Partners In Health began the HIV Equity Initiative in 1998, providing lifesaving antiretroviral therapy to patients dying of AIDS at no cost to them. As one of the first projects in the world to do so, the initiative was used as an example of the effective delivery of antiretroviral therapy in a poor, rural setting, providing evidence for the massive scale up of access to treatment for millions of poor HIV patients around the world. Below, the patients receiving treatment through the initiative stated their solidarity for patients without access to the lifesaving drugs. 

We, the patients of Zanmi Lasante (Partners in Health) in Cange, have a declaration we would like to put before all of you. It is we who are sick; it is therefore we who take the responsibility to declare our suffering, our misery, and our pain, as well as our hope. We hear many poignant statements about our circumstances, but we feel compelled to say something more categorical and more resounding than what we have heard.

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

In addition to our health problems, we have other tribulations. Even while preoccupied with being sick, we still have the problem of paying for housing. We have trouble finding employment. We remain concerned about sending our children to school, and every day we face the distressful reality that we cannot find the means to support them. Not being able to feed our children is the greatest challenge faced by mothers and fathers all over the nation of Haiti. We have learned that such calamities occur in other countries as well. As we reflect on all these tragedies we must ask: is not every human being a person?

Yes, all human beings are people. It is we, the afflicted, who are speaking. We have come together in Cange to expose the difficulties facing the sick. We also have some ideas in our knapsacks that we would like to share with you who are in authority, to see what you can do to resolve the health problems of the poor.

We have a message for all those who are concerned about us and who care about our health: we would like to thank you for the heavy load you carry with us.

When we the sick, who are living with AIDS, speak on the subject of "Health and Human Rights," we are aware of two rights that ought to be indivisible, inalienable. Those who are sick should have the right to health care. We who are already infected believe in prevention too. But prevention will not cure those who are already sick. We need treatment when we are sick, but for the poor there are no clinics, no doctors, no nurses, no health care. Furthermore, the medications that are available are too expensive. For HIV treatment, for example, we see in the newspaper that it should cost less than $600 per year. Although that is what is quoted in the press statements, here in a poor, small country like Haiti, it costs twice as much.

The right to health is the right to life. Everyone has a right to live. That means if we were not living in misery but in poverty, we would not be in this predicament today. Having no resources is a great problem for poor people, especially for women and those with small children. This is what in our abject Haitian reality is recognized as "the very struggle for life which inherently destroys life"; that is, as we scrape for life, we encounter death.

If everyone had a right to food, education, health—the way it ought to be—we would not be in such dire straits today. It is imperative that we resolve the problems of poor or no roads, water, and electricity so that everyone may live like a human being.

Why are they destroying us so? Is it because we are the poorest that they do not take our survival into consideration? Is it because we are the poorest that we are marginalized, that they do not care about us?

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

For those who are listening today, we have another message: this message is for those who manufacture medications. We would like to encourage you to develop and generate medications and to continue doing research. But if you do not lower the prices, we, the abject poor, will not be able to buy the medicines essential to our survival and, inevitably, we will get even sicker. We will continue to die before your very eyes, fully aware that our already insufferable situation grows worse every day.

We are making an appeal to you, Mrs. Titide (Haiti's then first lady, Mildred Aristide, who was in attendance). We, the patients of Cange, take our hats off to you for your pronouncements on our behalf at the United Nations meeting. We know you have the conviction and the will; we know you are fighting for US. Nonetheless, we ask that the government make more of an effort to rally around those of us who are sick by helping to provide us with good doctors, good nurses, good medications. We dispatch this same request to the minister of Health. It would be wise for you who are in authority to do this work quickly, before more of us who are poor die.

We have a message for all those who are concerned about us and who care about our health: we would like to thank you for the heavy load you carry with us. We who are sick love you very much, and we ask you to hang in there, to persevere with us. We recognize that it is not easy to find dedicated people like you. We are speaking specifically about the "accompagnateurs," auxiliaries, nurses, doctors, administrators and everyone all around who attends to us, including all those who cook, wash, and iron for us.

We have a message for you who suffer from the same sickness as we do. We would like to tell you not to get discouraged because you do not have medications. We pledge to remain steadfast in this fight and never to tire of fighting for the right of everyone to have necessary medications and adequate treatment.

We also have a message for the big shots—for those from other countries as well as from Haiti, and from big organizations like the World Bank and USAID. We ask you to take consciousness of all that we continually endure. We too are human beings, we too are people. We entreat you to put aside your egotism and selfishness, and to stop wasting critical funds by buying big cars, constructing big buildings, and amassing huge salaries.

Please also stop lying about the poor. It has been alleged that we don't know how to tell time and that is the reason we are ineligible or unworthy of medications that have to be taken at scheduled intervals. Stop accusing us unjustly and propagating erroneous assumptions about our right to health and our unconditional right to life. We are indeed poor, but just because we are poor does not automatically mean we are also stupid!

It is our ardent wish that this message not be put aside or relegated to the files as just another paper document. As Haitian popular wisdom asserts, "As long as the head is not cut off, the hope of wearing a hat remains."

Partners In Health supports three public health facilities in the Dominican Republic, just across the border from Haiti in the province of Elias Piña. With funding and support from the U.S. Agency for International Development, PIH and our Dominican sister organization, Socios En Salud, work to prevent HIV and improve the quality of HIV care for vulnerable migrant populations, many of whom are Haitian. 

Dr. Alexandre Widner, the project’s director since March 2013, is familiar with the dynamics of border towns. The Haitian doctor grew up in Anse-a-Pitre, another town on the porous border between the Dominican Republic and Haiti. He answered our questions for World AIDS Day.

Where did you study medicine, and how did you become the director of Socios En Salud?

I studied medicine for seven years in Cuba. It was an incredible experience, to be part of the Cuban medical system. They have a great system that is based in community health, and so the population is very involved in their health. It’s a well-developed system.

In the past, I worked on the border in Anse-a-Pitre, in the south of Haiti, with an organization called Batey Relief Alliance. We supported a clinic, operated a food program, and educated people about HIV/AIDS. It was through that position that I learned about Zanmi Lasante’s work in the Central Plateau.

The people served by Socios En Salud face difficult barriers to health. Could you explain some of their challenges?

Our patients are people who have a lot of problems with poverty and health. They’re facing HIV, as well as social, psychological, and cultural barriers to care. We work to break the cycle of poverty and disease so that people can continue living with hope.

About 45 percent of our patients are Haitian migrants, many of whom live in the DR without documents. They have four strikes against them. First, they are migrants who don’t speak the language or know the culture of the DR. Second, they don’t have legal immigration documentation. Third, they are living with HIV. Finally, they’re Haitian, and face discrimination and racism. Most of the Haitians are in the DR to look for work and better economic opportunities, but sometimes they end up in commercial sex work because of their economic difficulties.

The team here at Socios En Salud is a mix of Haitians and Dominicans, and we’re working together to improve the situation for them. One of our biggest challenges is to establish a binational referral system that allows our patients to continue receiving care no matter what part of the island they’re in. People who cross the border are living in an unusual situation, and we’re here to attend to their needs and improve their lives.

What services does SES provide to these patients?

For four years, we have worked to prevent HIV and strengthen care for HIV patients on the Dominican border. There are many aspects to this. We work closely with Dominican Ministry of Health staff at public hospitals in Elias Piña to prevent HIV and provide treatment to people living with HIV. We also do a lot of community counseling and testing of HIV, to help people understand their status and enroll in care if they are HIV positive.

Something that has impressed me a lot is the love and care the staff gives to people with HIV.

In the hospitals, we prevent the transmission of HIV from mother to child by training doctors and nurses to conduct HIV testing on all pregnant women and enroll the women who test positive on antiretroviral therapy, which wasn’t always happening before. To improve HIV care at the hospitals, we acquired a mobile testing device that allows us to determine the immune system health of HIV patients, which helps us determine when they need to start antiretroviral therapy. Before that, the hospitals had to send blood samples all the way to Santo Domingo to be tested.

We also provide food support to patients with HIV and tuberculosis, and we connect them with community health workers who ensure they are taking their medicines every day. However, our 32 community health workers, called acompañantes, do much more than that. They are confidantes to these patients and work with them on many social or psychological problems they have, such as stigma or discrimination, and refer them to the social worker at SES and help link them to psychosocial support services. We also work with Zanmi Lasante, Partners In Health in Haiti, to support the hospital on the Haitian side of the border, in Belladère.

How has your experience been so far working in this program?

Something that has impressed me a lot is the love and care the staff gives to people with HIV. In medical school, there’s a special focus on taking care of people with HIV/AIDS. To me, it’s wonderful to work with young people and others to help them be healthy. All of PIH’s work, including in Haiti, has this social mission to attend to victims of injustices such as poverty. I believe that we’re working for justice not only on the border but around the world, so I’m enthusiastic to work with this team.

Read the story of one Dominican community health worker who goes the last mile to care for people with HIV.

This Sunday, December 1, is World AIDS Day. To mark the occasion, Blessing Banda, HIV and nutrition coordinator for PIH’s Malawian sister organization, shared the story of a patient he first encountered two years ago.

A group of young children ran toward the Toyota Land Cruiser. It was late afternoon in Malawi’s Neno District, and the vehicle was approaching a rural homestead that consisted of one house made of iron sheets and three grass-thatched homes. 

As I got out of the car I heard a voice say, “Uncle Bule.” I looked down and saw a little girl running toward me. She hugged me. I picked her up and began walking toward the homes. I couldn’t believe it was Rachel. She looked so beautiful, so healthy.

I remember when Rachel was admitted to Neno District Hospital’s Nutrition Rehabilitation Unit. It was November 2011, two years ago this month. Back then, she was 2 years old and gaunt with swollen legs. She looked sad and weak and wouldn’t allow anyone to talk to her. The only thing she wanted was to play with a stuffed sunflower toy we had at the hospital.

Rachel’s mother was nervous when they came to the hospital. The 22-year-old woman, who worked in people’s fields during rainy season to piece together a living, didn’t know what was wrong with her child. We tested Rachel and her mother for HIV. As soon as the test results came back positive, both mother and daughter began taking medications. PIH/APZU counselors met immediately with the mother to provide psychological support.

There are many children in need. We will work collectively to save these precious lives.

But Rachel was also malnourished. She stayed in the Nutrition Rehabilitation Unit for nearly two weeks. Slowly we began to see progress. Still, her mother was confused and anxious when she was instructed to feed Rachel only the therapeutic formulas we provided.

After Rachel was discharged, PIH/APZU staff, including myself, began making home visits. Rachel lives with her mom and grandparents. They’re farmers, and it’s hard for them to earn enough income. Through our Program on Social & Economic Rights (POSER), we were able to help Rachel’s mother enroll in school and provide a small stipend of about 3000 Malawian Kwacha, or about $7. That helped enroll Rachel in preschool at age 3 and cover basic supplies—notebooks, pens, uniforms—for the mother. Others provided support to make sure the extended family was getting care, too.

Rachel at age 2 and her mother, Mphatso. Credit: PIH

Because Rachel and her mother are now connected to the health system, APZU staff continues to accompany them through HIV care and nutrition evaluations.

Seeing Rachel, now 4 years old, run across that field was a powerful reminder of how we can change lives. She looks so much healthier than when we first met. She is charming and loves hide and seek and playing in the fields with other children.

Her mother makes sure they both adhere to their medication. She’s still in school and doing well—she wants to be a nurse to help people from her home village and to help other people in Neno who are facing the same problems she has faced.
When I think of Rachel’s story, I think of how an integrated health system that delivered nutritional care and HIV care helped her. I think of ways we can integrate social care and accompaniment into this system. It is our voice that speaks for those children who cannot speak. It is our hands that touch what they cannot touch. There are many children in need. We will work collectively to save these precious lives.

Multidrug-resistant tuberculosis used to be a death sentence for poor people, and it still is for many.

Today, a third of MDR-TB patients around the world die from the disease. A cure requires at least two years of treatment, including daily injections of antibiotics that cause serious side effects such as loss of hearing and liver damage. Many MDR-TB patients permanently lose some lung capacity.

But one Peruvian patient with MDR-TB decided that he wouldn’t let his illness hold him back.

Carlos Cántaro, 27, lives in the hillside shantytowns of Lima, Peru. In 2012, he began treatment for MDR-TB, which caused problems with his hearing and contributed to his depression. A few months ago, he participated in a group therapy session provided by Socios En Salud, Partners In Health’s sister organization in Peru, which supports patients with MDR-TB in partnership with the Peruvian Ministry of Health.

“I was depressed for a long time, but therapy helped me,” Cántaro said. “Sharing my experience, I felt like I could vent. I felt more confident in myself.”

With his disease under control through treatment, he decided to take up sports again. In school, he had excelled in running and won several competitions on the district level. But his physical abilities had deteriorated because of his illness and the treatment.

Cántaro knew what was ahead of him. Slowly, he began training to improve the capacity of his body and lungs. He worked up to running every other day in the mornings, and on his days off, doing other exercises at home or in parks close to his home in San Juan de Lurigancho.

Then he decided to run a 10K race, which was part of an event themed “Together, nothing can hold us back.” Cántaro asked PIH/SES for support, and clinicians evaluated him to ensure he was well enough to run. He was in relatively good health, with fewer lesions in his lungs than many patients. Half a dozen staff from Socios En Salud turned out on race day, Oct. 13, to cheer for him.

“It’s not easy to have this illness and take up running,” said Vanessa Carrillo Montenegro, SES communications officer. “At first, the disease forced him to quit sports for a while, but he has such an athlete’s spirit that his goal is to continue doing what he did before he got sick.”

And he did. Cántaro completed the race in 55 minutes, a pace just under nine-minute miles.

“I want to start my own business and continue running to be an example to others,” he said. “They too can make this choice, to believe that it can be done.”

Cántaro has been responding well to treatment. The Peruvian Ministry of Health provides his medications, and PIH/SES provides additional support, such as psychotherapy, food packages including meat and vegetables, and home visits from a nurse. In a few months, he will undergo a medical evaluation to determine whether he is finished with treatment or requires another year of care.

“I will finish treatment and continue working for my family,” said Cántaro, who is married and has a 3-year-old son. “God willing, I’ll always have my passion for sports.”

The World Health Organization recommends that a country have 2.3 health care professionals—physicians, nurses, and midwives—for every 1,000 residents. Rwanda falls far below this ideal with 0.84 physicians, nurses, and midwives per 1,000 residents.

An article published today in The New England Journal of Medicine—co-authored by Rwandan Minister of Health Dr. Agnes Binagwaho, U.S. Global AIDS Coordinator Dr. Eric Goosby, Dean of Medicine at the National University in Kigali Dr. Patrick Kyamanywa, and PIH’s Dr. Paul Farmer, among others—lays out the details of the Human Resources for Health Program, a clear and bold partnership to remedy this shortfall.

The Human Resources for Health Program represents the largest global health partnership forged between U.S. academic institutions and a low-resource country. The seven-year program will bring in hundreds of clinicians and educators from 25 American medical institutions, including Harvard Medical School, Brigham and Women’s Hospital, Duke University Medical School, and Yale School of Medicine. After seven years, the authors write, Rwanda will operate the residency and training programs within its own budget and with its own teachers and clinicians.

According to the article, more than 500 Rwandan physicians will be trained in specialty and subspeciality areas by 2018.

"The Human Resources for Health Program focuses on knowledge transfer, sustained collaboration, and the establishment of new medical residency, nursing specialty, health management, and oral health programs within the Rwandan education system,” the authors write, going on to note that the consortium will play an “integral role in strengthening global health curricula.”

The shortage of clinicians in low-resource countries is well delineated.  It’s something that many of us have come to associate the term “brain drain” with. But the authors of the article caution that “one important consideration for the retention of health professionals that is often overlooked in discussions of “brain drain” is the persistent lack of basic equipment and supplies at facilities; physicians who benefit from improved training will not be retained if they cannot apply these skills to their clinical practice and to teaching future clinicians.”

Over the past decade, Rwanda has achieved some of the most impressive health gains in the world. With this fresh approach to academic collaboration, the country is poised to build on these gains far into the future. 

Click here to read the full New England Journal of Medicine article.
 

Tuesday, November 19 at 7 p.m. ET
McKenna Hall Auditorium, University of Notre Dame

Introduction: Rev. John Jenkins, CSC
Book presentation: Dr. Paul Farmer

Commentary:
Rev. Gustavo Gutiérrez, OP
Robert Ellsberg, Editor-in-chief, Orbis Books
Ophelia Dahl, Executive Director, Partners In Health

To mark World Diabetes Day, The New York Times published an opinion piece examining the challenges to treating the disease in Haiti. 

The authors of the piece, Palav Babaria and Aisling O'Riordan, know Partners In Health and our Haitian sister organization, Zanmi Lasante, well. Babaria, now a primary care physician at Highland Hospital in Oakland, worked with PIH in Hinche, Haiti, from 2012-2013 through the University of California, San Francisco's Global Health-Hospital Medicine Fellowship. Similarly, O'Riordan, who graduated in 2011 from the Royal College of Surgeons in Ireland, volunteered with PIH and worked with the pediatrics team in Hinche during the same period.

Babaria and O'Riordan draw lessons from a specific patient encounter during their time in Haiti. The piece weaves an anecdote about the needless death of a 12-year-old boy, Jean-Paul, with a critical discussion of the factors that contributed to it.

The story of Jean-Paul illuminates the supply chain challenges that persist not only in Haiti, but in nearly all resource-poor countries. It also showcases how woefully inadequate public infrastructure impedes the delivery of quality health care. This is why PIH is committed to forging enduring partnerships with a variety of stakeholders that strengthen the entire health system. As rates of noncommunicable diseases such as diabetes climb, PIH will continue to work to make medications and diagnostics cheaper and easier to access for the world's poor. 

In the op-ed, Babaria and O'Riordan write:

Jean-Paul was 12 when he died. A diabetic, he might well have lived if not for a tragically simple problem, common in rural Haiti: the glucose test strips available did not match the only glucometer we had access to in our rudimentary district hospital.

We are doctors—one American, one Irish—who worked as volunteers at the town hospital in Haiti’s desperately poor central plateau last spring. On the storm-drenched night that Jean-Paul arrived at the emergency room, we rushed to him through corridors clattering as if glass were breaking, as rain pelted down and leaked through the tin roof, forming puddles and muddy rivulets on the floor.

To continue reading the piece, visit The New York Times.

To learn more about our work in Haiti, click here. 

Dr. Ketly Altenor is one of 14 new medical residents, all young Haitian doctors, who recently began on the wards of University Hospital in Mirebalais, Haiti. After graduating from Haiti’s state medical school last year, Altenor, 27, worked with Partners In Health/Zanmi Lasante at Hôpital St. Nicolas in her hometown of St. Marc, where she completed her required year of social service at a rural hospital. She was kind enough to tell us about her life and career plans once she completes her three-year pediatrics residency at University Hospital.

You grew up in St. Marc, Haiti. What was your childhood like?

My mom had six children, three girls and three boys. I’m the second youngest. I was born in St. Marc, and I went to school there through the ninth grade. My mom and dad worked in agriculture for a living. My dad died in 1999, when I was 12 years old. My family lost all our land, and my mom had to work as a street vendor after that. I left St. Marc to go to school in Port-au-Prince. Despite all these problems, I persevered, and I finished school and enrolled in medical school.

How did your father die?

My dad didn’t seem sick. He died suddenly, and nobody could explain why. But when I started studying medicine I came to think that perhaps it was a heart attack.

How did you become interested in medicine and pediatrics?

Since I was little, I always said that I wanted to do medicine. The older I got, the more I was sure of that. When I finished high school, I didn’t hesitate to enroll in medical school. I really knew that I didn’t want to do anything else. When I started rotations in different specialties, I realized that pediatrics interested me most. I love to help children, and I think that I can be most useful as a pediatrician.

What kind of clinical training did you receive during medical school?

I graduated from medical school in December 2012. I was lucky to do all my service in the general hospital in Port-au-Prince, where there are a lot of patients. I’m accustomed to seeing sick people because I saw a lot already at the general hospital. The hospital was missing many things. There wasn’t follow-up care, we didn’t concern ourselves with the social life of the patients, and there were problems with the lab and medicines.

I saw a lot that I couldn’t have imagined.

Where did you work for your required year of service? How was that experience?

I did my social service year in St. Marc, at another university hospital. I was well-supported by the training doctors. I was lucky to work with the PIH family medicine residents, and I learned a lot in the pediatrics ward. I had a good social service year.

What did you see during the year that showed you the need for health care in the country?

My experience made me see that most of the pediatricians in the country are in Port-au-Prince, and the villages and provinces hardly have any. St. Marc has about two or three pediatricians, but they are in the city, which means that the remote areas don’t have any.

I was in the Artibonite region, and I saw a lot that I couldn’t have imagined. I saw children dying from dehydration because they had diarrhea for several days and their moms didn’t know how to rehydrate them. I saw children dying with malnutrition and tetanus, and mothers who died in childbirth during home deliveries. All of this left an impression on me and showed me that there are places in Haiti where people don’t know to go to the hospital when they’re sick.

How did the experience of your social service year change your perspective on your work as a doctor?

I still have plans to return to St. Marc to work, but now I understand that’s not enough. I also need to work in rural areas, to do mobile clinics and home visits and education for everyone. I think it will be easier for me to find the patients than for them to find me.

How did you learn about the opportunity to be a resident at University Hospital?

It was one of my professors at medical school who told me about the residency program at University Hospital. He told me it was a good program, and that I wouldn’t regret choosing to do my residency there. When I went to learn more, I came to understand. It was like I always dreamed of doing my residency, and I jumped on the opportunity. I will never stop thanking my professor because he showed me this path.

How did you feel when you learned you were accepted?

I couldn’t get into Port-au-Prince to get my results, so a friend picked it up for me. When he told me I was accepted, I was so happy that I put the phone down, I jumped into the arms of the person who was with me, and I cried with happiness because I didn’t want to do my residency anywhere else in Haiti than University Hospital.

What kind of relationship do you have with the other residents?

The 14 residents didn’t go to the same university, which means that we didn’t know each other, but it didn’t take us long to feel at ease. We get along well, and we joke together. It won’t take us long to become like family.

Learn why Paul Farmer believes in medical education at University Hospital in Mirebalais.

End poverty. Save lives. Cure disease. Fix the world. These are just some of the taglines that appear on the cover of Wired magazine’s December issue. With such bold and selfless calls to action, it should come as no surprise to learn that the guest editor of this month’s issue is none other than global health champion Bill Gates.

The issue is packed with interesting analysis of potential solutions to the world’s most pressing challenges. But one article in particular stands out, at least to us at PIH. 

Wired Senior Editor Caitlin Roper sat down for a conversation with PIH's Dr. Paul Farmer and Melinda Gates, co-chair of the Bill & Melinda Gates Foundation. From community health workers to transportation infrastructure, Gates and Farmer discuss how to improve health systems and make health care more accessible for the world's poor.

When asked how human-centered design is manifesting in low-resource settings, Farmer says:

In Haiti I would see people sleeping outside the hospital with their donkey saddle under their neck — they’d been waiting there for days. And no one was asking them, “What are you eating while you’re waiting? What is your family eating while you’re gone?” We have to design a health delivery system by actually talking to people and asking, “What would make this service better for you?” As soon as you start asking, you get a flood of answers.

Visit Wired to read the full article.

Partners In Health’s mission is to provide a “preferential option for the poor” in health care. The phrase—which means to make an option for poor people and to work on their behalf—is articulated in the liberation theology of Father Gustavo Gutiérrez, a Peruvian priest and longtime mentor and friend to PIH co-founder Dr. Paul Farmer.

The two men have co-authored a book, In the Company of the Poor, in which they discuss their shared commitment to a “theology of accompaniment”—a lifelong practice of not only walking with people who are poor, but working to change the conditions that keep them poor. In the following chapter, Farmer tells us about his introduction to Gutiérrez and how his writing came to provide the intellectual framework for PIH’s work.

Reimagining Accompaniment: A Doctor's Tribute to
Father Gustavo Gutiérrez

In 1971, when Gustavo Gutiérrez published A Theology of Liberation, I was eleven years old and living in small-town Florida. To me, and to my siblings, church was a place one went to fulfill obligations to parents and grandparents: First Communion, Confirmation, high holy days. It meant sitting through homilies—often boring ones, I’m sorry to say, and almost always remote from our experience. Perhaps the priests made too little effort, or felt little need to make the effort, to address people our age; more likely, we made too little effort ourselves. The arcana of theology were of course completely beyond us. Once we had advanced to high school, we saw little reason to continue going to Mass. Our parents, who shared our ambivalence, did not insist.

A few years later, the boundaries of my world had expanded significantly. I was a college student in Durham, North Carolina, and learning at last about the world we inhabited, pushing back the boundaries so that more and more of this very real world was revealed to me. I learned about conflicts taking place in Central America. For me and most of my college peers, those conflicts were remote and hard to understand. But in fact they were so profoundly connected to our world that a journalist reporting the Salvadoran army’s massacre of an entire village in that beleaguered nation would discover that the headstamps on the bullets read Lake City, Missouri. I learned about the resistance to tyranny and violence offered by many members of the church and thought: same church, same world. Not two or three worlds, but one. I stood in front of the Duke Chapel with more than a hundred fellow mourners, gathered in shock to grieve for the murder of Archbishop Romero of San Salvador. He had been cut down in the middle of Mass while intoning the very words, no doubt, that had recently seemed to me so dull and uninspiring.

After graduation, I spent the better part of a year in Haiti. If conflicts in distant countries were what it had taken to revive my interest in Catholic social teaching, proximity to suffering and poverty taught me even more about what these lessons might mean in the last years of the twentieth century. And it was the patient, scholarly work of Gustavo Gutiérrez that helped me make sense of the poverty I saw around me in Haiti, elsewhere in Latin America, and back home in the United States.

Understanding poverty as “structured evil,” and understanding how it is perpetuated, is not the same as fighting it. But if we believe that knowledge can inform practice—if we believe in pragmatic solidarity as the best confirmation of theory—then it is best to have intellectual accompaniment. I have had Father Gustavo as my accompagnateur for many long years, including the decade before I had the chance to meet him in person.

A preferential option for the poor informs our clinical work and also our efforts to move beyond individual patients to remedy inadequacies, inefficiencies, and gaps in health systems.

Let me give an example. One day, early in my stay in rural Haiti, I was in my room in the rectory of an Episcopal Church in Mirebalais, a market town in the center of the country. I’d spent the day in a hot, overcrowded clinic. My job was to take vital signs, and to give moral support to the beleaguered young Haitian physician in charge. We quickly became good friends. In time he confessed how much he hated the work he had been called to do: “It’s like a mediocre medical factory. No lab. No real chance to examine the patients or do more than the most perfunctory work.” But he never did much to change it. These conditions were seemingly as immovable as fate. Not yet thirty, the doctor had been socialized for scarcity and failure, I came to understand, even as I had been socialized for plenty and success.

In other words, poverty had worked its way into the doctor’s life too, even though he was not poor. This is exactly what is meant by the concept of structural violence: inequity that is “nobody’s fault,” that is just “the way things are,” that we live with because we cannot or will not or do not know how to address the conditions that create unequal outcomes for rich and poor. This idea, of an unjust social order that was in itself a form of structured violence, seeped into my consciousness throughout that year. It was, incidentally, one of the last years of the Duvalier family dictatorship.

Late on that Wednesday afternoon, after a copious meal (the two of us never lacked for food and clean water), we repaired to our rooms to read. I heard a ruckus outside. A crowd was chanting, marching down the street. The food riots and political demonstrations that would bring down the dictatorship were still more than a year away, and noises like this were almost always associated with some sort of local unpleasantness.

I could hear the crowd very well.

Madame Providence manje de ti moun.

I knew enough Creole to know that the crowd was singing, “Mme Providence ate two children,” and had read enough about Haiti to know that this was likely a sorcery accusation. I looked out and saw a crowd of people, pushing and pummeling a woman as they paraded her down the street toward the police station and could envision the fate reserved for her. I learned later that she was arrested on God-knows-what charges, and her beatings continued in the foul jail down the road. The brutality of it all revolted me. And what made me feel really lonely was that almost everyone I worked with, including the talented young doctor, seemed to take it all in stride, or to agree that Mme Providence might indeed have performed some sort of magical poisoning that felled a neighbor’s two previously healthy children. “Who knows?” he asked, an eyebrow arched.

I did not, and still do not, believe in sorcery; I see accusations of sorcery as one outcome of injustices that people endure until they can endure them no longer. By then I had seen kids die of malaria and of other acute infections. But how to explain all of this to myself or to others? The Haitian priest with whom I worked, and still work, dismissed the sorcery accusation as “peasant superstition” with a gruff and somewhat embarrassed wave. That was the end of that conversation. For my part, I read about history, anthropology, demographics, cosmology, and anything else that might clarify Haiti. Even though I didn’t know Mme Providence, much less believe her capable of magical poisoning, I understood why such modes of explaining misfortune flourished in Haiti and even, to some extent, where they’d come from. Similar forms of accusation and symbolic reparation flourished across the plantation economies of the Caribbean and southern United States and parts of Latin America. These attitudes, although they might be nonsense etiologically, made sense to me as a certain reflection of social conditions in rural Haiti.

Extending a hermeneutic of generosity to those who rely more on a hermeneutic of suspicion (like the suspicion to which Mme Providence was subjected) has been an enduring intellectual and personal project for me. Those first years in Haiti taught me to understand the force that sorcery allegations, and rumor and umbrage of all sorts, can have. Like the doctor’s resignation, it was a response to being socialized for scarcity, to zero-sum solutions and diminishing returns. It was then that I began reading the work of Gutiérrez and others seeking to interpret not only scripture but its meaning in Latin American contexts. Recently, a fellow physician-anthropologist and friend asked me how Paul Ricoeur’s work had informed my own passing commentary on hermeneutics. It was true that I’d slogged through three volumes of Ricoeur’s book on time and narrative—in French no less—in graduate school. But that wasn’t what hermeneutics meant for me. I saw it, in the spirit of Gutiérrez, as a much older endeavor, and one predicated on an ethical stance. What I learned from Gutiérrez above all was that hermeneutics was praxis. He’d taught me to look for the hermeneutics of hope that might follow the hermeneutics of generosity I’d sought to extend to my hosts.

Liberation theology continues to be, for me, an inexhaustible font of inspiration. I see the spirituality associated with it as, at the very least, aspirational: any of us can aspire to be better—but only if all of us seek to attack contemporary poverty and to remember that we live in one world, not three. Nothing that I’ve seen, from plague to famine to flood to quake, could persuade me otherwise.

***

Later, Gutiérrez himself inspired me. On one of my early trips to Lima in the early 1990s, the first person I wanted to meet, beyond my new hosts and patients in a squatter settlement north of Lima, was Father Gustavo. Although he did not know me, a newly minted gringo doctor, I came with a friend and colleague, Dr. Jaime Bayona, the founder of Socios En Salud, as Partners In Health is called in Peru, and with Dr. Jim Kim. I brought Father Gutiérrez copies of my first two books, works of medical anthropology that drew heavily on his thinking. He received us in Rimac, where he was a parish priest and running a center for study and reflection. It was a tough time in Peru: the tail end of a huge cholera epidemic, itself the tail end of a civil war. Fujishock was what our hosts termed the fiscal austerity programs of the government. There was ill will to spare. Our first project in the slums of Lima, a pharmacy for poor people, had just been blown up by a pipe bomb.

Poverty is not some accident of nature but the result of historically given and economically driven forces.

The core of Father Gustavo’s teaching has always been that we must make a preferential option for the poor. I distill this teaching into three simple points: first, that real service to the poor involves understanding global poverty. (The converse is also sometimes true.)

Poverty is not some accident of nature but the result of historically given and economically driven forces. Human beings constitute the social world, and we will always shape it. Understanding poverty and inequality requires multiple disciplines: economics, ethics, law, sociology, anthropology, epidemiology, and so forth. Most of all, it requires listening to those most affected by poverty, which is to say the poor and otherwise marginalized. Listening is also a significant part of accompaniment, and of clinical medicine. Listening is thus both engagement and research. It would not be remiss to think of reverent listening as encompassing the four traditional pillars of Dominican life: prayer, study, service, and community. “Your desk is your prayer bench,” as Dominic said. This academic, information-seeking approach is how option-for-the-poor medicine should work, too. If there is anything that distinguishes Partners In Health from other nongovernmental organizations, it is less an insistence on social justice—many organizations make similar claims—and more an insistence on linking our service work to training and to research. It is why our efforts are so often linked to a research university.

Father Gustavo’s theology stems from a similar conviction, even though he wasn’t always rewarded for it. Until less than a decade ago, he’d never had an academic appointment; his research and writing were additions to his priestly vocation. Yet this has not resulted in an intellectual profile that anyone would call amateurish. As Father Dan Groody puts it, “Gutiérrez would bring his claims of faith into dialogue with such thinkers as Albert Camus, G.W.F. Hegel, Jean-Paul Sartre, and Gabriel Marcel; film directors such as Luis Buñuel and Ingmar Bergman, and writers such as Peruvians José María Arguedas, Felipe Guaman Poma de Ayala, and César Vallejo.” Along the same lines, we succeeded, in 1995, in bringing Father Gustavo together with Noam Chomsky for a day-long, wide-ranging conversation. Somewhere, I hope, this conversation has been taped and archived.

Second, an understanding of poverty must be linked to efforts to end it. Father Gustavo has often noted, in his writing and in his speaking, that poverty means death. Nowhere is this more evident than in medicine; and most medical specialists and institutions are aware of the need to do something about it. Imagine trying to do clinical research in an American teaching hospital without providing any clinical services. The study of poverty without an expressed concern with ending it is seen with a hermeneutic of suspicion by most of the people with whom I’ve lived and worked.

A preferential option for the poor informs our clinical work and also our efforts to move beyond individual patients to remedy inadequacies, inefficiencies, and gaps in health systems. To show how much we’ve been influenced by this and related notions, let me go back to 1987, when we founded Partners In Health. Our mission statement, duly filed with public authorities in order to start a public charity, reads as follows:

Our mission is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, Partners In Health strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. We draw on the resources of the world’s elite medical and academic institutions and on the lived experience of the world’s poorest and sickest communities. We are dedicated to providing the highest level of clinical care possible while alleviating the crushing social and economic burden of poverty that creates obstacles to health. At its root, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When our patients are ill and have no access to care, our team of health professionals, scholars, and activists will do whatever it takes to make them well—just as we would do if a member of our own families—or we ourselves—were ill. We stand with our patients, some of the poorest and sickest victims of poverty and disease, in their struggle for equity and social justice.

In the intervening quarter of a century, our mission has spread to a dozen countries. But it’s the same mission. Only the word “elite” has been dropped from our description of the institutions from which we channel resources. It was replaced with “academic.”

Third, as science and technology advance, our structural sin deepens. This is no Tea-Party assertion; we love science and technology. It is just an observation to the effect that our increase in knowledge and power brings an increase in responsibility.  As the effectiveness of medical interventions grows, our failure to use such interventions justly widens the “outcome gap.”

Let me take cholera as an example. I have already mentioned Peru’s cholera epidemic. The decades since that epidemic have brought new medical developments: new antibiotics, better formulations of oral rehydration salts, and new preventives, including safe vaccines. There have been new developments in water purification and sanitation, and new communications platforms have altered the way we report epidemics.

Despite these advances, in 2010 cholera appeared for the first time ever in Haiti, introduced inadvertently by a soldier from a region of the world where the disease is endemic. Cholera exploded like a bomb in Haiti, becoming the world’s largest epidemic—both in absolute terms and proportionally. Yet with more than half a million sick and thousands dead, relief agencies still haggled over whether or not to use the vaccine, which was not available during the previous Latin American epidemic but has since gone through trials showing it to be safe.

The harm done by this twenty-first-century epidemic is worse in some ways than any of the larger ones that may have preceded it, for cholera is now, in contrast to nineteenth-century epidemics, a disease exclusively of the poor. In other words, the pathogen has made a far more radical preferential option for the poor than have those fighting it.

***

“Structural violence,” “immodest claims of causality,” and “a hermeneutic of generosity”—these concepts figure heavily in my written work, even when they are not called out by name. Far from suffering from the “anxiety of influence,” I am proud of my debt to Gustavo Gutiérrez and to liberation theology.

Making a preferential option for the poor ought to be easy in medicine—just follow the pathology, and that’s where it leads you—but it’s not. There are a million traps, so many of them analytic, but the most cunningly laid traps are perhaps best termed spiritual ones: failures of imagination, failures to extend a hermeneutic of generosity (or suspicion) when warranted, failure to listen patiently, much less reverently. These failures afflict all of us, which is why, no doubt, all of Father Gustavo’s work can be seen as spiritual. Father Groody put it this way in introducing Gutiérrez as a “spiritual master” when compared to many less humble proponents of liberation from poverty: “Beneath the theological words and the social analysis were attitudes of self-righteousness, judgmentalism, and aggressiveness that left me wanting to fight for liberation from a deeper place. I began to appreciate not only that one fights for liberation but how one does it. I was drawn particularly to those whose fight for justice emerged from a quality of soul and deep spirituality.”

As long as poverty and inequality persist, as long as people are wounded and imprisoned and despised, we humans will need accompaniment—practical, spiritual, intellectual.

One could paraphrase: the self-styled liberators from poverty are too often those who want to preach, rather than listen, to the poor. The theme of receptive hearing as linked to humility runs throughout Father Gutiérrez’s work as both pastor and as a theologian. “Working in this world [of the poor] and becoming familiar with it, I came to realize, together with others, the first thing to do it to listen.” Gutiérrez wrote these words in 2009, but has instantiated them throughout his five decades as a priest and theologian. Listening might seem easy in a classroom at Harvard or Notre Dame, or in a rectory in Rimac or in Rome. It isn’t. Among the poor, especially those who are sick, it’s hard and often painful.

My experiences in Mirebalais and elsewhere in Haiti, including those registered after the January 2010 earthquake, tried me in ways I would not have anticipated. Regarding Mme Providence, I was appalled that a woman could be publicly excoriated and worse for “eating” two children, but I was determined to understand how such explanatory models might come about. I tried not to turn away. I still work in Mirebalais, as do Ophelia Dahl and so many of our co-workers, including a new generation of physicians and nurses and a host of partners that has grown quickly since the earthquake. Soon we will open what will be Haiti’s largest teaching hospital, not more than a few hundred yards from where the unfortunate Mme Providence was jailed and beaten. The prison still stands and has not been much improved over thirty years, as we discovered to our great shame when cholera ripped through it, killing several prisoners before we acted with sufficient force to end the epidemic behind bars.

As long as poverty and inequality persist, as long as people are wounded and imprisoned and despised, we humans will need accompaniment—practical, spiritual, intellectual. It is for this reason, and for many others, that I am grateful for Father Gustavo’s presence on this wounded but beautiful earth.

We at Partners In Health were distressed to learn of the devastation of Typhoon Haiyan and stand in sympathy and solidarity with the people of the Philippines. Our own experience working in Haiti after the 2010 earthquake showed us that poor and vulnerable citizens suffered disproportionately, and that disaster aid that utilizes local resources is the most effective for short-term relief and longer-term rebuilding.

We encourage international donors to support disaster relief organizations that are highly coordinated with the government of the Philippines and grassroots organizations that can provide local aid to relieve the emergency needs of the population— medical assistance, food, water, and shelter. Going forward, we encourage rebuilding efforts that focus on longer-term assistance for those who have the least.

Partners In Health is not actively involved in providing health care or disaster relief in the Philippines. If you would like to support disaster relief efforts there, may we direct you to Médecins Sans Frontières and the Red Cross.

Wadley Germain, 10, has had an eventful few years.

The Haitian girl and her family lost their home in the 2010 earthquake in Port-au-Prince. Afterward, Partners In Health supported them with health care and other services in the camp where they lived.

Her education interrupted by the earthquake, Wadley wanted to attend classes at a makeshift school in the camp, but her mother didn’t have money to pay tuition. But Wadley insisted, and she was allowed to stay.

Her story inspired the filmmakers behind Girl Rising, an innovative documentary that tells the story of girls around the world who persevered in gaining access to education. Wadley starred as the first character in the film, which was released this year.

Then came fame. She attended showings of the film in Port-au-Prince, dressed in a lacy white gown. She made friends with Edwidge Danticat, the renowned Haitian author who wrote Wadley’s story for the film. Then, this week, she met U.S. Secretary of Education Arne Duncan at an education conference in Petionville. Duncan and other top U.S. education officials visited Haiti this week to announce a grant to increase access to education in the country.

In the meeting, Wadley asked Duncan what he was doing to help Haiti, and he asked her what she thought he should do. Wadley told him Haiti needs more trained teachers, books for students, and Internet for students to learn. She told the secretary that she wants to study informatics when she's older.

When Wadley told Duncan that her favorite subject was math, the two challenged each other to solving math problems.

“It was really sweet to see how the major education policy leaders of the U.S. were starstruck meeting Wadley and all wanted pictures with her,” said Cate Oswald, PIH senior program officer for Haiti, who befriended Wadley after the earthquake and helped translate at the meeting. “They've all seen the movie Girl Rising and are huge fans of Wadley and her perseverance that kept her in school.”

Wadley delivered a hand-written letter to U.S. Secretary of Education Arne Duncan with a drawing, beside which she wrote, “It’s a drawing for you.” Photo: Cate Oswald/Partners In Health

Wadley took a group photo with U.S. Secretary of Education Arne Duncan, to her left; PIH Senior Program Officer for Haiti Cate Oswald, behind; and USAID Senior Advisor for International Education Christie Vilsack, to her right.

“When you reduce child mortality, you increase life expectancy. We should therefore collaborate to ensure that no baby dies, because all babies count,” said Dr. Christian Rusangwa, the Southern Kayonza District clinical director for Partners In Health’s Rwandan sister organization, Inshuti Mu Buzima (PIH/IMB).

Rusangwa delivered this remark during the initial session of the All Babies Count (ABC) Neonatal Learning Collaborative. In the language of Kinyarwanda, the ABC initiative is known as Impinja Ntizigapfe, which comes from a community folk song about a mother's wish that no baby ever die.

Launched in July 2013, ABC is a collaboration between IMB and the Rwandan Ministry of Health that’s aimed at reducing the country’s stubbornly high neonatal death rate through training and mentorship, systems-strengthening initiatives, and quality improvement strategies. This holistic approach is creating change throughout the health care system, from the community to the hospital level.

Although Rwanda has hit the U.N. Millennium Development Goal target for reducing child mortality, the neonatal death rate is not declining as quickly. According to the 2010 Rwanda Demographic Health Survey, there are 27 neonatal deaths for every 1,000 live births in Rwanda.

At the recent two-day training, Rusangwa dwelled on this statistic and urged the approximately 50 nurses, community health workers, data managers, and other health workers to do everything in their power to reduce it as a team. The participants, most of who work in maternity wards, had come from PIH/IMB-supported Rwinkwavu  District Hospital, as well as from eight other health centers. In various seminars and training sessions, participants discussed best practices and examined specific ways they can contribute to preventing needless newborn deaths. There was a strong emphasis on strengthening neonatal care processes, bolstering antenatal care services, and improving delivery management.

“We can change the health of our babies if we keep active, share knowledge and skills, and intensify our efforts to save babies by coming up with creative solutions from the real experts in this area—you as health care providers in the field every day in your communities,” Dr. Hema Magge, director of pediatrics at PIH/IMB, told the group. “We should utilize the chance to learn the best practices from this training and from one another. This will pay off in the long run.”

The skills taught in the classroom will be reinforced at the bedside through ongoing clinical mentorship and quality improvement coaching

Virginia Uwingabire, a line manager in the pediatric unit at Rwinkwavu Hospital, said she picked up several new skills through the trainings and that she was eager, albeit a tad nervous, to apply the newfound tools in a clinical setting.  “We have learned so much that will enable us to save lives, but putting this into practice is the challenge,” Uwingabire said. “There is a need for commitment to put into action what is taught in the trainings. We also need continuous trainings to build our capacity and help us achieve our goal of saving babies.”

Fortunately, the ABC initiative was designed with that exact sentiment in mind. The skills taught in the classroom will be reinforced at the bedside through ongoing clinical mentorship and quality improvement coaching to help the teams implement their new ideas, measure the impact, and effect change. To further build capacity, future training sessions will focus on sharing lessons learned from each facility’s quality improvement efforts, communicating across levels of the health system to tackle complex issues such as transport and referrals, and provide clinical updates in topics such as essential newborn care and kangaroo mother care. 

“Through supporting each other and learning from one another, we will surely reduce child mortality and save the lives of babies,” concluded Dr. Fuldgence Nkikabahizi, the medical director of Rwinkwavu District Hospital.

"The work that Partners in Health do in Haiti benefits the whole world. They worked out how to treat drug-resistant TB and HIV, and then they train Haitians who then go to Rwanda and teach the Rwandans how to do it. It’s an interesting situation because on one level, it should be possible: It’s smaller than a city, and a lot of the basic infrastructure problems shouldn’t be impossible to solve. When we played SNL with Mick Jagger, the after-party was at Rockefeller Centre outside the ice-skating rink. Looking around, I realized there was more money and infrastructure in two square blocks of Manhattan than in all of Haiti, where there is 15 million people. There was literally more money in Rockefeller Centre than will ever be in Haiti," Arcade Fire frontman Win Butler during a recent interview with Maclean's.

This week, Partners In Health published the first issue of “PIH Reports,” a new series that explores innovations in global health care delivery. Each issue focuses on a single subject, drawing on the expertise of our clinicians in the field.

For the inaugural issue, Dr. Hind Satti, country director for PIH/Lesotho (PIH/L), Dr. K.J. Seung, deputy director for PIH/L, and Megan M. McLaughlin of Harvard Medical School provide an in-depth look at how maternity waiting homes at remote clinics in Lesotho are increasing the number of facility-based deliveries, making childbirth safer in a country burdened with significant challenges.

In 2010, nearly 300,000 women around the world died in childbirth. The vast majority of these deaths occurred in developing countries. Lesotho has one of the highest maternal mortality ratios in the world. The concept of maternity waiting homes isn’t new, but their efficacy in reducing maternal mortality is debated. Yet, as detailed in the report, by engaging traditional birth attendants, conducting extensive community outreach, and providing comprehensive accompaniment, maternity waiting homes can be an extremely effective intervention.

The report provides a wealth of data demonstrating how maternity waiting homes at seven remote PIH/L-supported clinics have led to dramatic increases in the number of women giving birth in a health care facility. Take for instance Bobete Health Center, which saw average monthly deliveries increase from 3.8 in the year preceding the program to 18 in the second year following the program’s implementation.

“In PIH/Lesotho, the maternity waiting homes are one component of a comprehensive maternal health program called the Maternal Mortality Reduction Program,” write the report’s authors. “The goal of the Maternal Mortality Reduction Program is to ensure that 100% of women in the PIH catchment area deliver at a health facility that is adequately staffed and resourced to provide high-quality basic obstetrical care and can refer to a higher level of care for emergencies.”

Download the full report by clicking here.
 

Dr. Ralph Ternier, director of community care and support for Partners In Health in Haiti, spoke at a congressional briefing on Oct. 24 to build support for eliminating cholera in Haiti and the Dominican Republic. 

Following are his prepared remarks:

Honorable representatives of the Congress and all other organization members,

First of all, on behalf of my organization, Partners In Health, and my countrymen, allow me to express my gratitude to the U.S. government and other authorities and friends for their faithful support since the first cases of cholera appeared in Haiti. The epidemic has taught us a lot, and we are still learning more. We have lost many people these three years, and although there have been a lot of improvements, we are still at risk to lose many again.

Honestly, I would prefer to be with my colleagues in Haiti, where even this week in Lascahobas some were seeing 30 to 45 patients a day. But I think it's also important for me to be here to let you know that the battle against the disease is not even close to being finished. It's also an opportunity for us to use this unfortunate situation as a battle horse to strengthen the country’s health system, especially primary care, and the water and sanitation conditions. We need to be more consistent and restless in our initiatives; we ought to take advantage of this momentum of low mortality and morbidity to avoid acting as firemen responding to crises after they have emerged.

Lastly, it's important for us to offer the Haitian and Dominican patients and people every chance to fight the disease through a comprehensive approach of treatment and prevention, including vaccine and water and sanitation improvements.

Once again, I offer my deepest gratitude, and we hope we will continue to receive your support.

Read more about PIH's response to the cholera epidemic in Haiti.

Visit the special section on cholera in Haiti in the American Journal of Tropical Medicine and Hygiene.

Three years since cholera broke out in Haiti, prevention and treatment efforts have helped control the epidemic, but the disease is far from gone.

An infectious disease that causes vomiting and diarrhea, cholera can lead to deadly dehydration in as little as 24 hours. In Haiti, where most people lack access to clean water and sanitation, cholera spread rapidly through waterways, accelerated by heavy rains and flooding. Since it appeared on Oct. 19, 2010, it has killed more than 8,000 people and caused about 650,000 cases, sickening approximately one in 15 Haitians.

Haiti’s Ministry of Health and aid groups responded quickly to help control the epidemic. Partners In Health, with our Haitian sister organization, Zanmi Lasante (PIH/ZL), has treated more than 105,000 cases in the Central Plateau, representing almost one-sixth of total cholera cases in Haiti. Cholera has declined since the peak of the epidemic, but persists: Last month, PIH providers treated more than 1,700 cases in clinics and hospitals. Meanwhile, funding for cholera prevention and treatment has diminished since the initial emergency.

“We’re making progress, and we know what we’re doing,” said Dr. Louise Ivers, senior health and policy advisor for Partners In Health, who reported some of the earliest cases of cholera in Haiti. “We need funds to keep a sustained response going.”

The governments of Haiti and the Dominican Republic have created a 10-year strategy to eliminate cholera from the island of Hispaniola, which they share. Haiti, which has seen the vast majority of cases, has called for a comprehensive response, including short-term measures such as vaccination, to stay the disease during the long-term work of building latrines and piped water systems.

Still, funding to put the plans into action has come up short. Donors have committed only about $30 million of the proposed $2.2 billion plan.

“We have the opportunity now, as cholera is decreasing, to invest in building water and sanitation systems to prevent the kind of outbreak that we had in 2010,” said Dr. Ralph Ternier, director of community care and support for PIH/ZL. “Cholera has killed so many people these past three years. We shouldn’t forget that.”

Cholera cases have continued to spike throughout the epidemic with increases in rainfall, both during the spring rainy season and in the tropical weather season in the late summer and fall. Just a few weeks ago, heavy rains caused severe flooding in a community near Mirebalais in the Central Plateau. About 120 families lost their homes and crops in the floods. A PIH/ZL team responded the following morning, distributing chlorine and buckets to disinfect drinking water, oral rehydration solution to treat dehydration from cholera, and materials to improve hygiene.

Ternier said the PIH/ZL clinic in Lascahobas has been overwhelmed by cases lately. Many people in that area don’t have latrines, which creates conditions ripe for transmission.

“That shows you the fight is really not behind us,” Ternier said.

Over the course of the epidemic, PIH has monitored cholera cases and deaths to improve care and target vulnerable communities with additional prevention and treatment. Data have shown a decrease in the number of cholera patients who died. In the first two and a half years, about 1 percent of cholera patients that came to PIH clinics died. In the last year, that figure dropped by half to .6 percent, demonstrating that it’s possible to manage cholera with a very low fatality rate in Haiti. PIH’s work to monitor cholera data and use it to improve care will be presented at the annual meeting of the American Public Health Association in November.

Partners In Health has advocated for a comprehensive response to the epidemic since its start, including the use of vaccination, publishing these views in The Lancet. In early 2012, in partnership with the Haitian Ministry of Health, PIH delivered the vaccine to two rural communities hard-hit by cholera in the Artibonite region. The successful results of this project were recently published in The American Journal of Tropical Medicine and Hygiene.

With evidence from PIH’s vaccination project, the World Health Organization recommended in 2012 to expand access to the vaccine in Haiti and the Dominican Republic. The Haitian Ministry of Health has also conducted targeted vaccination campaigns in the Central Plateau and the north of Haiti.

Vaccination is just one part of a comprehensive response that also includes improvements to water and sanitation systems and health care facilities where people can receive treatment.

“We have to take care of cholera, and we also have to take care of other diarrheal diseases,” Ivers said. “We need to ensure that funding to support cholera treatment and prevention is also used to strengthen the health system as a whole. Only a strong health system is going to be able to deal with cases of cholera as they come.”

Dr. Charles Patrick Almazor, from Port-au-Prince, Haiti, is director of clinical services for Zanmi Lasante, Partners In Health's sister organization in Haiti. He has worked for PIH and ZL since 2001, and was one of the doctors who saw the first cholera patients in St. Marc. He wrote the following reflection about the disease, which had never been reported in Haiti before the Oct. 19, 2010, outbreak three years ago.

Haiti is known for its torrential rains. Sometimes they begin slowly and build to a crescendo, and other times they fall suddenly and loudly and wildly. The sound of the Caribbean rain hitting your rooftop can be enjoyable and soothing if you are in a safe place—warm in your bed or lying on your sofa. The very same rains can be a nightmare for those living in flooded areas or tents. For me, the rains bring back a flood of unpleasant memories.

These memories include the hundreds of patients I saw during a past rainy season in cholera treatment centers (CTCs) in the Artibonite region of Haiti. The patients—the lucky ones who were taken to a clinic—were transported by family and community members on traditional stretchers, a straw mat on an iron bed supported by two thick sticks and carried by four men. Our patients’ eyes were sunken into their skulls, their skin as parched as the dry season. Because of their appearance, they were referred to as zombi lage, fleeing zombies. Patients of all ages laid on their cots, throwing up what they hardly found to eat, since for most of them food is a scarce resource.

I still remember a young man who was the head of his household. He was terrified of dying because he did not want to leave his family behind in dire poverty. I asked him where he lived. His wife was quick to tell me they lived in the Chaos Mountains, dramatically named for the steepness of the mountain chain. It took them six hours to walk to the hospital. Even more tragic, the patient told me he knew about the risk of cholera, but the family ran out of chlorine to treat their drinking water. His wife added that the market was closed because of the continuous rains.

When I left the CTC, the patient had already received eight liters of intravenous fluids to treat the deadly dehydration that accompanies cholera. His face had changed completely. He once again looked like a normal, living human being. I went away with the confidence he would make it.

Cholera is a good illustration of the vicious cycle of poverty and disease, in which the most vulnerable people are most likely to be victims.

I’m a doctor and I have been working in Haiti for more than 10 years. This was my first exposure to such a severe diarrheal disease capable of killing so many people so quickly. On October 20, 2010, I cared for some of the first patients who came to St. Nicolas Hospital in St. Marc, Haiti, the epicenter of the cholera outbreak. It was painful to see so many patients and too few nurses and doctors.

I worked all night at the hospital with a few colleagues; we were two doctors and six nurses for more than 300 patients who needed IV fluids. We were overwhelmed by the immensity of this tragedy. Many of those 300 patients died that day. They came too late to the hospital and from too far away to be taken care of by too few providers.

Cholera is a good illustration of the vicious cycle of poverty and disease, in which the most vulnerable people are most likely to be victims. It is a water-borne disease. Haiti has been struggling to provide clean water to its citizens since its independence in 1804. Will it be feasible to do so in the next decade?

Cholera is spread through bacteria in fecal matter that contaminates water that people ingest; poor sanitation creates conditions ripe for transmission. How much time will it take before we can provide basic sanitation to the 83 percent of Haitians without latrines? It’s these questions and the lack of answers that frighten me—not the rains.

Cholera killed 5,000 Haitians in its first year. Today, three years after the outbreak, about 8,400 Haitians have died from cholera and more than 685,000 have become sick—approximately one in 15 people. The outbreak was quickly classified as the worst cholera epidemic in the world. In one year, a germ we never had was introduced into our country, followed by a disease we’d never seen. How can we protect our patients and their families from this disease? How can we protect the thousands more who live far from any health facility?

These days, it’s been raining heavily. If you are reading this, you are probably safe, warm, and dry. In Haiti, these rains put people at risk. In an ideal world, we would have a comprehensive approach for fighting cholera—preventing transmission with clean water sources, hygiene education, and latrine construction.

Unfortunately, it will take many years before most Haitians have access to potable water and latrines. I don’t know how many years it will take. But what I do know is that there are scientifically proven measures to prevent and treat cholera—including oral vaccine—that can stay the worst of the illness while long-term water and sanitation improvements are made.

My hope for the very near future is that we bring all these tools to bear on an epidemic that has caused needless suffering and death for the last three years.

On April 28, Dr. Paul Farmer stood before a microphone in a large conference room in Haiti's University Hospital.

Several days before, bomb blasts at the marathon in Boston, Massachusetts, had killed three people, but not a single person who made it to a hospital died. In that grim emergency, teaching hospitals made a difference, Farmer told the crowd.

“I love working at a great Boston teaching hospital, Brigham and Women’s. I love being able to train the next generation of physicians and nurses. And I want Haiti to have something like it, too,” Farmer said.

This month, University Hospital in Mirebalais, Haiti, took a significant step toward becoming the teaching hospital envisioned after Haiti’s 2010 earthquake, which devastated the country’s already-fragile medical infrastructure. On Oct. 1, the hospital’s first medical residents—all young Haitian doctors—began hands-on training in pediatrics, general surgery, and internal medicine.

The application process was intensive and merit-based: 238 people applied and took an entrance exam. Of those, 45 were interviewed, and 14 were selected. Class members hail from all over Haiti. Some studied at Haiti’s state medical school or private schools in Port-au-Prince; others went to the Dominican Republic. Some just graduated from medical school and completed their social service year; others have been practicing for a few years. By coincidence, the class is evenly split between men and women.

Dr. Jean-Louis Willy Fils, 29, from the northern city of Cap-Haïtien, has wanted to be a doctor for as long as he can remember. He describes surgery as his “true vocation,” so to be selected for a University Hospital residency was more than he hoped for.

“One year ago, I couldn't have even imagined learning surgery in a hospital with an international standard of quality, for the good reason that such a hospital didn't exist in the country yet,” Fils said. “That's the proof that great things can be done in Haiti.”

Over the next several years, these 14 doctors will receive instruction from Haitian and foreign physicians—some of whom are faculty at the same teaching hospital where Farmer trained and now teaches. The curriculum for their training was developed through special working groups and designed to follow the Accreditation Council for Graduate Medical Education International’s (ACGME-I) standards.

After completing orientation this month, residents will begin caring for patients as well as rotating in departments such as emergency medicine, TB/HIV clinic, and oncology. Each day, they will spend an hour in special education sessions for residents, and once or twice per week they will be on call throughout the night. They will also conduct research to improve the quality of care. The ACGME-I guidelines require they work no more than 80 hours a week, but they’ll probably come close.

"The residency program at University Hospital represents the most serious attempt, to my knowledge and during my lifetime, to systematically create a critical mass of Haitian physician specialists that will have the opportunity to be fully useful to all Haitians," said Dr. Paul Pierre, PIH senior advisor. He added that he and his physician colleagues have traditionally questioned the poor outcomes of Haiti's health sector, but now feel questioned themselves about their responsibility to improve health care in Haiti. "University Hospital and its new residency program stand as formidable evidence of the efforts that young Haitian health professionals are making to restore, in a sustainable way, hope and dignity in the future of health in Haiti."

As new classes of residents begin each fall, the number of physician trainees will double and triple. And the programs will expand to include other health professionals, such as nurse anesthetists and other nurse specialists, as well as more medical specialties—such as emergency medicine—which would be the first such training program in the country.

In addition to hands-on training, the curriculum includes lessons on social medicine and the root causes of disease, such as poverty, which have been part of PIH’s work since its early days in Haiti. The programs are designed to train and retain a new generation of doctors to the poor who work outside of Port-au-Prince, the traditional mecca for medical training.

“We envision a workforce of doctors, nurses, and other health professionals who are driven by medical excellence and committed to high-quality care for all Haitians,” said Michelle Morse, PIH deputy chief medical officer for Haiti. “The start of these residencies brings Haiti one step closer to this vision.”

Too little training, too few doctors

The American Medical Association describes the training for doctors in the United States as “lengthy.”

Four years of college. Four years at medical school. Up to seven years in a residency program and three years in a fellowship for specialists, who make up 95 percent of American doctors.

Add it up, and many doctors have had more than a decade of medical training. Much of it takes place through hands-on coaching from senior physicians in teaching hospitals with all the latest diagnostics and treatments.

In Haiti, one reason for needless sickness and death is the lack of trained professionals to provide health care. There are only 25 physicians per 100,000 Haitians. The United States has more than tenfold that number: 280 doctors for every 100,000 Americans.

In Haiti, half of doctors are generalists who have completed medical school and a social service year but no specialty training. Each year, about  450  graduating doctors compete for only about 150 residency positions.

Those residencies allow Haitian doctors to become specialists in fields such as internal medicine and pediatrics, but even those additional years of training are wanting. Most residencies are based in hospitals that are ill-equipped and under-staffed, with limited supervision by experienced doctors. Attending physicians are underpaid, leading many to spend their time in private practice, instead of teaching physician trainees.

PIH conducted a survey of Haitian residency programs to better understand the country's medical education needs. The survey found that 55 percent of residents don’t have Internet access at the hospitals where they work, and 80 percent of the programs do not have an exit exam for residents.

“These residencies are operating in hospitals that are severely short on resources, from staff to equipment,” Morse said. “University Hospital has electronic medical records, an emergency department, a CT scanner—it allows us to have a whole new level of quality care and training at a hospital with the appropriate resources.”

Double brain drain

Dr. Ketly Altenor, 27, graduated from Haiti's state medical school and is now a pediatrics resident at University Hospital. Photo: courtesy of Ketly Altenor

The lack of opportunities leads many young Haitian doctors to seek training and employment in other countries, causing a brain drain in the health workforce. A staggering 80 percent of all physicians trained in Haiti leave within five years of graduation to practice abroad. Of the doctors who stay in Haiti, most practice in Port-au-Prince, which makes it difficult for rural people to access care. The medical education programs at University Hospital aim to slow or even reverse that double brain drain—from rural to Port-au-Prince or abroad—by encouraging talented young doctors to train in Haiti and stay there to practice medicine.

Dr. Ketly Altenor, 27, hopes to return to St. Marc, Haiti, to practice medicine. Growing up there, Altenor lost her father at 12 years old, and her mother supported the family as a street vendor. Despite her family’s poverty, Altenor excelled in school and earned a competitive spot at the state medical school. She graduated with the support of a scholarship from the nonprofit Haitian Education and Leadership Program, which provided housing, a stipend, and mentorship. She was accepted into the pediatrics residency at University Hospital after graduating from medical school.

“After my training I intend to return to work in my hometown, where there aren’t enough pediatricians,” Altenor said. “I will try to extend pediatric care to remote areas of the Artibonite region. I want to work in social medicine and really help people.”

Though University Hospital’s medical residencies are just starting, other training activities have occurred since the hospital opened. Since Farmer delivered his talk, or “grand rounds,” to inaugurate medical education at University Hospital, staff have participated in daily continuing education sessions to improve care, from training on using ultrasound to sessions to help faculty become better teachers.

As Farmer said, “University Hospital was built to be a teaching hospital because the hypothesis, here, is that the quality of medical care will be improved whenever training and research—the ‘feedback loops’ that allow us to learn—occur in tandem with compassionate care.”

Annually, more than 3 million child deaths around the world are linked to undernutrition. Put another way, nearly half of all children who die each year die because they don’t have access to enough food or the right food.  

Partners In Health sees the far-reaching effects of malnutrition at many of our sites. Without food, a child’s physical and cognitive growth is stunted. Without food, taking daily medications can be a painful chore. Without food, it’s hard to muster the energy to get through a school day or workday.

Recently, we took an in-depth look at the newly opened Nourimanba Production Facility and how it’s helping provide lifesaving treatment to malnourished children in Haiti’s Central Plateau and Artibonite regions. In the course of reporting the story, we interviewed Marie Landy Zamor, the nutrition coordinator at Zanmi Lasante, PIH’s Haitian sister organization.

Zamor, 28, began working for PIH/ZL in 2008. Over the past five years she has cultivated an intimate knowledge of malnutrition in rural Haiti. To mark World Food Day, we asked Zamor to share insights and reflections on her work.

As nutrition coordinator, what does an average day entail?

I provide technical supervision for all activities under the malnutrition program. I work very closely with nurses. The malnutrition programs at our clinics are run by nurses—they educate patients and families, give out Nourimanba, weigh patients, and take care of all the activities related to screening and treating malnutrition.

I travel among ZL’s sites often to make sure we’re all following national protocols and that everything is running smoothly. If there are many patients, I’ll help with the clinical work.

And there is a lot of reporting to do to help with monitoring programs and patients.

I believe in a preferential option for the poor and PIH/ZL’s mission of giving services to those who can’t access them. In the nutrition program, I see this firsthand every day.

You have a daunting job. What motivates you?

I believe in a preferential option for the poor and PIH/ZL’s mission of giving services to those who can’t access them. In the nutrition program, I see this firsthand every day.

Every person has the right to eat food. Unfortunately, Haiti is such a poor country that many people don’t have the means. If you have the opportunity to go out into the countryside—to the houses people live in, the conditions they live in every day—it would leave a lot of bad memories for you.

But because of ZL’s level of service, I get to see results. By monitoring patients and accompanying them, we’re able to track their progress.

What’s the biggest challenge?

The biggest challenge is adherence. Kids come each week and from very far away. We do weekly appointments to closely monitor kids because they are at high risk of developing complications, so we need to provide constant supervision. Some families walk three hours to reach the clinic. They have to walk because they don’t have transportation.

There is a relationship between how far people live from the clinic and how sick they are. Those who are far don’t have access to health care and there is the issue of access to food. If you live near a market town you have better access to food.

That’s where adherence becomes a challenge and that is why we are rooted in the communities we serve.

Can you talk about the importance of educating patients and families about nutrition?

Some parents don’t understand what malnutrition is. It’s important to educate the parents so that they come to the clinic and aren’t embarrassed. Showing the family how to prepare different meals for their children with food that is accessible helps. We provide this information in the clinic when children are screened for malnutrition. And then the nutrition team makes a monthly home visit to continuing working with the family.

We also have a monthly meeting for parents to discuss nutrition and other issues that relate, such as hygiene, how to treat water, and how to wash fruit and vegetables. The immune system is weaker in malnourished kids, so this is all very important for families to know.

How do you foresee the Nourimanba Production Facility improving ZL’s ability to treat malnutrition?

The most important thing is having enough Nourimanba for the patients in our catchment area, and the facility will help achieve this. The facility also represents a better quality product. Many tests are done to make sure we’re delivering the best treatment possible to our patients.

I want to say that treatment is important, of course. But so is prevention. Economic conditions, social conditions, schools, agriculture—they all need to improve before you can properly solve the problem.

Research reporting the results of Partners In Health’s cholera vaccination project in Haiti was released today in a special section of The American Journal of Tropical Medicine and Hygiene.

The journal’s October issue, released just before the third anniversary of the cholera outbreak on Oct. 19, 2010, features a variety of public health research on cholera in Haiti.

As part of the special section, PIH Senior Health and Policy Advisor Dr. Louise Ivers and colleagues discuss the results of PIH’s rural cholera vaccination campaign in early 2012. The demonstration project was executed in collaboration with Haiti’s Ministry of Health and sought to vaccinate two vulnerable communities in the Artibonite region and build support for using the vaccine more broadly.

“Vaccines should not be viewed as a silver bullet that can subdue cholera in Haiti,” Ivers said. “But wider use of them, such as in campaigns targeting particularly vulnerable populations, can play a meaningful role in protecting people from illness and death.”

The journal article explains the project’s design and successful results. A total of 45,417 people in two communities received at least one dose of the two-dose vaccine, representing 77 to 93 percent of the targeted population. Even more, 91 percent of people who received the first dose also received the second, an excellent completion rate.

Another article reports the results of a similarly successful campaign in Port-au-Prince, conducted by the nonprofit health care organization GHESKIO.

These projects proved that delivering the vaccine in the midst of an epidemic was possible in Haiti. The evidence contributed to the World Health Organization’s recommendation in 2012 to expand access to the vaccine in Haiti and the Dominican Republic.

Ivers said that community involvement was critical to the project’s success. In advance of the vaccination, community health workers conducted a census of the community and registered people to receive the vaccine. PIH and our Haitian sister organization, Zanmi Lasante, also worked with community leaders to ensure support of the campaign. Ivers said it wasn’t hard to convince community members to be vaccinated because they knew the danger through personal experience.

“We interviewed people in focus groups before the vaccination campaign and they had very emotional stories to tell about their experience with cholera,” Ivers said. “So it was not a far-off, distant issue, but a real and immediate threat.”

Read the full text of Ivers’ research here and access the journal’s special section here.

Dr. Paul Farmer had done his homework.

He sat at a desk in the front of a lecture hall, surrounded by 60 of his biggest fans—volunteers for Partners In Health from across the United States—and rattled off facts about them.

Where was the infectious disease fellow at Tulane? Abby Lau raised her hand. Why the curious concentration of people from Bainbridge Island, in Washington State? He was impressed that one attendee was a midwife who performs aerial dance and is also learning to speak Navajo.

Farmer had studied the biographies and photos of a crowd that knew all about his life from Tracy Kidder’s book Mountains Beyond Mountains. The group was thrilled to hear from the PIH co-founder whose story had inspired many of them to get involved in global health and social justice.

“It was inspiring and humbling to hear Paul speak—and slightly spooky that he knew so much about us individually in the room,” said Ashley Dyer, 31, a regional organizer for PIH | Engage who volunteered as a community coordinator in Chicago last year. “I kept thinking to myself, ‘what a gift.’”

At the three-day training late last month, more than 60 community leaders paid their own way to Boston to learn how to turn their passion for PIH into action in their own communities. They practiced engaging others, learned how to fundraise, and heard from PIH leaders, including Farmer, Chief Medical Officer Dr. Joia Mukherjee, and co-founder and Executive Director Ophelia Dahl.

“There’s so much work still to do,” Dahl told the group, after sharing some of the early experiences that led her to devote herself to social justice. “I have no doubt that there still will be for the rest of my life, probably for the rest of your lives, but we’re making headway together.”

Over the next year, these community leaders will meet regularly with others interested in the work of PIH. The groups will educate themselves and others about global health, take advocacy actions, and conduct grassroots fundraising campaigns with their friends and family.

“A lot of our supporters want to know what they can do to help Partners In Health, and we need all the help we can get,” said Jon Shaffer, community engagement coordinator and former executive director of GlobeMed, a global health student organization. “We started PIH | Engage to create an opportunity for people to act locally in their communities to advance our global work.”

The initiative began last year with a small pilot training institute. Over the year, communities in Seattle, Milwaukee, and elsewhere held awareness events and raised funds. For the release of Girl Rising, a documentary film that features a former PIH patient in Haiti, groups organized screenings to educate their communities about the impact of girls’ education on health.

This year, the effort has expanded, with more than 100 people applying for leadership positions in their areas and more than 60 attending the training institute. Shaffer hopes each group will grow to about 10 people committed to supporting PIH and the movement for health as a human right.

Don Jones, 59, an environmental consultant from Annapolis, said he was excited but anxious to take on the challenge of leading a local group in support of PIH. The training helped him feel he had the tools to reach out to friends and family and move them to action.

“As I transition from my chosen career to one more focused on social justice, community activism, and service to the poor and disenfranchised, being a part of PIH | Engage is a perfect fit,” Jones said. “I have a real passion for only a few nonprofits, and PIH is at the top of the list.” 

Farmer thanked the volunteers for committing themselves to PIH | Engage, and said that a movement is necessary to help medical innovations reach the poor. Advocates like those in PIH | Engage can help challenge arguments that scientific advances are too costly for the poor, he said.

“How can you possibly do this work without a movement? Because if it’s for poor people, they’re going to say it’s too expensive,” Farmer said, adding that the price of medicine is socially constructed, and therefore malleable. “It's not God up in the sky that determines the price of a chemo regimen, it's you and me."

To learn more about how to get involved with PIH | Engage, click here.

Ronith Desperot was six months pregnant and worried.

Desperot, 31, lives in Port-au-Prince. In nine years of marriage, she had been pregnant five times—and had no surviving children.

Four times, her pregnancies ended in miscarriage between six and eight months. After her fifth pregnancy, she gave birth to a baby who seemed healthy, but a few days later he became sick. She and her husband went from hospital to hospital and couldn’t find care for him. He was 8 days old when he died.

“I have suffered a lot over those pregnancies and the baby I lost. It has been so hard,” Desperot said. “I have really been longing to have this baby.”

Deciding to seek health care far from home wasn’t easy. But on July 22, she left Port-au-Prince and traveled with her sister Wideline to Mirebalais, a city in the Central Plateau about two hours from the capital. She had heard there was a new hospital there—University Hospital, operated by Partners In Health in collaboration with the Haitian Ministry of Health.

Desperot was admitted to the antepartum unit, the specialized unit for pregnant women at risk for complications. After learning her history of complicated pregnancy, doctors and nurses monitored her closely as her due date approached. Then, at 33 weeks, Desperot began to show symptoms of severe preeclampsia.

Preeclampsia—a sudden rise in blood pressure during pregnancy—is a dangerous condition for both mother and baby. In Haiti, preeclampsia and eclampsia—seizures that follow preeclampsia—are the leading cause of maternal death. The only known solution is to deliver the baby.

But Desperot’s pregnancy was still seven weeks short of full-term—the baby would be very premature. In the United States and other wealthy countries, developments in neonatal medicine now help premature babies breathe, eat, and stay warm, dramatically increasing the survival rate of infants with access to the latest medicine.

Today, close to 99 percent of newborn deaths occur in developing countries. In Haiti, an estimated one in 40 newborns does not survive the first 28 days of life. Trained caregivers and equipment to provide specialized care—incubators, oxygen, breast pumps, even the electricity that keeps such technology running—is unavailable in many places. Fragile newborns must sometimes be transferred long distances on difficult roads to reach care.

University Hospital was built to handle such complex cases, and to receive at-risk pregnant women and infants from other public clinics around the Central Plateau. Since July, more than 550 babies have been born at University Hospital. The pediatric ward, which includes the neonatal intensive care unit, has hospitalized more than 50 children since it opened in late August. The NICU has capacity for 12 patients, and contains 11 incubators, five radiant warmers, and three bassinets.

Counting on support from the NICU, Dr. Christophe Millien, an obstetrics and gynecology physician at University Hospital, decided Desperot needed to deliver the baby. On Sept. 10, he performed a cesarean section: it was a boy.

“The baby was very premature, and we brought him immediately to the neonatal intensive care unit,” said midwife Meredith Casella Jean-Baptiste. “We’re so thankful the NICU is open now, and so close to where our patient delivered.”

Dr. Christophe Millien visits his patients in the NICU at University Hospital. Photo: Jon Lascher / PIH

Jean-Baptiste helped Desperot pump breast milk for the baby with a donated breast pump, and a few days later her son, Samuel Victory Fédé, was able to breastfeed. She stops by the NICU every few hours to feed her son. After they are discharged, Desperot will return to have her stitches removed and receive other follow-up care from the surgery. She’ll also receive a routine check-up for her high blood pressure. If she chooses, she’ll receive counseling and options for family planning.

“I'm really so happy now,” Desperot said. “I feel so good to bring the baby home with me to our house. So many people have been praying for me, and they are happy as well.”

“May the good Lord continue to give blessings to aid all the people who need help too,” she said.

A crew of Haitian workers clad in white lab coats, rubber-soled boots, safety goggles, and hair nets pass through a corridor and into a sterile production area that’s lined with hulking stainless steel devices, one of which looks like a giant KitchenAid Mixer. At 8:30 a.m., the machinery starts whirring and roaring. Before long, the distinct aroma of crushed peanuts hangs in the air.

From the outside, the two-story beige and white building looks like a standard warehouse you’d encounter on the outskirts of Des Moines or Bakersfield. But located in Haiti’s Central Plateau, the Nourimanba Production Facility—or Sant Prodiksyon Nourimanba in Haitian Creole—is a state-of-the art  operation that’s helping tackle one of the country’s most pressing challenges—malnutrition.

In Haiti, malnutrition is the leading cause of death among children 5 years old and younger, according to UNICEF. The rural Central Plateau, where Partners In Health has worked for more than 25 years, has some of the highest rates of malnutrition in the entire country. And it’s not just children who are affected—pregnant women, teenagers, and HIV-positive patients, among others, all experience the disastrous consequences of poor nutrition.

“Every person has the right to eat food,” says Marie Landy Zamor, the nutrition coordinator at Zanmi Lasante, PIH’s Haitian sister organization. “Unfortunately, Haiti is such a poor country that many people don’t have the means.”

For decades, PIH has tackled malnutrition through a multipronged approach intended to alleviate the clinical, economic, and social factors that drive the condition. A key component of the strategy is Nourimanba, a ready-to-use therapeutic food. It’s similar in taste and texture to peanut butter, but it’s fortified with vitamins that are crucial to physical and cognitive development. 

Quality & Quantity 

Reginald Cean, director of agriculture for the Zanmi Agrikol vocational school, inspects the soil of a peanut farm in Corporant, Haiti. Photo: Rebecca E. Rollins/PIH

Making Nourimanba isn’t terribly difficult. But scaling up production so that every PIH/ZL patient who needs it gets it—while simultaneously bolstering the local economy and improving agricultural practices—poses a number of challenges. That’s why in 2010 PIH teamed up with Abbott and the Abbott Fund to build the Nourimanba Production Facility.  Within a few months of officially opening this year, the facility has already created more than two dozen jobs and churned out more than 6,000 kilograms of the lifesaving treatment.

Most importantly, perhaps, it has spawned a reliable market for local peanut farmers to sell their yields, as PIH only sources locally grown peanuts.

“This center will have a major impact on the community—a lot of people are working here, and new industries help develop communities,” says Myrlene Arthus, production supervisor at the facility. “I love what I do because I am working for children that are sick. The product I make is helping save children’s lives.”

Peanuts and peanut-based products are finicky and prone to aflatoxins, a byproduct of mold that can be harmful. To ensure safety, the Nourimanba Production Facility has two on-site labs that are used to run a barrage of quality-control tests.

“The base of everything that we do is ensuring the quality of the product that we provide to our patients,” Oyama Michel Romain, director of operations at the facility, said. “It is a job that brings more value than simply money—it’s to help malnourished children and the country of Haiti.”

While important, the lab tests are only one part of a sophisticated production process that mitigates the risk of contamination and maximizes output.

Awe-inducing Automation 

Oyama Michel Romain, director of the Nourimanba Production Facility, oversees day-to-day operations. Photo: Jon Lascher/PIH

The production process is a display of awe-inducing automation. Peanuts are first put through a propane-powered dryer then tested for aflatoxin, water content and similar indicators. When the all-clear is given, they move to the aptly named shelling room; remnant shells are collected and later turned into mulch while the nuts drop to a conveyor belt, where staffers carry out visual inspections. From there, the peanuts hit a corkscrew conveyor that directs them toward the roaster, which kills all bacteria. After roasting, the peanuts enter a cooling area that quickly reduces the temperature. Then it’s on to the grinder and mixer, where the “wet” ingredients are added. The final stop is a piston-filler that squeezes 1 kilogram of the now ready-to-use therapeutic paste into a plastic tube.

Each batch that moves through this process yields about 200 kilograms of Nourimanba, and PIH/ZL has the capacity to complete multiple batches a day. Technicians and sanitation staff, all of whom are locally hired and thoroughly trained, break down the machinery daily and meticulously clean it.

Zamor, the nutrition coordinator, is confident the increased output and high-quality treatment will allow PIH/ZL to treat more cases of malnutrition. But she says that massive, deeply ingrained challenges will continue to loom for decades to come.

“Treatment is important, of course. But so is prevention,” she notes. “Economic conditions, social conditions, schools, agriculture—they all need to improve before you can properly solve the problem of malnutrition.”
 

The road to San Rafael, Mexico, is not long, but it is steep, with twists and turns that carry ominous nicknames like “Espinazo del Diablo,” or the “Devil’s Backbone.” To get to San Rafael from Reforma, the small community in which a Partners In Health/Compañeros En Salud-supported clinic is located, you have to ford a river, which often becomes impossible during the rainy season. If you can cross the river and navigate the tortuous road, you’ll bump out of the woods and into San Rafael, a small town nestled atop one of the Sierra Madre Mountains’ many peaks. Fewer than 400 residents live there, many of whom are coffee farmers.

Among them is 55-year-old Don Fausto Velasquez, a big man with crystal blue eyes and grey hair tucked under a cowboy hat. It was nearly a year ago when Velasquez started having chest pain. The pain was so bad he could barely walk a block without resting. Frightened for their father, Velasquez’s sons took him to a series of clinicians that were hours away, but none provided a clear diagnosis.

Finally, the sons took Velasquez to the state capitol of Tuxtla Gutierrez, four hours from their home in perfect weather, significantly longer should the mountain sky open up. There, a cardiologist diagnosed Velasquez with hypertension and stable angina. Thankfully, the conditions were manageable.

This heartbreaking tradeoff between care and economic security is one faced by the rural poor around the world.

The family, however, was devastated to learn that to receive care, the coffee farmer would have to make the costly four-hour-long trek to Tuxtla once a month. This heartbreaking tradeoff between care and economic security is one faced by the rural poor around the world. As death and disability from noncommunicable diseases increases in low-resource countries, more and more families are facing this predicament.

PIH-supported physician Dr. Enrique Valdespino first met Velasquez in January 2013, several months after the hypertension and angina diagnoses were delivered.

Dr. Valdespino recalls that Velasquez’s dual heart conditions were completely uncontrolled. “He came in and he was taking two medications—one a diuretic and the other for people who’ve had a heart attack or a stroke,” recalled Dr. Valdespino. “Nothing really to treat the symptoms of his angina, to treat his chest pain.”

Velasquez explained that he had stopped making the monthly trip to his cardiologist after only two or three visits because “there just wasn’t any money.” Coffee farmers in Chiapas often earn a meager living. But 2013 has been particularly brutal as a plague called the Roya (coffee rust) devastated local coffee crops. “I was spending a thousand pesos [around $80] to buy 20 pills. I couldn’t keep doing that, so I stopped going [to the cardiologist],” Velasquez said.

Dr. Valdespino listened intently to Velasquez, taking in the clinical and social challenges the patient faced. Soon after, PIH/CES started traveling to San Rafael so that Velasquez and other residents of the tiny town could consistently access high-quality care. Now Dr. Valdespino and at least one other PIH staff or volunteer physician make the treacherous trip, ford the river, and traverse the “Devil’s Backbone” once a month. “During the rainy season, we sometimes have to go on horseback or donkeys,” Dr. Valdespino says.

Velasquez started receiving aspirin and beta blockers, which quickly led to clinical improvements. His hypertension is under control as well; he can now walk four blocks without resting and can tend to a small crop of corn.

For Velasquez and the 24 other citizens of San Rafael with chronic diseases, PIH’s presence has not only provided the medication and treatment to prolong and improve the quality of their lives, but it has also saved them catastrophic spending in search of medical care. As the Roya plague continues to decimate crops in the area, PIH’s commitment to accompany the patients of San Rafael is stronger than ever. “We have our corn and our beans, so we’ll survive,” Velasquez says. “But it’s going to be a hard year. At least we no longer have to go down the mountain to find medical care.”

Emma Goodstein has been collaborating with the PIH team in Chiapas, Mexico, since June 2012. Originally from Portland, Oregon, she graduated from Wesleyan University in 2010 with a degree in history and has since worked in various positions in the health care field in Portland and New York City.

Disasters present substantial challenges for rapid emergency response, including the delivery of mental health services. The devastating 2010 earthquake in Haiti was no exception. While mental disorders comprise a substantial share of disease-related burden and disability globally, delivery of mental health services in low-resource settings has lagged behind that of other services. In the wake of the Haiti earthquake, an entirely new set of challenges to delivering effective mental health care emerged. But so did an opportunity.

Recently, a team of mental health experts from Partners In Health and Zanmi Lasante, led by PIH Mental Health Director Giuseppe Raviola, published a paper in Psychiatric Clinics of North America that provides a detailed overview of the 2010 Haiti earthquake response from the perspective of mental health.

The authors note that the earthquake has been a catalyst for efforts to identify and integrate mental health as a critical part of the post-earthquake health care system, lack of resources notwithstanding.  They note that, “Complexity and challenge has tended to only aggravate the tendency to approach post-disaster needs in an episodic fashion with deployment of external resources, rather than as an opportunity to build local capacity and purposefully lay the groundwork for sustained delivery with attention to building the foundation for services and long-term development.”

The hope is that ongoing post-earthquake mental health efforts can lead to the articulation of innovative care delivery models that blend strong traditional perceptions and beliefs, religious influences, and contemporary biopsychosocial approaches.

PIH has worked tirelessly in recent years to build a foundation for the kinds of services the authors discuss: We’ve collaborated with Grand Challenges Canada to scale up and integrate community-based, culturally appropriate mental health services in Haiti’s Central Plateau. We’ve deployed mobile mental health clinics to make sure the hardest-to-reach patients have access to care. And we’ve partnered with the Program in Global Mental Health and Social Change at Harvard Medical School to build local capacity. 

The need for more comprehensive, community-based mental health services in Haiti, however, remains significant. To read the paper in full, please visit the Knowledge Center by clicking here. To learn more about PIH’s mental health program, click here.
 

Through more than 25 years of service to the poor, Partners In Health co-founders Dr. Paul Farmer and Dr. Jim Yong Kim have helped shape the burgeoning field of global health into an academic discipline taught at universities around the world. Drawn from a Harvard College course developed with their mentor, Dr. Arthur Kleinman, and their student, Matthew Basilico, Reimagining Global Health (University of California Press) provides an original, compelling introduction to the field. The work takes an interdisciplinary approach to global health challenges like delivering complex care in rural settings.

The case studies presented throughout Reimagining Global Health bring together ethnographic, theoretical, and historical perspectives in a new and exciting investigation of global health. Students will find the book useful in schools of public health, nursing, and medicine, but also in undergraduate and graduate classes in anthropology, sociology, political economy, and history, among others.

In the first chapter, adapted below, the editors explain why biological and sociological perspectives—medicine and history, epidemiology and anthropology—are necessary to address the suffering of a patient such as Mpatso, a Malawian sick from tuberculosis, AIDS, and poverty.

To read the full work, you can order the book on Amazon.

1 Introduction

A Biosocial Approach to Global Health

Paul Farmer, Jim Yong Kim, Arthur Kleinman, Matthew Basilico

A View from the Field

Mpatso has been coughing for two months. Coughing consumes his energy and his appetite. When his skin begins to sag, he takes the advice of his relatives and makes the two-hour journey to a health center. Mpatso has AIDS and tuberculosis. In his village in rural Malawi—an agrarian, landlocked nation in Southern Africa, hard hit by AIDS and resurgent tuberculosis—Mpatso's diagnosis carries a very poor prognosis. Malawi, like most of the countries in sub-Saharan Africa, faces the combined challenges of poverty, high burden of disease, and limited health services in the public sector. But Mpatso's case is an exception: shortly after he arrives at the Neno District Hospital—a public hospital in the rural reaches of southern Malawi—he is seen by a team of clinicians. That same afternoon, he is diagnosed and begins treatment for both diseases. The treatment involves a dizzying number of pills, but his are delivered daily by a community health worker who also helps him follow his therapeutic regimen. Mpatso's life will likely be prolonged by a decade or more.

Down the hall from Mpatso's exam room, a neighbor gives birth with the support of a nurse-midwife. In an adjacent room, six women are in labor under the watchful eye of the clinical staff and within feet of a clean, modern operating room. In this and in many other respects, Neno District Hospital differs from most health facilities nearby (and throughout rural sub-Saharan Africa). The hospital is a comprehensive primary care facility, providing ambulatory care for more than one hundred patients each day. It has about fifty beds, a tuberculosis ward, a well-stocked pharmacy, and an electronic medical records system. The facility is staffed by doctors and nurses from the Ministry of Health. In the midst of one of the poorest and most isolated areas in Malawi, a robust local health system is delivering high-quality care, free of charge to the patients, as a public service.

How was this system put in place in a country where effective health services are typically unavailable, and how can comprehensive health systems be built across the developing world? How is the double burden of poverty and disease experienced by individuals like Mpatso or his neighbors across the border in Mozambique? How can history and political economy help us understand the skewed distributions of wealth and illness around the globe? These are a few of the questions that motivate our investigation of global health.

Biosocial Analysis

As the preface notes, global health is not yet a discipline but rather a collection of problems. The authors of this volume believe that the process of rigorously analyzing these problems, working to solve them, and building the field of global health into a coherent discipline demands an interdisciplinary approach. Describing the forces that led Mpatso to fall gravely ill with tuberculosis—a treatable infectious disease that has been banished to history books in most of the rich world yet continues to claim some 1.4 million lives per year worldwide—requires both biologic and sociological inquiry, an intrinsically biosocial analytic endeavor. The roots of the limited health care infrastructure in rural Neno District, a former British colony long on the periphery of the global economy, are historically deep and geographically broad.

Most textbooks of public health have been written by epidemiologists, and we of course draw heavily from this field, relying as well on insights from clinical medicine and public health disciplines such as health economics. But the course we teach at Harvard College (like the courses we have long taught at Harvard Medical School and the hospitals with which we're affiliated) is not the same as those taught by public health specialists. Those who have developed this course and this book are all jointly trained in clinical medicine and in anthropology or political economy. Thus we also seek to critique prevailing global health discourse with what are called the resocializing disciplines—anthropology, sociology, history, political economy. Our approach hinges on social theory, which we explore in the second chapter, and aims to interrogate concepts and claims of causality widely used in the literature on global health.

Our experience as medical practitioners has also shaped our approach to this volume. As we demonstrate in chapter 6, adapting a fully interdisciplinary investigation to basic questions—how did Mpatso become ill, and why?—has directly informed our practice. We see this close coupling of inquiry and implementation—the vitality of praxis—as central to our work: traversing the space between reflection and pragmatic engagement is necessary in any attempt to distill a core body of information about global health. Limitations exist in any team's knowledge of a particular field, and this book is of course based on material with which we are especially familiar, including the work of the nongovernmental organization (NGO) Partners In Health, the focus of chapter 6.

An Overview of Health Inequities: The Burden of Disease

We begin by taking a look at the global distribution of poor health and the factors that structure this distribution. Globally, heart disease was the leading killer worldwide in 2004 (see table 1.1); cerebrovascular disease and chronic obstructive pulmonary disease ranked in the top five. This picture looks different, however, when we compare high- and low-income countries. Five of the leading causes of death in low-income countries—diarrheal diseases, HIV/AIDS, tuberculosis, neonatal infections, and malaria—are treatable infectious illnesses that are not found on the leading list of killers in high-income countries. Nineteenth-century diseases like tuberculosis, malaria, and cholera continue to claim millions of lives each year because effective therapeutics and preventatives remain unavailable in most of the developing world. Although effective therapy for HIV has existed since 1996, and medicines now cost less than $100 per year in the developing world, AIDS is still the leading killer of young adults in most low-income countries. In fact, 72 percent of AIDS-related deaths occur in a single region, sub-Saharan Africa, which is also the world's poorest. Diarrheal diseases are often treatable by simple rehydration interventions that cost pennies, yet these diseases rank third among killers in low-income countries.

Table 1.2 presents similar data, this time using a measure that takes into account both disability and death. This measure, the disability-adjusted life year (DALY), which is a way of quantifying years lost to poor health, disability, and early death, is not without its flaws; we will examine it in chapter 8. This tool, reflecting morbidity, shows a similar picture of health disparities between high- and low-income countries. It is also apparent that noninfectious conditions—such as birth asphyxia and birth trauma, together ranked number seven in DALYs lost for low-income countries—are disproportionately distributed in low-income countries. Like the treatable infectious diseases just described, these forms of morbidity and mortality are often preventable with modern medical interventions and are thus much rarer in the wealthier parts of industrialized countries. Another stark picture of this disparity can be seen in map 1.1: despite some improvements over the last two decades, average life expectancy in low- and middle-income countries in sub-Saharan Africa stands at 49.2 years-fully 20.2 years less than life expectancy in high-income countries.

The relationship between gross domestic product (GDP) and health is one starting point for an examination of global health inequities. But national measures of wealth such as GDP and GNP (gross national product) are well worth pulling apart. "Domestic" and "national" data often (perhaps always) obscure local inequities, such as those seen within a nation, state, district, city, or other local polity. We will grapple with the many layers of these inequities throughout the text, beginning with a theory of structural violence in chapter 2. Figure 1.1, compiled by the World Health Organization's Commission on the Social Determinants of Health, illustrates one example of the substantial differences in health outcomes between rich and poor households within single countries. Figure 1.2, from the same report, highlights another measure of social status across countries—in this case, mother's education level—that correlates with health outcomes such as infant mortality. The impact of social class, among other social, political, and economic factors, on health is taken as a given in this book, as it is in others. But we will also delve into the complexities of causation and the structures that pattern both the risk of ill health and access to modern health services, even as we explore effective and ineffective interventions in global health. Why is Mpatso able to attain good health care despite living in poor, rural Malawi, while so many others in similar circumstances cannot?

Defining Terms

One question quickly arises in any study of this field: what do we mean when we use key terms such as "public health," "international health," and "global health"? More fundamentally, how should we define "health" itself? The World Health Organization (WHO) defines health as a state of physical, mental, and social well-being. But is this how Mpatso understands health? Can any definition of health capture the subjective illness experiences of individuals in different settings around the globe? Beyond the direct experiences of individuals are social, political, and economic forces that drive up the risk of ill health for some while sparing others. Some have called this structural violence. Such social forces become embodied as health and disease among individuals.

Though they share the goal of improving human health, "public health" and "medicine" are in many ways distinct. Public health focuses on the health of populations, while medicine focuses on the health of individuals. But in reifying the distinctions between them, we risk perpetuating unhelpful visual field defects in both professions. Clinical insights inform public health practice, and public health analysis guides the distribution of medical resources. But we believe both fields must also utilize the resocializing disciplines to address the fundamentally biosocial nature of global health problems. Microbes such as HIV and Mycobacterium tuberculosis cannot be understood properly at the molecular, clinical, experiential, or population level without analysis spanning the molecular to the social. Jonathan Mann, physician and public health expert, put it this way: "lacking a coherent conceptual framework, a consistent vocabulary, and consensus about societal change, public health assembles and then tries valiantly to assimilate a wide variety of disciplinary perspectives, from economists, political scientists, social and behavioral scientists, health systems analysts, and a range of medical practitioners." All fields have myopias. The restricted gaze of each discipline can illuminate certain global health problems; but only when they are taken together with a fully biosocial approach can we build, properly, the field of global health.

A word on the term "global health." An antecedent term, "international health," emphasized the nation-state as the base unit of comparison and implied a focus on relationships among states. Global health should more accurately encapsulate the role of nonstate institutions, including international NGOs, private philanthropists, and community-based organizations. Pathogens do not recognize international borders. But much churn—social and microbial—is introduced at borders. Further, we seek to examine health disparities not only among countries but also within them—including our own. Boston (like Cape Town and São Paolo and Bangkok) has some of the world's finest hospitals but also great disparities in burden of disease and access to care; it is on the globe, too.

A final note on definitions: "global health delivery" refers to the provision of health interventions, a process distinct from discovering or developing such interventions through laboratory research or clinical trials. Global health delivery begins with the question, "how can a health system efficiently provide health services to all who need them?" More efficient and equitable delivery of existing health interventions could save tens of millions of lives each year. But even the best models of global health delivery cannot alone raise the standard of health care available to people worldwide. The health of individuals and populations is influenced by complex social and structural forces; addressing the roots of ill health—including poverty, inequality, environmental degradation-requires a broad-based agenda of social change.

Organization of this Book

The chapters in this volume have been drafted by course faculty, guest lecturers, teaching fellows, and—in a few instances—outstanding former students from our Harvard undergraduate course Case Studies in Global Health: Biosocial Perspectives. In developing the syllabus and course content, we observed that despite the wealth of scholarship in this area, the number of introductory texts approaching global health from a biosocial perspective was limited. In positive reviews during the first year of the course, students encouraged us to find ways to make the course material accessible beyond our classroom. We decided that this project could achieve two aims: make our course material available to a broader audience, and begin to fill the gap of introductory materials on global health. An exhaustive treatment of global health would be impossible in a single volume; our goal here is thus to introduce some of the principal challenges, accomplishments, and complexities that constitute global health.

The book is divided into twelve chapters. Chapter 2 lays out a framework of social theories to support the analysis of important questions in global health. We have found these theories a helpful toolkit for understanding both the material covered in this volume and our own varied practices within the field of global health. Though we assume no background knowledge in social theory, we draw on work by some of the great theorists of the past century, such as Max Weber and Michel Foucault, as well as more recent health-focused work, such as the notion of social suffering offered by Arthur Kleinman, Veena Das, and Margaret Lock. For readers with some background in social theory, we hope that our focus on health will elicit new insights from this material and spur consideration of the relevance of other theoretical frameworks.

Chapters 3, 4, and 5 continue to build our analytic framework by examining three key historical periods critical to an understanding of global health today. Chapter 3 offers an account of colonial medicine and its legacies. One particular focus is the development of major global health institutions, including the World Health Organization, and the patterns of priority-setting for health interventions in the developing world. We trace the ways in which the economic and political priorities of wealthy nations informed assumptions about local populations and corresponding modalities of intervention. These trends have often continued to structure academic inquiry and the design of health interventions well beyond the colonial era. We also study global fascination with the power of biomedical intervention, such as the development of the first antibiotics and the pesticide DDT, in the context of two of the most important global health campaigns of the Cold War era: the smallpox and malaria eradication campaigns, which achieved markedly different results.

Chapter 4 analyzes two pivotal and tumultuous decades for international public health, the mid-1970s to the mid-1990s, that profoundly influenced health systems in developing countries and shaped contemporary discourse among global health policymakers. The chapter begins with the antecedents of the 1978 International Conference on Primary Health Care, where delegates from around the world adopted the goal "health for all by the year 2000." We then trace the development of neoliberalism and the shift toward a selective primary health care approach in the 1980s. The chapter details how these geopolitical shifts led to the rise of the World Bank as perhaps the most influential institution in global health during the 1990s and considers the effects of its approach on the health of the global poor.

In Chapter 5, we examine one of the most astonishing events in the history of global health: the AIDS movement. Why, after decades of austerity in the face of yawning health inequities around the world, did rich countries begin to devote billions of dollars in new resources every year to global AIDS efforts? Describing the rise of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, we suggest that a broad coalition of practitioners, patients, policymakers, advocates, and researchers helped to expand what was deemed "possible" in global health. Global policy and resource flows shifted dramatically, demonstrating the elasticity of assumptions such as "limited resources" and "appropriate technology" and underscoring the force of vibrant social movements in global health.

Chapters 6, 7, and 8 build on the historical and theoretical frameworks set out in earlier chapters and confront many of the key questions in global health, beginning with those posed by Mpatso's case. Chapter 6 contextualizes these historical trends at the point of care by exploring the resuscitation of public-sector health systems in Haiti and Rwanda, focusing on the experiences of Partners In Health. It offers a chance to see the biosocial approach in practice, in the principles behind the organization's strategy and in the delivery of context-specific health interventions.

Chapter 7 outlines a generalizable framework for effective global health delivery. We begin by defining several principles of global health delivery and then analyze contemporary efforts to strengthen health systems in resource-poor settings. The chapter calls for a true "science of global health delivery" capable of improving health system performance around the globe—in areas poor and rich.

Chapter 8 investigates the social construction of disease categories and health metrics in the context of mental illness and multidrug-resistant tuberculosis-two pathologies that pose unique challenges to global health practitioners. The history and political economy of these illnesses illustrate many of the themes treated in this text and highlight the role of biosocial analysis in unpacking some of the complexities of global health. We hope the chapter will offer lessons for other global health challenges that, unlike AIDS, rarely see media attention and are widely misunderstood—often at the expense of those who encounter them as illness experience.

Chapter 9 examines moral aspects of global health work, including the human rights tradition. It traces the genealogy of several ethical frameworks invoked by practitioners, examining their core premises and also the practical implications of their application in global health. Many people are led to global health work by an intuitive sense that it is the right thing to do; we believe that a critical investigation of several moral frameworks can both facilitate productive introspection and expand the sphere of discourse for public engagement in global health.

The last three chapters, 10, 11, and 12, sketch the landscape of global health today. Chapter 10 critically examines the rise in foreign assistance for health and development. The chapter goes beyond the question "does foreign aid work?" to ask "how does aid work?" What lessons have been learned during the past decades that might improve the machinery of foreign aid in the decades to come? We argue for a novel way of delivering effective foreign aid, which we call the accompaniment approach.

Chapter 11 outlines a number of key global health priorities for the next decade. It suggests that scaling up the model of health care delivery and health system strengthening introduced in chapter 7 offers great promise in addressing these priorities. Such an effort offers a platform to reduce the burden of disease, address social determinants of health, and build long-term care delivery capacity that will allow us to adapt to new demands as they arise. But such scale-up and the ability to advance global health equity will not be possible without broad-based social change—which is the subject of Chapter 12, the concluding chapter of this book.

When Marcela Mamani starts cooking at 4 a.m. each day, the streetlights still burn bright along the dirt roads of her Lima neighborhood.

She breaks eggs into a bowl and mixes them into a steaming vat of corn and chicken stew, which she sells on the street to chilly Peruvians hungry for a hot meal. Then, with a series of firm pats, she wakes up her three children, who sleep huddled together in a single bed.

Mamani, a survivor of multidrug-resistant tuberculosis (MDR-TB), earns about $30 a day with this small business she started with a microloan and training from Socios En Salud, Partners In Health’s sister organization in Peru (PIH/SES). The program helps recovered MDR-TB patients enter the workforce after two or more years of arduous treatment that leave many without jobs or support from friends and family.

“Socios En Salud gave me the opportunity to open my own business, and I had to make the most of it,” Mamani said. “With little experience but a lot of desire to get ahead, I became an entrepreneur.”

PIH/SES believes comprehensive health care for poor people must improve the social and economic conditions that often accompany disease. To that end, PIH/SES has worked to help 384 tuberculosis and HIV patients find employment since 2006.

Now I’m not afraid of getting out of bed. I know that there are good days and low days, but not bad days.

With a variety of partners, the program provides several ways for recovered patients to begin working: continuing education to find a skilled job, including nursing, accounting, welding, and cosmetology; counseling on job searching; and support to start small businesses, including microloans and training. PIH/SES has also worked to develop partnerships with government and private enterprises to help patients get hired after treatment.

A Dark Hole

Mamani earns a meager living, but it’s a big improvement from her situation just a few years before, when she became ill with MDR-TB.

“When the sickness started, I fell into a dark hole so deep that I was afraid to keep living,” said Mamani, whose husband abandoned her. “To get up every day was agony. I didn’t know how to tell my children that there wasn’t anything to eat. I was alone and sick.”

Mamani began treatment for MDR-TB that was provided by the Peruvian Ministry of Health, but the medicines made her sick and weak, and she couldn’t work. One day, after going two days “without touching a piece of food, ” Mamani’s neighbor told her she should give up her children to someone who could care for them. She couldn’t do it: “They are my children,” she said.

Just then, a community nurse from PIH/SES knocked on her door. She wanted to see how Mamani was faring with her MDR-TB treatment. She offered support designed to complement the clinical treatment she received, including visits from a community health worker, food, and psychosocial counseling.

“It’s not often that people help you with no interest in getting anything in return,” Mamani said. “I couldn’t believe it, but they always came with food and other things for me and my children.”

With clinical care and social support, Mamani completed treatment in 2011 and enrolled in the PIH/SES income generation program. Participants receive loans and training on how to operate a small business, including sessions on taxes, marketing, entrepreneurship, business management, and customer service. The average loan in the program is $775, with a monthly payment of $65. Mamani used the loan to buy the pots, pans, and plates she needed to cook.

"Now I’m not afraid of getting out of bed. I know that there are good days and low days, but not bad days,” she said.

The Fight Continues

PIH/SES has been fighting MDR-TB in Peru for more than 17 years, but our role has shifted dramatically as the Peruvian government has taken on treatment of the disease.

When Partners In Health discovered an epidemic of MDR-TB in 1995 in the shantytowns of Lima, the World Health Organization called for treating only TB that could be cured with standard, first-line drugs in poor countries—letting patients with MDR-TB die. “MDR-TB is too expensive to treat in poor countries,” one WHO document stated.

PIH/SES pioneered a strategy to cure patients and stop transmission of MDR-TB through accompaniment—daily visits by community health workers who deliver individualized treatment to patients in their homes. Research proved that cure rates among PIH’s MDR-TB patients in Peru rivaled rates at hospitals in the United States. With this documented success, PIH and our partners pressed for reduced drug prices and changes in global policies. In 2006, the WHO released new guidelines calling for universal access to treatment for MDR-TB.

The Peruvian government now provides treatment to all MDR-TB patients, and PIH/SES continues to support the most vulnerable patients with services that help them complete the taxing treatment. In 2012, more than 75 percent of PIH/SES patients were cured, as compared to a national MDR-TB cure rate of 39 percent in 2009, according to a 2013 article in The Lancet.

Learn more about our work in Peru.

Neza Guillaine had a seemingly simple task for the 16 young women who sat in front of her in a small classroom in Gashora, Rwanda:  Provide step-by-step instructions for drawing a smiley face on the chalkboard.  But there was a catch. “They should very literally follow the steps in such a way that any impreciseness, such as a student telling me to draw a circle without first telling me to pick up the chalk, causes problems,” Guillaine says.  

Guillaine, 26, is a Java developer for PIH’s Rwanda sister organization Inshuti Mu Buzima. She spends her days tackling tech issues, designing new features for PIH’s open-source electronic medical record system, and helping improve the documentation process for clinical teams. It’s been a challenging career path to pursue.  From Silicon Valley to Shanghai to South Africa, the gender gap in science, technology, and engineering is enormous. And in settings such as Rwanda, where access to computers is limited and cultural barriers plenty, it’s exceedingly difficult for women to get a foothold in the field.

“There are many challenges for women in science and technology. Some girls just think they can’t make it or that the technology world is only meant for men. Some girls don’t get enough support from their families at a young age,” Guillaine says. “I knew what I wanted to do and started work early on at university so that when I finished I had knowledge that could help me get a small internship.”

Guillaine has always been keen on sharing tips with women interested in pursuing a career in tech, so she was excited when presented with the opportunity to lead three seminars for the weeklong Camp TechKobwa at the Gashora Girls Academy of Science and Technology. Organized by three groups—Peace Corps, Girls in ICT Rwanda, and kLAB—Camp TechKobwa hosted 48 female students from a handful of nearby high schools, who were introduced to a variety of tech issues. Students learned how to set up an email account, the basics of blogging, and the fundamentals of programming. Over the week, advice on personal health and financial planning were weaved into the seminars.

For her lessons, Guillaine decided to introduce students to Scratch, an educational programming language and multimedia authoring tool created by the Massachusetts Institute of Technology that teaches the basics of designing an algorithm. “The objective of this lesson was to equip students with programming skills by explaining to them what an algorithm is (a set ordered list of steps used to solve a problem) in a real life situation,” she says.

That’s where the smiley face came in. By making sure the students listed every step Guillaine had to take—from picking up the chalk to drawing the actual smile—they came to understand how algorithms make up a program and how programs execute larger-scale tasks.  Once the basics were mastered, students began looking for ways to incorporate Scratch into their daily lives and peppered Guillaine with questions on additional programs.

And Guillaine wasn’t the only PIHer leading seminars at the camp. Marie Paul Nisingizwe, a data analyst with PIH/IMB, taught classes on how to use Microsoft Excel.  Nisingizwe is well aware of the challenges women face as they pursue careers in science and technology. When she started studying statistics at the Kigali Institute of Science and Technology in 2009, she was one of only two women in her class. The situation compelled her to start volunteering with nearby high school girls, with a focus on building their confidence and instilling the notion “to be confident that they can do anything.”

As the Camp TechKobwa week went on, both Guillaine and Nisingizwe stepped back from the nitty-gritty details of spreadsheets and algorithms and gave broader advice on career development.

One suggestion Guillaine isn’t shy about sharing:  “When you are a girl, sometimes you might need to work even harder to prove you can make it.”

Across the world, PIH employees like Guillaine and Nisingizwe continue to break down antiquated barriers and usher in a new era of gender equity.   

Spend a day at any Partners In Health site and there’s a good chance you’ll hear a phrase you’re unfamiliar with. Perhaps it’s a clunky acronym or polysyllabic drug name. But don’t worry: Keeping up with the ever-evolving world of global health is hard, even for insiders. In Need to Know, we cut through the complexity and deliver the most pertinent and interesting information on a single subject. Today, we fill you in on the Pima CD4 Analyzer.

What is it? 

The Pima Analyzer is a mobile device about the size of a toaster that measures CD4 counts of HIV-positive patients. Also known as T-helper cells, CD4 cells are a type of white blood cell that helps our bodies fight infections. The lower a patient’s CD4 count, the weaker their immune system and more advanced their HIV. 

Why is it important?

CD4 counts are used to determine when an HIV-positive patient should begin antiretroviral therapy, commonly referred to as ART. In many hard-to-reach rural areas where PIH works, determining a patient’s CD4 count can be a cumbersome process. For instance, before Socios En Salud—PIH’s sister organization in the Dominican Republic—had a Pima Analyzer, blood samples would be sent to a national lab five hours away by car. Sometimes it would take weeks for the lab to send back results. This lengthy turnaround may have delayed patients from getting on lifesaving medication. It also meant that patients had to make a second trip to the clinic to get their results, a costly and time-consuming process that not every patient was able to afford. 

So how fast does Pima deliver a CD4 measurement? 

Our lab technician draws a sample of blood from the patient and enters it into the Pima device on the spot. From there, it takes about 20 minutes to deliver a CD4 count. 

Does such a quick turnaround actually help close the treatment gap? 

Yes. A recent peer-reviewed study in Plos One notes that point-of-care testing for CD4 counts has been shown to increase the number of patients in need of antiretroviral therapy who start treatment within three months of being tested. The study also found that the availability of testing at the point of care (one goal of Pima) helped reduce the number of patients not yet needing treatment (“pre-ART”) who were lost to follow-up care.

And what happens after the CD4 count comes back? 

Well, that depends. If the patient’s CD4 count is high enough, meaning that he or she is not yet eligible for antiretroviral therapy, we will continue to monitor CD4 levels, schedule a follow-up clinical appointment in six months, and provide other needed support such as food, housing, and education on how to stay healthy. In these cases, our community health workers will make home visits and check on patients to make sure there haven’t been any changes in their health requiring earlier follow-up. 

But what if the patient’s CD4 count is low?

In the Dominican Republic, if a patient’s CD4 count is 350 cells/mm3 or less, he or she is immediately enrolled on antiretroviral therapy and assigned an acompañante, a community health worker who will meet with the patient on a daily basis to provide directly observed therapy, making sure the patient is taking his or her medication properly. By getting the patient on medication within hours of receiving the CD4 count, we’re closing the gap and making it easier for patients to receive timely care.

PIH/SES' work along the DR-Haiti central border is made possible with generous funding from the United States Agency for International Development.

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Fifteen doctors, nurses, and HIV specialists are bunched in small groups, writing on chart paper and engaged in animated discussions that echo through the small room at the Rwinkwavu Hospital Training Center in eastern Rwanda.

“Why don’t you start?” a nurse asks a member of her group. “You can invite participants to volunteer in a role-play about how to counsel serodiscordant couples [where one partner is HIV-positive and the other isn’t]. Then, I will ask for feedback about what the nurse did well in the role-play and what could have been improved.” Further discussion of teaching methodology ensues, and after a few moments the group is writing out ground rules and expectations for the exercise.

The 15 participants are in the middle of a weeklong “Training of Trainers” session. Manzi Anatole, director of quality improvement at PIH’s Rwandan sister organization Inshuti Mu Buzima (IMB), floats around the room offering feedback and support as the groups work to craft HIV training activities that they’ll soon be facilitating in their respective districts around the country.

Together, IMB and the Rwandan Ministry of Health launched the National Training of Trainers (TOT) model for HIV providers and program leaders. It’s a new way of working with Ministry departments and clinicians to improve the quality of training throughout Rwanda. By the end of the week, everyone here will be qualified HIV trainers.

“This is an innovative strategy to improve training methodology for clinicians in Rwanda. Many of these providers have not yet participated in a TOT to build competency in the skills necessary for high-quality training; we are working with the Ministry to address this challenge,” says Chadi Cortas, IMB’s director of medical education and training. “This new model should improve training quality across Rwanda’s 30 districts.”

TOT participants pass through three phases: Phase I introduces adult education methodologies and allows participants to apply their new knowledge through use of PIH’s HIV curriculum; phase II is where the trainers train other HIV health professionals in participatory methodologies; and in phase III, where they become “master trainers,” participants learn to design training materials themselves. 

The importance of skilled trainers cannot be overstated. For efforts such as PMTCT—the prevention of mother-to-child transmission of HIV—guidelines and protocols change frequently, and so program leaders are often asked to train colleagues on new standards for delivering care. Without sufficient integration of high-quality methodology into program development, trainings can be time-consuming activities that do not always enhance participants’ clinical skills.

TOT also supports the Ministry of Health’s push toward “task-shifting,” or delegating tasks traditionally reserved for doctors to nurses and community health workers, a process that depends heavily on effective training initiatives that can be shared and replicated throughout the country.

“Task-shifting is very important for our national strategy for improved health care provision. In order to achieve this, we need skilled trainers to ensure that health providers are able to take on new responsibilities,” explains Dr. Aimable Mbituyumuremyi, the national coordinator of task-shifting who has been at the forefront of the TOT initiative.

Now Mbituyumuremyi, who’s one of the eight current advanced trainers, is preparing to transition into a new program for master trainers. Beginning this fall, he’ll attend workshops designed to teach clinical leaders how to independently develop and revise participatory curricula. With these newly acquired skills, the master trainers will play a hands-on role in shaping future training initiatives for Rwanda.

“We expect this program to lead to the formation of a cadre of HIV professionals who are highly skilled in training methodologies and curricular design,” says Celia Reddick, IMB’s outgoing curriculum and training specialist.  “Ultimately, we hope this model will spread beyond the HIV division to inform future training initiatives.”

Indeed, with training continuing to play a vital role in the Ministry of Health’s work, this partnership is sure to set the stage for a new wave of health leaders and educators and to serve as a model for future partnerships that support clinical training.

Emma Hiza is the incoming curriculum and training specialist at Partners In Health in Rwanda. 

The temperature was nearing 88 degrees when seven cyclists pulled up to the glass doors of the Partners In Health headquarters in Boston recently.

Part of FACE AIDS, a student organization dedicated to ending AIDS, the group was near the end of a 63-day bicycle journey that started in San Francisco—4,000 miles away—to raise money and awareness about PIH’s work to provide HIV care in Rwanda. FACE AIDS supports our work through a network of 80 chapters at high schools, colleges, and universities around the United States.

“I think we’re all a bit dumbfounded that we’re here. It’s hard to believe we’re not going to bike tomorrow,” said Amanda Feairheller, an aspiring medical student who said the trip has made her want to pursue a career providing care to marginalized people in poor countries.

For the last leg of the ride—the six miles from the PIH office to the beach at Pleasure Bay, Boston—a handful of PIH staffers joined them. We peppered them with questions about their motivation and about the trip—including, "did you visit the world’s largest ball of twine?"

“It was a lot of—in all honesty—corn and roadkill,” Amanda said.

Road trip

Their journey began nearly a year ago, when the seven—all college students but one—applied for the sixth annual Ride Against AIDS.

They met in San Francisco last June for orientation and explained why they committed to the trip. Eric Steinbrook, 20, was motivated by stories he'd heard from his parents—medical residents at San Francisco General Hospital in the early '80s, when the first patients with AIDS began seeking care. As Eric got more involved in the ride, his dad opened up to him about his experience. His father described feeling powerless as a mysterious, terrible illness killed his patients.

Amanda, from Dayton, Ohio, summarized her motivation this way: “Because of nothing I have done in my life, I have been granted health care. I find it hard to argue that the level of care a person receives should be dependent on their bank account, social status, or any other factor.”

The participants were understandably nervous, with varying cycling backgrounds and levels of training. They would be spending the next 60 days with these strangers, unsure of how they would work together to plan each day's route, set up speaking events along the way, and arrange homestays or camping for each night. They would bike in all weather, their only refuge a hand-me-down white van that members of the team took turns driving ahead of the cyclists with their supplies.

The FACE AIDS riders' route took them from San Francisco to Boston. Photo: FACE AIDS

After dipping their tires in the Pacific Ocean in San Francisco, they headed north and then cut east. Nevada was an early test of their wills. Team members described Highway 50 as the loneliest road in America, cutting through the desert with no shelter from the sun. Amanda recalls pulling over to take advantage of the shade cast by a street sign. One day, Dana Ballard, of Silver Spring, Maryland, biked five hours alone on that highway and wondered if she would make it, and if she’d ever see anyone she knew again. That day, the group rode 115 miles.

But Nevada is also where they met Leonard, a lanky, elderly resident of Eureka. At 6 a.m. the day they left town, he rode with them up the first summit out of town, hardly breaking a sweat in his long-sleeve collared shirt and boat shoes.

Leonard, a resident of Eureka, Nevada, rode with the cyclists in solidarity. Photo: FACE AIDS

Leonard wasn’t the only person the team inspired along the way. Dana met a woman at a coffee shop who thanked her for riding because her best friend died of AIDS. In front of a bike shop in Cleveland, a passerby saw “Raising 100K for HIV” painted on the van and asked how she could help. When the cyclists told her they were fundraising, she handed them a $100 bill and walked off.

The trip also contained low points. Eric and Max Smith got food poisoning from a meal in Ohio, so Max spent six days in the van and lost about 10 pounds. Bouts of illness hit the rest of the team around then, too. When they crossed from Ohio to Pennsylvania, only two—Dana and Laura Karson—were healthy enough to ride.

But on the ferry from New Jersey to New York City, they watched with joy as the sun gleamed off the skyscrapers of lower Manhattan just before sunset. During their three rest days, they visited an exhibit on the early days of AIDS in New York City and the activists who demanded their city and country respond.

“It was really easy to get caught up in the biking. It was great to see really why we were there,” Dana said.

The riders reached New York City and took three days to rest and see the city. Photo: FACE AIDS

The last mile

In Boston, the riders set out for the last leg from the PIH office, changing a flat tire with the teamwork and efficiency of a NASCAR pit crew. “It wouldn’t be day 63 without changing a flat,” Amanda said.

PIH staffers joined them and the group cycled down Commonwealth Avenue, the four-lane highway that cuts into the heart of downtown Boston. On this last day of the trip, the cyclists were flawless city riders. They signaled road hazards with pointed fingers, slid their shoes in and out of their clipless pedals at red lights, and deftly plucked their iPhones from the back pockets of their jerseys to check directions.

Soon the ocean came into sight. “Water, guys, water!” Amanda yelled. Dana caught up, bouncing up and down on her pedals. “I’m so excited.”

They rode the last mile to Pleasure Bay, where Boston meets the Atlantic Ocean—and no road leads further east, only water. A small group of FACE AIDS staff, moms, dads, and relatives cheered as they pulled up to the beach.

Margo Watson, executive director of FACE AIDS, gave the final tally: The group had raised $51,000 for Partners In Health to provide HIV care in Rwanda. “You will never know how many lives you’ve touched,” she said.

The cyclists climbed down the stairs to the beach, took off their shoes, and dipped their front tires in the Atlantic, mirroring the moment that started the trip, when they dipped their back tires in the Pacific.

Laura reached down and splashed Max. Soon the crew was running into the water, one after the other. They waded waist deep, and then drew together in a circle, shoulder to shoulder.

The final moments: FACE AIDS riders dip their tires and embrace at the end of the ride. Photo: FACE AIDS

Learn how to start your own personal fundraising campaign.

Meet the Riders

Dana Ballard
Age: 24
Hometown: Silver Spring, Maryland
Bike: Trek Lexa SLX
Most inspiring moment: Reaching the top of Loveland Pass at 12,000 feet and realizing that I really can climb mountains. And if I can do that, I can probably do a few other cool things, too.

Lisa Fawcett
Age: 21
Hometown: San Francisco area
Bike: Trek Lexa SLX
Hardest part: Team dynamics and making things work interpersonally. We haven't killed each other yet, so I think it ended up working out.

Laura Karson
Age: 22
Hometown: New York City
Bike: Trek Lexa
Most inspiring moment: The moment I first saw the New York City skyline was when it really hit me that I had just biked across the country. We were on a bumpy, slightly dangerous bridge into Jersey City, but none of that mattered to me. I started to tear up when I saw the sun reflecting off of the skyscrapers—I couldn't believe I had actually made it home.

Kate Pipa
Age: 23
Hometown: Shelton, Conn.
Bike: Giant Avail 1
Favorite thing to eat: Home-cooked dinners at homestays and ice cream after a long day of riding.

Max Smith
Age: 23
Hometown: Santa Rosa, Calif.
Bike: Jamis Bosanova
Most amazing sight: From the sidelines, watching our "Why we ride" video at the New York Red Bulls Arena 15 minutes before kickoff in front of 50,000 people. I was shaking with excitement, standing 20 feet from Thierry Henry and knowing that our cause is worth the applause of 50,000 people.

Eric Steinbrook
Age: 20
Hometown: Lincoln, Mass.
Bike: Surly Cross Check
Most inspiring moment: In the weeks leading up to the trip, I was working as a bartender at the Amherst College 40th reunion. I had put out some of the pins made in Rwanda that we sell to raise money for FACE AIDS and PIH, and three men came up to me to talk about what I was doing. They were all HIV positive, they told me, and had been living with the virus for 20 or more years. That was the first time I had ever met anyone who was HIV positive, and hearing about how so many of their friends had died of AIDS and how hard they had fought for better research, health care, and awareness really put the epidemic in perspective. I thought of them throughout the trip to remind myself why I ride.

By training physicians, nurses, health workers, and administrators in settings of poverty, Partners In Health is developing a new generation of health care providers to deliver comprehensive, community-based care in the poorest and most remote places.

We recently sat down with two people on the front lines of PIH’s training efforts in Haiti: Emily Dally, a curriculum and training specialist from Central Valley, NY, (pop. 1,857), and Vernet Etienne, general training coordinator from Cap-Haitian, Haiti, (pop. 190,000).

What kind of work do you do together?

Etienne & Dally: We’ve been collaborating since June 2012 and working together directly since Emily transitioned from the Boston training team to the Zanmi Lasante (ZL) training team in September 2012. We work together to develop curricula, improve training methodologies, and to organize trainings for Zanmi Lasante and ZL’s partners. We also develop tools to help trainers as well as training materials and tools for participants. Finally, we collaborate on the production of a quarterly bulletin to share the work of ZL among our colleagues and partners.

The training team is based at the National Training Center in Hinche, Central Plateau, Haiti. However, our team oversees training initiatives across ZL sites, so we travel frequently between sites.

How do you describe what you do on a daily basis?

Etienne: I plan, organize, implement, and report on the trainings we host at the National Training Center and other ZL sites. On average, we have about 10 trainings each month—the participants include doctors and nurses, but also community health workers, accompagnateurs, and others. I also gather and edit articles for a quarterly bulletin that we produce, and manage weekly and monthly meetings to structure our work at the NTC and increase collaboration.

Dally: I work mostly on revising and writing training curricula and brainstorming with Vernet and other team members about how we can improve our trainings and the training process at ZL. Some of our large trainings, such as the accompagnateur training, is written in English and translated into Creole, Kinyarwanda, etc., for various PIH sites. I work with the ZL team to develop or adapt curricula to the Haiti context, and to integrate ZL and Ministry of Health protocols.

Why is training important? How is it improving ZL's work in Haiti? How does your work fit with all the services ZL provides? 

Etienne: Training is important because it is an opportunity for professional development. Second, through training ZL can inform staff of new protocols or information that is important to their work. Trainings help to create unity among ZL staff and consistency with service delivery–the standard of care provided at one site is the same as that provided at another. Through training, we build capacity to break down the gap between theory (what one learns in school) versus what the individual is expected to do on the ground.

Dally: Vernet, you raise a great point about turning theory into practice. The trainings we deliver are not just an opportunity for the trainer to deliver information from his or her own point of view; they are opportunities for the participants to discuss what they are learning, draw from their own varied experiences, and question each other about best practices. We always try to incorporate role-plays or simulations into the trainings. For example, we just worked on a curriculum for accompagnateurs (community health workers who are responsible for accompanying our TB and HIV patients) on active tuberculosis case finding, so we incorporated a training session on sputum collection using the materials the accompagnateurs will use in the community. The main purpose of training is to provide knowledge and skills that will help participants perform their jobs, and this gives them an opportunity to practice these skills before they hit the ground running.

How did you find your way to ZL and your job today?

Etienne: In October of 2010, I was working as a cholera-training translator for Doctors Without Borders-Spain during the cholera outbreak in Port-au-Prince. I translated trainings for nurses and doctors on cholera care and treatment. I realized how important training was in continuing professional development and to quickly respond to problems that were not well understood. After my contract ended, a friend told me about a vacancy with the ZL training team. I really love to work for ZL and I share ZL’s philosophy “ for helping those most in need.”

Dally: As a graduate student at the Yale School of Public Health, I spent a summer working in the Artibonite region of Haiti (at Hôpital Albert Schweitzer) to develop an exclusive breastfeeding curriculum for community health workers. When I returned, I knew I wanted to work on training initiatives in Haiti and found the perfect opportunity with PIH. The PIH approach to training—providing quality and comprehensive training opportunities for a range of stakeholders in community health—was what drew me to the position. I started working with PIH a few weeks after graduating with my master's degree in public health and transitioned to working full-time with ZL in Haiti a few months later.

It was planned that Emily would only be in this position for one year. What was the thinking behind that? 

Dally: In my role I accompany the ZL team to support a variety of initiatives, specifically curriculum development and monitoring and evaluation. I act as a liaison between the PIH Boston and ZL training teams and support both teams’ work. The thought behind the defined timeframe for this position is that as I transition from Haiti to Boston, a liaison between the ZL team and PIH team will no longer be necessary. I will have worked with both teams to set up a system in which the teams collaborate on projects without a designated point person. 

What about your work together embodies the ZL approach or "model"?

Etienne: ZL strives to deliver high-quality care to those most in need—and this is the approach we use for delivering trainings as well: We deliver quality trainings and training materials to those most in need. Our trainings are not only for doctors. They are also for nurses and nurse auxiliaries, psychologists, social workers, and above all, community health workers and accompagnateurs, who are the pillars of the ZL system.  We also train those functioning outside the traditional medical system, such as matrons—traditional birth attendants who take care of a majority of pregnant women at the community level—and oungan (“witch doctors”), who see many patients before they present at the clinic or hospital.

Dally: In training, it’s important to recognize that a significant portion of medical care and preventative care happens at the level of the community health worker and accompagnateur. Community health workers administer childhood vaccinations, check in on women during pregnancy, educate families on methods of family planning, and search for cases of malnutrition and refer to the clinics. Accompagnateurs ensure that HIV patients take their medications properly and find active TB cases in their communities. Their roles are crucial to the success of the ZL model, and training gives them the knowledge and tools necessary to perform their jobs. 

Social justice and solidarity with the poor are core values for ZL. How do you incorporate those values into your work?

Etienne: First and foremost, the ultimate goal of any training is to improve the care we provide to patients and in communities through enhancing the knowledge and skills of our participants. But trainings also serve to influence the attitudes of the participants. Our trainings always respond to real social and economic problems faced in rural Haiti. It is important that we set an example and deliver our trainings within the context of a human rights approach as we show respect for our training participants by providing them with all materials and meals and a comfortable and secure training location.

Dally: These values are the threads that bind our trainings together. In training, it is important to incorporate discussions of the social and economic context in which we are working. How can we ensure access to health care? Why is it important that women have access to appropriate family planning? When we train on cholera prevention and hygiene and sanitation, for example, we can consider these issues in the context of human rights: The people in our communities have the right to access clean, safe drinking water. Now how can we improve their access?

What gives your trainings the "Zanmi Lasante" spirit? 

Dally: I think we do a great job of integrating adult learning principles into our trainings. We avoid using traditional training methodologies in which the trainer stands in front of the room and lectures at the participants. We use things like case studies, role-plays, and group discussions. 

Etienne: We make sure to keep our trainings small (no more than 25 participants) so that each participant is involved in the activities. A majority of our trainers participate in a “Training of Trainers” to prepare them to be effective facilitators. The entire ZL team, not just the training team, is responsible for ensuring quality training for the most in need.
 

“I believed I would die from cancer, since I didn’t think there was any cure,” Delphine Musabeyezu told a group assembled in front of the Butaro Ambulatory Cancer Center in Rwanda Tuesday. “I’m here now to say I am doing well. I’m here as someone that is cured.”

The just-opened Butaro Ambulatory Cancer Center (BACC) is part of the Butaro Hospital campus, which sits at the top of lushly terraced hills in the northern district of Rwanda—and where Musabeyezu was treated. She and others gathered this week to celebrate the opening of the ambulatory center, which is designed to treat cancer patients who need regular IV chemotherapy but who don’t need to be admitted into the hospital.

The BACC will relieve pressure on medical staff who have been caring for an overwhelming number of patients in the hospital, which sits a few hundred yards away. The hospital’s inpatient oncology ward at the Butaro Cancer Center of Excellence—which contains 22 inpatient beds and three isolation rooms--regularly overflows with patients. More than 1,000 patients have been registered for treatment at the center since it opened in July 2012.

Starting next week, many of these patients—up to 20 a day—will now be seen in the BACC.

Patients entering the one-story building will first be registered and their vital signs taken. As they move through the compact facility, they’ll see a meeting room, an area where chemotherapy drugs are mixed, and then reach an open, sunny room whose large windows take full advantage of the views outside. When the first patients arrive next week, they’ll receive chemotherapy here, sitting in comfortable blue or cream chairs with seating around them so family members and attending medical staff can remain close by.

“The only way to make deaths from cancer drop is to integrate prevention, diagnosis, and care,” PIH co-founder Paul Farmer told the group gathered for the opening celebration.

The facility—designed by the MASS Design Group and built by Partners In Health—also holds several consultation rooms, an exterior waiting area, and a private patient garden.

“The only way to make deaths from cancer drop is to integrate prevention, diagnosis, and care,” PIH co-founder Paul Farmer told the group gathered for the opening celebration. “Bringing those three things together is doable. It will be done here in Rwanda, and it will light the way for other countries around the world, not just in Africa.”

The BACC is the third phase in a five-phase Butaro Hospital expansion project. Phase 1 included construction of the main hospital campus, phase 2 was the doctor and staff housing that opened in November 2012, and phases 4 and 5 will be an expansion of doctor, nurse, and staff housing and room, beds, and services for patients.

BACC is generously funded by the Cummings Foundation, led by Bill and Joyce Cummings, who also attended the event. Partners include the government of Rwanda, Rwanda Biomedical Center, Dana-Farber/Brigham and Women's Cancer Center, and MASS Design Group.

“This is a great day,” said Dr. Agnes Binagwaho, Rwanda’s minister of health, as she wrapped up the celebration. “This is a challenge we give to the world. We just showed them what is possible with good partnership.”
 

With the opening of University Hospital in Mirebalais, Haiti, we’ve celebrated several firsts: The first patients logged into the electronic medical record system; the first babies born in the maternity ward; the first cancer patient to receive a lifesaving mastectomy. Then there are the firsts that are less joyful, the inevitabilities that we’ve trained extensively for. 

In late July, 14 patients were rushed to University Hospital’s emergency room. They were in the nearby town of Morne Couleuvre, riding in a tap-tap—pickup trucks or buses that have been converted into makeshift taxis—that crashed. The range of traumatic injuries was daunting. Four patients sustained serious head injuries, one suffered a critical cervical spine fracture, and another had a fractured femur.

Globally, traffic accidents kill approximately 1.24 million people each year, according to the World Health Organization. More than 90 percent of these deaths occur in low- and middle-income countries.

Tap-tap accidents occur with depressing frequency in Haiti, and PIH has seen the horrific consequences countless times over the past 25 years. In Mountains Beyond Mountains, author Tracy Kidder details a deadly crash that PIH co-founders Paul Farmer and Ophelia Dahl came upon during their early years in Haiti. “Accidents happen. Sure,” Kidder writes. “But not every bad thing that happens is an accident. There was nothing accidental about the wretchedness of the road down Morne Kabrit or the overloaded tap-tap, or the desperation of a peasant woman who had to get to the market and make a sale because others in her family would go hungry.”

In Haiti’s Central Plateau, roads are still rough, tap-taps are still overloaded, and poverty is still pervasive. But the network of PIH/Zanmi Lasante facilities has grown more robust each year, forging a spectrum of care that spans from small clinics to the 300-bed University Hospital, which offers many services and technologies that were never before available in this area. The 14 patients who were rushed to the hospital in the wake of the accident put those services and technologies to the test. Clinicians from both the emergency department and surgical department worked seamlessly to provide timely, thorough, and compassionate care.

All of the patients survived.

“Having a modern and well-equipped emergency department and a highly trained team will dramatically improve our ability to reduce morbidity and mortality related to trauma in the Central Plateau,” says Dr. Regan Marsh, the director of emergency services at University Hospital. “The ED physicians and nurses are able to quickly assess, stabilize, and manage both minor and major injuries—and have access to essential resources, such as bedside ultrasound and CT scans.”

There will be many more accidents in the coming months and years. With your support, we’ll be prepared.
 

What can Lebanon learn from Mexico? That question rattled around the mind of Kareem Raad as he made the nearly 24-hour trek from his home on the outskirts of Beirut to Jaltenango, Chiapas, where PIH’s Mexican sister organization, Compañeros en Salud (CES), is based.

Raad, a young Lebanese medical student, was drawn to CES because of its focus on revitalizing and rebuilding a primary care system. “We need to build a model of excellence in primary care in my country,” he says, echoing the CES vision statement. Lebanon, he says, spends a similar percentage of its GDP on health care as Mexico and has similar health indicators. There are numerous lessons in health-system strengthening gleaned from CES that could be adapted and deployed in his country, but exactly how remained to be seen.

Since 2012, CES has been placing Mexican social service year physicians—known as pasantes—in clinics throughout isolated areas in the Sierra Madre Mountains of Chiapas, recruiting them with unique education and mentorship opportunities.

We’ve built a system of partnerships and accompaniment that the Mexican Ministry of Health and other developing countries can learn from,” says Dr. Hugo Flores Navarro, director of CES. “There are lessons that we’ve learned, especially in terms of primary care in rural settings, that could be applied elsewhere in Mexico and in other countries.”

It took only a few days for the pasante-staffed clinics to inspire Raad and stoke his imagination. The way in which the young doctors were invested in the community stood out. “In Mexico I felt like I was working in clinics that could serve as a model of excellence for chronic and preventive care,” he says. “They were deeply embedded in a community, with physicians who lived the same daily experiences as their patients.”

Like all great partnerships, the learning exchange went both ways. In a monthly course given to the pasantes, Raad delivered a lecture on the intricacies of Lebanon’s health system, highlighting similarities and differences to Mexico, successes and failures.

“He really showed us that there is social injustice everywhere, and how much government systems can influence quality of care,” notes Hector Carrasco, who started working with CES as a pasante in February 2013.

For Raad, the most important lesson was that ideas and insights can be exchanged across borders, across cultures, and across languages with tremendous results. “These conversations can help create radical transformations in the way we think about and design health systems,” he says.

When asked how he was going to utilize his experience with CES in Chiapas, Raad joked that he wants to “copy and paste” with a few tweaks.

“A crucial and very classic Partners In Health idea that I picked up during my recent experiences is the importance of seeing the whole person,” he said. “In seeing the history, culture, economic, and political factors that bring a patient to you with a particular biological problem, you come to understand that beyond the medication, the solution is nonbiological.”

Green Mountain Coffee Roasters generously supports PIH’s work in Mexico.

Emma Goodstein has been collaborating with the PIH/CES team in Chiapas, Mexico, since June 2012. Originally from Portland, Oregon, she graduated from Wesleyan University in 2010 with a degree in history and has since worked in various positions in health care in Portland and New York City. She will be entering Emory School of Medicine this fall.

To learn more about Kareem Raad's pursuits, check out his blog. 

Blessings Banda stood at the lectern in the atrium of the Harvard School of Public Health, wearing a black vest and white dress shirt with a Malawian flag draped over his shoulder. It was late July, the end of his first trip to the U.S., where he had spent the sticky summer weeks crammed in a classroom digesting case studies as part of an intensive program in global health delivery. Now, with his final exam completed and a few dozen peers, instructors, and friends standing in front of him, Banda wanted to lay bare exactly what the course meant to him.

“If the Global Health Delivery program was introduced in 1994, I wouldn’t have lost my mother who died of TB as a result of AIDS in 1995,” he said. “If it were introduced in 1992, I wouldn’t have lost my father from cancer in 1993. And if it were introduced in 2000, I wouldn’t have lost my uncle in 2003 to a disease that I do not even know yet.”

Banda, 27, was born and raised in Lilongwe, the largest and capital city of Malawi. In 2011, he moved to the district of Neno in the southwest region of the country and began working for PIH’s Malawian sister organization Abwenzi Pa Za Umoyo (APZU) to support its malnutrition program.

“People were like, ‘are you seriously going to Neno?’” Banda recalled during a recent interview. “I knew of Neno as the district that had been abandoned, where nobody cared what happened.”

Malnutrition is pervasive throughout Malawi—nearly half of all children under 5 years old are “stunted.

Malnutrition is pervasive throughout Malawi—nearly half of all children under 5 years old are “stunted,” meaning they are abnormally short for their age. In Neno, the situation is more severe. A quarter of all children under 5 are underweight. Severe acute malnutrition, an advanced state of the disease that can be lethal, afflicts 1.5 percent of children in Neno.

Soon after Banda arrived in Neno, the Nutrition Rehabilitation Unit opened at the nearby district hospital. On opening day of the facility, he admitted three kids who were severely malnourished. Banda quickly realized that it wasn’t just that kids didn’t have enough food—they weren’t getting the right food. Some children ate sweet potatoes and Irish potatoes for 30 days straight. And between September and March, “it’s hard to get food; they really don’t have anything,” Banda said.

While the burden was staggering, Banda and his APZU colleagues worked steadfastly on a treatment program that spanned from increasing malnutrition screenings to improving agricultural practices to bolstering family planning. The approach wasn’t new. APZU started working in Neno in 2006, making significant inroads on malnutrition and HIV. But Banda’s aura of compassion and ingenuity stands out, allowing him to connect with staff and patients while helping bring new partners into the fold.

“He really cares about interacting with patients. His style is very social, so they feel comfortable and open to counseling,” said Chisomo Kanyenda, an antiretroviral therapy officer at APZU who works regularly with Banda. “He is also very good at motivating staff. He is a self-starter. He sets a strong example for other staff members to respect the dignity and privacy of patients.”

Banda’s commitment has paid off. In the first half of 2012, APZU achieved a 95 to 100 percent cure rate among children in various stages of malnourishment. The cure rate among severely malnourished children in Neno for the same period was 97.4 percent, compared with 89 percent nationally. The results were so impressive that APZU was tapped to take a national leadership role in addressing malnutrition, and Banda was named one of eight national facilitators for a program designed to cut the number of children whose development is stunted.

Never one to bask, Banda attributes the success to his staff, particularly the village health workers who live in the communities they serve and actively seek out new patients. “They screen each and every child,” he says. “Each day every month, they’re going out and making sure everyone in need of care is getting it.”

Standing at that lectern in the Harvard School of Public Health, Banda was able to step back from his day-to-day efforts in Malawi and close on a broad message for his classmates who’d soon be returning to Sierra Leone, Mexico, Canada, and South Africa, among other places, to fight a plethora of health challenges.

“Evil goes where good people do nothing,” Banda said. “We are the good people.”

To learn more about PIH's work in Malawi, click here. 

This story originally appeared on the Brigham and Women’s Global Health Hub blog.

Homes are isolated, with no running water and often no refrigeration. Heat is produced by a wood-burning stove in the kitchen. Landline phones are a rarity.  Access to preventive health services, such as cancer screening and immunizations, is often limited, and patients travel long distances to obtain medical care.

Despite these incredible barriers faced by the American Indian communities in New Mexico, physicians volunteering with the Brigham and Women’s Outreach Program and COPE are able to provide services and perform activities that positively impact the health and wellness of the Navajo people.

Margo Hudson, MD, made her first trip to Shiprock in 2009 and has since visited Gallup several times to improve the inpatient management of diabetes. There, along with Jamie Redgrave, MD, local physician Maricruz Merino, MD, (a former BWH resident) and Josh Valgardson, PharmD, they developed a program to assist the physicians with ordering insulin safely during hospitalization in patients usually managed on oral agents, a program that has involved hospital wide training (nursing, dietary etc). They just presented their findings of improved glucose values and improved physician acceptance to the American Diabetes Association Meeting in June in Chicago.

Through the Brigham and Women’s Outreach Program, Hudson and Redgrave came to collaborate with COPE, another global health initiative based in Gallup. COPE strives to strengthen the existing Community Health Representative Outreach program of the Navajo Nation to improve health outcomes of high risk patients with diabetes and other chronic conditions in American Indian communities.

Hudson and Redgrave collaborated with the BWH Division of Global Health Equity’s Sonya Shin, MD, a BWH-trained infectious disease specialist and director of the COPE Program, to improve the Gallup Indian Medical Center and affiliated communities’ diabetes outreach programs. These physicians have witnessed firsthand the poverty and poor health so common to American Indian communities that exists right here in the U.S.

“I have gone out with the community health representatives to see patients in their homes, which can be many miles from the outpatient clinic on dirt roads,” says Hudson.

The community health representatives speak to the patients in their Navajo language, making sure they understand how to take their medications and seeing if they have new problems. They also perform basic physical exams. Hudson felt that these home visits improved her understanding of the barriers to care and the tremendous work that the community health representatives perform. She believes that the COPE teaching tool developed by Shin for patient education can be adapted for many environments, especially an urban one like BWH.

While in Gallup, Hudson and Redgrave helped give educational updates to the community health representatives in new developments in management and diagnosis of diabetes, as well as physical diagnosis and history taking. Hudson also had the chance to look over the truly comprehensive low literacy teaching program for patients that Shin created, offering modest suggestions.

And Redgrave taught yoga classes to elders in the council houses, led other exercise classes, shared healthy food options and gave educational talks to the doctors in the IHS, noting that she “ found the patients we visited to be incredibly grateful and receptive to learning how to best take care of themselves, very gratifying to visit.”

Margo Hudson, MD, and Jamie Redgrave, MD, are among several BWH physicians who volunteer at Gallup Indian Medical Center and the Indian Health Service hospital in Shiprock through the Brigham and Women’s Outreach Program (BWOP) with Indian Health Service.  This centralized volunteer program is dedicated to providing specialty expertise in direct patient care and staff training in the Navajo Nation, where about 37 percent of people live in poverty.

Interested in learning more about PIH's work in Navajo Nation? Click here.

With his warm, friendly smile, Jean Bosco Bigirimana is winning over a roomful of eager listeners with a presentation on the groundbreaking cancer care work he and his colleagues are doing in Rwanda.

“When I began nursing, we thought that cancer meant death or suffering,” says the 28-year-old oncology nurse. “But with education and access to improved treatment we found this not to be true. People can live for a long time if they are diagnosed early. Even those at the end stage can live free of pain and the quality of life can be improved.”

After the presentation, he greets new acquaintances with a warm embrace—the type many Americans would reserve for an old friend. He follows one hug with, “What is your name again?” and smiles at the response. “Ahhh, that is good,” he says, as if the proffered name is itself intrinsically blessed or fitting.

Bigirimana’s personality has played no small part in his success as oncology coordinator for Inshuti Mu Buzima, Partners In Health’s sister organization in Rwanda. His colleagues describe him as a rising star in Rwanda’s rapidly advancing field of cancer care, citing his clinical skill as a nurse on the ward and his talent as a trainer and in the classroom. 

Bigirimana’s role is a highly demanding amalgamation of clinician, trainer, patient counselor, public health educator, and nursing advocate. His tasks include coordinating cancer care in the three districts of Rwanda where IMB works; calling patients to inform them of test results; scheduling patients; educating patients on different topics related to cancer; and mixing and administering chemotherapy.

This deceptively short list belies the complexity of Bigirimana’s daily work. Patient education, for instance, takes on a new meaning when the patient has never heard of cancer—or believes the illness is caused by witchcraft or is punishment for a past wrongdoing.

Nor are misconceptions confined to patients. Chemotherapy drugs are inherently dangerous to both the patient and the administrator. Without proper protective equipment, those mixing and administering the drugs may expose themselves to serious harm—sterility or even cancer in the most extreme examples. Convincing his fellow nurses that cancer can be treated safely sometimes proves challenging.

These partners have replaced the case-by-case approach with national protocols and a national training program together with a formal cancer care program at Butaro Hospital with hopes of bringing trained cancer care nurses and doctors to every corner of Rwanda.

“Rwanda has a lot of talent, a lot of dedicated, patriotic citizens. They just don’t have a lot of skilled personnel when it comes to cancer,” says Dr. Neo Tapela, IMB’s director of noncommunicable diseases.

To address this skills gap, a coalition of partners—including the Rwanda Ministry of Health, the Rwanda Biomedical Center, Partners In Health, the Dana-Farber Cancer Institute, and Brigham and Women’s Hospital—formed to implement a multiyear training effort. The initiative is also generously funded by GlaxoSmithKline.

“PIH has been supporting cancer care in Rwanda since 2006,” Tapela says. “In the beginning, it was on a small scale, case-by-case, and it followed the same principle PIH has for all patients. Cancer patients started showing up—and you can’t say we don’t provide cancer care—so my predecessors figured out how to diagnose and how to get the medicines.”

Today, these partners have replaced the case-by-case approach with national protocols and a national training program together with a formal cancer care program at Butaro Hospital with hopes of bringing trained cancer care nurses and doctors to every corner of Rwanda.

A major component of this effort is the national Baseline Cancer Care Training for doctors and nurses, which launched in March 2012. Tapela—who holds positions at Brigham and Women’s Hospital, the Rwanda Ministry of Health, and IMB—describes the one-week course as intense and participatory, “with lots of role plays, ‘Jeopardy,’ and visits to the Butaro Cancer Center of Excellence to see cancer care live.”

Under the direction of trainers, including Bigirimana, participants gain foundational knowledge on questions such as, what is cancer? What is the epidemiology of cancer right now? What are the main cancers seen in Rwanda? Which cancers are treatment priorities of the Rwandan government? And what are the treatment options, including palliative care? The trainers are Rwandans, as well as medical oncologists, surgical oncologists, and oncology nurses from Dana-Farber Cancer Institute led by Dr. Lawrence N. Shulman, the Institute’s director for Global Cancer Medicine and PIH’s senior oncology advisor.

Bigirimana examines Jeanette, who is being screened for cancer after the discovery of breast and abdominal masses in her body. Photo: Aubrey Davis / Partners In Health

“A lot of that is to lay the theoretical foundation because nobody [in Rwanda]—not nurses, not doctors—gets enough exposure to cancer in the standard curriculum right now in nursing and medical school,” Tapela says. There is a paucity of trained oncology physicians and nurses in Rwanda, and collaborators from Dana-Farber and the other Harvard hospitals have filled that gap.

While these collaborators have provided world-class expertise, Tapela and her colleague Celia Reddick, a PIH curriculum and training specialist, and other IMB team members helped adjust the curriculum to reflect the needs of course participants, as well as the clinical realities of delivering cancer care in a resource-limited setting. For instance, many participants in the training are A1 nurses, who have the equivalent of two years professional training following secondary school.

Each course consists of about 30 doctors and 30 nurses. To date, three groups of students from facilities throughout Rwanda have cycled through the course. But the purpose of the course isn’t simply to impart knowledge to the attendees; it’s also to identify and train expert trainers, Tapela says. True to PIH philosophy, the program’s end goal is to build a cadre of skilled Rwandan trainers who can then pass along knowledge to their colleagues.

The approach is working. The majority of trainers for the first course were foreigners, but in the most recent session, nine of the 12 trainers were Rwandan.

The Baseline Cancer Care Training is just a beginning. The Rwanda Ministry of Health envisions an ongoing package of trainings, including three-month-long rotations for Rwandan post-graduate physicians and specialty nurses at Butaro Cancer Center of Excellence, a PIH-supported national specialty facility for cancer care.

Rwanda still faces many challenges when it comes to effectively treating cancer on a national scale—for example, adding oncology curriculum content to the pre-service training clinicians receive and ensuring that trained clinicians have access to the necessary drug supplies—but Tapela is optimistic.

“There is definitely a motivation, individually, to do more—you can see this with Jean Bosco—and nationally that is what the government is doing. The government has sent three Rwandans to train as pathologists in South Africa and Kenya. They’re also sponsoring a couple of doctors to train in cancer specialty services …. [They are] actively trying to build capacity so that important services are provided—and by skilled Rwandans.”

In the end, it is dedicated Rwandans such as Bigirimana who are poised to shape their country into a model for developing nations around the world. “I see him being a leader nationally. He definitely has the skills and the heart for it,” Tapela says.