Zerida Nyinaguhirwe is one of the first breast cancer patients to complete cancer treatment at Butaro Hospital, a Ministry of Health hospital in Rwanda that is supported by Partners In Health—and where the national Cancer Center of Excellence was inaugurated July 18, 2012. Her story demonstrates the importance of timely care while reminding us that cancer does not discriminate between the rich and the poor.

My name is Zerida Nyinaguhirwe. I am 53 years old, from Burera District in the northern province of Rwanda. I am a subsistence farmer and live by myself; after my husband and I learned that I was unable to conceive children, he divorced me.

One Wednesday morning while digging in my garden three months ago, a stick accidentally hit my breast. After two days, my breast had swollen. This was not normal for me, and the following week I visited a nearby health center for a checkup. Because the health center had no specialist or equipment to diagnose my problem, I was referred to Butaro Hospital. In January, a tissue sample was taken from my breast for testing, and the doctor told me to wait until they called me with my results.

In March, I had a phone call from the hospital letting me know that my results were ready. At the hospital, I was put in a beautiful room with bright lights. “Zerida, your results show that you have breast cancer and it’s treatable,” the doctor said.

I was shocked to hear this and knew it was my time to die. I asked the doctor, “What do you mean that it is treatable, yet I have never seen anyone who has survived it?”

“Many people have been treated for breast cancer and have survived. You are going to be among them,” the doctor said.

This encouraged me. Right away, I asked the doctor what the treatment would be—I was willing to receive any type of cancer treatment.

I was told that I was going to have chemotherapy and surgery to remove the breast. My initial treatment was scheduled at Rwinkwavu Hospital, another government hospital supported by PIH in the eastern province that had been treating cancer for some time. As Rwinkwavu is a five-hour drive from where I live in Burera District, I could not afford the transport costs; thankfully, they were to be covered by PIH. I had never received such complete care. I had great hope that my treatment would be successful.

In the first weeks of my treatment, I felt okay, but as I continued it became very difficult and I thought I was going to die. The drugs’ side effects turned my nails black, suppressed my appetite, caused my hair to fall out, made me feel weak all the time, and I thought I was going to lose my eyesight. My family, friends, and fellow cancer patients also thought I would die, so I pretended to them that I was strong and would get better.

In May, I was given a transfer to Butaro Hospital for the continuation of my treatment. This change was amazing for many reasons. Butaro Hospital is near my home, therefore my transport bills would be less costly to PIH and my family was given much relief. Throughout my time in Rwinkwavu Hospital, my family had always asked to accompany me, but I never allowed it because it was too expensive and I was given enough care at the hospital. But still, my family members were not comfortable with me being alone.

I stopped taking medicine in mid-June, and the doctor told me to come back on July 19 for breast surgery. During this break my hair started to grow, I got my appetite back, and my nail color normalized. My family, friends, and I were encouraged by the recovery, which positively prepared me for my surgery. Deep inside, I was wondering what I was going to look like with one breast and how I would explain this to others.

The surgery was a success. All my family members, friends, and I were happy about it and we believed that my cancer would be cured. While at Butaro Hospital, I met many other cancer patients—we encouraged each other and became like a family.

To my fellow women, breast cancer is common these days and requires prompt attention. In case of any unusual feeling in the body, you should visit the nearby health center right away. For those that also have cancer, following your treatment plan is the first step to recovery, despite difficult side effects. More so, it is important to be positive and encourage others to be aware that treatment is possible for cancer.

I am grateful for Partners In Health and the government of Rwanda, because they have made cancer care available and affordable. As a poor woman of my age, I would not have managed cancer treatment and transport costs on my own. For my entire treatment, I only paid 7,800 RWF ($12.50).

Thanks to medications and surgery, I am now treated for breast cancer and hopefully cured. I am doing well, although the doctors warned to be careful about any unusual feelings. “Cancer can always come back and to any other part, anytime” the doctor said. I now can’t carry heavy material or dig because I still feel some pain where I had surgery.

Lastly, I would like to thank the doctors and nurses at Butaro and Rwinkwavu hospitals, who took care of me tirelessly. Above all, I would like to send my sincere gratitude to His Excellency President Paul Kagame, for his good governance and for inviting Partners In Health to Rwanda, as they have taken cancer care to another level.

March 8 is International Women’s Day, a global day to celebrate the social, economic, and political achievements of women while advocating for women’s rights. Founded in 1910 by German women’s rights leader Clara Zetkin, International Women’s Day is honored across the world and is an official holiday in nearly 30 countries, including Kazakhstan, Nepal, and Russia—three countries with deep ties to Partners In Health. 

Even as we celebrate progress in women’s rights globally—for example, in Rwanda women hold 56 percent of seats in Parliament—women continue to face significant inequities in health care. In the developing world, women without access to modern contraception accounted for an estimated 63.2 million unintended pregnancies in 2012. A recent study in The Lancet estimated that more than 100,000 women could be saved from maternal deaths each year if they simply had access to effective contraceptive methods. And data from the World Health Organization show that 99 percent of the more than half a million maternal deaths each year happen in developing countries.

Women face health inequities because of their specific needs around sexual and reproductive health care, and because they often lack adequate resources to pay for care. All the factors of gender inequity—including limited access to education, legal systems that fail to protect women, and gender-based violence—are exacerbated by poverty. For these reasons, HIV disproportionately affects women and girls: More than 50 percent of people now living with HIV/AIDS globally are women.

So how does Partners In Health address the particular challenges poor women face? First, by taking a rights-based approach to health. We believe health is a human right for all people—women and men—and that our work must be done in a human rights framework that values participation, empowerment, and equality. This is most evident in our community health worker programs, largely staffed by women, who are tasked with the critical role of educating and accompanying community members. By paying community health workers, PIH engenders economic opportunity and independence that allows women to help feed their families and keep their children in school.

Second, PIH develops programs and health services that address the unique health care needs of women. These include prioritizing broad access to modern family planning methods that meet the specific health and cultural requirements of the population, as well as actively reaching out to women for care before, during, and after pregnancy.

For example, PIH/Lesotho has made tangible progress toward Millennium Development Goal 5, which aims to reduce maternal mortality around the world. Through its Maternal Mortality Reduction Program, PIH employs community health workers specially trained in accompanying women through pregnancy and birth, thus ensuring that pregnant women have access to skilled care at a health clinic in the remote, mountainous terrain of Lesotho. This effort has paid off already: In a country where one in 32 women will die of pregnancy- and childbirth-related conditions, there have been few maternal deaths reported at the government clinics supported by PIH/Lesotho.

Third, by targeting poverty as the root cause of disease, PIH seeks to change systems that perpetuate inequality. Removing financial barriers to health care, whether by eliminating user fees or providing transport stipends, makes it easier and safer for women to get care. By working with governments and the public sector to build health systems that meet the needs of their citizens, we’re disrupting the cycle of poverty and disease.

As PIH celebrates the achievements of women, we remember there is still much to do. Preventing the “stupid deaths” of women—whether due to maternal causes, HIV, or gender-based violence—requires that we all commit to realizing the political, economic, and social rights of women in every country.

Thank you for standing shoulder-to-shoulder with our patients, community health workers, and staff around the world as we break down the barriers that drive inequality.

Erin George is a nurse-midwife and a 2012-2013 Yale Law School Gruber Fellow in Global Justice and Women's Rights. Through this fellowship, she is serving as the nursing and midwifery advocacy coordinator for PIH in Boston and Haiti. Jennie Riley is the project coordinator for PIH/Lesotho, providing programmatic management and support for all aspects of PIH’s work in Lesotho. Together they lead the PIH Women's Health Working Group.

Social service year physician Dr. Valeria Macias and Dr. Patrick Newman from Brigham and Women's Hospital conduct a patient consultation. Credit: Eva Quesada, S4C

“I didn’t know what to expect,” Dr. Abelardo Vidaurreta says. “I didn’t know where I was going.”

Such uncertainties were rare for the 27 year old. But after finishing medical school at Tecnológico De Monterrey, an elite university that produces some of Mexico’s finest physicians, Vidaurreta ditched the urban commodities he was accustomed to and went to work with Partners In Health’s sister organization Compañeros En Salud (CES) in southeast Chiapas. It’s among the poorest and most isolated regions in Mexico, nestled at the tip of the country along the Guatemalan border. 

The move wasn’t entirely impulsive. In Mexico, newly graduated medical students are required to spend a year working in a public health clinic to earn their professional license. Often they’re assigned to far-flung outposts with few resources and even less oversight. This baptism-by-fire approach can be overwhelming. It can also be frustrating, especially for the community members who are left seeking medical care from a rotating cast of fresh-faced doctors who’ll stick around for only a year. 

Vidaurreta had heard of CES when his social service year arrived, but he didn’t know much about the group, let alone its plans to revitalize a primary health care system in a long-neglected region. Doubts loomed when he agreed last February to be among the first doctors to spend a year working alongside CES in Chiapas.

“I thought I was going into the jungle,” Vidaurreta says. “I thought I was going to be alone.”

Dr. Abelardo Vidaurreta, among the first social service year physicans to work with CES, stitches up a patient's kneee. Credit: Balam-ha' Carrillo, S4C

Now, as CES—whose work is supported by Vermont-based Green Mountain Coffee Roasters—celebrates its first anniversary and more than 10,000 patient consultations, Vidaurreta jokes that he was wrong on both counts. The landscape is more Martian than jungle, marked by towering mountains and a startling lack of infrastructure. And while he would encounter countless challenges in the field, he wasn’t going to be tackling them alone.  A core mission of CES is to alleviate that daunting sense of solitude by pairing the new doctors, known as pasantes, with resident physicians from Brigham and Women’s Hospital in Boston. 

“They’re doing all the work,” says Dr. Patrick Newman, 29, one of the first resident physicians from Brigham and Women’s to take part in the program. “But we see their consults with them, answer their questions, help guide their thinking, help to challenge their thinking, and encourage their ongoing growth.”

Learning Exchange

Newman is quick to point out that the exchange of insight flows both ways. For instance, he recalls visiting a family whose newborn had a cleft palate. His instinct was to hospitalize the baby, insert a feeding tube, and perform surgery when the child reached an appropriate weight—standard procedure in the U.S. 

“That was my first suggestion. But it was obvious after talking with the pasante and visiting the family that doing so would result in absolute and total financial ruin for the family,” Newman says.  “You have to understand that there are cultural aspects to care that the pasantes are going to understand better than we ever will.”
 

Dr. Abelardo Vidaurreta, one of the first social service year physicans, checks a patient's eyes at a clinic in Chiapas, Mexico. Credit: Balam-ha' Carrillo, S4C

In the area where CES works, patients might travel more than an hour for a simple blood test. Getting to a hospital could take half a day. And though there are brick-and-mortar clinics, it’s been years in most cases since a full-fledged physician has staffed one. To make sure the pasantes are equipped to provide the best possible care in this difficult setting, they receive monthly visits from CES staff and attend regular workshops.

“Accompaniment is present at all levels throughout CES. It’s really the backbone to what we do,” Newman says. “This project is unique in that it was set up to tackle a different set of health issues than many other Partners In Health sites. We are very much focused on establishing a primary health care system in the same way you would think about going to your primary care doctor here in the U.S.”

As a middle-income nation with ample doctors, Mexico presents as many opportunities as it does obstacles. While infectious diseases such as HIV and tuberculosis exist, they don’t pose the same burden as chronic ailments such as diabetes, metabolic disease, and high blood pressure.

An Epidemiological Transition

“I expected to find more patients with infectious diseases,” Dr. Jafet Arrieta, CES’ director of operations, says. “But we started finding these diseases that are supposed to be first-world diseases. Then I realized Chiapas is already facing an epidemiological transition. They live in third-world conditions, but they are facing first-world diseases. That is a challenge because there is no comprehensive primary care system.”

To lay the groundwork, CES partnered with local Ministries of Health to pilot its program in two clinics last February. By August, the program had expanded to six clinics. Now CES is seeing an average of 1,500 patients per month. As the pasantes and other members of CES gained credibility in the communities, new opportunities to engage residents on health issues opened up.

“We have offered 35 workshops that have covered 20 different topics, from dental health to family violence to chronic disease,” Arrieta says. The workshops have attracted more than 3,500 attendees. “Even when people live in this level of poverty they want to learn about their health. They’re eager to learn, they just haven’t had the chance.”

Dr. Patrick Elliott from Brigham and Women's Hospital accompanies social service year physician Dr. Valeria Macias through a patient consultation. Credit: Balam-ha' Carrillo, S4C

With a year down, Arrieta can reflect on CES’ successes. News that those who spend their social service year in Chiapas with CES work closely with resident physicians trained at Harvard spread quickly. It’s a good selling point that helps attract new medical talent to what might otherwise seem like an undesirable location. But ensuring that the positive outcomes of CES are sustainable and replicable will take time. The pasantes, Arrieta hopes, will be compelled to stay in Chiapas and help break the cycle of poverty rather than heading to a major hospital or big city when the social service year ends.

There’s progress toward that direction: Vidaurreta’s year as a pasante has come to an end, but he’s continuing to work in the region as a CES program supervisor. He still encounters new uncertainties and difficult cases in the field. But when he has to, Vidaurreta knows he can reach out to his colleagues in Boston for advice.

“They now know how we work, how we live, and how the people here live. We have learned a lot from them, and I think they have learned a lot from us,” Vidaurreta says. “This experience touches everyone.”

In the past decade, deaths associated with HIV in Rwanda have plummeted by 78 percent—the largest such drop in the world. Meanwhile, the likelihood of a child dying before turning 5 fell by 65 percent. Between 2005 and 2010, more than 1 million Rwandans lifted themselves out of poverty. These are just a few of the many jaw-dropping statistics cited by Partners In Health Co-founder Dr. Paul Farmer and colleagues in a recent BMJ analysis that explores how Rwanda’s comprehensive approach to strengthening its health system after the 1994 genocide has transformed the country.

Rwanda’s turnaround is largely the result of its leaders prioritizing equity, human development, and health care for the poorest and most vulnerable. Since 2005, PIH and our sister organization Inshuti Mu Buzima (IMB) have partnered with the Rwandan government to improve access to health care in three rural districts: Butaro, Rwinkwavu, and Kirehe. We serve more than 800,000 people through 40 health centers and three hospitals—all public facilities.

A strong foundation of community health workers reinforces the health system and brings health care into every home. We work to support the Rwandan government’s efforts, including its remarkably successful National HIV Program. At the same time, we partner with the Ministry of Health (MOH) and local communities to develop low-cost, high-impact solutions that can be scaled up to improve health outcomes across the country.

Together with the MOH, we’ve built Butaro Hospital into a Center of Excellence in Cancer Care that is now a flagship center for medical care and education in east Africa. We laid the groundwork for a mentorship program that has dramatically improved nursing skills and is now being deployed countrywide. Our push to link communities with clinics and clinics with hospitals has greatly expanded access to health care.

But our commitment extends far beyond operating rooms and pharmacies. To counter the root causes of illness in Rwanda, we offer socioeconomic support to those in need, including transportation assistance, payments for school and health insurance fees, and microloans to start small businesses.

Of course, many challenges remain. Childhood malnutrition, high anemia rates among women and children, and neonatal mortality persist. Rwanda’s government is acutely aware of these issues and is collaborating with myriad stakeholders to effectively tackle them.

Still, as detailed in the BMJ article, Rwanda is poised to become the only country in the region on track to meet each of the health-related Millennium Development Goals by 2015. This isn’t a fluke, nor is it due to a stroke of good luck. It’s the result of a targeted and strategic approach.

Other countries struggling to improve health in the face of persistent poverty would do well to look toward Rwanda for insight.

Published February 22, 2013, in The New York Times:

A Chance to Right a Wrong in Haiti
by Louise C. Ivers

On Thursday, the United Nations secretary general, Ban Ki-moon, rejected a legal claim for compensation filed in 2011 on behalf of cholera victims in Haiti. Through a spokesperson, Mr. Ban said the claims, brought by a nongovernmental organization, were “not receivable” because of the United Nations’ diplomatic immunity.

Regardless of the merits of this argument, the United Nations has a moral, if not legal, obligation to help solve a crisis it inadvertently helped start. The evidence shows that the United Nations was largely, though not wholly, responsible for an outbreak of cholera that has subsequently killed some 8,000 Haitians and sickened 646,000 more since October 2010. The United Nations has not acknowledged its culpability.

Now, as the cholera epidemic appears to worsen, Mr. Ban and the United Nations have an opportunity to save thousands of lives, restore good will — and, yes, fulfill the mandate that brought the organization to Haiti in the first place: stabilizing a fragile country. The United Nations should immediately increase its financial support for the Haitian government’s efforts to control the epidemic. While that may not satisfy everyone, it will go at least some way toward compensating the people of Haiti for the unintentional introduction of the bacteria that caused the epidemic.

Before October 2010, cholera — a diarrheal illness caused by consuming water or food contaminated with the bacterium Vibrio cholerae — had never been reported in the country. In the epidemic’s first year, the striking loss of life attracted international media attention. Even in its third year, the outbreak continues to sicken thousands.

There were 11,220 cases nationwide during the month of December — significantly more than the 8,205 cases seen during December 2011. Our clinic in St. Marc treated more people with the infection last month than in the previous eight months combined.

That soldiers at the United Nations camp were responsible for introducing the bacteria seems apparent. After local and national protests and an Associated Press investigation, Mr. Ban empaneled a group of international experts to determine the disease’s source. Their report stated that evidence “overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type Vibrio cholerae as a result of human activity.” The strain was not indigenous to Haiti.

The report also found that sanitation conditions at the United Nations camp were not sufficient to prevent contamination of the local waterway with human waste. Investigators found that the potential existed for feces to enter the tributary from a drainage canal in the camp and from the open septic disposal pit that was used to handle the waste.

A research study published in January 2011 in The New England Journal of Medicine lent further support to the claim that the cholera came from the United Nations camp, as did an August 2011 study in another scholarly journal.

The interplay of biosocial factors inherently involved in epidemics make it difficult to pinpoint causality. If Haitians had better access to clean water and sanitation, of course, the cholera epidemic would have had a smaller impact and thousands of deaths might have been averted. (By comparison, there were few, if any, deaths from cholera in countries with effective water and sanitation systems where the organism appeared as part of this same epidemic — including the United States.)

But all of this is background to the urgent matter at hand. The United Nations recently started a 10-year initiative to eliminate cholera in Haiti and the Dominican Republic, based on a plan that was developed with multiple partners, including the governments of both countries. It is a collaborative and comprehensive approach that aims to eliminate transmission of the disease with substantial investments in water and sanitation infrastructure, as well as through prevention and treatment.

On Feb. 27, Haiti’s minister of health will introduce one important component of this plan — an initiative to expand access to cholera vaccination.

If the United Nations were to finance this initiative, along with the rest of the government’s anti-cholera program, it could have a significant and immediate impact on stemming this epidemic. As of now, however, the United Nations plans to contribute just 1 percent of the cost. That is not enough.

Meanwhile, the organization’s stabilization mission in Haiti is budgeted for $648 million this year — a sum that could more than finance the entire cholera elimination initiative for two years.

It’s time for the United Nations to rethink what true stabilization could be: preventing people from dying of a grueling, painful — and wholly preventable — disease is a good start.

Louise C. Ivers, a senior health and policy adviser at Partners In Health and associate professor at Harvard Medical School, has been leading cholera treatment and prevention activities in Haiti.

February 20, 2013, marks the seventh annual World Day of Social Justice, a day dedicated to advancing a world that promotes a peaceful and prosperous coexistence. 

Partners In Health has worked to pioneer and galvanize a social justice approach to global health since its inception 25 years ago, working alongside displaced peasants in the Central Plateau of Haiti. But what do we mean by a social justice approach to global health, why does it matter, and how is it different than other approaches? 

For PIH Co-founder Dr. Paul Farmer, social justice means providing a preferential option for the poor in health care. For us, this means that the poor and their interests should always be the top priority in all our efforts. We take this approach because it is a moral imperative, but also because it makes good epidemiological sense. Those who live in the throes of extreme poverty bear the brunt of ill health and preventable disease.

Furthermore, these efforts should be carried out in “pragmatic solidarity” with those facing injustices. As Dr. Farmer explains in his book Pathologies of Power, "Solidarity is a precious thing: people enduring great hardship often remark that they are grateful for the prayers and good wishes of human beings. But when sentiment is accompanied by the goods and services that might diminish unjust hardship, surely it is enriched. To those in great need, solidarity without the pragmatic component can seem like so much abstract piety."

Therefore, a social justice approach requires immediate, pragmatic action paired with a larger critical analysis of, and fight against, structural violence. In other words, in our fight to eradicate structural violence, we cannot overlook those suffering now. As Dr. Farmer puts it in Pathologies of Power, "The destitute sick ardently desire the eradication of poverty, but their tuberculosis can be readily cured by drugs such as isoniazid and rifampin."

But what are we supposed to do if we are not a doctor, nurse, or public health professional? What actions can we take in our daily lives to advance the human right to health?

For me, a non-health professional, these are questions I’ve wrestled with long and hard. As someone based in the U.S. with little in the way of technical skills, what difference can I make in the lives of a Haitian man with tuberculosis or a woman in need of a cesarean section in Neno, Malawi?

To me, community organizing—identifying and recruiting volunteer leaders, building community around that leadership, and generating power from that community—is a mechanism through which each of us can contribute to help shift the structures that prevent much of the world from being able to live healthy, dignified lives.

A heartening trend is the ballooning interest in global health among college students, young professionals, religious congregations, and even companies and their employees. Many organizations have grown in response to this inspiring trend: GlobeMed, FACE AIDS, and the Global Health Corps to name three. Each is focused on building deep communities of solidarity and leadership around the common purpose of advancing and realizing the human right to health for far more people around the world.

Looking forward, we need to explore new ways of collaborating to learn, teach, and raise the profile of the social justice approach to global health. We need grassroots fundraising teams so that more people support PIH and other organizations with similar mandates. And most importantly, we need to build more aggressive advocacy campaigns and actions that improve the way foreign aid and development assistance impact the rights of the poor.

PIH’s Chief Medical Officer Dr. Joia Mukherjee once said, “No data in the world, no good vaccine, no potent medicine will get to the poorest of the poor without you. There will be no equity without solidarity. There will be no justice without a social movement.”

On this World Day of Social Justice, let’s reflect on the fact that just as there will be no justice without a social movement, there will be no social movement without community organizing.

If you are interested in joining us in this movement to advance social justice and the human right to health, sign up to be a Community Organizer with PIH | Engage.

Thank you for all that you do—it means the world to us.

Jon Shaffer is the community engagement coordinator at Partners In Health. In this role, he is working to build a community organizing strategy that can strengthen the growing movement for health as a human right. Previously, Shaffer served for two years as the executive director of GlobeMed. He loves tossing the Frisbee, drinking good coffee, and being from Portland, OR.

A small group of people with a common goal: in American mythology, this is where famous rock bands and big businesses often begin. It is where in fact Partners In Health got started 25 years ago—with five American friends who were appalled by the great sickness of poverty in the world and who dreamed of seeing it cured. Needless to say, Partners In Health (PIH) has not succeeded yet. But it has made progress.

In its earliest days, PIH’s infrastructure was a two-room office over a seafood restaurant in Cambridge, Mass., and a one-doctor clinic in a squatter settlement in the Central Plateau of Haiti—in those days a wilderness of extreme poverty and disease. PIH was a grand idea then, and it is a grand idea today, but with a lot more behind it: some 14,000 employees who manage dozens of hospitals and clinics and have built and still are building schools and water and sanitation systems and houses for the very poor. PIH is doing that work in eastern Europe, Asia, South America, Africa, and of course in Haiti, the heartland of PIH, where it is struggling now to stanch a dreadful cholera epidemic and to lay durable foundations for the country’s post-earthquake reconstruction.

In all, PIH directly serves about 2.5 million of the world’s poorest people. It directly serves about 1.3 million in Haiti, in 12 different hospitals and clinics, providing medical care on the scale of a couple of big Boston teaching hospitals but at vastly smaller cost. Some aid organizations are notoriously self-serving, using large portions of the money they receive for their own administration and comfort. PIH spends only 7 percent of the money it receives from private donors on administration and fundraising.

It is mainly because it has grown in service that PIH has also grown in influence. PIH played an important part in the international debates about whether AIDS could and should be treated in places like Haiti and sub-Saharan Africa, debates that have largely been resolved in favor of treatment. But PIH’s role had less to do with talk than with its own AIDS treatment program in Haiti, which provided vivid, incontrovertible proof that the disease could be treated successfully in a deeply impoverished setting.

PIH did much the same thing with drug-resistant tuberculosis. They proved that controlling this disease was possible by devising and administering effective treatment in a peri-urban slum in Peru. They also played the central role in driving down the prices of the necessary drugs. Since then more than 100 countries have adopted PIH’s prescriptions for dealing with that dread and still widespread disease. Last summer PIH opened the first comprehensive cancer treatment center in all of rural East Africa. In this and many other ways, the organization continues to defy assumptions that many illnesses can’t be treated in the world’s impoverished places.

The scope of PIH’s work is international, and the heart of it is local. All its work relies on well-trained and salaried community health workers, more than 8,000 of them now, who serve patients in their own communities—“accompanying” those patients, in PIH parlance. This is the essence of PIH’s grand strategy, to address particular problems in particular places, and to learn how solutions in one place can be tailored to another. Part of this strategy lies in making projects indigenous. All too often aid organizations fail to do this, virtually guaranteeing that their projects won’t last, let alone flourish and spread. By contrast, all but a tiny fraction of PIH employees come from the countries and communities that are being served.

Waking up in the morning to news of the world, one can justly feel that violence and chaos are fully in charge. Just personally, I find it more than reassuring at such moments to know that there are some effective counterforces, some people out there trying to offer cures for the world’s great sicknesses. Nothing but hope suggests that these counterforces will prevail. But some basis for hope is far better than none. PIH’s vivid proofs of what can be accomplished in the face of poverty and disease is such a basis. It is, I feel, one of PIH’s most important gifts to the world.

Tracy Kidder, a longtime PIH supporter, is the author of Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, and Strength in What Remains, among other books. His latest is Good Prose: The Art of Nonfiction.

The burden of tuberculosis in Lesotho, a small landlocked country surrounded by South Africa, is among the highest in the world.

Today Partners In Health Co-founder Dr. Paul Farmer and Executive Director Ophelia Dahl celebrated the opening of Lesotho’s National TB Reference Lab, the first biosafety level 3 lab in the country and one of only two such state-of-the art tuberculosis testing facilities in southern Africa.

The burden of tuberculosis in Lesotho, a small landlocked country surrounded by South Africa, is among the highest in the world. There are 633 new cases of TB per 100,000 people each year. Located in the capital city Maseru, the lab will allow cases of extensively drug-resistant tuberculosis (XDR-TB) to be identified without having to send samples outside of the country. Until now, identifying XDR-TB required samples to be shipped to labs in South Africa, a cumbersome and costly process that hindered care.

“This facility will help us diagnose tuberculosis sooner, thereby reducing transmission and decreasing mortality,” said Dr. Hind Satti, Lesotho country director for PIH. “The lab also provides the capacity to run a national drug resistance survey for the first time and conduct ongoing surveillance for TB throughout the whole country.”

Cases of multidrug-resistant tuberculosis (MDR-TB) and XDR-TB pose significant challenges in the resource-poor and geographically rugged country, where patients often have to travel hours through mountain paths to see a doctor. One study by PIH’s sister organization Partners In Health/Lesotho found that about 70 percent of adult MDR-TB patients also had HIV, and about half had low Body Mass Index, suggesting that they were extremely ill.

PIH/L takes an aggressive approach to fighting TB. If patients are extremely sick, clinicians will often treat them for MDR-TB based on their symptoms and history before tests results come back to ensure nobody dies while waiting for the results of diagnostic tests. After treatment has begun (treating MDR-TB typically takes two years), paid community health workers visit patients daily to make sure they’re taking their medications properly and to monitor for side effects.

This thoroughness has paid off. PIH/L has treated more than 800 MDR-TB patients with a success rate of 63 percent, similar to the success rates seen in settings where far fewer patients have both MDR-TB and HIV. Perhaps most impressive is that less than 1 percent of MDR-TB patients treated by PIH/L refused follow-up care.

But in Haiti’s Central Plateau, the flow of energy is intermittent at best. Consider that in Mirebalais, located 30 miles north of Port-au-Prince, the power goes out for an average of three hours each day. This poses an enormous challenge to running any hospital; surgeries are jeopardized, neonatal ventilators stall, the cold chain is interrupted, and countless everyday tasks get derailed. As Partners In Health co-founder Paul Farmer noted during a recent lecture at the Harvard School of Public Health, “It’s not great if you’re a surgeon and you have to think about getting the generator going.”

To make sure the patients and staff at Hôpital Universitaire de Mirebalais (University Hospital) aren’t left in the dark, PIH and its partners looked toward the sun. Stretched across the roof of the new 200,000-square-foot hospital is a vast and meticulously arranged array of 1,800 solar panels.

On a bright day, these panels are expected to produce more energy than the hospital will consume. Before the facility even opened its doors—the official opening is slated for March—the system churned out 139 megawatt hours of electricity, enough to charge 22 million smartphones and offset 72 tons of coal. Perhaps most important is that the excess electricity will be fed back into Haiti’s national grid, giving a much-needed boost to the country’s woefully inadequate energy infrastructure.

Scaling Up

PIH is no stranger to solar energy. In 2007, we collaborated with the Solar Electric Light Fund (SELF) to install small-scale solar-energy systems at five clinics in rural Rwanda. Soon after, similar programs cropped up at PIH sites in Malawi, Lesotho, and Haiti. But scaling this technology to deliver reliable power for a 300-bed hospital demanded elegant design and extensive collaboration.

“The challenge was in the design and engineering, and getting the solar power produced to mesh with the often unstable grids and the backup generators,” said Jim Ansara, University Hospital’s director of design and construction. “At each step of the way, we were attempting things that had never before been done in Haiti.”

Solon, a German company, supplied the solar panels while Massachusetts-based Solectria Renewables manufactured the inverters, devices that convert the electricity and send it to the grid. To get the system up and running, engineers from Sullivan & McLaughlin Companies traveled to Haiti and trained six local electricians how to install and maintain the system. Two of the Haitian electricians will continue working at the hospital full-time when it opens (overall, it's estimated the hospital will create more than 800 new jobs for Haitians).

In order to maximize energy production, researchers from the University of Oregon provided sun charts that showed how to best position the panels. Though Haiti’s ample sunshine is what powers the hospital, the scorching temperature of a sunbaked roof could actually cause the panels to produce less electricity. To work around this conundrum, engineers floated the panels about a foot above the roof and added a coat of white paint, which lowers the surface temperature and bounces more sun rays on to the panels.

“This is an incredibly simple system to maintain once installed,” Ansara said. “All we need to do is rinse the panels quarterly with water.”

Sustainable Savings

In a country ravaged by deforestation, the ecological benefits of this alternative energy source cannot be overstated: Annually, the system is expected to save 210 metric tons of carbon emissions. 

And while a sea of solar panels perched atop a hospital in the mountains of Haiti is certainly eye-catching, it’s just one part of a comprehensive environmental strategy. Other green-friendly features at the hospital include natural ventilation that minimizes the need for air conditioning and motion-sensor activated lights that cut energy consumption by 60 percent when compared with traditional lighting.

This push toward sustainability and energy self-sufficiency translates into significant financial savings. In Haiti, electricity is expensive: The price per kilowatt hour is 35 cents, compared with 5.5 cents in New England. Using solar is expected to slash $379,000 from the hospital’s projected annual operating costs.

When fully operational, University Hospital is expected to be the largest solar-powered hospital in the world that produces more than 100 percent of its required energy during peak daylight hours, an impressive feat for the first-ever teaching hospital in central Haiti. The many lessons learned from the project will prove invaluable as PIH, its partners, and others undertake similarly ambitious and sustainable projects. 

This work was made possible by generous support from the Barr Foundation.

As the three-year anniversary of the earthquake in Haiti approached, a flurry of news articles reported on failures in development and missed opportunities for rebuilding the country. Yet a Jan. 15, 2013, article in The Lancet, “Cautious optimism on public health in post-earthquake Haiti,” shows that significant progress has been made in addressing some of Haiti’s toughest health problems in the wake of the disaster.

Yes, Haiti achieved remarkable gains in public health after the earthquake in some of the most difficult circumstances imaginable.

In the past three years, access to life-saving antiretroviral therapy for HIV patients doubled, according to the article. Meanwhile, treatment coverage of lymphatic filariasis, commonly known as elephantiasis, which causes severe pain and disability, jumped from 35 percent to 90 percent in the same period. Furthermore, the cholera fatality case rate “has been maintained at less than 1% since January 2011.” At the same time, the country’s HIV program made significant progress in prevention of mother-to-child transmission of HIV/AIDS, and a successful measles–rubella and oral polio vaccine campaign for children launched in 2012.

From the perspective of Partners In Health and its Haitian sister organization, Zanmi Lasante, these results are not unexpected. For more than ten years, we have worked shoulder to shoulder with the Haitian Ministry of Health, the U.S. Centers for Disease Control and Prevention, and other partners to strengthen the health system in the Central Plateau and Artibonite regions. Major investments from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) have provided consistent, long-term support to build the capacity of Haiti’s public health workforce, facilities, and community-based programs. These efforts have created a solid foundation for improving health in Haiti. And that platform has grown even stronger after one of the worst disasters in modern history.

Soon the Haitian government will release the details of its plan to eliminate cholera. We urge the U.S. government and other partners in the public and private sector to support this plan and increase their support for health care services.

Based on Haiti’s recent track record in health, we know they will be sound investments.

We remember and mourn those who were killed—friends and colleagues, mothers and fathers, brothers and sisters—as well as those who continue to suffer its effects.

Since then, Partners In Health and its Haitian sister organization Zanmi Lasante (ZL) have continued to provide health care to hundreds of thousands of people, including earthquake survivors, with the help of our supporters and partners. We created the Stand With Haiti Fund to address the immediate needs of victims and to work alongside the Haitian government to build and renovate the country’s public health infrastructure, strengthen its public medical education system, and expand PIH’s programs for community development and poverty alleviation.

PIH has fulfilled its pledge to spend the $123 million raised after the earthquake on these efforts. While there is much still to do, the following are examples of some of our work in Haiti.

An aerial view of Hôpital Universitaire de Mirebalais taken Dec. 12, 2012, shows 1,800 solar panels on the hospital's roof.

Hôpital Universitaire de Mirebalais (University Hospital)

PIH completed construction of the $17 million, 300-bed national public teaching hospital that will open in March 2013. Located 30 miles north of Port-au-Prince, the hospital will provide primary care services to nearly 185,000 people in Mirebalais and central Haiti, and provide advanced care to patients who are referred to University Hospital from community hospitals throughout the Central Plateau and Artibonite departments, as well as parts of Port-au-Prince. The teaching hospital will eventually employ up to 800 Haitian staff and serve as the first university teaching hospital in central Haiti, providing residencies and clinical rotations for Haiti’s national medical and nursing schools.

In addition, the hospital’s 1,800 solar panels will produce 100 percent of its energy needs during peak daylight hours and feed surplus energy back into the grid, the first agreement of its kind with Électricité d’Haïti.

University Hospital is PIH’s largest undertaking to date and will improve both the standard of health care for Haitians and strengthen Haiti’s public health infrastructure.

Mental Health Care

PIH responded to the psychological needs of Haitians affected by the earthquake by more than doubling the size of its mental health and psychosocial support team. This work is supported by a recent $1.5 million Grand Challenges Canada grant to improve mental health care in countries affected by disaster and poverty.

In 2013, PIH will train community health workers to identify and support people suffering from mental health problems, including depression and post-traumatic stress, and refer them to appropriate medical facilities. A pilot program will also incorporate the use of mobile phones by community health workers to diagnose and refer patients. The new program will develop a decentralized model of mental health care to be expanded nationally in Haiti.

Dr. Thelusma checked on a 2-year-old patient at a PIH/ZL cholera treatment center in Mirebalais, Haiti, last November.

Oral Cholera Vaccine Campaign

Cholera has killed 7,750 people in Haiti since October 2010. In spring 2012, PIH successfully pioneered Haiti’s first oral cholera vaccine, delivering vaccines to nearly 100,000 people in partnership with Haiti’s Ministry of Health and the nonprofit organization GHESKIO. Since then, the World Health Organization has called for the creation of a global stockpile of 2 million doses of the vaccine.

The United Nations recently included the use of the vaccine as part of a $2.2 billion plan to eliminate cholera in Haiti and the Dominican Republic. Dr. Paul Farmer, PIH co-founder and U.N. Deputy Special Envoy to Haiti, has been appointed U.N. Special Advisor for Community-Based Medicine and Lessons from Haiti as part of this cholera elimination plan.

A container of Nourimanba stands ready for distribution to malnourished children.

Treating Malnutrition

In partnership with Abbott Laboratories and the Abbott Fund, PIH will open a new production facility in early 2013 to combat the long-standing challenges of malnutrition. Located in Corporant, the facility will be used to produce a minimum of 60 tons of Nourimanba (a ready-to-use therapeutic food) to treat up to 6,000 cases of pediatric malnutrition in its first year.

The factory will create dozens of jobs and provide a guaranteed market for more than 250 local peanut farmers. This project also will be integrated into PIH’s agricultural initiatives to improve local farmers’ skills and expertise and strengthen their ability to supply the facility with a reliable supply of high-quality peanuts. Nourimanba has been locally produced and distributed by PIH on a smaller scale since 2006.

Our work of accompaniment is not over. We will continue to provide high-quality care to our patients, and to work with the Haitian government and communities to build and strengthen public health systems. As we remember those who lost their lives, we stand in solidarity with the millions of Haitians who are rebuilding their country, while also mobilizing around all that is left to do.

Once inside the clinic consultation room, Nurse Solange Bazirete weighed Niyonsaba, measured her blood pressure, and took her CD4 count (a measure of immune system strength) before asking a series of questions: Do you take your antiretroviral medicine every day? Do you have any side effects? Does the community health worker come every day?

Bazirete moved on to a squirming Iratuzi, checking the infant's weight and nutritional status and continuing with her questions. Is Iratuzi getting her medicine every day? Is she sleeping under a bed net? Is she up to date on her vaccinations?

At the end of the consultation, Bazirete wrote the next appointment date in a small notebook Christine carries that contains her CD4 counts, appointments, and measurements.

Without treatment, a mother with HIV has a 41 percent chance of transmitting the disease to her newborn infant. However, with new medication regimens and proper medical care, it’s possible to reduce this chance to less than 1 percent.

To achieve that goal, PIH/Inshuti Mu Buzima has created “combined clinics” like the one Niyonsaba and Iratuzi are visiting in this rural village. Called Clinique Combiné, the clinics provide a one-stop medical home in which HIV-positive mothers and their newborn infants can receive care in a single place. This makes it easier for mothers to access services, which improves treatment adherence and retention, reducing the transmission of HIV and maximizing their infants’ growth and development.

It can also take a full day and a week’s wages to travel to a clinic in rural Rwanda, so it’s important that mothers receive the maximum possible care in one monthly visit.

“At IMB, we’re committed to not only preventing the transmission of HIV from mother to child, but we’re striving to eliminate new cases of childhood HIV altogether,” said Dr. Felix Cyamatare, IMB’s director of clinical programs.

In partnership with Rwanda’s Ministry of Health, IMB has established 37 of these clinics at rural health facilities across three districts, starting in November 2010. The clinics integrate services that had previously been offered separately: maternal HIV services, infant services, family planning services, and maternal, newborn, and child health services.

At the “combined clinics,” HIV-positive mothers receive support that includes post-partum care, antiretroviral medication, CD4 testing, breastfeeding support and education, family planning information, nutritional support, and psychosocial services. Their children receive post-partum care, tuberculosis and malnutrition screening, malaria prevention, and continued testing to determine HIV status. Both mother and child receive regular visits at home from a designated accompagnateur. And for those who can’t afford to pay, the costs are covered through IMB’s support of Rwanda’s mutuelle (national health insurance) program.

IMB-supported combined clinics have served more than 1,000 mother-infant pairs since October 1, 2012, and achieved an overall rate of HIV transmission to these infants of less than 2 percent, which achieves Rwanda’s targets for elimination of mother-to-child-transmission. Across sub-Saharan Africa, 17 percent of infants born to mothers with HIV still become infected with the virus.

“This model is one of a kind in sub-Saharan Africa and shows that integrating many services into one point of care is, in fact, possible,” said Dr. Neil Gupta, director of IMB’s infectious disease program. “This has never been done before, and the Rwandan government is interested in scaling up this model for the entire country.”

The combined clinics are just one part of IMB’s broader work to prevent mother-to-child transmission of HIV (PMTCT).

Since 2005, IMB has delivered lifesaving care to HIV-exposed children. Children receive HIV treatment, routine vaccinations, treatment for diarrheal disease, nutritional support to treat and prevent malnutrition, and their families receive home visits and socioeconomic support.

A recent IMB study published in the Journal of Acquired Immune Deficiency Syndromes found a fourfold increase in the number of infants enrolled in the PMTCT program from 2007-2010. During that time, IMB enrolled 1,038 infants, of whom only 27 tested positive for HIV. One of the 27 children died, and none were lost to follow-up. Of the pregnant women enrolled in the program, 94 percent delivered their babies in a health facility, where they received care and medications that prevent HIV transmission during delivery, and 99 percent of the infants received medications to prevent HIV transmission after delivery.

Additional PMTCT innovations include the development of a new electronic medical records system that registers all infants born to HIV-positive mothers, which allows staff to track down any children who miss appointments or have adverse outcomes. IMB also has developed expert nurses in PMTCT who provide ongoing mentorship and training to health centers. Rwanda’s Ministry of Health is currently adopting these models for the national PMTCT program.

“Together, IMB and the Rwandan Ministry of Health are showing that elimination of mother-to-child transmission of HIV—and an AIDS-free generation—is possible,” said Gupta. “And for mothers like Niyonsoba, that possibility is already becoming a reality.”

When community health workers found Esther two years ago, she was living in a remote area of central Haiti, plagued by paranoia and voices in her head. Esther was taken to one of Zamni Lasante’s 10 hospitals, where she received social assistance, psychological support, and medication. Today, Esther reports that she is happy and symptom-free.

Fortunately, Esther’s condition was treatable. But the challenge in Haiti—and in the majority of developing countries—is that access to mental health care is extremely limited. In Haiti, there are just five psychiatrists and one neurologist for a population of 10 million.

PIH sister organization Zanmi Lasante (ZL) officially launched a new program today to both expand mental health screening and treatment in the Central Plateau and Lower Artibonite, and serve as a national model for mental health care throughout Haiti.

“This program will provide hope for patients who haven’t been able to face mental illness because of a bare lack of available resources,” said Father Eddy Eustache, ZL’s director of mental health and psychosocial services. “It provides hope for Haitian doctors, nurses, and community health workers who have been craving appropriate training. And it will provide a future for the Haitian people and government to see the eventual creation of a national mental health plan.”

The ZL program is one 15 initiatives around the world to receive funding as part of a $19.4 million Grand Challenges Canada grant to improve mental health diagnosis and care in developing countries, many of them ravaged by conflict, disaster, and poverty.

Over the next year, community health workers in Haiti will be trained to identify people in the community with potential mental health issues, make referrals for psychological and psychiatric treatment, and then provide community-based follow-up care. A pilot program will also incorporate the use of mobile phones by community health workers to help diagnose patients, improve patient monitoring, and report real-time data.

While the new program will improve care for ZL patients, the goal also will be to provide a decentralized model of mental health care to be expanded nationally in Haiti.

Addressing mental illness in Haiti and around the world is critical: The World Health Organization predicts that by 2030, depression will become the number one cause of disability. This burden is greatest in poor countries—where 85 percent of patients like Esther don’t receive the treatment they need.

Members of a PIH/ZL breast cancer support group discuss their challenges with the disease in Cange, Haiti.

In Haiti, the stigma women with breast cancer face carries an emotional weight, but it also can keep them from seeking help before it’s too late.

This year, Partners In Health's sister organization Zanmi Lasante began hosting regular support groups for women with breast cancer. During a recent meeting for mastectomy patients in Cange, oncology social worker Oldine Deshommes encouraged the dozen women attending to share their experiences and challenges with the disease, and their hopes for cancer prevention. One woman who is undergoing chemotherapy following a mastectomy in May told the group she “feels like a new person, rich in life.”

Their courage is remarkable given the fear and misunderstanding about cancer that exists within many communities. Every woman in the group had encountered some kind of resistance from loved ones while deciding to undergo a mastectomy. One 52-year-old patient received phone calls from family, friends, and neighbors pleading with her to decline the surgery, insisting she would die. Women in the group nodded their heads in agreement. One young woman explained how she was abandoned by her family following her diagnosis.

Deshommes encouraged the women to educate others about breast cancer and tell them about their own experiences. “We see women come to us too late, because others tell them they’ll die from the disease,” she told the group. “If women wait too long, cancer can spread. This is why coming in as soon as you find a lump is so important.”

Deshommes led a discussion about staying healthy and reminded the women to regularly check their other breast, demonstrating the proper method for a breast self-exam. The women enthusiastically reported that they already conduct breast self-exams and that they encourage women in their families and communities to do the same or to visit the clinic.

This kind of community outreach is working. Dr. Ruth Damuse, PIH/ZL’s oncology program director, now screens an average of 50 women each week at the breast cancer clinic in Cange—an increase from 15 women a week just one year ago. While some women are referred to the clinic by their doctors, many have begun visiting the clinic on their own. Perhaps most encouraging is that many of them arrive with less advanced stages of cancer.

The women in Deshommes’ support group are living proof to those around them that a breast cancer diagnosis doesn’t have to be a death sentence. From September 2011 to August 2012, ZL surgeons performed 158 cancer-related surgeries—the majority of them breast-cancer related. And access to chemotherapy is increasing—25 patients are currently on IV-administered chemotherapy. ZL also is treating 52 more patients with oral medications, both chemotherapy and other cancer treatment drugs.

As Deshommes brought the group to a close, she distributed breast prosthetics and bras to the most recent mastectomy patients. The women were glowing while they helped each other select the appropriate sizes and reclaim a piece of their self-confidence. “We are all each other’s mothers,” one woman pronounced.

The PIH/ZL oncology program is made possible largely with support from the Avon Foundation and the LIVESTRONG Foundation.

The hospital grounds were filled with the residents of Mirebalais, local and national government officials, representatives of nongovernmental partner organizations, and staff of Zanmi Lasante, PIH's sister organization in Haiti. All were gathered for a ribbon-cutting ceremony to celebrate the end of the hospital’s construction phase. The hospital will officially open the first part of next year.

Kim’s visit marked a return to the area in which he, Dr. Paul Farmer, and Ophelia Dahl began the work of Partners In Health years ago.

“In 1988 I came to the Central Plateau for the first time, and I met Père Lafontant,” he told a small group just before the ceremony. “In the middle of very little else that was going on, we saw this wonderful hospital [in Cange], and the question that we asked during that first visit was what do the people of the Central Plateau deserve? The constant refrain from all around us was ‘you have to lower your expectations. Haiti is a difficult country to work in; there’s only so much you can do.’”

The HUM radiology suite is fully equipped with state-of-the-art technology.

“I’m so proud to see that the government of Haiti, Zanmi Lasante, the community, and so many other people have answered the question by building this hospital,” he continued. “What the people of Haiti deserve is the best that we can possibly offer. As president of the World Bank Group, the lessons you have taught me—the people of the Central Plateau—will always be in my heart.”

Michel Joseph Martelly, president of the Republic of Haiti, addressed the crowd, along with Florence Guillaume, Haiti’s minister of health. They spoke in front of the hospital’s emergency room, on the driveway that ambulances will use to transport critically ill patients to HUM and then moved to the hospital’s front entrance for the ribbon-cutting.

“L'Hôpital Universitaire de Mirebalais will offer services that have no match anywhere else in Haiti,” said Dr. Pierre Paul, the hospital’s deputy director. “It is a practical example of the willingness to build something stronger and more sustainable—to build better.”

Further reading:

Mirebalais: Hospital construction complete—Drs. Maxi Raymonville and David Walton, physicians for PIH/Zanmi Lasante and members of the executive leadership team of Mirebalais National Teaching Hospital, give an update on the the hospital.

The construction of Hôpital Universitaire de Mirebalais, just north of Port-au-Prince, Haiti, is complete, thanks to the support of hundreds of people in Haiti, the United States, and around the world. Drs. Maxi Raymonville and David Walton, physicians for PIH/Zanmi Lasante and members of the executive leadership team of Mirebalais National Teaching Hospital, give us an update on its progress—and what’s to come.

Q: Why did PIH/Zanmi Lasante decide to build Mirebalais Hospital?

After the January 12, 2010, earthquake devastated Haiti’s largest public teaching hospital, nursing school, and other critical medical infrastructure in Port-au-Prince, Haiti’s Ministry of Health asked us to dramatically scale up our existing plans for a small community hospital we were planning to build in Mirebalais, just 60 kilometers north of the capitol. The result is the Hôpital Universitaire de Mirebalais—HUM for short—a 205,000-square foot, 300-bed facility. The hospital will fill a huge void, locally and nationally, for people who previously had limited access to quality health care, as well as improve access to training for Haitian physicians, nurses, and allied health professionals.

Q: Now that construction is nearly complete, what is your team focused on?

At this point we are currently focused almost exclusively on operational planning—we’re setting up structures for governance and staffing, developing plans for hiring, and creating standard operating procedures for how everything will run when the hospital opens. We’re also working on curricula, developed with our main educational partners at the Université d’État d’Haiti to train Haitian nurses, doctors, community health workers, and other health professionals, which will strengthen the next generation of health providers.

We're also looking forward to Nov. 6, when Dr. Jim Yong Kim, a PIH co-founder, makes his first official visit to Haiti in his role as president of the World Bank. In honor of his visit, ZL and the Ministry of Health will host a ribbon-cutting ceremony that will mark the completion of our hospital construction efforts. This event celebrates PIH/ZL’s partnership with Haiti’s public sector, and we’re especially excited that President of the Republic Michel Martelly will attend.

We’re continuing to work with the Ministry of Health to open the hospital as soon as possible and will have a dedication ceremony in early 2013 to celebrate the culmination of this work and the partnerships that have made it possible.

Q: How many people do you expect will use the hospital?

The hospital will provide primary care services to approximately 185,000 people in Mirebalais and two nearby communities. But patients from a much wider area—all of central Haiti and areas in and around Port-au-Prince—also will be able to receive secondary and tertiary care at this facility. We could see as many as 500 patients every day in our ambulatory clinics when we are fully operational.

Q: What are some of those primary care services?

They include everything from community health services to HIV/AIDS and TB care, care for non-communicable diseases, and prenatal care. Patients will receive vaccinations and treatment for malnutrition, for example, as well as basic primary care and dental services. We will also offer secondary level services including mental health, emergency medicine, and general and orthopedic surgery. Our women’s health services include family planning, reproductive health, and comprehensive emergency obstetric care. We aim to provide the same services you would find at any U.S.-based hospital.

Once the hospital is running at full capacity, we’ll have more than 30 outpatient consulting rooms, six operating rooms, and space to host trainings for 200-plus participants.

Q: How many people will the hospital employ?

We’ll eventually employ more than 1,000 people—including 175 community health workers—drawn primarily from the Mirebalais area.

Q: How much did it cost to build the hospital? And how much will it cost to run each year?

Thanks to incredibly generous supporters, we have raised $17 million to design, build, and outfit the hospital and residences, and we have received another $5-6 million in in-kind donations. When it opens, the hospital’s operational budget is estimated to be about $12.5 million for each of the first two fiscal years. PIH/ZL and the Ministry of Health are still finalizing the budget and both entities will share the cost of running HUM, providing high-quality health care to poor people through Haiti’s public sector.

We will continue to rely on our friends and supporters who believe we can—and should—provide health care to people everywhere, and especially to people living on the margin of extreme poverty. We are also working out a mechanism for long-term financing with the Ministry of Health and other sources.

Q: How will the hospital be governed?

ZL and PIH will operate the hospital under a Memorandum of Understanding with the Ministry of Health for several years. We hope, with the Ministry’s consent, to form an HUM Advisory Board shortly after opening the hospital. The board would ideally be comprised of executives from the Ministry of Health, Zanmi Lasante, PIH, and private citizens who would be advocates and supporters of the hospital. We would hope that within two years, the Advisory Board could become a governing board. Composition of the board(s), timing of their formation, authority, and other related issues will be agreed with the Ministry of Health after the hospital opens.

Eventually the Ministry of Health will manage the hospital, but in the meantime we’ll use an accompaniment and mentorship approach to pair Haitian leaders with international experts from the United States and elsewhere who will help launch the hospital and then steward this transition. This will enable HUM to demonstrate best practices in hospital management, and establish a strong Haitian leadership team that can make the hospital a success and a model for public hospitals throughout the country.

Q: Explain more about the hospital’s role in improving nursing and medical education in Haiti.

Haiti’s public health sector lacks resources to provide attractive career options for young health professionals—many decide to work in private facilities and a vast majority leave the country altogether. We want to help retain health professionals for the public sector here by creating an environment that offers the tools, resources, supervision, and mentoring and academic environment they need to be satisfied in their jobs and advance in their careers.

To that end, PIH/ZL is working with l’Université d’Etat d’HaÏti, l’Ecole Nationale des Infirmières [the national medical and nursing schools, respectively], and other international partners to develop academic programs to train future generations of nurses, doctors, and other health professionals. We will offer medical residencies at HUM in several areas, including internal medicine, obstetrics and gynecology, and surgery.

The hospital also will serve as a site for clinical rotations for Haiti’s national nursing schools, and offer nurses advanced training in several specialty areas, including emergency care, neonatal intensive care, and surgery.

Q: How will HUM impact the economic life of Mirebalais?

Based on PIH’s experience opening a full-service hospital in the rural settlement of Cange, the town of Mirebalais can expect to see remarkable growth and opportunity with the opening of the hospital. We anticipate seeing larger economic growth in the form of new hotels, restaurants, and other small businesses to cater to the increased flow of goods and people in and out of Mirebalais.

Ultimately, we expect HUM will affect the community’s economy on three levels. First, direct employment of more than 1,000 staff in Mirebalais; second, the benefit of those salaries on their families (the ability to keep their kids in school, for example); and third, business growth that will stem from fulfilling the needs of these new professionals.

Q: Talk about some of the building’s “green” aspects—how did the hospital incorporate sustainable building practices and green technology?

Our green technology plan incorporates electricity conservation measures, natural ventilation and lighting, water-efficient plumbing, and a solar energy system that’s among the most ambitious health sector solar projects ever undertaken in a developing country. In fact, according to publicly available data, HUM will be the largest hospital in the world that can be powered entirely by solar energy.

Working with the Ministry of Health, we chose to use solar power as a cost-effective, reliable, and environmentally responsible way to help power the facility and avoid the burden of Haiti’s frequent blackouts. On most sunny days, the system’s 1,800 solar panels will generate more electricity than the hospital consumes, allowing the surplus energy to feed back into the electrical utility.

In addition to solar power, the hospital minimizes energy needs through high-efficiency fluorescent light fixtures, motion sensors for lights that will save up to 60 percent in energy usage, and natural ventilation that reduces both the spread of infection and the need for air conditioning. On the roof, reflective white coating keeps the building cooler and makes the solar panels up to 15 percent more efficient.

All this new technology is being introduced with an eye toward sustainability—all the equipment will be regularly serviced by professionally trained Haitian staff.

Q: What does this hospital symbolize for you?

HUM offers an incredible opportunity to raise the standard of health care for our patients in Haiti. In partnership with the government, we have the capacity to provide high-quality services drawing on international best practices for healthcare delivery, administration, and education. We hope that our work will improve care both throughout our PIH/ZL network and across Haiti.

In March, PIH/ZL community health workers prepared to give the first dose of Shanchol, an oral cholera vaccine, to a woman living in the Artibonite Valley region of Haiti.

When cholera arrived in Haiti two years ago, it spread through communities quickly, killing some of the most vulnerable people in just one day. In mid-October 2010, staff at Zanmi Lasante, Partners In Health’s sister organization, saw the first case of cholera in the town of Mirebalais. Since then, the outbreak has killed more than 7,500 people, sickened more than 600,000, and become one of the world’s largest epidemics in recent history.

This two-year mark of the cholera outbreak can serve as a turning point in Haiti’s battle against the epidemic.

We can continue our commitment to treating victims, educating communities, vaccinating citizens, and advocating for a nationwide water and sanitation system, or we can accept needless deaths as the new norm. It is important to remember that Haiti had not seen a case of cholera prior to October 2010.

We have made great progress in addressing cholera through emergency funding from international donors, support from individual donors, and determination from our staff. When the outbreak began, PIH/ZL mobilized an extensive network of community health workers, nurses, and physicians who have now treated more than 100,000 patients. PIH/ZL opened 11 cholera treatment facilities and hired and trained more than 3,300 community health workers to identify and treat cases of cholera and run public hygiene education campaigns. PIH/ZL psychosocial and mental health teams also counseled and conducted memorial services for more than 4,000 families who lost loved ones to cholera or suffered from stigma associated with the disease.

In the spring of 2012, determination and planning led to a big step in preventing the spread of cholera. PIH/ZL, Haiti’s Ministry of Health, and the nonprofit organization GHESKIO successfully vaccinated nearly 100,000 people. Just months later, The Pan American Health Organization’s Technical Advisory Group on Vaccine-Preventable Diseases (PAHO TAG) recommended expanding the use of the oral cholera vaccine throughout Haiti, based in part on data presented by PIH/ZL and GHESKIO officials.

Fortunately, reported cholera deaths have decreased nationwide within the last year of the epidemic. From October 2010 to September 2011, cholera killed 6,510 people—from September 2011 to the present, cholera has killed 1,025. But because of this, the urgency to address the outbreak—and the funding that came with it—is coming to an end. If we continue treating cases at the rate we are now, our dedicated cholera funding will be exhausted in February. We have no new funds on the horizon.

Cholera remains a leading cause of death among young adults in Haiti and cases continue to spike during rainy periods. In July, cholera sickened 5,600 people across the country, and in September PIH/ZL staff treated 900 people. According to our doctors, these spikes have potential for real danger: fewer staff members available to treat a sudden influx of patients can lead to an increase in deaths. The disease moves so rapidly that in the one or two days it takes for reinforcement staff to arrive, patients can die. Also, fewer treatment centers means fewer patients can be treated.

Just this month, Partners In Health and Zanmi Lasante became the newest members of the Regional Coalition on Water and Sanitation for the Elimination of Cholera in the Island of Hispaniola. This is because we remain committed to a multi-tiered approach to managing cholera: aggressive case findings and treatment, expanding access to the cholera vaccine, and providing access to safe drinking water and sanitation.

If cholera is here to stay in Haiti, so too must be funding for this kind of comprehensive prevention and treatment. Without it, we may lose the gains we’ve made. Join us—we need your support.

Teaming up to educate girls and change the world

Partners In Health is proud to partner with 10x10, a documentary and social action campaign created to deliver a single message: educating girls in developing nations will change the world. When you share the Girl Rising trailer using the share buttons above, each share raises $1 for 10x10's partners.

Join the 10x10 campaign

10x10's Girl Rising is not a documentary. Not a work of fiction. Girl Rising is a hybrid film that brings to the screen stories of real girls from around the world, all pursuing the one thing that will change their lives--and the planet. Coming Spring 2013.

Mirline Olisse, a 40-year-old cancer patient, wears one of Jawan's brightly-colored scarves. With her is head onocology nurse Yolande Nazaire. Photo by Amy Banham.

How do scarves play a role in cancer treatment? For dozens of cancer patients in Haiti, they provide a chance for dignity—and give hope and comfort when it’s needed most.

Partners In Health has increased the integration of cancer prevention and care across many of its sites, including training community health workers to test for cervical and breast cancer. In Haiti, women who have various types of cancer can undergo chemotherapy at Clinique Bon Sauveur in Cange.

Although vital to recovery, chemotherapy causes many women to lose their hair—an unusual and often uncomfortable side effect for women in Haitian society. While these women are physically healing, they often face additional stigma and pain during the process.

Thanks to two organizations from opposite sides of the world, beautiful head scarves are helping to mitigate that pain. An Afghanistan-based business called Jawan and the nonprofit organization Afghan Scholars Initiative (ASI) have donated 30 scarves to chemotherapy patients and will provide scarves to all women undergoing chemotherapy this year—expected to be about 100.

ASI founder Qiam Amiry helped bring together PIH and Jawan, which promotes fashion with a mission. Sales of their scarves support ASI, a program that brings high-performing Afghan students to study at top-level schools in the United States and India.

“When needs and opportunity meet, true partnership can happen,” Amiry said. “We have hope that 100 women will not only live to see tomorrow, but will walk again with pride.”

Jessie Stoop, an oncology nurse at Zanme Lasante in Cange, carried the initial 30 scarves to Haiti and immediately began distributing them to patients.

“The scarves are simply beautiful, and our hope is that they help our patients feel beautiful, too,” she said. “This partnership allows us to give our patients a simple, practical gift and also acknowledge and offer understanding that this is indeed a difficult treatment they are embarking on, but we are here to support them—physically and emotionally.”

We know how to treat multidrug-resistant tuberculosis—and have for decades—yet barely 0.5 percent of newly diagnosed patients worldwide receive appropriate treatment, write Drs. Salmaan Keshavjee and Paul Farmer in the latest issue of The New England Journal of Medicine.

In “Tuberculosis, Drug Resistance, and the History of Medicine,” they argue that shifts in tuberculosis policy have played a key role in the inadequate response to this disease. Keshavjee is a physician in the Division of Global Health Equity at Brigham and Women’s Hospital. Farmer, co-founder of Partners In Health, is chief of the division. Both are faculty in Harvard Medical School's Department of Global Health and Social Medicine, which Farmer chairs.

As tuberculosis was brought under control in the United States and other wealthy countries, funding for research and implementation programs elsewhere dried up.

“The U.S. response to the outbreaks of MDR tuberculosis in New York City and elsewhere was bold and comprehensive; it was designed to halt the epidemic,” write Keshavjee and Farmer. “A similar response has not yet been attempted in low- and middle-income countries. Instead, selective primary health care and ‘cost-effectiveness’ have shaped an anemic response to the ongoing global pandemic.”

Tuberculosis kills almost 2 million people every year.

“We want to encourage the international tuberculosis community to redouble its efforts to battle this disease, including adopting a goal of zero tuberculosis deaths,” said Keshavjee in a statement from Brigham and Women’s Hospital. “That means proactively looking for those who are already sick, ensuring they are rapidly diagnosed and putting them on appropriate treatment. It also means treating those with latent infection and implementing infection control measures that can stop the spread of the disease. This is the approach we’ve used in the United States and Western Europe, and it needs to become the global standard of care.”

Read the full essay.

For Djencia Eresa Augustin, helping to administer the oral cholera vaccine this spring was one thing she could do to fight the cholera epidemic raging through her country. Thanks to her efforts—and the partnership of hundreds of other community health workers, Haiti’s ministry of health, and the nonprofit organization GHESKIO—nearly 100,000 people received the vaccination earlier this year.

“From everything I’ve seen, there is no one who was eligible for the vaccine who didn’t want it,” Augustin said.

Djencia Eresa Augustin is one of hundreds of community health workers who made the oral cholera vaccine campaign in Haiti a success.

For her and others on the front line of cholera epidemics—in Haiti and around the world—the announcement last week from a working group of the World Health Organization (WHO) comes as a welcome affirmation of their efforts. The Pan American Health Organization’s Technical Advisory Group on Vaccine-Preventable Diseases (PAHO TAG) recommended expanding the use of the oral cholera vaccine in Haiti, based in part on data that Dr. Louise Ivers, PIH’s senior health and policy advisor, presented on behalf of PIH and its sister organization Zanmi Lasante. Dr. Bill Pape presented data from GHESKIO’s portion of the campaign.

“An important part of our campaign was to ensure that our experience informed the control of cholera in Haiti and in other countries,” Ivers said. “While cholera vaccines aren’t ‘golden tickets,’ we must move quickly to save as many lives as we can with the tools we have now.”

During last week’s meeting in Washington, DC, Ivers presented data from the successful vaccine campaign, which began in April and finished in June. For example, in a rural area near St. Marc, 45,368 people were vaccinated, and 90.8 percent were confirmed to have received the second dose—a very high completion rate.

In another piece of good news, the World Health Organization also endorsed a recommendation that a global stockpile of 2 million oral cholera doses be created to respond to outbreaks around the world—a major policy shift on the emergency use of cholera vaccines.

In Haiti, the work that PIH, the government, and other partners are doing to improve the country’s water and sanitation infrastructure continues—and is critical. But vaccines are a necessary component of a comprehensive strategy to fight an epidemic that has killed more than 7,000 Haitians, sickened half a million, and continues to claim lives.

“The PAHO TAG recommendations to scale up use of the vaccine in Haiti and the WHO endorsement of a stockpile of cholera vaccines are both great strides forward for those at risk of cholera in Haiti and worldwide,” said Ivers.

Twelve U.S. engineers. 150 Haitian technicians. 200,000 gallons of water. These impressive numbers add up to something extraordinary: a water system installation in Haiti’s central plateau that will serve about 10,000 residents with purified and filtered water.

Over the past year, engineers and students from Clemson University’s Engineers for Developing Countries (CEDC) joined forces with Zanmi Lasante—Partners In Health’s sister organization in Haiti—and two South Carolina-based church congregations to renovate and expand a town-wide water system in Cange, Haiti.

The group of engineers and Haitian water technicians—two of whom had traveled to the United States to learn about the pump’s mechanics—installed nine fountains and showers, four large cisterns, and a powerful turbine that propels water up a steep mountainside to Cange.

The system was inaugurated this past June in a ceremonious parade that wound its way through Cange’s main streets, passing by each fountain and culminating next to the water source, where a plaque was erected to commemorate the work of CEDC and its partners.

“We all saw on the back of the [volunteers’] T-shirts ‘water is life,’” said Dr. Jean Robert, a doctor in the community. “The people of Cange have new life with this new system.”

A generations-long partnership

The Episcopal Diocese of Upper South Carolina (EDUSC), the project’s main funder, initially installed a water system in Cange more than 25 years ago. Its congregations, as well as partners from South Carolina’s Christ Church, returned a generation later as volunteers to help replace the system’s infrastructure and expand its capacity, from 80,000 gallons to 200,000.

“It is an extraordinary testament to the bonds of affection that exist between the people of Cange and the people of EDUSC that the sense of shared mission and solidarity has been transmitted from one generation to the next,” said Alison Lutz, PIH’s Haiti special projects manager. “These kinds of relationships are what make development projects sustainable.”

The water system is also environmentally sustainable. The power of the river current propels a turbine that in turn pumps water two miles up a hillside through a 4-inch galvanized pipe. The turbine and the pump both use few resources aside from the force of the current, and the component that filters the water and sterilizes it with ultraviolent light and chlorine runs on a very small amount of electricity.

A half-ton challenge

From all accounts, the installation wasn’t easy. Once built, the half-ton turbine had to be transported through a field, across a stream, and down more than 500 stairs to be installed. A team of workers carried it, singing in unison to ensure they all moved at the same rhythm.

“This project was full of physical challenges, and the team was able to overcome all of them, from connecting 300-pound pieces of pipe up the side of a steep mountainside, [to] digging an 80,000-gallon pit into sheer rock,” said project manager Michael LaDue, who will graduate from Clemson University in December with a degree in civil engineering.

“I cannot sufficiently express the magnitude of the efforts that the workers in Cange put forth to make this project possible.”

Bringing bread and water

The same week as the inauguration of the water system, Zanmi Lasante and EDUSC opened and dedicated the Centre de Formation Fritz Lafontant, a vocational school named in honor of Father Fritz Lafontant, the organization’s founding director.

Both the school and the water system were part of The Bread and Water Capital Campaign, a multi-year initiative begun by EDUSC, in partnership with Zanmi Lasante, to provide nutritional and educational assistance to Cange. Through a series of fundraisers, mission trips, and volunteer initiatives, congregation members and rotary club members from South Carolina supported the construction of both projects.

“It was as if we were in a desert, but now we have a river among us,” said Robert. “We promise South Carolina that we will protect this system so that our children’s children can enjoy clean water.”

The water system will serve about 10,000 people in Haiti's central plateau with purified and filtered water. Photo by William Watson.

IHSJ Reader   Issue 29  
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HAITI

Cholera and the Road to Modernity: Lessons from One Latin American Epidemic for Another (Jonathan Weigel, Paul Farmer, Americas Quarterly, July 2012)

The authors discuss what lessons can be learned from the Latin American cholera epidemic of the 1990s and what these lessons mean for vaccination efforts in Haiti. Farmer and Weigel assert that the decline of cholera in Latin America cannot be solely attributed to improved water and sanitation systems because these improvements were not universal across countries, and the persistence of other water-borne diseases indicates that water insecurity remained a problem. Instead, they argue that "claims of causality about the ebb and flow of cholera will always be fraught with biosocial complexity," including environmental and climatic factors. As such, a glorification of the effects of sanitation interventions should not be used as an argument against vaccination. All tools should be employed to fight cholera today.

HIV/AIDS

The Long Uphill Battle against AIDS (The New York Times, July 27, 2012)

The International AIDS Conference was held in the United States for the first time in more than two decades, due partly to a travel ban on HIV-positive individuals being lifted in 2009. While the conference covered many topics, there was a particular emphasis on the possibility of a “cure” or an effective vaccine to allow people to stop taking the drugs that turned AIDS into a chronic disease. While many fear this is far off in the future, there are also concrete steps to take in the present to reduce the spread of the virus and create an “AIDS-free generation.” However, while steps to control the AIDS epidemic in the foreseeable future are feasible, the global community continues to lack the political will and financial contributions to make that vision a reality.

Untangling the Web of Antiretroviral Price Reductions (Medecins Sans Frontieres, July 2012)

By 2015, World Health Organization (WHO) initiatives aim to halve the number of new HIV infections by drastically increasing the number of people on antiretroviral treatment (ART). In order for ART to be scaled up in resource-limited settings, drug prices must be decreased and remain low. This report offers an overview of ART regimens used over time, with an explanation of how generic competition has kept first-line regimens at a low cost, but how second-line regimens for patients who have resistant strains remain expensive due to a global increase in patenting and other intellectual property measures. The authors argue that more governments should use compulsory licenses, which, under international trade laws, can override patents and allow for open generic competition, thereby keeping prices low for public health initiatives. This report also provides a detailed profile of ART drugs and regimens, including dosage, quality and cost over time, in order to better understand how policies have affected drug affordability and accessibility, especially in resource-limited countries.

HEALTH SYSTEMS STRENGTHENING

What We Can Learn from Third-World Health Care (Pauline Chen, The New York Times, July 26, 2012)

Chen presents the American healthcare system as a great international paradox: a nation with the highest health expenditures alongside underperformance in crucial health indicators. Chen suggests that perhaps strengthening the U.S. healthcare system can be best achieved through "reverse innovation," or looking at the ways in which high-quality health care is delivered in low-resource settings. Health Leads, Partners In Health, and PACT are all cited as model organizations that look beyond traditional assumptions regarding the delivery of health care, and instead consider models that incorporate food support, housing, and community health workers to improve overall health. Applying these broad definitions of care has both helped to achieve success in terms of health indicator performance and decreased health spending among the most vulnerable populations.

HUMAN RIGHTS

Associations between Human Rights Environments and Health Longevity: The Case of Older Persons in China (Bethany Brown, Li Qiu, Danan Gu, Health and Human Rights, July 2012)

Human rights are fundamental, universal rights based on personal dignity and worth. Within the range of human rights, civil, political, economic, and social rights are often neglected. This study examined more than 18,000 Chinese adults to quantify the impact of human rights on an aging population. Not surprisingly, results showed that those with adequate access to nutrition, shelter, education, health care, and clean-air environments lived longer, healthier lives than their counterparts whose fundamental rights were not fulfilled. To provide better human rights environments, governments need to support and strengthen comprehensive health systems that provide medical care, but that also treat the underlying determinants of health.

RWANDA

First Cancer Treatment Center in Rwanda Breaks Ground (Archinect, July 2012)

The recent opening of Rwanda’s Butaro Cancer Center for Excellence marked the culmination of a multi-year collaboration between Partners In Health, the Rwandan Ministry of Health, and MASS Design Group, an architectural firm that focuses on designing buildings that improve health and strengthen communities. MASS’s innovative approach to building construction is based on the idea that a building’s design and layout are an integral part of the healing process. For instance, the Butaro Cancer Center utilizes natural cross-ventilation and UV lighting to reduce transmission of airborne infectious diseases. MASS also utilized local labor and resources in the construction process. Mindful of how design and architecture impact patients’ lives, MASS is at the forefront of what Paul Farmer calls “an architecture of social justice.”

Achieving High Coverage in Rwanda’s National Human Papillomavirus Vaccination Programme (Agnes Binagwaho, Claire Wagner, Maurice Gatera, Corine Karema, Cameron Nutt, Fidele Ngabo, Bulletin of the World Health Organization, May 23, 2012)

The average difference between vaccine introduction in rich and poor countries is 15 to 20 years. In an effort to prevent the millions of deaths that would result from such a delay in access, this article outlines how Rwanda’s “public-private-community partnership” has made it the world’s first low-income country to provide universal access to the HPV vaccine. With an initial coverage rate of more than 93 percent after the first course of vaccination, these results indicate that placing an emphasis on health systems strengthening, national ownership, and public-private collaboration is crucial for long-term success.

Trends in Malaria Cases, Hospital Admissions and Deaths Following Scale-Up of Anti-Malarial Interventions, 2000-2010, Rwanda (Corine Karema, Maru Aregawi, et. al, Malaria Journal, July 23, 2012)

Using data collected at hospitals over a 10-year period, a research team was able to retrospectively measure the effects of new malaria interventions on the number of malaria cases, hospital admissions, and deaths. These interventions included the large-scale distribution of insecticide-treated nets (ITN) and the delivery of a new anti-malarial drug, artemether-lumefantrine (ACT). The expansion of treatment and prevention methods resulted in a decline of over 50 percent in malaria cases and deaths after the scale-up of ITN distribution and the advent of ACT delivery.

MULTIMEDIA/ADDITIONAL RESOURCES

U.S. Government Accountability Office (GAO) Reports – Ensuring Drug Quality in Global Health Programs and Reform Agenda Developed, but U.S. Actions to Monitor Progress Could be Enhanced

These two recent reports from the U.S. Government Accountability Office summarize research on global health to report to Congress. “Ensuring Drug Quality in Global Health Programs” focuses on medicines being purchased with U.S. funds for global health and highlights the potential for ineffectiveness or harm from drug resistance. The second report discusses how the World Health Organization’s (WHO) reform agenda could be adapted to strengthen monitoring, transparency, and assessment mechanisms.

XIX International AIDS Conference Closing Session (Bill Clinton, Kaiser Family Foundation, July 27, 2012)

Listen to former President Clinton's speech about the need for increased investment to achieve universal access to HIV treatment by 2015 to achieve an AIDS -free generation.

Expectant mother Gina Anderson and her husband, Brent—our supporters of the month—have found a way to incorporate their passion for social justice into a unique celebration of their baby’s arrival.

Instead of a traditional baby shower, Gina and Brent held a “shower for the world.” Attendees took turns reading stories of mothers around the world who have been helped by Partners In Health. In lieu of gifts, the couple started a fundraising campaign and requested that friends and family donate to Partners In Health.

We asked Gina more about her inspiration for the shower, and why this cause is so important to her.

How did you learn of PIH, and why have you chosen to raise money on our behalf—specifically for our work in women’s health?

I first learned about PIH in 2006 when I interned at the University of San Francisco. I decided to join the school-wide book-read of Mountains Beyond Mountains and attend a lecture by Paul Farmer later that semester, both of which I thoroughly enjoyed.

Since then my path has converged with PIH in other ways—hearing a local representative in my community speak about their work in Chiapas, and organizing a speaker at my school to describe his time with PIH in Haiti. Therefore, PIH has continued to stay in the back of my mind as an effective nonprofit striving to alleviate poverty and empower structural change among the people it serves.

Once I became pregnant, I began reflecting on other women abroad that were also expecting. I thought about how they may not have access to health care, clean water, electricity, or proper nutrition like I do. I could not fathom what that would be like. Slowly, I began having a growing desire to do something for the women and children who, by no fault of their own, were born into a different circumstance than my own.

Why did you have family and friends read the stories of women aloud?

Reading the stories of expectant mothers brings this reality closer to home and hopefully stirs awareness, compassion, and an understanding that "this could have just as easily been me" if I were born in a different context.

One statistic that is excruciating to read is that 750 women die each and every day due to childbirth complications.

What do you hope your fundraising will accomplish for other moms around the world?

My hope is that this small gesture of raising money will save more lives of women and children. My hope is simple. I would pray that every child can grow up in a safe and peaceful community, have access to affordable health care, receive a quality education, and go forth to share their gifts with the world. This can be accomplished when we share our resources.

I think of a quote from Dr. Maya Angelou's book Letter to My Daughter that I recently read: "I seem to have more than I need and you seem to have less than you need. I would like to share my excess with you."

In this day and age, we have the knowledge and resources to prevent poverty-related deaths, and therefore this must become a concern for all of us. Everything changed for me upon believing that no one life is more important than another.

Any funny stories or moments from your pregnancy that you’d like to share?

I'm approaching my eighth month of pregnancy and have enjoyed every minute of it. Some of the highlights have been attending three different weddings this summer. One thing I have noticed at each of the receptions is that I seem to leave quite an impression on the guests with my dance moves! I guess people aren't expecting a pregnant woman to boogie-on-down, but I just love to dance.

Although we have decided to find out the baby’s sex at our delivery, one thing I’m certain of is that he/she will be a great dancer.

View Gina and Brent’s campaign.

Start your own fundraising campaign.

Mosa's story: Returning an abandoned child
to home and health

When Mosa was first referred to Partners In Health Lesotho (PIHL), she was just 13 years old but she had already received four courses of tuberculosis (TB) treatment in the previous four years. With each new course, her doctors had added one more TB drug to the treatment regimen—the kind of misguided treatment approach that can lead to more drug resistance.

When the clinicians at PIHL met Mosa, her left lung had collapsed from the damage caused by TB and she weighed only 55 pounds. She had been abandoned by her mother at a public hospital in the capital of Lesotho because she was seen as a burden on the household. After PIHL clinicians learned that Mosa’s father was a TB patient who had died while receiving first-line TB treatment, which is very effective at curing drug-suspectible TB, they suspected that her father had been infected with multidrug-resistant (MDR) TB and the disease had spread to Mosa. Realizing that if they waited to confirm the diagnosis—which is very difficult in children—Mosa might not survive, they instead started her on MDR-TB treatment immediately. The clinicians and her community health worker counseled Mosa’s mother and convinced her to take Mosa back so she could finish the rest of her treatment at home.

Six months later, the results of the drug susceptibility testing showed that Mosa indeed had MDR-TB. Twenty-five months after starting treatment, she was cured.A recently published study in the scientific journal PLoS ONE shows that children being treated for multidrug-resistant tuberculosis (MDR-TB) in the small, mountainous country of Lesotho have achieved a treatment success rate of 88 percent–one of the highest in the world.

Led by Dr. Hind Satti, country director for Partners In Health Lesotho (PIHL), the researchers reviewed the records of 19 children–ranging in age from 2 to 15–enrolled in the organization’s MDR-TB program between 2007 and 2011.

Three-quarters of the children included in the study were also infected with HIV, and 63 percent were malnourished before starting treatment. Additionally, the mountainous terrain often made traveling to clinics difficult for patients and their families. However, the results from this study indicate that, as the authors write, “it is possible to achieve favorable outcomes … despite the geographically challenging setting and the high rate of baseline malnutrition, severe lung damage, and co-infection with HIV.”

Of the 17 children for whom final outcomes were available, the study reported treatment success for 15. Two of the patients, both of whom were also infected with HIV, died. None were lost to follow-up. The study defined treatment success to mean either that the patient was cured, with five consecutive negative cultures, or that the patient had completed the full course of treatment and had no symptoms or evidence of TB.

While many children living with MDR-TB simply go untreated because of the difficulty diagnosing and managing the illness, PIHL’s findings prove that children affected by the disease, if addressed with a proper standard of care, can have strong results. 

Building a successful model of treatment

PIHL’s success rate is largely attributed to two factors.

First, clinicians didn’t wait weeks or months for slow and often inconclusive tests to confirm a diagnosis of MDR-TB. If they had evidence that children had been exposed to MDR-TB or had not responded to standard TB treatment, they started them on a course of treatment for MDR-TB right away. This “empirical” diagnosis and treatment avoided delays that could prove deadly for the children and lead to further transmission of MDR-TB.

Second, PIHL’s system of comprehensive and continuous care ensured uninterrupted support for patients and their families. In addition to providing the children with free medical care, the team relied on a "community-based treatment delivery model," in which trained community health workers closely monitor patients and evaluate their family situations, helping them overcome psychological and social factors that may impede their access to treatment.

For example, the program helped the patients reenroll in school, covered the costs of transportation to appointments, provided food supplements, and partnered with families experiencing financial instability. The workers assessed each patient’s household and worked to provide income-generating activities for families without stable earnings. “Providing for these psychosocial needs likely helped to achieve zero defaults and favorable treatment outcomes,” the article states.

Achieving results in challenging circumstances  

MK's story: With treatment, orphan gains weight—and hope

Fourteen-year-old MK is a double orphan and lives in an orphanage in Lesotho. Infected with both HIV and TB, she was first treated for TB last year with first-line TB drugs, only to have large lymph nodes develop on both sides of her neck after a few months. These lymph nodes are painful and limit her ability to turn her head left or right. After sampling one of these lymph nodes, and testing the sample with GeneXpert MTB/RIF, a state-of-the-art TB detection technology at PIH Lesotho, she was diagnosed with first-line TB treatment failure and was referred to Botsabelo Multidrug-Resistant TB Hospital in Maseru. 

As is common for pediatric HIV/TB patients, MK is severely malnourished and has significant growth stunting. When she arrived at our hospital, she weighed 40 pounds and was 3 feet 10 inches tall. At Botsabelo Hospital she is receiving nutritious meals as well as supplements to help her gain weight. She's also receiving directly-observed standardized treatment for MDR-TB and antiretrovirals for her HIV. As of early July, MK's doctors reported that she is responding well to treatment and is almost ready to be discharged from the hospital to continue her treatment at home.

Lesotho suffers from one of the world’s highest incidence rates of tuberculosis infection–634 people per 100,000 are infected annually, compared to just 4 per 100,000 in the U.S. More than 75 percent of those affected are also HIV-positive. The World Health Organization estimates that roughly 8.8 million people worldwide fell ill with TB in 2010, with 1.4 million dying as a result of the disease.

Globally, children make up roughly 10 to 15 percent of those affected by MDR-TB. However, little research has been published about the prevalence, diagnosis, or treatment of MDR-TB among children, and even less has been written about children living with the disease.

Since 2007, Partners In Health has partnered with Lesotho’s Ministry of Health to provide community-based care to children and adults infected with MDR-TB across the tiny nation. PIHL’s treatment success rate with children treated for MDR-TB far exceeds both the national success rate for treating adults with MDR-TB and the nationwide estimated cure rate for drug-susceptible tuberculosis–a much easier disease to treat. That national number stands at roughly 70 percent.

The positive results of this study indicate that a strong and coordinated treatment strategy, combined with a community-based approach to patient care, can be an effective means of targeting MDR-TB—even in a setting with high HIV prevalence and pervasive undernourishment.

In addition to Lesotho, Partners In Health has provided care to more than 13,000 patients infected with MDR-TB in other international sites, including Peru, Haiti, Russia, and Kazakhstan.

Read “Outcomes of Comprehensive Care for Children Empirically Treated for Multidrug-Resistant Tuberculosis in a Setting of High HIV Prevalence” in the journal PLoS ONE.

Learn more about PIH’s work in Lesotho.

by Amanda Schwartz and Robbie Flick

If you're looking for hope, you probably wouldn't look for it in a warehouse.

It's dark, dusty, and cramped. Boxes stacked ceiling-high teeter precariously overhead. Everything feels a little too big and heavy to carry, let alone disseminate across hundreds of kilometers of pitted, axle-snapping dirt roads in Neno, one of Malawi's most remote and rural districts.

Neno is the kind of place where a simple health commodity -- a mosquito net, a wheelchair, a satchel of therapeutic food -- drastically changes lives. This simple truth, combined with the generosity and solidarity of our staff and our many partners dedicated to addressing the needs of our patients, has transformed our warehouse in Malawi. Those dusty, precarious stacks of boxes are packed full of the kinds of health commodities that every day save and improve countless lives. Partners In Health's warehouse in Neno is not only a story about hope in commodities (though if you're barefoot or hungry or handicapped, there is hope enough in that); it is also a story about hope in partnerships.

Partners In Health was built on the kind of pragmatic solidarity that is found only in partnership. From our earliest days, we’ve known that our partners—from our government partners in local ministries of health, to our implementing partners who help us deliver basic rights, to our funding partners who make this work possible—are the cornerstone to breaking the global cycle of poverty and disease. And yet, while we've long known that our work is built on the pillars of partnership, we've simply never seen hope as clearly as we can when we are standing in a dusty warehouse in Neno, staring up at boxes stacked, ever so precariously, upon boxes.

What does hope in a warehouse look like? Here are five ways our partners are making a difference in Neno.

Ruth, a cerebral palsy patient, received her wheelchair and learned how to use it in June, when staff from the Walkabout Foundation visited Neno, Malawi. Photo by Robbie Flick.

Dignity in Mobility

For all of her young life, Ruth, a cerebral palsy patient, was unable to access even the most basic medical devices. Her condition left her unable to walk, sentencing her to a lifetime crawling across the ground. Thanks to our partnership with the Walkabout Foundation, Ruth and dozens like her now have functional wheelchairs custom-sized to meet their specific dimensions, bringing both mobility and dignity to their lives. In line with PIH's long-term commitment to both the rights of our patients to receive care, and the capacity of community health workers to deliver it, the Walkabout Foundation provided training for disability health workers in sizing, assembly, and maintenance. If Ruth's wheelchair needs repair, or if over time she needs a new one, our local staff now has the tools and skills to ensure that she receives it.

Reaching Every Child in Neno District

Through our partnership with TOMS Shoes we have the privilege of not only distributing new shoes at every school in Neno district, but also implementing important health interventions, such as administering de-worming medication and conducting rapid nutritional assessment to actively identify malnourished children across the district and increase our capacity for public health surveillance. For the first time, PIH will be able to reach every child in Neno district twice a year through these distributions— an unprecedented opportunity to improve the delivery of health care to tens of thousands of children living in some of the hardest-to-reach areas of the country.

Blessings Banda, PIH's HIV and nutrition program manager in Neno, Malawi, with his young patient, Rachel Namazango. Rachel was treated for malnutrition with help from PIH partner Two Degrees. Photo by Robbie Flick.

Treating Malnutrition

When Rachel, a young HIV-positive child, arrived at our hospital severely malnourished, our clinical staff quickly treated her with specially formulated calorie-rich food satchets, provided through our partnership with Two Degrees, which helped nurture her back to health. Just two weeks later she was able to go home, and continues to receive Likuni Phala, a fortified porridge blend enriched with vital micronutrients, also provided by Two Degrees.

Preventing Malaria

In Malawi—a country of 15 million people—malaria is a notorious killer, afflicting 7 million Malawians last year alone, almost half the population. Individuals in remote districts such as Neno are at particularly high risk, as they have traditionally had poor access to long-lasting insecticidal nets (LLINs), a key element for malaria prevention. Our partnership with TAM TAM changes that, making LLINs accessible for our most vulnerable patients. Now, thousands of infants and pregnant women sleep comfortably under LLINs, a simple commodity that means all the difference between a healthy childhood and an excruciating and unnecessary death.

HIV Testing and Prevention

When we faced an acute shortage of condoms, the Red Hot Organization acted quickly with a donation that ensures that every community health event includes this important intervention. Knowing that prevention goes hand-in-hand with testing, the Red Hot Organization is also supporting the costs of our HIV test kits this year, which will be used at our 13 clinical facilities across Neno.

Amanda Schwartz is partnerships manager at PIH, and Robbie Flick is health programs coordinator in Malawi.

by Dr. Louise Ivers
PIH Senior Health and Policy Advisor

In April, Partners In Health responded to Haiti’s cholera epidemic by providing oral vaccinations to 45,000 people living in the country’s Artibonite region—specifically, to two rice-farming communities hit hard by cholera. In partnership with Haiti’s ministry of health, hundreds of community health workers fanned out across the rural, flood-prone area, delivering two doses to each person by the end of May.

The vaccination campaign had an immediate impact. Providing a second dose ensured that people received the vaccine’s full protective effects, which—while not perfect—reduces the likelihood that they will get cholera for up to three years. For example, in a previous study where cholera is prevalent, the oral vaccine provided 65 percent protection to people in the third year after vaccination. We explained this less-than-perfect protection to recipients, who also received information about the importance of hygiene and potable water in minimizing their risk to cholera.

In April and May, Partners In Health distributed oral cholera vaccinations to thousands of people living in Haiti's Artibonite region. Photo by Jon Lascher.

The wider community also benefitted because of the vaccine’s “herd protection” effects—that is, the more people who are vaccinated in a particular area, the higher the protection for all, including the unvaccinated. Between 60 and 80 percent of all people in the two communities we targeted received both doses of the vaccine—an outstanding completion rate—which also lowered the risk for the remaining unvaccinated people. We will continue to evaluate the impact of the vaccine in the next six-12 months and will share the information on the campaign’s effectiveness.

But the vaccination campaign also had more far-reaching effects. Going forward, Haiti’s ministry of health now has information it can use to plan future vaccination campaigns, including “real-time” feedback about logistical challenges and how to solve them, the costs involved, and the acceptability of the vaccine. Haiti’s health workers also now have the benefit of a training curriculum PIH developed on administering this vaccine, and the materials we purchased to keep the vaccine cold can be used by the ministry of health for any future vaccination campaign, not just cholera.

At an international level, other countries that have considered a similar campaign can now learn from Haiti’s experience. And researchers will be able to follow the impact of this vaccine on rates of cholera in the region.

Clean water is a basic tenet of public health, and we remain strong advocates for improvements in Haiti’s water and sanitation systems. Improving these systems will reduce not just cholera but other waterborne diseases. But building public water systems takes time. In the meantime, we will continue to advocate for expanded use of oral cholera vaccine for people who are most vulnerable.

Lacking access to clean water, people use water from rivers and canals to bathe, clean, and cook. Photo by Jon Lascher.

IHSJ Reader   Issue 28  
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FOREIGN ASSISTANCE

Hired Gun Fight (John Norris, Foreign Policy, July 18, 2012)
Rajiv Shah, administrator of the U.S. Agency for International Development (USAID), continues to push for increased local and regional procurement. Currently, American for-profit companies capture more USAID contracts, with the 10 largest receiving more than 27 percent of the agency’s overall funding. Aside from the millions of dollars American companies waste on overhead, Shah recognizes that development is impossible if there isn’t a focus on building sustainability and local capacity. Despite the slow progress, USAID still hopes to reach its target of having 30 percent of aid channeled directly to governments and local organizations by 2015.

FOOD SECURITY

U.S. Food Aid Programme Criticised as ‘Corporate Welfare’ for Grain Giants (Claire Provost and Felicity Lawrence, The Guardian, July 18, 2012)
This timely piece exposes how the vast proportion of food aid money goes to large multinational food trading corporations, just as Congress continues to debate the 2012 farm bill, which controls this international food aid. The writers contend that U.S. food aid legislation is outdated and awards over 70 percent of its contracts to only three corporations that ship food overseas in a process that is uncompetitive and incurs tremendous shipping costs. While USAID, Canadian, and EU aid programs have recently shifted away from spending aid money at home, U.S. food aid policy stands as it did in the 1950s. Contrary to an aid approach that would strengthen systems in developing countries, the U.S. approach undermines local markets and rewards large corporations, ensuring dependency on food aid for years to come.

HAITI

Cholera Vaccination Test Reached Targets in Haiti (Richard Knox, NPR, July 17, 2012)
A year and a half after cholera was first detected in Haiti, two cholera vaccination campaigns were successfully completed last month. Partners In Health, working in rural Haiti, and GHESKIO, working in Port-au-Prince, reported last week that almost 90 percent of the target population received the vaccine. The cholera vaccine campaign initially received pushback from a number of different institutions and governments, yet with dedicated training and accompaniment of each community, PIH and GHESKIO were able to prove that a complicated vaccine campaign could be successfully carried out in resource-poor areas. Though successful, the cholera vaccine is only one step in a comprehensive approach to ending the epidemic, which has killed more than 7,300 people since October 2010.

Disease Outbreaks: Support for a Cholera Vaccine Stockpile (Agnes Binagwaho, Thierry Nyatanyi, Cameron Nutt, Claire Wagner, Nature, July 5, 2012)
In May, nine patients became sick with cholera at the crowded Nkamira refugee camp in northwestern Rwanda. The camp, currently at four times its capacity, was faced with the prospect of a large-scale outbreak. However, infected patients were quickly treated and cured, other preventative measures were taken, and no further cases were reported. In a recent letter to the editor, global health advocates—including Dr. Agnes Binagwaho, Rwanda’s minister of health—commended the camp’s containment efforts and emphasized the importance of keeping a large supply of the cholera vaccine available and ready to distribute in case initial treatment methods fail.

HIV/AIDS

Barbara Lee Introduces Bill Providing Policy and Financing Framework to Achieve an AIDS-Free Generation (Congresswoman Barbara Lee, July 19, 2012)
Congresswoman Barbara Lee of California has introduced a bill called “The Ending HIV/AIDS Epidemic Act of 2012,” which is a comprehensive plan detailing the steps that can be taken to achieve a future without AIDS. The bill, H.R. 6138, lays out a five-year strategy with specific policy, action, and financing targets for the federal government. Lee calls the bill “a critical measure” in the movement to end the AIDS epidemic.

How Food and Nutrition Can Help Turn the Tide on HIV (Martin Bloem, ONE, July 19, 2012)
Martin Bloem, chief of nutrition and HIV policy at the U.N. World Food Programme (WFP), discusses the impact of providing nutritional assistance and counseling to HIV-positive patients struggling with food insecurity. For patients who begin treatment with severe malnourishment, their chance of death is increased six-fold. The WFP offers food rations and vouchers to HIV-positive individuals. Nutrition assistance serves a dual benefit—it increases the health and safety of patients and provides an incentive for them to continue receiving treatment.

Sex Workers at Risk: Condoms as Evidence of Prostitution in Four U.S. Cities (Human Rights Watch, July 19, 2012)
This report examines how the use of condoms as evidence in prostitution charges ties the hands of sex workers and transgender women, those at highest risk for contracting HIV. Reluctant to carry condoms in case they are confronted by police, they are unable to fully claim their right to protect their own health, leading them to engage in sex without protection and putting them at risk for infection. Based on this study’s findings, Human Rights Watch denounces the criminalization of HIV prevention as both an endangerment to the public health and a breach of rights, and calls for a bar on the use of condoms as evidence in criminal proceedings.

Eliminating Mother-to-Child HIV Transmission Will Require Major Improvements in Maternal and Child Health Services (Health Affairs, July 2012)
Over the past decade, efforts to eliminate mother-to-child HIV transmission have dramatically increased, yet meeting the Millennium Development Goal of reducing HIV infections in children by 90 percent by 2015 will be impossible without ensuring that mothers in low- and middle-income countries have access to HIV care. Recent results from modeling research show that if current treatment and prevention programs in resource-poor communities are not expanded to increase access to care, mother-to-child HIV transmission will not decrease. In addition, comprehensive, wrap-around services provided in rural communities need to be expanded to provide sufficient support to HIV-positive mothers.

MENTAL HEALTH

Fighting Depression, One Village at a Time (Tina Rosenberg, The New York Times, July 18, 2012)
This article highlights how the community health worker model has been effective at treating depression in resource-poor settings. Even though three-quarters of the world's mental health disorders are in developing countries and while depression creates the largest health burden in the world today, only recently has attention been brought to treating mental health in the developing world. In several studies, community health workers and interpersonal support groups are delivering impressive results. The success of this model is bringing more attention and funding to the fight for mental health care in low- and middle-income countries.

WOMEN’S HEALTH

Gates Foundation Contraceptive Funding Will Save Lives, Improve Health for Millions (Seattle Times, July 14, 2012)
This editorial applauds the Bill & Melinda Gates Foundation's plan to target $1 billion over eight years to increase access to contraceptives for poor women. Although the emphasis on birth control may be controversial with religious and conservative groups, a recent Johns Hopkins study demonstrates that access to contraception may reduce maternal mortality by nearly a third. The Gates Foundation has chosen to emphasize family planning, following efforts to combat childhood mortality with vaccines and other strategies.

SOCIAL JUSTICE MOVEMENT

Beyond Charity: Helping NGOs Lead a Transformative New Public Discourse on Global Poverty and Social Justice (Martin Kirk, Ethics and International Affairs, July 2012)
Despite lofty goals of driving permanent social change, nongovernmental development organizations (NGOs) often resort to a paradigm more rooted in charity than in social justice. While many of these NGOs have significant marketing power, they often struggle to shift public attitudes toward development in a manner that is compatible with real social change. The author advocates for increased collaboration between academics and NGOs, particularly through the group Academics Stand Against Poverty, to use theory and evidence to increase the effectiveness of the NGO sector.

MULTIMEDIA/ADDITIONAL RESOURCES

AIDS Turning Point (John Donnelly, et. al., GlobalPost, July 2012)
John Donnelly and a group of reporters have teamed up on a project investigating the turning point in reversing the HIV epidemic. This website provides extensive coverage of the epidemic, from stories of people living with HIV across the world to treatment successes as a result of community health worker accompaniment.

Journal of Acquired Immune Deficiency Syndrome Supplements (JAIDS, July 2012)
The Journal of Acquired Immune Deficiency Syndrome released three supplements in advance of this week’s International AIDS Conference. Each supplement contains a different focus—from National Institute of Health reports to the vision and essential steps for reaching an AIDS-free generation.

AIDS 2012: XIX International AIDS Conference Online Coverage (Kaiser Family Foundation, July 2012)
For those who were unable to attend events in Washington, D.C., around the International AIDS Conference this week, recordings of plenary sessions and select press conferences are available from the Kaiser Family Foundation.

Over 23,000 thousand clinicians, researchers, policymakers, and activists gathered in Washington, D.C., this week to attend the international conference AIDS 2012. As the conference highlights recent breakthroughs in treatment and prevention under the theme “Turning the Tide Together,” Partners In Health staff members from Rwanda, Malawi, Haiti, and Boston are presenting evidence of how we and our partners have turned the tide already, achieving universal access to treatment and retention rates of well above 90 percent with programs that support patients with daily visits from community health workers to provide medical, social, and economic support.

A community health worker (right) with an HIV patient in Rwanda.

Dr. Peter Drobac, director of Inshuti Mu Buzima (IMB), PIH’s sister organization in Rwanda, is presenting the impressive results of a study of HIV-positive patients who received treatment at two clinics in Rwanda between 2005 and 2010. The proportion of patients enrolled on treatment who were still alive and receiving care after five years was 93.5 percent—a truly “exceptional” figure, according to Cheryl Amoroso, IMB’s director of health information systems, monitoring and evaluation, and research. Elsewhere in Africa, a review of 33 studies found median retention rates of 70 percent after three years.

The Rwanda study presented by Drobac is one of few that also examines viral loads—the amount of virus in a patient’s blood—over an extended period of time. Of the group of patients who were enrolled in 2005, 96.6 percent had their viral loads suppressed.

“These patients have very high rates of program retention and HIV virus suppression, a success we attribute to a strong treatment program in partnership with the Ministry of Health and the critical community-based component of our model of HIV care,” said Cheryl Amoroso.

Other PIH participants at the conference are presenting posters and speaking on panels highlighting key elements of programs that have contributed to outstanding retention rates and clinical outcomes for patients, including nutritional support for HIV patients and electronic medical record systems to monitor their treatment.

A satellite session co-hosted by PIH, Harvard Medical School, and the United Nations World Food Programme focused on the relationship between hunger, malnutrition and poor health, presenting evidence of the impact that nutritional assistance can have on HIV treatment and adherence.

In another poster presentation, Amoroso and her colleagues are presenting the role of electronic medical record (EMR) systems in improving the care patients receive at different stages in their HIV treatment. The system, implemented with Rwanda’s Ministry of Health, is designed to manage clinical profiles of patients, alerting doctors to missed appointments and identifying potentially at-risk patients. It was put in place in clinics in rural Rwanda, where the high numbers of patients and limited access to resources made it difficult to ensure patients receive continuous care.

“By providing automated alerts of patients who are at risk or need further medical attention, the electronic medical record system ensures that patients don’t fall through the cracks,” said Amoroso. “Implementation of the EMR by PIH in Rwanda has been successful, and the government of Rwanda is currently leading expansion of the program across the country.”

PIH’s monitoring and evaluation team in Malawi found similar results in an analysis of their EMR system. The system is being used in the rural district of Neno, where PIH sister organization Abwenzi Pa Za Umoyo (APZU) supports a hospital serving more than 125,000 patients. The team’s findings indicate that with proper accuracy and supervision, an EMR system can help improve the quality of data and clinical management at sites with a high number of patients.

“The quantity and the quality of work PIH is presenting demonstrate both our engagement in research and the success of our programs,” said Amoroso. “We are excited to see what happens next.”

Other PIH presentations at the conference include:

• IMB’s Peter Celestin Niyigena discussing methods to improve child survival among infants in Rwanda who are exposed to HIV;
• Alice Nyirimana, also of IMB, discussing the unique needs and care of adolescents with HIV; and
• Junior Bazile, of APZU, presenting an evaluation of the Program on Social and Economic Rights, which provides food, shelter, and access to education and income-generating opportunities to HIV-infected patients and affected household members in rural Malawi.

The research presented by PIH staff may be available for viewing after the conference—please check back for more information. You can also learn more about the conference here.

Compañeros En Salud (CES), PIH’s new project in Chiapas, Mexico, has taken a major step to improve delivery of quality health care to more than a thousand people in and around the isolated community of La Soledad. After four weeks of training, the project’s first four acompañantes (community health workers) began visiting patients in their village at the end of June, providing both medical and social support and bridging the gap between the clinic and the community.

In Chiapas, CES is targeting diseases that frequently go undetected and untreated for months or years, causing needless disability. These include chronic diseases such as diabetes and hypertension, as well as asthma, epilepsy, and mental health disorders. As CES Director Dr. Hugo Flores explains, “These illnesses require long-term treatment and other therapies. Accompaniment by a caring person helps encourage patients to continue treatment, and helps patients feel they are not alone.”

The first group of acompañantes consists of four women who were nominated for the job by their neighbors in the community, selected by CES, and approved by the community. According to CES program manager Lindsay Palazuelos, they all share skills, experience, and personality traits essential to the work of accompaniment: caring personalities; the ability to read and write; experience at helping people; the ability to commit several hours a day to the job; and a compassionate style of communication. In order to encourage the women to participate and build capacity in the community, CES is providing several incentives, including ongoing training that opens up new career opportunities and monthly food packages for the acompañantes and their families.

CES Director Hugo Flores trains acompañantes Floridalma Pérez and Adelaida López on hygiene and sanitation.

Trainings for the acompañantes included topics such as the basics of chronic disease management, how to build trust with a patient, and how to know when to refer a patient to a higher level of care. “We are thrilled with this initial group,” said Dr. Jafet Arrieta, CES’s operations director. “Each woman is truly motivated by a desire to help her community, and we know they will each make a difference in patients’ lives.”

The first class is a pilot that will allow CES to refine the acompañante program and then expand it to additional clinics throughout the Sierra region.

The unpleasant truth

• The World Health Organization expects 16 million new cancer cases worldwide by 2020, with 70 percent in developing countries such as Rwanda.
• More than 2.4 million cancer deaths could be avoided each year in developing countries by using prevention and treatment interventions that are affordable and available in rich countries.
• Developing countries account for almost 80 percent of the global cancer burden (loss from death and disability) but only 5 percent of global spending on cancer.
• In Rwanda, 3,430 cancer cases were registered from 2007-2011; 320 were in children under 15. This doesn't include the great number of cases that go undiagnosed and unreported.
• A Rwandan child diagnosed with acute lymphoblastic leukemia was assured of a virtual death sentence. This cancer has an 80 percent cure rate in the United States.

Hope for the future

The Butaro Cancer Center of Excellence, in Butaro Hospital in northern rural Rwanda, vastly improves Rwandans' options for diagnosis and treatment. The Center is the first of its kind to bring comprehensive cancer care to rural East Africa.

Patients seeking treatment at the Butaro Cancer Center receive the full spectrum of care, including screening, diagnosis, chemotherapy, surgery, patient follow-up, palliative care, a pathology lab, mental health and social work services, and socioeconomic support, such as food, transportation, home visits, and community health worker accompaniment. Patients needing radiology treatment are referred to Mulago Hospital in Uganda. The Center also is an accredited national referral site for cancer.

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Dr. Lawrence Shulman of Dana-Farber Cancer Institute joins former President Bill Clinton and Chelsea Clinton in an inaugural tour of the new Butaro Cancer Center.

From left: Dr. Lawrence Shulman, the Honorable Dr. Agnes Binagwaho (Rwanda's minister of health), Chelsea Clinton (PIH trustee), former President Bill Clinton, NASCAR driver Jeff Gordon, and Dr. Paul Farmer participate in the Butaro Cancer Center inauguration July 18, 2012.

Center features include:

• 24 beds for adult and pediatric cancer patients, plus three isolation rooms
• A patient-centered design—each bed faces a beautiful view
• Care from trained nurses who are mentored by visiting specialty cancer nurses from Dana-Farber Cancer Institute (DFCI)
• Care from general practitioner doctors with special training in oncology, and Butaro-based internist and pediatric specialists
• Visits, conference calls, and frequent email communication with oncology specialists from DFCI and Brigham and Women's Hospital to provide mentorship and guidance
• Large-radius fans and louvered windows, which ensure frequent air flow and lower the risk of infection
• Bilingual signage that is color-coded and contextually appropriate for patients of all levels of literacy and mobility
• The use of local materials, including volcanic stone from the Virunga Mountains

Catalyzing lasting change

The Center also will serve as the first facility to implement standardized cancer training and protocols that align with Rwanda's new national guidelines. The Center's contributions to national cancer care will include:

• Developing and implementing standardized national cancer protocols to improve the quality of patient care
• Collaborating with national partners and colleagues to share experiences and strengthen strategies for procuring necessary equipment, consumables, and medications
• Creating a comprehensive paper chart system and sophisticated electronic medical records to streamline communication and reduce medical errors
• Developing indicators to facilitate monitoring and evaluation
• Developing cancer training programs for nurses, doctors, medical and nursing students, medical residents, and pathology support

Partners

The Butaro Cancer Center is a critical element of Rwanda's ambitious five-year plan to introduce cancer prevention, screening, and treatment on a national level. It was built and will operate with support from a unique partnership brought together through the Clinton Global Initiative. Key partners include:

• Rwandan Ministry of Health
• Partners In Health
• Dana-Farber Cancer Institute
• Brigham and Women's Hospital
• Boston Children's Hospital
• Jeff Gordon Children's Foundation

It has been a personal honor to work with such an incredible group of global nursing leaders, and I am incredibly pleased that—thanks to a generous $462,800 grant from the Clinton Bush Haiti Fund—we will have the opportunity to continue this partnership for years to come.

The Regis College Haiti Project is a collaboration among the Regis College School of Nursing, Science, and Health Professions, Haiti’s Ministry of Health, and the University of Haiti to train nursing leaders in Haiti. At the completion of the three-year program, the 12 nursing faculty members will graduate from the University of Haiti as nurse educators and leaders with advanced educational and research skills and continue to teach the next generation of Haitian nurses. Next summer, Regis will host two cohorts simultaneously—the first cohort will return as teachers for the second group who will be at Regis for their first summer session of classes.

The 12 Haitian nursing professors enrolled in the project’s first cohort spent six weeks continuing their program by taking two masters-level courses at the Regis College campus in Weston, MA. The nurses also spent time shadowing nurses at local Boston hospitals. It was another summer of hard work and perseverance, and the 12 nurses will return to Haiti having gained critical experience in advanced nursing research, problem solving, and community health.

My colleague Nadia Raymond—a Haitian nurse herself and PIH’s liaison to the Haiti Project—summed up well our gratitude to Regis College and all those involved.

“I would like to thank the president of Regis College, Antoinette Hays, RN, PhD, for her perseverance and patience making the Regis College Haiti Project a reality. Along with the team at Regis College, Partners In Health, Haiti's Ministry of Health, and other supporters, President Hayes has worked tirelessly to make this dream come true.

This is my second year assisting with the program, and I have enjoyed every second of it. In the process I have learned so much from the struggles and triumph of these 12 nurse leaders. I had the privilege of attending classes alongside them and providing English to French interpretation. I remain impressed with their eagerness to learn and their commitment to this program.”

The Clinton Bush Haiti Fund grant is a watershed moment for this joint project. I look forward to updating you further on the progress of these nurses and their tireless efforts to improve medical education in Haiti.

IHSJ Reader   Issue 27   
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FOREIGN ASSISTANCE

Global Health Solidarity at a Crossroads (Agnes Binagwaho, Project Syndicate, July 5, 2012)
Dr. Agnes Binagwaho, Rwanda’s minister of health, reflects on the impact of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and calls on donor governments to increase lifesaving contributions to end the Global Fund’s funding problems. With support from the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) over the past decade, Rwanda has remarkably improved the health of its citizens by providing comprehensive care—from universal access to antiretroviral therapy to integrated treatment for infectious disease, primary care, and noncommunicable diseases. To ensure Rwanda’s successes are sustainable and replicable, the world’s largest economies need to fulfill their pledges to the Global Fund. The Global Fund’s critical country-owned support has made it possible to improve the lives of the world’s poorest, but Binagwaho argues that failing to continue funding these advancements will be a standard by which history will measure our “capacity for justice.”

Obama Administration Closes Global Health Initiative Office (John Donnelly, Global Pulse, July 3, 2012)
Only three years after President Obama launched the Global Health Initiative (GHI), the office is closing, and the work of GHI will now be incorporated into the State Department’s Office of Global Diplomacy. GHI Executive Director Lois Quam explained that the shift in focus toward diplomacy will “bring more resources to achieve GHI targets”; however, others are skeptical. Could one less global health program in Washington really mean that the Obama administration’s global health plan will get more rather than less attention?

Failure to Launch: A Post-Mortem of GHI 1.0 (Amanda Glassman and Rachel Silverman, Center for Global Development, July 9, 2012)
This article presents a critical assessment of the Obama administration’s decision to close the Global Health Initiative (GHI), which was established to encourage an integrated approach to global health. The authors argue that the GHI closure reflects a lack of political will to face the issues of integration and transparency. The numerous disconnected initiatives launched by multiple U.S. agencies in health and development highlight the increasing need for the fully integrated and financed strategy the GHI had promised.

HEALTH EQUITY

The Legal Reasoning that Preserved ACA’s Individual Mandate (Lawrence Gostin, The JAMA Forum, July 2, 2012)
Two weeks ago, the U.S. Supreme Court ruled in National Federation of Independent Business v. Sebelius that the Affordable Care Act (ACA) was constitutional under Congress’ power to tax. In advance of the ruling, the constitutionality of the ACA and its individual mandate had been based on congressional commerce power. Gostin discusses the negative impact of the Supreme Court’s rejection of the commerce power. While celebrating the ACA’s goal of universal access, he points out that the Supreme Court’s opinion focuses on protecting personal freedoms over the “greater” freedom of access to care and treatment in the event of an injury or illness.

The Crusade for Health Equity (British Medical Journal, June 27, 2012)
The financial crisis in Europe has exacerbated the effects of poverty on many worldwide, including Europeans themselves, where countries such as Spain and Greece are experiencing health care cutbacks and widening disparities. The need for international movements promoting equitable health care is greater than ever. While the “Occupy” movement with its “99%” motto exposed the world to wealth disparities, another less publicized but continually growing movement directly targeting health disparities is on its way. The People’s Health Movement (PHM), a network of health professionals, NGOs, advocacy groups, and academics, produces reports that criticize the lack of structure in global governance of health and development, while demanding that rich countries provide more debt relief to countries with smaller economies and that low- and middle-income countries better protect their citizens’ health. PHM is currently holding its third global assembly in Cape Town and is calling for European policy makers to increase access to universal health care, much like Thailand, Brazil, and Vietnam have done.

Pillars for Progress on the Right to Health: Harnessing the Potential of Human Rights through a Framework Convention on Global Health (Eric Friedman, Lawrence Gostin, Health and Human Rights, June 2012)
Despite the increasing presence of “the right to health” in conventions and constitutions around the world, for millions it remains a right that is far from being realized. The authors propose a four-step approach to expedite the fulfillment of the fundamental right to health. Implementing a global health agreement, a Framework Convention on Global Health (FCGH), could create each of these pillars and amplify the voice of communities suffering from health inequities. The momentum for a FCGH is being led by a civil society coalition, of which PIH is a member, and is aimed at promoting health equity.

NONCOMMUNICABLE DISEASES

Tracking Global Funding for the Prevention and Control of Noncommunicable Diseases (Amitava Banjeree, WHO eBulletin, July 2012)
This editorial explains why transparently tracking funding, delivery, and outcomes of global health programming is essential for effective global health funding. Improving tracking and reporting mechanisms is especially relevant as international attention shifts to treating noncommunicable diseases, which require the development of new metrics, targets, and methods of healthcare delivery. The editorial demonstrates the importance of PIH's approach of combined service, training, advocacy, and research, as effective research is needed to design the right interventions as well as advocate for ongoing funding and support.

RWANDA

Health Care Coverage that Eludes the U.S. (Tina Rosenberg, The New York Times, July 3, 2012)
This opinion piece speaks to the astounding progress seen in Rwanda's health outcomes as the result of a revitalized public health system and a national insurance scheme grounded in a preferential option for the poor. Hospital utilization rates have tripled due to increased financial access to care, and maternal and childhood mortality dropped precipitously in the last 10 years. Rwanda, one of the world’s most impoverished nations, is perhaps the closest in Africa to achieving the U.N. Millennium Development Goals. Rwanda’s demonstrable commitment to the right to health of its people is a standard to which all countries, rich and poor, should be held.

TUBERCULOSIS

CDC Grand Rounds: The TB/HIV Syndemic (Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, July 6, 2012)
This issue focuses on combatting the global syndemic of tuberculosis (TB) and HIV. Though TB causes more than 1.5 million deaths each year, diagnosis and treatment of the disease haven’t advanced for decades. Communities in low-resource areas face high rates of HIV and TB co-infection because the relatively archaic TB diagnostics are even less effective for people living with HIV. In response to this dual burden and recent research, the authors ask international leaders to call for improvements in TB screening, diagnosis, and treatment, particularly in settings with high prevalence of HIV/AIDS.

MULTIMEDIA/ADDITIONAL RESOURCES

Is an AIDS-Free Generation within Reach? (All Things Considered, National Public Radio, July 3, 2012)
Ambassador Eric Goosby, U.S. global AIDS coordinator for the President’s Emergency Plan for AIDS Relief (PEPFAR), reports on PEPFAR’s progress and the program’s challenges and successes with increasing access to antiretroviral therapy for HIV/AIDS patients in Haiti and sub-Saharan Africa. In Haiti, PEPFAR has reduced the costs of successfully treating an HIV/AIDS patient by more than two-thirds in less than a decade, and nearly 4 million people are now on PEPFAR-funded treatment worldwide. In the U.S., however, treatment remains expensive, ranging from $7,000 to $9,000 per year. Despite this gap and the difficulties of identifying HIV/AIDS patients early in resource-poor settings, Goosby is confident the U.S. will meet all the World AIDS Day goals with its current budget, thus edging the global community toward the AIDS-free generation called for by President Obama.

Universal Coverage: Can We Guarantee Health for All? (British Medical Center Public Health Supplement, June 2012)
This issue focuses on universal health care coverage. At a pertinent time in the U.S. and global political sphere, this supplement is a great resource for recent research and thematic reviews of attaining universal access to health care from a variety of authors and institutions.

By Paul Farmer
Photography by bec rollins

On a map of the world and to a doctor’s eye, Nepal is a rib-shaped slice of a country stretched laterally between two giants, hemmed in to the north by the Himalayas and to the south by India. It’s a place of stunning social complexity, in part because of developments over the past few decades during which Nepal has seen civil war and also a transition from a monarchy to a struggling democracy.

View of the Himalayas by plane, en route to Achham, Nepal.

It’s also complex because this region, even the forbidding higher elevations, has been settled for so long and by so many different, if often related, groups. To cite anthropologist Dor Bahadur Bista, “Nepal is such a complex social conglomeration seeking perpetually to accommodate, if not synthesize, its diverse discrete parts.” In spite of close to three centuries of national identity, groups defined variously by class, caste, ethnicity, language, region and religion jostle for the kind of security that people everywhere want: access to health care and education and the chance to make a decent living without risking life and limb.

In much of the country, and among the poor, precisely such risks are faced every day. Bista, Nepal’s first anthropologist, had a keen eye for the forces stymieing his country’s development. He worried in 1989 about fatalism not among the rural poor but among an “ossified” elite. Much has changed since then. Great grievances piled up over generations led to a conflict shaped, it seems, less by ethnicity or caste (which assumed growing importance in the last two centuries or so) and more by the fact that so many struggled with the penury common in what remains in many ways a feudal society. The Maoist uprising that began in 1996 ended in peace accords and a fractious sort of calm: a lot of political parties, a commitment to constitutional democracy, and a war of words rather than weapons as the citizens of this beautiful country push for economic growth that will lift the majority out of crushing poverty. Although the rules of feudalism have been abolished, landless poverty keeps millions in profound dependence. Most of the Nepalis we’ve met—from Kathmandu-based political leaders to academic doctors to women’s groups in rural regions to patients and providers here in Achham—seem to agree that attacking poverty is the biggest problem at hand.

Some recent estimates peg the fraction of Nepalis who live on less than $2 a day as high as 80 percent.

First-time visitors to Nepal see little evidence of the conflict, but much of the conditions that generated it. Some recent estimates peg the fraction of Nepalis who live on less than $2 a day as high as 80 percent. These are the people Nyaya Health, our “praxis partner” (more on this term below) in far-western Nepal, was established to serve. As Partners In Health has done in ten countries outside of Asia, Nyaya has established a sister organization here and works in partnership with local groups and public-health authorities—local, district, central—to promote the right to health and to help break the cycle of poverty and disease encountered everywhere. Whether among the poor and marginalized in wealthy or developed countries or among the great majority in the world’s poorest countries, the concept of justice in action—of actually delivering on lofty concepts regarding the right to food security, safe schools, housing, water, and health care—remains as powerful and important now as ever. Perhaps more powerful: it’s impossible to argue, in the 21st century, that any of these challenges are somehow technically insuperable. They’re not, and we all know it. The challenge is in delivering on age-old promises that a rising tide will lift all boats.

Physicians are trained to expect an often grim universality from pathophysiology. A bad chest x-ray looks familiar in Boston or Rwanda; lungs and hearts sound the same across the globe; a fracture is a fracture is a fracture. Anthropologists are trained to focus on cultural particularities and there are, as noted, no shortage of them here in a society as complex as any I’ve seen. And then there is the terrain: the mountains of Achham—mere hills to the Nepalis—bring to mind Haiti or Rwanda. So did the ten-hour drive from Dhangadi to Bayalpata Hospital, home base for Nyaya Health.

Crossing a narrow bridge by jeep on the final leg to Achham.

It sits on top of a grass-covered hill and girdled by higher ones, many covered by stands of pine and bamboo. The monsoon season has just started, and already the river a couple of thousand feet below is audible when we step out of the wards or clinics. We’re also reminded of Lesotho, in part because of the sheer verticality of the place but also because of the hard facts of labor migration to a booming economy to the south. Nepal has an open border with India, and many of the patients we’ve seen have returned sick after working there. Labor migration also has its particularities and generalities, but whether men—and it’s mostly men who migrate—descend from the mountains of Lesotho deep into the mines of South Africa or from the hills of western Nepal to serve as night watchmen in India’s cities, such social disruption carries its share of penalties. Achham is probably the epicenter of the country’s AIDS epidemic, which invariably drives up rates of tuberculosis, too.

Goat herding children on the Bayalpata Hospital campus in Achham, Nepal.

The mountains that ring the hilltop are tiny compared to the Himalayas, and form only a modest part of the barrier between the people of Achham and a shot at decent health care. Roads, where they exist, are treacherous. The district hospitals are by definition few and far between, poorly maintained and understaffed. The health centers and health posts in the villages and small towns are run by people doing heroic work but without the tools of the trade (whether preventives or diagnostics or therapeutics). There’s plenty of medicine for sale in the private sector, even in these villages and towns, but it’s easy to see, even on a first trip, that poor people are paying a lot for services of dubious value.

MDRTB patient x-ray and the mountains of Achham.

A few years ago, the medical students who founded Nyaya opened a health center in a warehouse in a small town in Achham, and brought in the district’s first biomedically trained doctor. Three years ago, the Ministry of Health sent them up the hill to re-open the abandoned public hospital, and now Bayalpata has three doctors, not counting the part-time volunteers—including Ruma Rajbhandari, Duncan Maru, Jason Andrews, and Ryan and Dan Schwarz—who are in training at the Brigham and Women’s and Massachusetts General hospitals. There’s the dynamo from Michigan, Dr. Payel Gupta, and two Nepalis, Dr. Bibhusan Basnet and—to the delight of the locals, a native son. Dr. Roshan Bista, recently graduated from Nepal’s finest medical school, is now the first Achhami doctor to serve a district that, only a few years ago, counted a quarter of a million souls but not a single physician. The doctors complement a dedicated staff of health assistants, nurses, paramedical employees, and administrators. A small but vigorous community-health team links Bayalpata to scores of community health workers.

Their work isn’t easy. It’s hot in Bayalpata: well over 100 degrees and humid enough to make us wish for rain. It feels and looks like Haiti in late summer. Inside the clinics and wards, the heat is all too familiar, as are the mortal dramas. Women with third-trimester catastrophes. Abscesses from injuries. Rheumatic heart disease. Enteric fever. Parasitic infestations from round worms to kala azar. Childhood malnutrition and its companion diarrheal disease. All manner of waterborne ailments (less than two weeks ago, almost 100 soldiers showed up one day with food poisoning, probably from Salmonella). Tuberculosis and AIDS (Achham probably has Nepal’s highest rates of these two chronic infections, long associated with poverty, gender disparities, and labor migration, all of which are also associated with conflict).

Drs. Bibhusan Basnet, Roshan Bista and Payel Gupta welcome healthy newborn twins to Bayalpata Hospital.

There are non-communicable chronic diseases, too: congestive heart failure, renal insufficiency, mental illness. It’s a well-known catalogue but with a few local twists. Dr. Payel referred to Nepal as “the ortho capital of the world without the orthopedists,” in part because of road accidents but in part because the terrain is so forbidding that people are injured while carrying produce to market—or by simply falling out of their own hillside plots. Kids work these plots too. Yesterday alone, the team provided services to three children with fractures. En route here from Kathmandu, after a one-and-a-half hour flight and in the course of a ten-hour ride, some stopped to say a prayer for the twelve people who’d just perished when their crowded bus went over a cliff—a depressingly common occurrence that makes headlines each week.

Nepali man undergoing testing for MDRTB is examined by Dr. Duncan Maru, of Brigham and Women's Hospital.

The good news is that every one of these problems can be prevented or palliated or cured by the basics of modern medicine and public health. By the basics I mean clean water and safer roads, of course, but also a fairly modest array of vaccines and diagnostics and treatments well within the reach of the sorts of partnerships that Nyaya and Nepal’s public health authorities are trying to forge. In an era in which we talk glibly of “value for money” or “return on investment” or “cost-effective interventions,” it would be hard to argue that the work at hand in Achham and in other regions of rural Nepal doesn’t offer a terrific bargain—to push the metaphor crassly—for those wishing to make a difference in a world riven by inequality and its attendant suffering. The team laboring here on the hilltop is anything but fatalistic. One of the great joys of this trip for me was leading clinical rounds, seeing scores of patients, and conducting sessions to discuss the hardest and most complex cases, from multidrug-resistant tuberculosis to an explosive and mysterious outbreak of food poisoning.

If you do this work long enough—and I still work with people I met in Haiti or at Harvard in 1983—life starts to be defined by this tension between the general and the specific, the universal and the particular, and is always linked to the mortal dramas mentioned above. These dramas can be hidden away, and often are, but they exist whether we acknowledge them or not. For those seeking to leave behind medieval conditions—and only those who have left it behind ever romanticize such poverty—there is no hiding from the afflictions or accidents that take so many lives so early. Acknowledging this injustice is not enough; linking knowledge to reparative action is what we’re all called to do, together; it’s the heart of the matter for partners in health, lower case, as it is for the many groups seeking to promote global health equity.

Dr. Paul Farmer comforts a patient undergoing testing for MDRTB.

It’s for these reasons that a group of us from PIH (I traveled with bec rollins, who took these photos and hundreds more, and Emily Bahnsen, who with me spans PIH and Harvard Medical School and the Brigham and Women’s Hospital) and Nyaya-PIH supporters Bruce Payne and Jeff Kaplan (also on the board of Nyaya) felt grateful to be part of an effort with much to celebrate but much left to do. The cause of global health equity will not be advanced by culling only the low-hanging fruit, though that is work enough. Beyond reducing fractures, beyond providing prenatal care and family planning, beyond vaccination and first aid, beyond primary care is a Pandora’s box of complex ailments. How can we promote global health equity without the tools of the trade? The fitting way to mark the third anniversary of the reopening of Bayalpata’s rebirth is to add essential instruments to the toolkit. We did this by cutting the ribbon on a new operating room and a laboratory.

Dr. Paul Farmer conducts rounds with doctors and medical students at Bayalpata Hospital in Achham, Nepal.

On that day, or shortly thereafter, we saw three patients who served as stern reminders of why we have to reach higher. One was a man who slit his own throat after he was told, in India where he was working, that his abdominal swelling, weight loss, and edema were due to cancer. His wound was stitched up but his underlying pathology is yet to be diagnosed; he might well have tuberculous peritonitis, which is eminently treatable. Another young woman, seven months into her fifth pregnancy, presented with fever and joint pain. She received antibiotics, but miscarried before she could be transferred to a hospital able to provide advanced obstetric care; there is no NICU in all of the Far West of Nepal.

A 42-year-old Nepali man who slit his throat after being diagnosed with cancer.

Last night, our final one in Achham, stretched into the morning. We spent a lot of our time evaluating a woman who looked twenty years my senior but said, as did her son, that she was 45. She had been coughing up bright red blood, lots of it, due to tuberculosis. She also had diabetes and weighed less than 90 pounds. She was first diagnosed and treated for TB in Bayalpata, but never really responded to the therapy. She wept throughout much of our evaluation, since she and her son were worn down by trying to negotiate, without planes or hotels or proper accompaniment, a steep path that led her, astoundingly enough, all the way to Kathmandu. It would be, I told the team, a blessed miracle and a surprise if she did not have multidrug-resistant tuberculosis. Duncan took her sputum to a reference lab in Kathmandu today. There are surely thousands of patients similarly afflicted in Western Nepal, but because Michael Rich and other members of the PIH TB team have worked with the Nepali TB Program, I think I have a pretty good notion of how many patients are receiving treatment: five, with a sixth slated to start hortly. It will be cold comfort to this woman and her family if we have deep knowledge of the disease and how to treat it but cannot manage to turn expertise into action. This has long been the challenge of global health equity: the delivery challenge.

By flashlight during a power outage, Dr. Paul Farmer examines a 45-year-old woman appearing far beyond her years, most likely due to MDRTB.

A chart from the makeshift isolation room at Bayalpata Hospital.

Twenty-five years ago, we made a pledge not to avert our gaze from these complex problems, which is why we’ve since been part of teams that have directly treated tens of thousands of patients with MDRTB. It’s why we are involved in the daily care of more than 15,000 people with AIDS. It’s why we will soon open, in partnership with the Rwandan Ministry of Health and Harvard-affiliated hospitals, what is likely rural Africa’s first cancer center. It’s why we’ve launched programs to train a new generation of physicians and nurses who wish, as do so many of the staff at Bayalpata Hospital, to address the pain endured by those who face both poverty and disease—especially those diseases that serve as a rebuke to hope and optimism.

To take on the noxious synergy of poverty and disease is tedious and hard and full of pitfalls and disappointments. But many people here have fought hard, and made sacrifices, in order to insist on something as simple as a hospital in this region of Achham district. I met one elderly man on the day of the inauguration and again in a town not far away, where we attended a meeting of a community-based organization established to improve care for people living with HIV disease.

We ran into Mr. Kadayat as we were leaving the village and stopped to say hello. He was happy about the improvements in the hospital in part because he spent three and a half years in prison for his role in a 1976 demonstration that turned violent. The story I heard from my co-workers was that people in the region were agitating for a hospital; security forces opened fire on the demonstrators and six people were killed. Six more people, including Kadayat, went to jail, and part of his sentence was served in Kathmandu. “I was taken there by helicopter,” he added. The airport here was later bombed, and is just now being rebuilt. On the positive side of the ledger, some of those who served time for the Bayalpata Hospital were on hand to see it reborn and growing. Speaking as a teacher of doctors, I’m proud to have been present to see some of our Brigham residents involved in reparative justice.

The hospital’s third birthday happened in the middle of PIH’s 25th. Over the past quarter century, I’ve been asked a thousand times a variant of the following question: “This work to provide health care as a right is a good thing, but is it sustainable? Can it ever be brought to scale?” And I’ve said a thousand times, especially to my own students, that it’s possible to tell whether these questions are asked to start the conversation or to end it.

For those seeking to start conversations about sustainability and scale, or about the right to health care, we have learned a great deal over the past decades. To sustain such efforts requires that a new generation of activists be engaged in global health equity. It requires investments in training on both sides of the great divide between rich and poor. To bring such efforts to scale requires that we engage the public sector, since only governments can confer rights to citizens and others within their borders. PIH cannot possibly bring services to all those who need them even in the ten countries where we work, to say nothing of the destitute sick elsewhere. But we believe those lives are just as valuable as the lives of those we meet directly. We’ve known this for 25 years, and that’s why we started, along with groups like Nyaya Health and Tiyatien Health in Liberia and Village Health Works in Burundi and Project Muso in Mali, the “praxis network.” In fact, the Sanskrit-based word nyaya means “justice in action”—it’s perhaps a shorter and more elegant term for global health delivery.

As we mark our 25th year, it’s our hope that the praxis network will grow. For some, any suggestion of filial descent—that somehow an older organization helped to beget offspring—rankles. But as Partners In Health celebrates its anniversary, let’s recall that Zanmi Lasante, our Haitian affiliate, is even older. It’s not about “branding” or “niches” or who came first but rather about building a movement for health and social justice. It’s about making rights real, tangible. It’s our hope that the Nepali and American friends who launched Nyaya Health just a few years ago feel as proud of this connection—this partnership—as we do.

Guest quarters at Bayalpata Hospital, Achham, Nepal.

Two nights ago, on the hilltop where cell phones were unknown a few years ago and where now signal works some times and not others, my phone rang. It was Jim Kim, who was halfway through his first day as the president of the World Bank. The Bank’s motto, emblazoned over the metal detectors in the lobby, reads “working for a world free of poverty.” Easy to say, hard to do. But for those who reject cynicism, including those we’ve been lucky to work with from Haiti to Siberia, from the Navajo Nation to Rwanda, and from Roxbury to Achham, the dream of global health equity takes root and grows wherever we turn cherished social goals into pragmatic efforts to meet them.

Achham-Kathmandu
July 3-4, 2012