: “We are deeply grateful for the opportunity to collaborate with Regis College and the Wagner Foundation and look forward to all that we will continue to achieve together.” 

For more on the program, read coverage in The Boston Globe.

On the grounds of Butaro District Hospital, a four-story building is rising rapidly. The construction is phase one of Partners In Health’s multi-year expansion project, launched in December 2021. And it seeks to widen access to cancer care and other specialized services in a region where there was once no hospital and where the current facility lacks enough beds for all patients in need of care.

“We are progressing well,” said Fabrice Nusenga, infrastructure manager at Inshuti Mu Buzima, as Partners In Health is known locally. “We want to hand over the building [to the Ministry of Health] as soon as possible so that it can start serving its purpose.”

The construction is part of a two-phase project to expand the capacity of Butaro District Hospital to serve more patients and become a university teaching hospital for students from the nearby University of Global Health Equity.

Just a decade ago, the rural district of Burera was one of only two districts in Rwanda without a hospital. In 2011, Inshuti Mu Buzima, in partnership with the Ministry of Health and MASS Design Group, built Butaro District Hospital to bring health care closer to those who most need it—ultimately providing quality care to a community of 350,000 people.

Now, the hospital has become a regional hub for cancer care, provided at the Butaro Cancer Center of Excellence. Approximately 1,200 new patients arrive at the cancer center each year from across the region and from as far as countries like Sierra Leone to receive comprehensive treatment. That growing demand has stretched the cancer center’s resources, making the expansion project crucial. When construction ends in 2023, the bed capacity is set to increase from 150 to 256, serving even more patients.

The progress made since construction began is notable. Most of the structural work is now complete, including foundations, floor and ceiling slabs, exterior walls, columns, and beams. Roofing, installation of electric wiring and water pipes, and wall finishing activities are well underway.

The 62-foot-long building will accommodate new departments and double the capacity of existing wards and services, including a modern emergency department, a new imaging unit with a CT scanner, and new pediatric and adult wards.

The new spaces are designed in a way that prioritizes the comfort and safety of patients. The floor plan is meant to ease the flow of patients and staff. Big windows and higher ceilings will allow natural light into the building. To create a more welcoming environment for young patients, the new pediatric ward will include a large outdoor playground. The expanded hospital will also have a cafeteria for students and health workers, while patients receive free meals at the nearby support center.

The project is boosting the local economy in Burera, where most people make a living from subsistence farming.

“We have an average of 150 daily workers working on the project,” said Nusenga. “Some of the materials we use are locally sourced to create more opportunities for the local community.”

Those materials include sand, water, and timber from local forests. 

A short walk from the construction site, the economic impact of the project is on display in the boisterous town of Rusumo. A gas station refuels construction trucks; banks have long queues of people waiting to cash their paychecks; hostels have seen a spike in demand since construction began.

Most importantly, though, the project will enable the hospital to provide quality care for the growing number of patients who walk through its doors.

Seraphine Uwimana, 46, was one of those patients. The mother, who lives in Kigali, was diagnosed with stage three breast cancer in 2019. Because this stage is considered advanced, she had to travel regularly between Butaro and Kigali for a CT scan as part of her treatment. The journey is three hours long and includes an hour of travel on a rocky dirt road. Once the new CT scanner is installed in the expanded facility, such a trek will no longer be necessary for future patients.

“The journey was long and unpleasant for a sick person,” said Uwimana. “But I now look back and realize it was necessary. People who saw me when I was very sick are always amazed to see how well I am doing.”

Through Inshuti Mu Buzima’s support, Uwimana completed her chemotherapy treatment and had a mastectomy, with all care free of charge. Now, she only returns to the hospital for follow-up appointments every six months. This has meant that she can spend more time with her two children, ages 9 and 5.  

Today, as Uwimana watches the expansion of the hospital take shape, she is grateful that patients will be able to access its lifesaving services in one place.

“The hospital has given me the treatment and care that was before not possible for someone who is poor,” she said. “It’s wonderful that in the future patients will access more services here in Butaro."

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The following op-ed was written by Katie Bollbach, executive director of Partners In Health United States. 

Despite a recent rise in COVID-19 cases, many communities across the country are grasping for a return to normal: vaccine mandates are being rolled back, masks are increasingly optional, and people are returning to their everyday social activities.

But local leaders and community-based organizations in Immokalee know the country––and their southwestern Florida town––are far from returning to normal. So, they continue scheduling testing fairs, prepping food packages for people in isolation, and conducting vaccine outreach and education. For them, adapting to shifting federal guidance is nothing new. And with COVID-19 likely to continue disrupting the lives of their community, local leaders are prepared to respond to COVID-19 long after the news cycle moves on.

Even as national cases increase and more subvariants emerge, federal funding is drying up. Medical care reimbursement funds for many millions of uninsured COVID-19 patients have already run out of cash. Claims for testing and treatment are being denied, leaving states scrambling to figure out their own short-term fixes. And lawmakers have not yet agreed to extend even a portion of the $22 billion in emergency funding requested by President Joseph Biden. Failure to pass this means fewer tests available to people living in the United States, less surveillance for future variants, and a risk of running out of vaccines and affordable treatments.

So, if nearly a million deaths since the start of the pandemic isn’t enough to generate political resolve and the federal dollars never appear, where does that leave us?

In the absence of a cohesive and comprehensive federal plan, local health departments, community-based organizations, and others across the country are stepping up to assume the responsibility of accompanying their communities through this new phase, just as they have throughout the entire pandemic.

At Partners In Health, we’ve seen the consequences of congressional inaction play out among individuals and families as we’ve worked with public health departments and local leaders to successfully navigate the impacts of COVID-19 on those most affected by this health crisis.

When elites – the predominantly white cadre of Americans with political and financial power – feel safe, the impetus and political will for protective measures evaporates, further exacerbating health inequities. But local leaders continue to forge ahead, adapting COVID-19 guidance, delivering resources, and providing critical support to ensure communities they deem most in need and at risk remain protected—and prepared.

In Immokalee, PIH and our partners have bridged gaps in response efforts by serving as community-based public health navigators to meet the needs of Immokalee’s residents. Through a group of health promotores, we worked alongside our partners at the Collier County Department of Health, the Coalition of Immokalee Workers, Healthcare Network, and Misión Peniel to provide individualized help to members of the community, from securing transportation to testing and vaccination sites, to delivering food and providing rental assistance, labor protections, and cash to help cover costs during quarantine and isolation.

Through this partnership, over $950,000 in direct transfers have been provided to over 800 households. This crucial support protected the livelihoods and well-being of local farm and packinghouse workers.

Departments of health in other parts of the country are applying a similar approach. Despite an uptick in cases across the state, the rate of COVID-19 infections in the port city of New Bedford, Mass., continues to decline. When Omicron threatened to reverse the progress New Bedford had made in controlling COVID-19, the local health department pivoted existing efforts, devising a strategy that doubled-down on access to testing and vaccination.

In December, even before the White House began distributing free, at-home tests to households across the country, the health department in New Bedford worked with community organizations to distribute 38,000 testing kits to local populations that were the least vaccinated and therefore most at risk for illness, as well as those that have seen disproportionately high case rates.

Across the country, local health departments and community leaders have developed and modified strategies, and built the human resources and infrastructure required to execute them. Federal funding must come through, full stop. If it doesn’t, we could be sending ourselves back to the darkest days of the pandemic, competing for limited tools to combat the spread of a debilitating disease. Such a scenario all but guarantees ongoing inequity in COVID-19 impact falling along familiar fault lines of historical and structural injustice.

In the meantime, while organizing for change, we can lift up and learn from the community preparedness and ingenuity exhibited in places like Immokalee and New Bedford as local response strategies that can both succeed on their own and inform the development of future interventions when federal funding does come through.

In many ways, Dr. Joia Mukherjee, PIH's chief medical officer, embodies “radical hope,” a concept she spoke about recently at Harvard Medical School’s Class Day in May. An associate professor in the Department of Global Health and Social Medicine at Harvard Medical School, and in the Division of Global Health Equity in the Department of Medicine at Brigham and Women’s Hospital, Mukherjee also delivered the lead commencement address at the University of Michigan Medical School, where she urged graduates to keep their patients in close “proximity” in order to evolve from “doctors to healers.” 

In other news, Mukherjee is also out with a second edition of her text book, “An Introduction to Global Health Delivery: Practice, Equity, Human Rights,” published by Oxford University Press. In the book, Mukherjee outlines the history of the global health movement; talks about the staff, stuff, space, systems and social support necessary to provide high-quality health care (PIH’s mantra of the 5Ss); and emphasizes the role that advocacy plays in building a larger community of globally minded citizens. The new edition is greatly expanded, she said, including “new content on pandemics, global leadership, and struggles against racism and colonialism.”  

For further wisdom from Mukherjee, read excerpts from her graduation speeches at Harvard and the University of Michigan, respectively:  

“The practice of medicine is rooted in HOPE,” Mukherjee said. “Hope that your action, our collective action, can lead to healing and change.” She stressed that the graduates are commencing medical practice “at a difficult time...one marked by despair and confusion” in which the failure of the market to deliver equitable health outcomes is painfully apparent. 

“And, as usual,” she said, “those who have borne the brunt of this pandemic are the poor, the marginalized, the vulnerable—the sufferers of the pandemics—biological and social—that have long plagued humanity.” 

Still, Mukherjee leaned toward optimism. 

“I offer this,” she said. “Hope is as important now than it ever has been. Hope is an act of solidarity with those who are suffering. Hope leads us not to a desire for normal, but toward action to achieve a better future. It powers a willingness to wade into messy waters of sickness and suffering, to analyze the milieu of social injustice, and to address the root causes of disparate suffering. Hope with analysis and action is radical—it is a rejection of cynicism and pessimism. 

It presents an alternative and brighter future. 

Hope is an antidote to despair.”  

And ultimately, Mukherjee said: “Hope and action, in solidarity with others, will help you cure a sick child, change a local system, and even move the levers of power. And while hope is never rewarded with complete fulfillment of a utopian ideal, it moves among us in innumerable acts of dignity and mercy, of healing and justice. It can trouble the waters of status quo. I have no doubt that you will save a life, contribute to a community, even change the world, but none of you will do it alone. The true art of medicine is rooted in the fundamental human action of caregiving, which is a team effort.” 

At the University of Michigan Medical School, she told graduates in relation to the pandemic: 

“The medical science we witnessed was breathtaking—the rapid understanding of the virus, the host response, the immunology, and the translation of that knowledge into vaccines and therapeutics. Bench to bedside at its finest. Yet, COVID-19 has provided for us all an object lesson in health inequity. Both in the U.S. and around the world, the risk of contracting COVID-19, the access to preventive vaccines and lifesaving therapeutics, and the health outcomes of those who fall sick with COVID-19 map the fault lines of our global society. Biomedical wonders alone have failed and will continue to fail to end the pandemic. Rather, social, political, and economic aspects of COVID-19—such as pre-existing poverty, high-risk living and working conditions, and the failure of the market to deliver equitable distribution—not the virus itself, drive the pandemic and all the related consequences the world faces.” Social medicine, she added, demands we address these forces and is rooted in proximity to suffering.  

“For the rest of your life, you will take the knowledge and skills you have learned here and shape your practice. I have no doubt you will be brilliant doctors, capable of curing disease, discovering new therapies, setting broken bones,” Mukherjee said. “But whatever path you take in medicine, choose proximity … and develop your own opening for your journey with your patients. Proximity will help you think about the whole person before you, an analysis of their struggles will help you work with them and others to find potential remedies. In developing your unique art of medical practice, the canvas of your life—your talents, your passions, and your approach—will transform you from a doctor to a healer.”     

Watch Mukherjee’s full speech at Harvard Medical School and the University of Michigan Medical School.         

Content warning: brief mention of violence, including rape

During the 1994 genocide in Rwanda, Mutima* watched helplessly while Interahamwe militia brutally murdered her husband. She also witnessed the massacre of her family and friends.

Mutima, now 56, survived. But she relived that trauma every day.

In April, the month when the genocide began, that trauma was magnified.

“I started to feel sick and really scared,” said Mutima.

During a vigil in 2019 in honor of survivors of the genocide, she had a severe panic attack that led her to be hospitalized for days.

In the hospital, Mutima was diagnosed with post-traumatic stress disorder, commonly known as PTSD—a mental health condition characterized by a failure to recover after experiencing or witnessing a terrifying event.

The Genocide

The genocide against the Tutsi claimed over one million lives in 100 days and left the whole country in ruins. Decades later, its effects can still be felt among the survivors and generations born after.

A study by the Ministry of Health found that at least one of five Rwandans has a mental health condition. Depression affects 11.9% of the general population.

As the country continues to rebuild, mental health is at the center of the Rwandan government’s recovery plan. Since 2005, Inshuti Mu Buzima, as Partners in Health is known in Rwanda, has been a crucial partner in that journey, supporting the Ministry of Health in building a world-class health care system that is accessible.

Symptoms of PTSD are wide-ranging and can include alertness or feeling on edge, anxiety, and flashbacks, among others.

For Mutima, those flashbacks came in vivid details that made her feel like she was reliving the past. Her husband was killed in front of her eyes; she was raped and contracted HIV; she survived a blow with a traditional mace; she walked through piles of dead bodies as she crossed the country to neighboring Democratic Republic of the Congo and later Tanzania, seeking refuge.

When the war was over, there were no family or friends to return to; the village she had lived in all her life had been destroyed. She decided to move far away and start a new life in Rwantonde village, approximately 137 miles from her birth village.

Even in her new home, the past followed her. She lived in constant fear, struggled to meet and talk with her neighbors, and cut herself off from the world. This came in addition to the strain of shouldering her day-to-day responsibilities as a single mother.

“I am getting old and I can feel my health declining,” she said. “But I still have to look after my daughter because I am the only person she has.”

Her daughter, born as a result of her rape, was married but evicted by her husband, with their eight-year-old, when she got sick with ascites, a disease that leads to abnormal swelling of the abdomen. She moved into Mutima's house.

The trauma, compounded with tough living conditions, led Mutima to feel depressed and alone.

One evening in April 2019, during a night of remembrance for the victims of the genocide, Mutima decided to face her fears and join others in honoring the victims. However, the pain was too much. She started trembling and screaming, as she experienced a panic attack.

That night, she was rushed to Partners In Health supported-Rwantonde Health Center, where she was diagnosed with PTSD.

Bringing Care Closer

Despite the high prevalence of mental health conditions in Rwantonde and across Rwanda, there is still a lot of misconception about such conditions. As result, many patients show up at the health center or hospital at a severe stage.

“Knowledge about mental health is still low,” said Augustin Mulindabigwi, Inshuti Mu Buzima’s mental health associate director. “Often mental health illness is associated with demon possession or being too fragile and not being tough enough to deal with difficult situations…The culture also stigmatizes mental health illness and discourages conversations around the topic.”

When mental health conditions are attributed to demon possession or witchcraft, he says, the person is often brought by friends or family to churches or traditional healers. But these efforts at intervention often lead to complications, delaying or preventing the patient from receiving medical care.

These are some of the challenges Inshuti Mu Buzima is trying to address.

Inshuti Mu Buzima has worked in Rwanda for over a decade, strengthening the health system in partnership with the Ministry of Health. Its mental health care program focuses on four core elements: education and awareness; pharmacology, or treatments with drugs; psychotherapy⁠, or treatments with verbal and psychological techniques; and rehabilitation of patients.

Kirehe, where Mutima lives, is one of the three districts supported by Inshuti Mu Buzima. Through Inshuti Mu Buzima’s support, in collaboration with the government, the number of people receiving mental health treatment and care has drastically increased, in large part thanks to community outreach and awareness campaigns.

But treatment alone isn’t enough. Patients need more than medical care—they must have their essential needs met.

“Mental health problems affect the socio-economic status of the patients and their families,” said Mulindabigwi. “Once they are recovered, we can’t send our patients home if their living conditions do not allow them to fit in the society. We continue following up on them to avoid any relapse and support them to reintegrate into the community.”

Much of that reintegration is carried out through support groups for patients and their families or caretakers—spaces where they can meet and share their experiences with the support of a trained psychologist.

“When I first joined the group I was lonely,” said Mutima. “But I have made friends who are supportive and understanding.”

In addition to these groups, Inshuti Mu Buzima supports patients through pscyho-rehabilitation activities such as farming and crafts, helping them develop skills that can help them earn an income—crucial for staying well in the long run.

Mutima and some 100 other members of her group recently received land for cultivation, crops, and training to start farming. Soon, they will start a beekeeping business. 

“Many of us struggled to do any activities when we started our group therapy,” she said. “But now we are expecting a big profit from our farming activities.”

Additionally, in collaboration with the Ministry of Health, Inshuti Mu Buzima has trained nurses to provide mental health treatment and care at the community level, as part of a larger effort to integrate the service into primary care. That approach emerged after a PIH-led study showed that decentralizing mental health to the community level led to significant improvements for patients.

"Our goal is to get mental health care closer to everyone who needs it," said Mulindabigwi.

A lot has changed since Mutima started treatment. She goes to therapy once a week. She was recently elected by her fellow members to lead her group’s activities. At the end of the day, one thing is clear: she feels less alone.

“I have people I can call when I am not feeling well,” she said.

*Name has been changed to protect privacy

When Mayra Ramirez began her role as a community health worker, she was filled with fear and doubts. She had never worked in health care before. But the desire to learn and develop new skills drove her to continue.  

"At first, I wanted to study something [in college], but because I had no possibilities, this was a good place to start,” she says. “It motivated me to learn new things.”

Today, as a supervisor, Ramirez trains and mentors 30 community health workers from three communities in the rural, mountainous Sierra Madre region of Chiapas, Mexico: Salvador Urbina, La Soledad and Laguna del Cofre.

Compañeros En Salud, as Partners In Health is known locally, has worked in Chiapas, Mexico since 2011, strengthening the health system and providing medical care and social support. Accompaniment is fundamental to that care. The relationship between health workers and the communities where they work is not limited to clinics, but goes beyond, into the communities themselves. That spirit is embodied by Compañeros En Salud’s team of over 100 community health workers, known locally as acompañantes.

Since 2012, the community health worker program has hired and trained people from the rural communities where Compañeros En Salud works to provide medications and basic health services such as screenings and education.

These community health workers, predominantly women, grew up in or live in the communities they serve, enabling them to bring cultural and linguistic expertise to their work. They receive training from Compañeros En Salud in various health topics and learn how to conduct home visits for patients with chronic diseases, respiratory symptoms, pregnancy, and other health needs.

During these home visits, community health workers help patients navigate the health system, follow their treatment plans, and cope with difficult emotions that may arise. The goal of the program, since its inception, has been to build a bridge of trust between communities and clinics.

"We can learn a little more about the lives of the patients by being guided by the community health workers, because they really are the eyes of the community,” says Ramirez. “They are the ones who know the people best and their work is very important.”

Ramirez is originally from Capitán Luis Ángel Vidal, a city in the Frailesca region of Chiapas. She applied to be a community health worker six years ago. She still remembers her first assignment: making house calls to seven chronically ill patients, among them people with diabetes, hypertension and epilepsy. Her job was to follow up with each of them to help them avoid complications and make sure they followed their treatment plans. Over the next several months, she accompanied her patients and helped them bring their health conditions under control.

When she was promoted to supervisor in 2019, Ramirez faced a new challenge: leaving her family and friends and moving to Ángel Albino Corzo, also known as Jaltenango, some 70 kilometers from her home—the city where Compañeros En Salud is based. But she decided to take the chance: moving cities and taking on a new position, in hopes that she could share her skills with other women aspiring to serve their communities and continue to strengthen her own.

Managing 30 community health workers comes with many challenges. But in spite of the difficulties, community health work, for Ramirez, is about strength.

"I am very satisfied to be able to work with each one of the community health workers, to feel that I am contributing, that I am helping the patients and also them," she says.

For Ramirez, it is important that women, especially those from communities in rural areas, have opportunities to learn, expand their horizons, and grow professionally. Women in rural Chiapas often don’t have access to education and traditional gender roles dictate that they stay at home and rely on their husbands for financial support.

Gender-based violence and stigma are daily realities for community health workers, who often face criticism for being women working in their communities. Ramirez acknowledges and applauds her team’s efforts, given all the obstacles they must overcome.

And she recognizes the motivation she sees in them—it’s the same drive she had six years ago, when she first began to accompany communities, and that has pushed her in the years since not to abandon her work.

"They gained courage, gave each other encouragement, and are still working day to day with patients," she says.

When a patient delivered her baby in the middle of her tuberculosis (TB) treatment, Gulnara Zhumakairova knew she would need to rally additional resources for the new mother, who was single and the sole caretaker of her newborn. A social worker and outpatient treatment coordinator on the Partners In Health Kazakhstan team in Almaty, Zhumakairova began scouring the internet for a charity that could support the family. 

She stumbled on a nonprofit called Baby, I’m with you, dedicated to helping new mothers, and reached out for help. She made a case for the woman and her unique circumstance undergoing TB treatment. The response was exactly what the mother needed: the charity provided diapers, baby formula, and clothing and has been steadily supplying these items for eight months. 

“The approach to each patient is very individual—each one has their life situation and their challenges,” says Zhumakairova. “I typically ask them, ’How can I help you?’” 

The question usually prompts the patient to open up about their family’s needs and socioeconomic situation, she says. Building this relationship of trust is key to knowing how to help the patient most effectively. 

Whether it’s helping with groceries, clothing, baby supplies, housing, finding employment, or simply having an encouraging conversation, Zhumakairova and her two colleagues on the PIH Kazakhstan team pave the way for their patients to fully focus on their treatment regimens by alleviating the challenges that stand in the way of recovery.  They are not alone in this effort. They draw on a network of local nonprofit organizations, which have become long-standing partners, and together they help patients navigate the practical and emotional challenges of TB treatment, while maintaining a hopeful perspective throughout the monthslong process. 

endTB in Kazakhstan

PIH has been working in Kazakhstan since 2010, primarily focusing on treating TB and multidrug-resistant TB (MDR-TB), a deadlier and more complicated form of the disease. As with PIH’s work around the world, medical care is paired with social, emotional, and economic support so that patients have everything they need—food, transportation, housing, counseling, and financial assistance–while they undergo treatment, ensuring a smoother path to recovery.

Kazakhstan is among 17 countries taking part in some aspect of endTB, or Expand New Drug Markets for TB, an international partnership launched in 2015 among PIH, Médecins Sans Frontières (MSF), Interactive Research and Development (IRD), and financial partner Unitaid to find safer and shorter treatment regimens for MDR-TB, using the first new TB drugs developed in more than 40 years–bedaquiline and delamanid. Since 2017, endTB partners have enrolled 754 patients from seven countries in clinical trials, including 184 from Kazakhstan. 

The treatment regimen for patients in the five experimental groups lasts nine months, and 18 to 24 months for the standard group of patients–which remains the World Health Organization’s recommendation. The full trial period for each patient is 104 weeks. While patients are in various stages of treatment, social workers are intimately involved in every phase, says Anel Belgozhanova, supervisor of the endTB clinical trial in Kazakhstan. “Regardless of what treatment or follow-up period—even if the patients had already finished taking the medication—we support them through the end of the clinical trial.” 

Partnership in Communities

For PIH Kazakhstan social workers, each day begins with a meeting, where they analyze the needs and priorities of each patient. In Almaty, Zhumakairova works with 46 endTB patients, including everyone in follow-up care and treatment. In Nur-Sultan, Kazakhstan’s capital, to which PIH extended the endTB clinical trial in 2020, PIH Social Worker Gulmira Tanatarova works with 16. After determining priorities, the team turns to their roster of nonprofit partners to match the patient’s needs with the aid partners provide.

Gulmira Tanatarova, another social worker at PIH, built relationships with nonprofit partners in Nur-Sultan, reaching out through social media and advocating for help on behalf of TB patients to meet their daily needs. 

One organization, the Club of Kind Souls, has provided grocery donations to patients three to four times a month. “It’s a solid support for families,” Tanatarova says, adding that it includes meat, flour, oil, tea, sweets, grains, pasta, and vitamins. Red Crescent Kazakhstan has also supplied grocery baskets, as well as cleaning supplies, diapers, and school supplies. Proper nutrition is especially key in TB treatment, as medication is easier to tolerate on a full stomach. Patients also often suffer from malnutrition and begin treatment underweight, so they require additional calories to recover.

One of Tanatarova’s patients, who was forced to live on the street when his family turned away from him after the stigma of a TB diagnosis, has received quarterly clothing donations through Nur Alemi Kazakhstan, a charitable foundation that provides mothers of multiple children with food and clothing. 

Other partners offer non-tangible services that are equally important for boosting patients’ morale. Sanat Alemi Kazakhstan, a nonprofit organization in Nur-Sultan, has hosted open conversation sessions with doctors and psychologists, creating a safe space for patients to ask questions and support each other. The organization and its sponsors have also helped patients integrate into regular life by funding their outings to movie theaters, plays, and ballet and opera performances. For one patient, a support group at Sanat Alemi turned into a job after she completed treatment. 

Baby, I’m with you; From Heart to Heart; and Umay are among other local nonprofit partners that have provided MDR-TB patients with support. 

But occasionally, the requests for help result in months-long delays. “These organizations often have their own pipeline of those they’re already helping, and we have to convince them why this help is important,” says Zhumakairova. 

The story of one patient in particular fills Zhumakairova with joy. When this patient joined the trial, he was homeless and struggled with alcohol addiction. Zhumakairova and her team leveraged the network of their nonprofit partners to help him finish treatment, sort through the process of getting his residency papers, and eventually find employment. 

“We really supported him from the beginning of the treatment to getting him back on his feet,” Zhumakairova says. Ultimately,“he found hope that there are kind people out there who are willing to help.”

Nurses and midwives are vital to health care systems. This is especially true in regions with health workforce shortages, such as southeast Liberia. On a daily basis, nurses and midwives help meet patients’ everyday needs and fill in during emergency situations. Simultaneously, they train nursing students.

To improve patient care and nurse training, strategic interventions must be carried out. In a new paper—published in Annals of Global Health in October 2021—Partners In Health (PIH) leaders and Tubman University partners call for sustained investment in education and training.

“Nurses and midwives are the first and sometimes the only health care workers patients meet in Liberia,” says Daniel Maweu, nurse-midwife for PIH Liberia and lead author of the paper. “Due to a shortage in the number of doctors in Liberia, nurses and midwives are expected to perform lifesaving tasks which ordinarily would be the preserve of doctors.”

Since 2015, PIH has worked with Tubman University faculty to prepare nurses and midwives in Liberia for the workforce through effective teaching methods, capacity building, and the promotion of nursing.

There is a deep gap in Liberia’s health delivery system and rural regions of the country bear the brunt of the problems, according to Maweu and Lydia Johnson, health science instructor at Tubman University and co-author of the paper. Maweu noted that the gap impacts educational interventions, which are key to equipping nursing students to deliver high-quality care.

In the paper and through various research projects, Maweu and Johnson investigated hard-hit areas of the health system in rural Liberia to identify optimal interventions, such as training nurses.

There’s not a single teaching method that is effective on its own, they say, but rather a combination of theoretical sessions, practical sessions, and group work. More specifically, reviewing case studies, practicing procedures through simulation training, and clinical training with real patients equips nurses with essential skills.

“When the capacity of nurses is built in rural Liberia, the positive impact of global health will be felt throughout the country,” says Johnson.

Nurse training is constantly evolving due to diseases like Ebola and COVID-19 and advances in technology and research. That makes continuous professional development and curriculum review all the more important. Another strategy for nurse education adopted by the Liberian Board of Nurses and Midwives is the Online Continuous Professional Development Program, which provides hundreds of free short courses for nurses and midwives.

“Investing in nurses and midwives has an undisputed potential to contribute to the sustainability of the health workforce, develop resilience of the health system and provide quality universal health access for all,” says Maweu, who hopes to expand the Nursing Center of Excellence in rural Liberia.

When the power goes out in a hospital, the lights aren’t the only thing that could shut off.

A power outage could disrupt surgeries and disable lifesaving medical equipment, including oxygen concentrators keeping patients alive.

In Peru, where power outages are common in impoverished areas, many hospitals and health centers face the daunting task of delivering care amid unstable electricity. Most are powered by generators, which run on fuel that can be costly and in short supply.

Stable electricity is essential in care delivery, enabling health workers to run medical devices like heart monitors, quickly heat water to disinfect surgical tools, refrigerate medication and vaccines, and carry out countless other tasks.

To tackle these challenges, Socios En Salud, as Partners In Health is known in Peru, plans to install solar panels at four health centers across the country. These solar panels come as part of Socios En Salud’s ongoing work to strengthen Peru’s health system in partnership with the Ministry of Health.

The first solar panels were installed in March at a health center in the southern Arequipa region. More panels will be installed in June and July at health centers in Ucayali, a region in the Amazon rainforest, and Cuzco, a city in the Andes mountains.

Renewable Energy

Peru is one of the most biologically diverse countries in the world, with climate zones ranging from the Andes mountains to the Amazon rainforest. But that biodiversity has come under threat in recent years due to climate change—a global phenomenon of long-term shifts in temperatures and weather patterns due to human activity, primarily the burning of fossil fuels.

In the last 15 years, Peru has lost 22% of its glaciers. Last year, it was among the 10 countries with the most tropical primary forest loss. As ice melts, forests dwindle, and sea levels rise, communities already living on the margins—including Peru’s indigenous peoples, who have cared for the environment for millennia—are most at risk of displacement, impoverishment, and lack of access to health care.

But there are ways to counter the effects of climate change.

Renewable energy such as solar, which currently accounts for just 1.1% of the world’s energy, will be crucial in responding to climate change and correcting global inequities in energy access, according to the United Nations. More than 80% of the world’s energy comes from fossil fuels, which emit greenhouse gases that contribute to global warming.

Solar panels work by converting sunlight into electrical energy. Some panels, like those installed by Socios En Salud, store this energy in a battery, which can be used when sunlight isn’t available. As a form of renewable energy, solar panels are more sustainable than traditional energy sources like a generator, which runs on fuel and emits greenhouse gases. They’re also more cost-effective in the long-term.

Powering Care

Peru is among the countries with the highest potential for solar energy, which relies on direct sunlight. But few health centers in Peru have solar panels due to the upfront costs of installation and technical expertise required.

Socios En Salud began working with the Ministry of Health earlier this year to buy solar panels at a low-cost and fund installations at four health centers across the country, as well as providing training on use and maintenance. The first solar panels were installed in March at a health center in Yura, a rural district in the southern Arequipa region.

At the Ciudad de Dios health center, 48 solar panels now bolster the electricity from the grid, which on its own was unreliable and lacked a backup source of energy to support medical devices like oxygen concentrators during a power outage. Some oxygen concentrators use more electricity than a refrigerator.

In addition to supplying more reliable electricity, the solar panels will also help the health center save money in the long run.

“This renewable energy will reduce the high costs of electricity, representing sustainable and economic development in the region,” says Dr. Leonid Lecca, executive director of Socios En Salud.

Annual savings from the solar panels are projected to be 26,000 soles ($6,995), with average monthly savings of 2,167 soles ($583).

Building Capacity

Access to electricity has dramatically increased in Peru over the past 15 years, with 96% of the country’s rural population having electricity. But the quality of that electricity varies widely, and the most rural and impoverished areas continue to lack reliable electricity, sometimes even lacking access to the national grid.

Before the solar panels were installed, Masisea Health Center in Ucayali did not have access to reliable electricity. Ucayali, a region in the Amazon rainforest, is home to 18 indigenous groups and has a poverty rate as high as 14%; the region has also been affected by drug trafficking and guerilla warfare.

During emergencies, the health center there used a generator, which was expensive and ran on fuel. The solar panels, installed by Socios En Salud in early June, now provide electricity that is reliable and sustainable, ultimately saving lives.

“One of the great health problems in Peru is access to health,” says Dr. Alvaro Lujan, who is coordinating Socios En Salud’s solar energy work. “The use of solar panels eliminates this gap…By having adequate electricity, we expand the capacity of the health system, allowing doctors to use the necessary equipment for patient care.”

COVID-19 has been devastating all around, but a new study evaluates its toll on new mothers in six countries where Partners In Health works.  

A report by an international team of academic and on-the-ground researchers, published in BMJ Global Health, found that across 37 PIH-supported health facilities, almost all experienced significant disruptions in the use of maternal health services. Specifically, the researchers identified declines in expectant mothers’ first prenatal appointments as well as deliveries at health facilities during the start of the pandemic in 2020.  

“That kind of drop really happened everywhere,” said Nurse Midwife Isata Dumbuya, a study author and director of reproductive, maternal, and newborn health at PIH in Sierra Leone, one of the countries studied, along with Liberia, Haiti, Malawi, Mexico, and Lesotho.  “People were scared. No one knew with COVID what it was, so their first reaction was to stay away until it’s all clear.” 

Overall, the study found significant declines in expectant mothers’ first prenatal care visits in Haiti (18% drop) and Sierra Leone (32% drop) and facility-based deliveries in all countries, except Malawi, from March to December 2020.  Presumably, more women gave birth at home, though that data was not collected in the research. Nor did the study compare the PIH-backed facility numbers with national rates of maternal health service use. 

In addition to analyzing expectant mothers’ use of hospitals and clinics, the study also assessed the strategies used in various countries to mitigate the pandemic’s impact on service disruptions. For example, extra outreach by community health workers (CHWs) and targeted communications campaigns to educate residents about COVID-19 and alert people to safety measures at health facilities, among other measures, helped allay patients’ fears and restore trust in the health system, researchers report.  

Each country responded with somewhat different results, but—taken together—they provide concrete evidence that the current pandemic had a deep impact on maternal health services where PIH works globally. 

Sierra Leone 

In Sierra Leone, which in 2020 was found to have the worst maternal mortality of any country worldwide, the decline in maternal health visits and the 16% drop in facility-based births was worrisome, Dumbuya said, especially since the numbers had been improving before the pandemic. 

“But it could have been a lot worse,” she added. Drawing from experience overcoming previous outbreaks, notably Ebola in 2014, Dumbuya said the local team had already established strong relationships with the community and put those connections to work as COVID-19 began taking hold. “We have a history with outbreaks,” she said, “so we were able to quickly gather the support network we’d had with Ebola to let people know we can manage this, and we’re open for business.”  

Community health workers were joined by doctors, nurses, midwives, mental health practitioners, and others to visit communities, sometimes in vans equipped with loudspeakers, to offer education and the latest guidance on COVID-19, as well as recommendations for pregnant women. Plans to counteract misinformation were put in place, researchers report, “dispelling women’s fear of becoming infected at health facilities.” 

Now, Dumbuya said, the number of women seeking maternal health visits has come back “even more.” Facility-based deliveries at Koidu Government Hospital were up by 30% in 2021 compared to 2019 before the pandemic, she said. 

Haiti 

Haiti’s decline in maternal health visits, “was likely due to the full lockdown initiated in mid-March 2020 by the national government in response to the rapid spread of the disease in other countries as well as fear of COVID-19 infection in facilities,” the study said.  To minimize the disruptions, Zanmi Lasante, as PIH is known in Haiti, collaborated with the Haitian Ministry of Health to adapt safe distancing in the prenatal waiting room and encouraged women to go to the PIH-supported  Hôpital Universitaire in Mirebalais to deliver their babies. Additional support through regular telephone outreach also helped. 

Lesotho 

Lesotho was the last country in Africa to report its first COVID-19 case, researchers noted, “however, an alarming number of COVID-19 cases were detected after the influx of people traveling from South Africa for Christmas vacation.”  From March to December 2020, PIH-supported facilities in Lesotho did not experience significant declines in the number of first prenatal visits, the study said, but facility-based deliveries were 12% lower than expected. 

Researchers identified several measures that supported ongoing maternal health services, including training on all aspects of COVID-19, providing PPE, screening, testing, and patient follow-up, as well as adapting spaces for safe distancing. 

Liberia

In Liberia, researchers found that “the advent of COVID-19 was accompanied by misinformation campaigns about the disease, which spread disbelief about its potential severity and mistrust in the management of the pandemic by health authorities.” That mistrust may have negatively affected the demand for maternal health services, researchers said. In response, PIH Liberia focused on increasing the public’s awareness about the virus and the availability of services.   

The most surprising finding in Liberia, said Dr. Sarah Anyango, deputy director for clinical services and maternal health lead for PIH Liberia, was the “drastic” decline of births at health facilities—21% lower than expected during the study period. “Every pregnant mom was scared they would get it,” Anyango said. “The CHWs gave the women reassurances, but at first, the CHWs were afraid too.” Ultimately, she said, the CHWs, “played a big part in making sure women eventually felt safe.”  The so-called “household model” of care, in which health workers are assigned to visit everyone in a single home, proved particularly effective during the pandemic, Anyango added. 

“We had already trained CHWs to identify mothers with high-risk pregnancies, so when COVID came we trained them to look for pregnant moms and help them get to health facilities if needed.”

Other safety measures included establishing separate COVID and non-COVID labor suites, and testing every woman entering a delivery room were applied, she said. 

Malawi 

PIH Malawi, locally known as Abwenzi Pa Za Umoyo (APZU), provides integrated maternal care to the women in Neno District, including prenatal, delivery, and postnatal care. This, said the study, is reinforced by the CHW program that helps link pregnant women, identified in their homes, to health facilities. 

From the study: “In April 2020, the Malawi government announced plans to impose a national lockdown; however, the lockdown was canceled. ...The lack of nationally imposed restrictive measures likely facilitated maintained access to health services compared with other countries.”  

Not only did the Malawi Ministry of Health quickly develop guidelines for maternal health during COVID-19, it also “embarked on the emergency hiring of additional health workers” and Neno District’s CHW support was never suspended, indeed outreach for pregnancy-related visits increased.  As a result, the study found: “Maternity care service use in APZU-supported facilities did not suffer any significant monthly declines after March 2020. It even experienced significant increases for first antenatal visits in the months of July, September, and December 2020. Looking at the entire study period, there were no significant variations in maternity care service use during the COVID-19 pandemic in 2020.”  Additionally, the study said: “The APZU team developed a communication plan to provide reassurance about the safety of care-seeking and to dispel the fear of getting infected in health facilities.” 

Isaac Mphande, an APZU primary nursing manager, said women in Neno District have become accustomed to relying on health facilities for childbirth due to fines imposed by traditional leaders or chiefs on expectant mothers who give birth at home. “When a woman delivers at home,” he said, “they are slapped with a fine which is in the form of cash or other things like goats or chickens. These fines are collected by the chiefs and not the health facility staff...to prevent home deliveries.” He said at this point “very few women” in Neno District are giving birth at home. 

Mphande said women consistently hear from CHWS and others about the benefits of receiving care at the health facilities.   Throughout the pandemic, he said, “facilities were kept covered by skilled birth attendants such that services were not disrupted.”   

Mexico 

After the COVID-19 pandemic was officially declared a national emergency by the government on March 2020, fear and uncertainty spread throughout the areas served by Compañeros En Salud (CES), as PIH is known in Mexico. A weekly radio message by the CES birthing center’s obstetric nursing team was canceled; CHWs spaced out visits to pregnant women; and the basic community hospital in Jaltenango stopped attending deliveries to prevent pregnant women from getting COVID-19, what resulted in the adjacent CES-supported birthing center attending all pregnant women from the surrounding areas.  

The result was major disruptions in maternity service use, the study said: “Overall, the number of [facility-based deliveries] was significantly lower than expected by 16% from March to December 2020.”  

The study found significant obstacles to care. “Some rural communities prohibited people from leaving and entering, making it difficult for women to access the birthing center to give birth, the study stated. “In addition, fear and uncertainty may have led women to seek other options for delivery care. This is consistent with some reports indicating an increase in home births supported by traditional midwives during the pandemic in Chiapas.” After the first months, things began to improve, researchers found. “Fear began to dissipate as women who had experienced a safe delivery at the birthing center shared their positive experiences with other women, potentially resulting in a gradual increase of pregnant women coming to the facility for delivery.” 

A statement from the CES team summed up the study’s major takeaway: “We hope that the lessons learned at the PIH sites will help other teams develop context-specific solutions to the challenges brought on by the pandemic in their local contexts.” 

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Jessica used to run away from home. Then her mother, desperate to keep Jessica safe, found a way to keep her there: a chain around her waist.

It wasn’t a punishment. It was a last resort.

Since she was 17 years old, Jessica has lived with schizophrenia, a mental health condition that affects 24 million—or 1 in 300 people—worldwide and can lead to hallucinations, delusions, disorganized thinking and behavior, and social isolation. Life expectancy for people living with schizophrenia is reduced by 15-25 years.

The 34-year-old used to be a familiar face around her neighborhood in Comas, an impoverished district in Lima, Peru, where she sold chewing gum, candy, and cigarettes. Although she was on treatment, her symptoms took a turn.

She began to hear voices that were even louder and more disruptive. She ran away. She once tried to set the house on fire.

That’s when her mother Irene, out of desperation, gave her sleeping pills and put a chain around her waist. Sedated, Jessica was unable to continue her schizophrenia treatment and spent her days sleeping on a mattress on the floor.

Even before the chain, the house was an unstable home.

A shack made of corrugated metal and plywood, with half of the roof unfinished, the house clung to the side of a steep hill, 170 steps up from where the paved road ended. Accessing the main room where Jessica lay chained meant winding through a narrow passageway formed of mounds of trash her mother hoarded and sold for scraps in the market. Stray cats, dogs, and chickens perched on the piles and hopped along the corrugated rooftop. Strangers also came and went through the open doorway, including teenagers who stole Jessica’s identity documents.

The neighbors knew Jessica needed help. But they didn’t know where to go. It wasn’t until a police report was filed against Jessica’s mother, for abandonment, that she was connected to Socios En Salud—and support.

Mental Health Care

Socios En Salud, as Partners In Health is known locally, has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the decades since, Socios En Salud has provided medical care and social support to hundreds of thousands of people in Lima and beyond.

Socios En Salud’s mental health program has served patients with conditions ranging from depression and anxiety to schizophrenia to other severe mental disorders. It’s rooted in a collaborative, comprehensive, and community-based model, dispatching teams of psychologists, social workers, and community health workers—local residents trained to provide basic health services—to patients’ homes to provide medications, therapy, and support in navigating the health system. Most people globally do not have access to formal mental health care, even as mental health is one of the leading causes of disability worldwide.

Socios En Salud has cared for patients with schizophrenia for years through its community health program, including 23 community health workers specializing in schizophrenia care and “safe houses”—homes providing 24/7 care for women with chronic mental health conditions and without family caregivers. In 2015, Socios En Salud launched the first-ever safe house in partnership with the Ministry of Health—a house that has since provided a model for care and inspired the Ministry of Health to build 50 more safe houses nationwide.

“Forgotten Cases”

Socios En Salud staff visited Jessica in November 2021.

Along with staff from the community mental health center in Wiñay, Socios En Salud staff had come on a mission: to help Jessica and her mother understand that free mental health care and social support were available.

Jessica’s mother Irene greeted them and led them inside. The team made their way through a narrow passageway formed from solid walls of trash and found Jessica, chained to a wooden pole in the middle of a clearing that served as their main room—her hair tangled, her clothes disheveled, and her face unwashed. She was disoriented and speaking incoherently.

Her health wasn’t the only concern the team had. She and her mother had no electricity, running water, or sewage. There was no place to prepare food, and the two women relied on leftovers Irene scrounged from the nearest market. Their living space was cluttered with bags, bottles, and garbage; flies swarmed around.

After speaking with Jessica and Irene, Socios En Salud and health center staff identified three main goals: help Jessica apply for a new national identity card and disability card, refer her to the health center for ongoing medical care, and connect her and her mother with free food and stable housing.

"Stories like Jessica's are plentiful in our country,” says Milagros Tapia, a psychologist with Socios En Salud. “Unfortunately, they are forgotten cases, victims of stigmatization, and without access to health services.”

Over the next several months, Socios En Salud and health center staff worked relentlessly to help Jessica access those health services, regularly making house calls to provide medications and accompaniment as she navigated the health system. With Socios En Salud’s support, Jessica restarted her medication and scheduled check-ups at the health center in Wiñay. She also received a COVID-19 vaccine.

Week by week, her condition improved. The voices and hallucinations subsided. She was no longer trying to run away or harm herself. The team noticed changes in her appearance, too. Her face and hair were washed. Her clothes were clean. And in late December, for the first time in years, the chain came off.

Social Support

Pills and injections weren’t the only resources Jessica needed to stay healthy and manage her mental health condition. Socios En Salud staff knew that social support—such as food, housing, and transportation—would also be crucial.

To help Jessica and her mother access free meals, instead of searching for food scraps at the market, Socios En Salud provided foods that didn’t require boiling, like crackers and tuna, and met with community leaders to help reopen a neighborhood soup kitchen, where daily hot meals were provided for free.

Socios En Salud also provided support for transportation, including fares for taxi rides to the local health center for Jessica’s appointments, and housing, with the goal of helping her move to safe house. Additionally, the team helped Jessica apply for a national identity card and disability card, which would make her eligible for government benefits.

Even as Jessica’s medical care and social support fell into place, maintaining her health was often a day-to-day struggle. Following her treatment was challenging given her situation. Her mother, who also lived with a mental health condition, also struggled at times to be a caregiver for her daughter.  

But Socios En Salud, the community mental health center, and Jessica’s community—including her neighbors and local government—were there to support her and her mother, each step of the way.

"Behind Jessica, there are many people helping her,” says Belinda Pineda, a neighbor and president of the neighborhood council in Jessica’s community. “There is the NGO, the community mental health center, the community itself, and the neighborhood council that supports them. The progress and improvement in Jessica's health is evident. I feel very happy for Jessica."

That support came from unlikely places, too.

In January, Socios En Salud staff found the phone number of Jessica’s estranged sister, Rosa, and gave her a call. Rosa was willing to help in any way she could. She agreed to help Jessica follow her treatment plan, attend her appointments, and hosted her in her home for a few weeks. She also helped Jessica pick up her national identity card—issued in March, after months of advocacy by Socios En Salud.

As Jessica continued her treatment, with the support of Socios En Salud and her community, she experienced a feeling she hadn’t in years.

"I feel more confident in myself,” she says. “I now go with my mother to the market and we buy groceries together. I am taking my pills daily and doing everything I can to get better...I now know I am not alone."

Shortly after Haitian President Jovenel Moïse was assassinated in July 2021, Belennda Joseph noticed an odd discharge leaking from her vagina. At first she thought it was stress: the country had descended into turmoil, violence escalated, and citizens were on edge. But two weeks later, when she noticed some blood, Joseph made an appointment to see an OB-GYN in Port-de-Paix, where she lived. The doctor said she was anemic, prescribed medication, and sent her home without performing an exam.  

But the bleeding didn’t stop, said Joseph, speaking in Haitian Creole through a translator. Over the next several months, through a maze of new doctors, delayed test results, and rising concerns, Joseph finally got a diagnosis: cervical cancer. It was stage 2, she learned--too advanced to remove surgically. 

The news hit her hard, she said, “it broke my heart.”  Even though cervical cancer is the leading cause of cancer-related deaths among women in Haiti, Joseph, 31, formerly a nurse at the University of Notre Dame Hospital in Port-de-Paix, said she’d never known another woman who had it. That’s not unusual in a country where treatment has been scarce and diagnosis can be spotty. Women with cervical cancer—many young, in their 30s or 40s— are often left to fend for themselves, doctors say, sent home with pain medication only, left to suffer, and eventually die. 

In wealthy countries, cervical cancer is highly preventable through routine screening, like pap smears, and with HPV vaccines. In Haiti, however, where Zanmi Lasante--PIH's sister organization--has worked for decades, such screening is not part of primary care; nor are the many mainstays of gynecological cancer treatment, such as radiation or a full menu of chemotherapy drugs. And, with no fellowship-level gynecological oncology training for clinicians, there are few specialists in the country to treat such cancers.  

A $10,000 Treatment—in Another Country 

The doctor who delivered Joseph’s diagnosis did suggest one option: travel to the Dominican Republic, where more extensive treatment would be available. “Get a passport as soon as possible,” he’d said. She considered this until she spoke to clinicians in Santo Domingo, who informed her that the cost of radiation treatment would be about $10,000. For her family of five siblings and a single mother whose farm was decimated due to drought, that price tag, in a country where the gross income per capita is about $1,250, was completely out of reach. 

All the while, Joseph continued bleeding. 

What Joseph didn’t know at the time was that for just over a year, an interdisciplinary team of clinicians from Zanmi Lasante's Hôpital Universitaire de Mirebalais (HUM), Dana Farber Cancer Institute in Boston, AdventHealth in Florida, University Hospital in Kinshasa, and Massachusetts General Hospital (MGH) and Harvard Medical School had been meeting weekly over Zoom to discuss a range of gynecologic cancers afflicting patients in Haiti. The global team was launched to broaden and support local clinicians’ capacity to care for patients with gynecological cancers, including ovarian, endometrial, vulvar, and others, with particular attention to cervical cancer. In the weekly case conferences, and monthly deep dives with experts, clinicians discuss new treatment options and emerging research and bring together specialists to work through difficult cases. For instance, a recent discussion centered on a complex case of gestational trophoblastic disease with a world class expert, a Harvard pathologist and local Haitian doctors, led by Dr. Christophe Millien, an OB-GYN and medical director of HUM.  The new collaboration also initiated “telepathology” consults in which pathologist volunteers in Boston review samples from Haitian patients.  

So far, the team has discussed about 50 complex cancer cases. At HUM, more than 20 cervical cancer patients have been treated under the new global consult system led by Millien, and OB-GYNS Dr. Jean Clause Ulysse and Dr. Jean Joel Saint Hubert. 

Improving Care, Now and Into the Future 

The evolution of cancer care at HUM has a familiar PIH arc: Rather than accepting the constraints of the setting—no radiation, a severely limited blood supply which impedes major surgeries, no gynecological cancer specialists—the team instead is thinking creatively, scouring the medical literature for evidence-based alternatives to improve care. At the same time, clinicians continually strategize on how to build a system that supports even more robust care in the future.  

For example, Dr. Tom Randall, gynecologic oncologist at MGH, and associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, cites a research study out of India which led to a paradigm shift in care.  

The study, by researchers at the Tata Memorial Centre in Mumbai and published in the Journal of Clinical Oncology in 2018, involved 635 patients with cervical cancer. Patients were assigned into two groups: one received neoadjuvant chemotherapy (that is, giving chemo first) followed by surgery; the other group received the standard of care, chemotherapy plus radiation. While the radiation patients showed slightly better survival rates, the gap was not huge: Researchers reported the 5-year disease-free survival in the chemotherapy plus surgery group was 69.3% compared with 76.7% in the chemo plus radiation group. 

For Haiti, that’s good news, said Randall: the Tata study shows that it’s possible, in resource-poor settings where radiation is unavailable, to provide cervical cancer patients a viable treatment option. “The study demonstrated that neoadjuvant chemotherapy followed by radical surgery is a feasible, safe, and effective treatment for locally advanced cervical cancer when radiotherapy is not available,” he said. 

A Radical Shift 

For Millien, at HUM, the ability to provide this improved level of care is a radical shift.

“I can testify to the difference,” he said. “At first, when I got a cervical cancer patient, I could not do anything for her—no care. Now it’s different, now there is something we can do." 

HUM is one of the first centers in the world to incorporate this approach to cervical cancer treatment in a very low-resource setting. 

And so, when Joseph showed up at HUM early one morning last November to wait at the front of the line outside the facility, she met with Millien, who said he could try to treat her cancer. “How much would it cost?” she asked. He replied: “It’s free.” 

The road would not be easy: Multiple rounds of harsh chemo, surgery to remove her uterus, and reliance on others to care for her through recovery, loss of her job.  All of this made Joseph nervous, unsure about whether to proceed with her treatment. But Millien told her it was a question of life and death. “God is arranging one thing after another for me,” Joseph said. But then she re-evaluated her options and agreed to the surgery.  She met with Dr. Joarly Lormil, the chief of oncology, psychologists, and social workers, who reassured her that she’d be taken care of at HUM.  After three rounds of chemotherapy, the mass still had not shrunk enough to operate, so Joseph needed an additional three rounds. 

On March 11, Joseph underwent surgery. Despite some post-operative complications, Millien said, the procedure went well. Joseph, in the end, said she is glad to now move forward.

She said that since she was unable to travel outside Haiti for treatment, without this surgery “the cancer would have eaten me, and I would have died.” 

To ensure better, and more comprehensive care in Haiti for others like Joseph, facing gynecological cancer, the international consortium is still pushing the boundaries of what’s possible. Ultimately, the goal is to make radiotherapy available more widely in Haiti, but this is likely to take many years.  

For now, clinicians are working to develop a deeper bench of specialists who can manage these complex cancer cases. Patients in wealthy countries take for granted the availability of gynecological oncologists, but in Haiti, no such training program existed—until now.  In late April, it was announced that the Mirebalais University Hospital Gynecologic Oncology Fellowship in Haiti, the first of its kind in the country, had been approved by the International Gynecologic Cancer Society. Now that the fellowship is official, the international consortium will work to finalize its global curriculum and mentorship fellowship based at HUM. “Our plan is to ultimately train one to two residents each year,” said Rebecca Henderson, an MD/PhD candidate at the University of Florida, who has been working with the team since its inception in early 2021. 

Randall of MGH said the program will provide Haiti’s first comprehensive two-year education and training program in gynecologic oncology by pairing Haitian trainees with expert mentors who track the trainees’ progress. The plan is for mentors to eventually travel to HUM biannually to provide trainees with hands-on surgical training, and fellows will likewise complete one to three months of clinical observation at the mentor’s institution. 

After several weeks recovering from surgery, and various complications due to her advanced cancer, Joseph was discharged from HUM in early April. 

"Cancer prognoses are always uncertain and good outcomes are never guaranteed," Millien said. "In Haiti, where many of the mainstays of cancer care are missing and diagnoses are often made late, this is especially the case. Belennda can at least know she has a care team who is going above and beyond to provide everything they can in this resource-limited setting."

Yesterday, Dr. Tedros Adhanom Ghebreyesus bestowed a WHO Director-General’s Global Health Leaders Award on Partners In Health (PIH) Co-founder and Chief Strategist Dr. Paul Farmer, who passed away unexpectedly in February.

The honor was given at the opening of the 75th World Health Assembly (WHO), the annual meeting of national representatives who make up the decision-making body of WHO, and broadcast worldwide.

“Paul was a true humanitarian and a tireless champion of equity and health as a human right,” said Tedros. “His work helped to empower health and care workers in communities around the world. He worked in places that others had given up on.”

Wingdie “Didi” Bertrand, co-founder and president of Women and Girls Initiative and widow of Dr. Farmer, accepted the award on his behalf.

“We owe it to Paul to collectively keep his legacy alive,” said Bertrand. “That is why today I am encouraging all in attendance to adopt policy decisions on behalf of your fellow citizens that prioritize treating every person as a person—and invest in the provision of high quality, lifesaving health care—as health is a fundamental human right.

"This is what Paul has inspired us to do, taking, always the lead, through hard work and commitment to his patients and their families and communities around the world.”

As an infectious disease physician, Dr. Farmer earned accolades for treating patients in impoverished countries with high quality care, including those suffering from HIV and cancer. As a medical anthropologist, he was known for popularizing and deepening understandings of “structural violence,” the idea that social systems are designed to impoverish, sicken, and sideline select groups. As chief strategist of PIH, he garnered plaudits for pioneering community-based treatment strategies, building teaching hospitals, and more.

Dr. Farmer authored multiple books, including: In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez, Reimagining Global Health: An Introduction, and To Repair the World: Paul Farmer Speaks to the Next Generation. His most recent book was released in November 2020: Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. He was also a professor at Harvard University.

Dr. Sheila Davis, PIH CEO, leads PIH and advances his vision. “On behalf of the entire Partners In Health team, we want to thank WHO for honoring Paul with this award,” she said. “Paul taught us all so much—how to treat clinical maladies; how to practice pragmatic solidarity; and how to integrate dignity, beauty, and social support into care delivery. But most importantly, he taught us that our lives are in service to others.” 

The first case, diagnosed in early March, was a 57-year-old man from southern Malawi. The second, an 11-year-old boy.  

Now, cholera, spreading through six districts in the south, has killed 12 people and sickened at least 300 as of May 19, 2022.  

One of those sick patients, suffering from severe symptoms, was a 1-year-old girl. She was treated last week at Lisungwi Community Hospital in the Neno District, where Abwenzi Pa Za Umoyo, (APZU), as Partners In Health is known in Malawi, has collaborated with the local Ministry of Health to activate rapid response teams to mitigate the impact of the outbreak and help with recovery efforts. 

“This is bad,” said the child’s mother, who declined to be named. “I was so afraid to look at my child. She has had diarrhea and vomiting before, but this was different.” The child was treated, and the mother, profoundly grateful for the medical attention, was able to take her daughter home today, said Dr. Brown Khongo, secondary healthcare manager at APZU. 

Outbreak in Neno 

Neno District, one of the hard-hit areas, has had 62 cases of cholera as of May 19,  2022 with one death—a 13 year old boy who was pronounced dead on arrival at one of the health centers in the district. 

Cholera is an extremely virulent disease that can cause severe diarrhea and vomiting and can be fatal if left untreated, according to the World Health Organization. It can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between 2 hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae. 

Khongo said that, typically, cholera is seen during Malawi’s rainy season, November through April, but years have passed with no cholera at all in Neno. The current outbreak, according to health leaders, is clearly the aftermath of Tropical Storm Ana and Cyclone Gombe that, earlier this year, caused torrential rain and flooding, leaving many people “no access to safe drinking water and sanitation facilities and thus, at risk of widespread disease outbreaks including cholera,” the WHO reports. 

The storms impacted over 221,000 households and 945,000 individuals nationwide, officials said; in Neno District, more than 7,500 homes were destroyed. 

Chronic Water Problems

The storm’s pounding rain, wind, and subsequent flooding disrupted already weak structures, including water sources, Khongo said. Homes across the region collapsed and most people lost their household items for sanitation and hygiene. “Outdoor toilets collapsed and utensils were lost,” he said. Many families are still sheltering with neighbors while rebuilding their own houses, leading to possible overcrowding and further demands on the few sanitation and hygiene facilities that are available. “This,” he said, “adds to the chronic water problems, especially in Lower Neno (where all cases are coming from now) and part of Upper Neno.” 

The main sources of water in the lower region are narrow wells, or boreholes, Khongo said, and there is no piped water supply. But the water from the boreholes and the few personal wells that exist are salty, he said, “so some parts of the community use water directly from the rivers and streams because they are less salty.” 

So far, there’s been no testing of water to pinpoint the source of the outbreak, Khongo said: “But the presence of the outbreak is enough to conclude that the water is contaminated.” 

Responding to an Emergency 

The APZU team, working with Ministry of Health colleagues and others, has mounted a strong emergency response, including setting up a cholera treatment center at Lisungwi Community Hospital with 20 beds, running water, and medicines and other medical supplies. So far, over thirty patients have been admitted to the center with seven currently being managed. 

The team is also conducting: 

• Epidemiological assessments to map areas reporting cholera cases; 
• Contact tracing for all confirmed cases in the community; 
• Risk communication and community engagement; 
• Safe water and household chlorine distribution. 

APZU continues to fill medical and other gaps, for instance, by helping to procure more cholera treatment and test kits and mobilizing a cholera vaccine plan, among other efforts. This is not new for PIH: successful cholera vaccination campaigns were launched previously in Sierra Leone and Haiti. Indeed, PIH's work in Haiti during a 2010 cholera outbreak, rapidly mobilizing to treat more than 145,000 Haitians and vaccinate another 45,000, was key to the development of a global stockpile of oral cholera vaccines by the World Health Organization and other partners in 2012.  

Climate Change and Infectious Diseases 

 Of course, no single storm or cyclone can be blamed on the warming climate. But scientists and climate experts acknowledge that climate change does affect the frequency and intensity of extreme weather events, which in turn can create human disasters, particularly for the socially vulnerable. More (and more intense) cyclones lead to flooding and water contamination from runoff or sewage, which can lead to the spread of contagious diseases, such as cholera. 

Dr. Kelsey Ripp, an internist working on climate change education for medical students at the University of Global Health Equity in Rwanda, a Partners In Health-supported university sees global health and climate change as intimately intertwined. 

 “We often call climate change a threat multiplier,” said Ripp, “because it worsens various health problems by exacerbating other widespread contributors to ill health, such as poverty.”