This week The New York Times and National Public Radio reported on Partners In Health’s contribution to both strengthening Rwanda’s national health care system and transforming the life of an individual AIDS patient in Haiti. Partners In Health is proud of the work we have accomplished with the support of visionary leaders in Rwanda. As the articles suggest, the successes allow for focus to shift from merely surviving to thriving.

THE NEW YORK TIMES

"In Rwanda, Health Care Coverage That Eludes the U.S."
By Tina Rosenberg

“In three very poor districts, Partners in Health has worked with the government to reconstruct the health system from the ground up, including building three hospitals. The newest, Butaro Hospital, has been called the best in central Africa.

Partners in Health has gradually moved from delivering health services to supporting the public health system as it gets stronger. “They don’t need our help figuring out how to take care of malaria and TB,” said Drobac. “We can focus on gaps like neonatology.”

Read the full article here.

NPR

"Treating HIV: From Impossible To Halfway There"
By Richard Knox

Listen here: http://www.npr.org/2012/07/03/156154794/treating-hiv-from-impossible-to-halfway-there

"The patient who most sticks in my memory is Francois St. Ker, a 44-year-old, 6-foot-tall man who barely weighed 100 pounds back in the spring of 2001. He was on the brink of death from AIDS when the American doctor Paul Farmer started treating him with new HIV drugs… I caught up with St. Ker recently. He's healthy and vigorous — a changed man.

‘By the grace of God I am very well,’ he beams, and takes me on a tour of his well-kept, prosperous-looking farm, with its sugar cane and mango trees and dovecote.”

In mid-July, Rwanda’s Ministry of Health, Partners In Health, the Jeff Gordon Children’s Foundation, and Harvard’s Dana-Farber/Brigham and Women's Cancer Center, will officially open the first comprehensive cancer referral facility in rural East Africa.

The Butaro Cancer Center of Excellence will offer a spectrum of oncology diagnostic and treatment services, including chemotherapy, surgery, a pathology laboratory, counseling, and palliative care.

Delivering chemotherapy to a cancer patient in Butaro

Finding Hope for Cancer Patients

Located in Burera District in northern Rwanda, Butaro Hospital has brought medical innovation and technology to a remote rural district that until four years ago did not have a functioning hospital to serve a population of over 320,000 people.

The World Health Organization estimates that 70 percent of cancer deaths occur in developing countries, often due to lack of access to medications, equipment, and trained health professionals that are routinely available in wealthy countries.

Many cancers that are common and usually fatal in sub-Saharan Africa can be effectively treated and cured with chemotherapy and radiation. In Rwanda, for example, there are currently no trained Rwandan oncologists, and cancer diagnoses are all too often viewed as a death sentence.

PIH has been collaborating with Rwanda's Ministry of Health since 2007 to provide care for cancer patients, including offering chemotherapy on a limited basis.

One of our first patients was Francine Tuyishime, a 10-year-old from an impoverished village. She was sick with rhabdomyosarcoma, a cancer of the muscle, which left her with a large and painful tumor on her cheek.

After traveling across Rwanda in an attempt to find a cure, Francine’s father brought her to Rwinkwavu, a PIH-supported hospital in eastern Rwanda, where her wound was dressed and she was treated with chemotherapy.

“I was very sick and everyone thought I was going to die,” said Francine. However, when she began chemotherapy, her tumor quickly shrank until all that remained was a small scar.

Now healthy, Francine has returned to school and hopes to become a doctor. “I wish others in this part of the world could be cured of cancer, just like me,” she says. Click here to watch Francine tell her story.

Joining Forces to Stop Preventable Deaths

The Butaro Cancer Center of Excellence will offer world-class care to patients like Francine with generous support from the Jeff Gordon Children’s Foundation (JGCF), which has pledged $1.5 million towards pediatric cancer care at Butaro over three years. Founded by NASCAR driver Jeff Gordon, the JGCF is a charity committed to battling pediatric cancer. This is its first international donation.

“A child suffering from cancer is a child suffering from cancer,” says Gordon. “The location of the child does not matter. They are all innocent children and they deserve the right to live, be healthy and enjoy life.”

The Cancer Center will also benefit from a unique partnership with the Boston-based Dana Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School. Expert oncologists from these sites have already started training and mentoring Rwandan staff to administer chemotherapy and care for patients, providing a sustainable and comprehensive system of education for the next generation of Rwandan health care leaders.

The opening of the Cancer Center of Excellence sets a new standard of care for a disease once considered certainly fatal. This message of hope leads PIH co-founder Paul Farmer to recall a similar battle.

“Just a few years ago we had no financing mechanism to diagnose and treat AIDS in Africa,” says Farmer. “People said it was too expensive and too complicated. But today nearly 7 million people in developing countries are receiving treatment for HIV. We can do the same with cancer.”

Read a Huffington Post article about Jeff Gordon’s visit to Butaro.

Learn more about PIH’s work in Rwanda.

Dr. Joia Mukherjee, Chief Medical Officer, Partners in Health, and Associate Professor, Harvard Medical School, joined Frontline Health Workers Coalition partners on Capitol Hill in early June to urge the U.S. Government to invest in frontline health workers as part of a comprehensive approach to strengthening health systems in resource-poor settings. Read a shortened version of Dr. Joia Mukherjee’s testimony below.

Dr. Joia Mukherjee with other members and supporters of the Frontline Health Workers Coalition in Washington, D.C.
Top L-R: Dr. Joia Mukherjee, PIH; Dr. Hailu Tesfaye, Save the Children/Ethiopia; Kelly Walker, Association of Women’s Health, Obstetrics, and Neo-natal Nurses; John Donnelly, Burnes Communications; Mathew Taylor, Intel Corporation. Bottom L-R: Sheena Curry, USAID Maternal and Child Health Integrated Program; Mandy Moore, Actress/Singer/Songwriter/Philanthropist

By Dr. Joia Mukherjee

Death, while the inevitable path of all human beings, is not distributed equally. Unequal is the suffering and disability that precedes the death of the poor. Unequal is the rate of death that occurs before the life cycle is complete -- during childbirth, infancy, childhood, and young adulthood. These inequalities are markers of the cruelest form of injustice: lack of access to health care.

If the United States leveraged our enormous power in the world to increase peace, justice, and prosperity, while improving access to health care the stark inequalities in life expectancy would be diminished and these measures would have the greatest of impacts among the poor.

But increasing access to medical care for the poor, the marginalized, and the vulnerable requires a strategic rethinking of how to achieve physical proximity to the communities who suffer most from these disparities. Partners In Health has committed to doing just that for 25 years; in our work, we have found that the most critical part of this equation is frontline health workers. Nurses, midwives, and doctors make a major commitment by living in the communities they serve, often sacrificing better pay in more comfortable urban surroundings in order to serve the vulnerable.

Our organization has more than 8,000 community health workers in the field who provide a variety of interventions from treating a malnourished child to accompanying an expecting mother to antenatal care. They make certain that patients living with HIV/AIDS, diabetes, or schizophrenia remain adherent to the prescribed treatment for their chronic diseases. They are local people who receive both longitudinal training and compensation for their work, thus creating accountability and economic development for communities. And they are supervised and supported by nurses as part of a larger health system--clinics and hospitals that have staff that are well trained and just as adequately supported to live and work in rural areas.

Partners In Health has documented that this network of frontline health workers significantly improves the retention of patients in HIV care. In Rwanda, adherence to the antiretroviral cocktail is good nationally -- 86 percent after one year. But it is even better at PIH sites -- 92 percent after two years. In Malawi, where from five to 30 percent of persons living with HIV/AIDS are lost to follow up, the PIH village health workers together with MOH clinics and staff have documented less than 2 percent of patients lost to follow-up. This difference could represent 500,000 lives annually.

The shift to frontline health workers does not only mean increasing the number of community health workers. It also means providing adequate training and compensation to nurses who are based in local clinics. In many poor countries "nurses" have a high school certificate and receive little support while being charged with delivering babies and diagnosing and treating diseases such as HIV/AIDS and tuberculosis.

Official development assistance typically funds training of trainers (TOT); this often involves taking health care workers out of the field, “training” them by PowerPoint, and paying them per diem, creating huge problems with absenteeism. This is not the side-by-side mentored training I was privy to as an American health professional. This approach to training is driven by an aversion to paying recurrent costs and does not afford frontline health workers the type of preparation they need to save lives.

In Rwanda, we have piloted a program called MESH -- Mentoring and Enhanced Supervision for Health -- where we have created a mentoring and quality improvement program in conjunction with the Ministry of Health. This program works where health workers are based, generating much better understanding and implementation of evidence-based protocols that are saving lives.

Partners In Health, in collaboration with governments and other partners, believes that donor dollars will be most effective when they help to support frontline health workers through adequate and ongoing training as well as appropriate compensation. Implementing governments need to be allowed to allocate their budgets to this goal -- to professionalize, certify, and compensate frontline workers through the public sector rather than being forced to have "volunteers" who receive a one-off training in the name of "sustainability." These practices only sustain the grossly unequal health disparities in this world.

We believe a million more frontline health workers must be trained, compensated, and integrated into government budgets in order to have the long-term effect of providing high-quality, accessible care to the poor and vulnerable.

I have spent the past week in the beautiful Neno district of Malawi with Abwenzi Pa Za Umoyo (APZU), PIH’s sister organization. I’m traveling with PIH Global Nursing Team volunteer Lynda Tyer-Viola, and we have had a great week so far.

John Paul Bizimungu is the new nursing coordinator here in Malawi, and he has been doing an amazing job on building the APZU nursing team.

Today we visited two rural clinics and arrived just in time to have John Paul assist the midwife there with the birth of a beautiful baby girl.

It was a magical moment for all of us.

I’ve got one week left in my trip, and I hope to provide more updates along the way.

Dr. Louise Ivers - Senior Health and Policy Advisor for PIH

Well done everyone.

This project started in November of 2010 when we wrote that cholera vaccine should be included as one of 5 complementary pieces of cholera control. It then got its wings at TAG meeting in Buenos Aires in July last year and a running start in December when the Minister gave the green light. You all made it fly and I'm really proud of the project and to be part of this team that did what "they" said was impossible.

Aba Kolera!!
Chapo ba ekip solid

Louise

Jon Lascher, PIH – Artibonite Region, Haiti

Ekip,

I am pleased to report that we have completed phase 2 and have reached over 90% of people who received dose 1! An incredible accomplishment that would not have been possible without the perseverance of this incredible team.

IHSJ Reader     June 2012     Issue 25         
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CHILD HEALTH
Child Survival Call to Action: Ending Preventable Childhood Deaths (UNICEF, USAID, Save the Children, et al., June 14, 2012)
On June 14 and 15, world leaders convened a Child Survival Call to Action in Washington, D.C., to build a global road map for ending preventable childhood deaths. Though significant progress has been made in recent decades, it is inconceivable that nearly 20,000 children still die every day from treatable and preventable diseases. The time has come for political leaders everywhere to devote the attention and the resources necessary to eliminate this global health injustice.

Outcomes of Comprehensive Care for Children Empirically Treated for Multidrug-Resistant Tuberculosis in a Setting of High HIV Prevalence (Hind Satti, Megan M. McLaughlin, David B. Omotayo, Salmaan Keshavjee, Mercedes C. Becerra, Joia S. Mukherjee, Kwonjune J. Seung, PLoS One, May 22, 2012)
In this recent study, Partners In Health researchers demonstrate that pediatric MDR-TB treatment programs can be extremely successful, even in a setting like the country of Lesotho with high rates of HIV/AIDS, malnutrition, and poverty. Though little is known about the burden of MDR-TB among children, PIH Lesotho’s MDR-TB program achieved an 88% treatment success rate.  These remarkable outcomes show that rapid initiation of individualized treatment and strong community health worker accompaniment can ensure the right to health for pediatric patients with MDR-TB.

GLOBAL HEALTH ADVOCACY & POLICY
HRH Policy Advocacy Leaders In Action Interview: Donna Barry (HRH, May 2012)
Donna Barry, Policy and Advocacy Director at Partners In Health, discusses the importance of strategic advocacy in solidarity with patients, health workers, and governments operating in settings of poverty. By working in coalitions to educate decision-makers about policies that advance global health equity—and fight policies that do not—advocates can influence the ways in which resources, power, and ideas are distributed so that people in the Global South have a more realistic chance at determining their own health and development.

HEALTH SYSTEMS STRENGTHENING
Universal Coverage is the Ultimate Expression of Fairness (Margaret Chan, World Health Organization, May 23, 2012)
Dr. Margaret Chan, Director-General of the World Health Organization (WHO), began her second five-year term with a bold call for universal health coverage based on need, and not on an ability to pay. In her acceptance speech to health ministers and other government officials, Dr. Chan pledged to advance comprehensive health services for the poor, and warned that today’s unprecedented momentum for equitable coverage and integrated health systems must not be compromised by the economic crisis.

DEVELOPMENT ASSISTANCE
Foreign Aid Works – It Saves Lives (Jeffrey Sachs, The Guardian, May 30, 2012)
Since the year 2000—when all 189 United Nations member states adopted the Millennium Development Goals, the World Health Organization issued a call for increased assistance, and African leaders hosted a landmark summit on HIV/AIDS—the world has seen a vital scale-up of development assistance for health. Increased support for global public health continues to face critics, despite the incredible improvements in global health attributable to having more resources available.  Economist Jeffrey Sachs applauds and outlines the progress that has been made over the past decade; continuing to save and improve lives depends on sustained support for global health programs. 

HAITI
***Oral Cholera Vaccine and Integrated Cholera Control in Haiti (Louise Ivers, Paul Farmer, William Pape, The Lancet, June 2, 2012)
In Haiti, the worst cholera epidemic of the post-antibiotic, post-vaccine era has been raging for over eighteen months. Partners In Health and Zanmi Lasante, in collaboration with GHESKIO, rolled out a vaccination campaign for 100,000 Haitians. Ending the epidemic requires comprehensive measures; the vaccination is one step in this response. Critics of this action in a comprehensive plan to reduce the spread of cholera based their resistance on the logistical constraints of delivering a vaccine in a resource-poor setting, the fear that inequities would result in social unrest, and concern that the vaccine would encourage Haitians to neglect other methods of prevention. Today, both doses of the vaccine have been successfully delivered, and the authors call for improvements to health, water, and sanitation infrastructure to bring the epidemic to an end.

RWANDA
Achieving High Coverage in Rwanda's National Human Papillomavirus Vaccination Programme (Agnes Binagwaho, Claire Wagner, Maurice Gatera, Corine Karema, Cameron Nutt, Fidele Ngabo, WHO Bulletin, May 23, 2012)
Every year, 275,000 women die from cervical cancer; 88 percent of these deaths occur in low and middle income countries. Before 2011, screenings for cervical cancer or the human papillomavirus (HPV) were not available in public health facilities in Rwanda. The development of a public-private partnership between Merck and the Rwandan Ministry of Health led to a nationwide vaccination and education campaign targeting school-aged girls. With all three rounds of vaccine doses delivered, Rwanda’s HPV vaccination program reached over 93 percent of sixth grade girls. Rwanda’s example should encourage other countries and partners to explore universal HPV vaccine coverage.

MULTIMEDIA
A World in Transition: Charting a New Path in Global Health (Secretary Clinton, U.S. Department of State, June 1, 2012)
Secretary of State Hillary Clinton delivered a compelling speech in Oslo, Norway, where she stressed the role of “country ownership” in achieving real gains in maternal and global health.  Implementing country-led planning and delivery is critical to the success of foreign assistance for health in building integrated and sustainable health systems and eventually breaking the cycle of disease and poverty. 

The Global Fund Reorganization: What are the Implications? (Kaiser Family Foundation, June 13, 2012)
Global health experts discuss recent organizational changes at the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and the implications for U.S. global health policy and financing. The GFATM is one of the most successful efforts in the history of public health, and donors must take urgent and coordinated action to address 2012-2013 funding gaps.

ODA 2011 Figures From a Different Perspective   (Marco Simonelli and Joachim Rueppel, Action for Global Health, May 2012)
In response to the announcement in April that the amount of foreign assistance from members of the Development Assistance Committee decreased last year, Action for Global Health, ActionAid, and Medical Mission Institute provide additional analysis of the decline in funding. The authors argue that the current method of calculating official development assistance provides a distorted picture of performance by including payments for debt relief, student costs, expenditures for refugees, and administrative costs and loans. Adjusting for these expenses results in an even greater deficit for health and development financing. 

Maya crossing the finish line.

For many of us, summer is a time to relax and put up our feet. However, one woman is choosing to lace up her sneakers and hit the pavement in support of a worthy cause. This summer, Maya Lopuch is running five half-marathons in five months to raise money for Partners In Health. A data analyst at the Spencer Foundation in Chicago during the week, Maya is racing to raise awareness for the need that still exists in Haiti. She has already completed two races and has three more to go—her next half-marathon is on June 24.

In early June, Maya surpassed her initial goal of $5,000, a feat she managed in just four weeks. Now she’s thinking even bigger. Her new goal is to raise $10,000 by the end of the summer.

We asked Maya to tell us a bit more about her inspiration for this ambitious and impressive fundraising campaign—and her take on the best meal to eat after a run.

When and how did you first learn about Partners In Health?

Last spring a friend invited me to join him on a cycling trip across Haiti. I knew close to nothing about Haiti at the time, but I was intrigued by the adventure and agreed to go.

Two weeks before our trip, I picked up Tracy Kidder’s Mountains Beyond Mountains to learn more about what I was getting myself into. I finished the book in one sitting.

Reading about the history of Partners In Health gave me a much stronger appreciation for the culture of Haiti, and it made my cycling trip all the more fascinating. We never made it to Cange, but my time in Haiti helped me understand why an organization like Partners In Health is so admired and beloved.

Maya after finishing a half-marathon.

What motivated you to fundraise for Partners In Health?

I left Haiti knowing that I wanted to join the humanitarian effort there, but I wasn’t yet sure how. I then read an interview with Paul Farmer about the cholera epidemic that inspired me towards action.

Dr. Farmer pointed out that volunteers at the New York Marathon could distribute thousands of gallons of water to runners but the international community could not provide the same to the Haitians most in need.

Being a runner myself, this was an image that stuck with me. In races there are always cheering volunteers eager to hand water to the runners, even though much of it splashes to the ground.

I decided to channel my own love of running into a fundraising campaign that would help distribute critical supplies in Haiti. Fundraising has been a way for me to maintain a connection with Haiti and pay homage to those who support me during races.

What keeps you going at mile 12?

The fundraising is motivation enough! I’ve been astounded by the generosity of my friends and colleagues throughout this campaign. I thought I was being ambitious when I set a goal of $5,000 over five months, but I’ve already surpassed that.

It’s truly inspiring to see how much goodwill and enthusiasm there is in my community, and I am endlessly grateful. If all it takes is a few half-marathons to mobilize that, then I have no doubt that every step I take is worth it.

What do you crave most after a half-marathon?

French fries and a beer. Was there ever a more perfect meal?

View Maya’s campaign.
Start your own fundraising campaign.
Read more about PIH's supporters of the week.

Paul Farmer delivering the commencement address at the College of the Holy Cross.
(Photo credit: Dan Vaillancourt, College of the Holy Cross)

At the commencement ceremony at the College of the Holy Cross in Worcester, Massachusetts this past May, Paul Farmer recalled a poignant memory, and the lessons learned.

The story began with an inhaler, carried in a young doctor’s pocket on a long walk through rural Haiti.

Farmer had just graduated from Harvard Medical School a year earlier, and had recently returned to work in a small medical clinic in Haiti’s Central Plateau. That day, he left his medical supplies at home, and took a walk to a village about eight miles away to speak at a town hall meeting.

Want to hear Dr. Farmer’s final commencement address of the 2012 season?

Farmer will be speaking at Northwestern University on Friday, June 15. 

 A webcast of his address will be broadcast live on their website at 10:30 am CDT (11:30 am EDT).

Anxious to beat the rain and rest his recently injured leg, Farmer intended to head home after the meeting. He hadn’t gone far when a community health worker stopped him and began leading him towards the home of a sick young man. He initially refused, explaining that he had no medical supplies—not even a stethoscope—with him. The community worker insisted, and Farmer relented.

A man’s life was saved because he did.

He entered a small hut and found a man weakened by a severe asthma attack, lying close to death. Farmer realized he did have the one tool that could save the man’s life—an albuterol inhaler, a device used to treat his own asthma. He slowly administered dosages into the man’s lungs. His gasping slowed, and he began breathing normally.

Dr. Farmer used the story, whose full text is available here, to illustrate the significance of both circumstance and solidarity.

He explained that without the nudging of the village’s community health workers, he might not have taken the time to travel up the hill and save a man from an easily preventable death.

The story of the inhaler, Farmer said to the class of 2012, could serve as a reminder of the power of social networks—a term not meant to refer to today’s online communities, rather the interpersonal support systems that surround and encourage each one of us.

These human social networks, he offered, allow us to see with greater clarity the inequalities that persist and grow today despite modern technological advances. “What does it mean to die unattended of a severe asthma attack in the age of Facebook or LinkedIn?” Farmer asked. “If we're really linked-in, what does that mean for the good stuff, such as albuterol?”

Farmer touched on the same theme of social networks while delivering the commencement speech at Dartmouth College’s Geisel School of Medicine on Saturday, June 9. There, he reminded graduates to acknowledge the privilege of teamwork that goes into a successful and meaningful medical career. He urged them, as they began their residencies, to “be open to the irruptive force of new ideas, new experiences, [and] unpredicted events,” and to ally with fellow nurses, doctors, patients, and families towards a unified desire for better health care.

To end his address to the young doctors, Farmer quoted the school’s namesake, children’s author Theodor Seuss Geisel. He said, “Dr. Seuss could have been referring to medicine when he wrote: ‘It's not about what it is, it's about what it can become.’”

On May 24, 2012, the Daily Times of Malawi called attention to the need for increased investment in the rural District of Neno, where Partners In Health and our sister organization, Abwenzi Pa Za Umoyo, have been working since 2007.

At the time, Neno did not have a district hospital and its ten health centers had fallen into disrepair. But in partnership with the Malawian Ministry of Health, PIH/APZU has helped build two hospitals, refurbish and staff clinics and provide comprehensive, community-based care to a catchment area of 125,000 people.

Still, without investment in basic infrastructure such as roads, housing, and water, the rural district remains isolated from economic development.

District Commissioner Hamisi Cassim Twabi has a better future in mind. “We have the potential to grow as one of the best district centers in Malawi if the Boma has adequate housing facilities, portable water and other amenities – yes, I agree with people in quest for those facilities and also understand people’s concern of a good road network to this place,” says Twabi.

PIH/APZU thanks District Commissioner Hamisi Cassim Twabi for his efforts to build the political will necessary to bring adequate housing, potable water, roads, and electricity to the people of Neno.

Learn more about PIH’s work in Malawi.

Dr. Max Raymond Jr., PIH - Artibonite Region, Haiti

We will soon be finishing up the vaccine campaign with the final dose for children 9 and under. So far, even with delays and the rainy season well upon us, we've reached more than 40,000 people... that's pretty good!

Maybe someday soon we will be here together scaling up the cholera vaccination to the national level with the Haiti Ministry of Health.

More than 30 CHW program leaders from across the globe came together in Boston this past week for the first annual PIH CHW Summit.

By Dan Schwarz

During the last week in May, Nyaya Health – the Nepalese-based medical NGO – had the opportunity to attend Partners In Health’s first annual Community Health Worker (CHW) Summit in Boston. More than 30 CHW program leaders attended the Summit, including representatives from Tiyatien Health (Liberia), Project Muso (Mali), Zanmi Lasante (Haiti), Inshuti Mu Buzima (Rwanda), Abwenzi Pa Za Umoyo (Malawi), Companeros En Salud (Mexico), Socios En Salud (Peru), COPE (Navajo Nation), and PACT (Dorchester, Massachusetts).  

Spanning four days, the agenda included sessions on CHW recruitment, training, management and supervision, monitoring and evaluation, retention, and related topics such as the implementation of mobile health applicationsand research strategies to improve CHW programs.

With regards to Nyaya’s own CHW program, we had the opportunity to present our program to the other participants, highlighting our progress and challenges to date, as we approach the notable milestone of two years of program implementation. A robust discussion of interim program evaluation and re-evaluations ensued, highlighting other programs’ challenges in the early identification of “vision drift,” and the importance of periodically re-assessing a program’s progress as measured by its stated goals.

This discussion is particularly salient as Nyaya undertakes a complete CHW program audit and review during the summer of 2012, with the hopes of ensuring that we stay true to the our patients’ needs and maintain and expand our program accordingly.

With gratitude to PIH and to all of our partners from around the world, we look forward to much more robust network collaborations in the future, such that we may learn from the lessons of those who have come before us, and humbly offer our own lessons learnt to those who are struggling for their own communities alongside us.

Learn more about Nyaya Health.

Dan Schwarz is a board member for the Nepal-based Nyaya Health and a medical student at Brown University School of Medicine. He completed his MPH at the Harvard School of Public Health.

Anne Elperin and Vedaste Hategekimana prepare one of the first doses of chemotherapy at Butaro Hospital, Rwanda.

This May, clinical staff in Rwanda took a momentous step toward offering comprehensive cancer care at Butaro Hospital in the northern, rural Burera District. During the week of May 13, the hospital – run by Inshuti Mu Buzima, PIH’s sister organization in Rwanda – began administering chemotherapy to nine patients undergoing treatment for cervical, breast, or rectal cancer.

Soon, patients with cancer will receive the full spectrum of oncology care when the hospital unveils the new Butaro Cancer Center of Excellence on July 18.

The new national oncology referral center will offer services never-before available in this region of Rwanda, including cancer diagnosis, chemotherapy, surgery, psychosocial support, and palliative care.

The Center is the product of a unique partnership with Rwanda’s Ministry of Health, Jeff Gordon Children’s Foundation, Dana Farber Cancer Institute and Partners In Health.

Anne Elperin, the first Oncology Nurse Fellow at IMB has worked closely alongside hospital staff to begin building oncology capacity as the program ramps up. Through PIH’s partnership with the Dana Farber, oncology nurses like Anne will spend three-month shifts training and accompanying Inshuti Mu Buzima staff. 

In the above picture, Elperin and Butaro’s new Oncology Nurse Coordinator, Vedaste Hategekimana, collaborating to administer inpatient chemotherapy.

Until now, IV chemotherapy has been offered intermittently on a case-by-case basis. Through Anne’s careful training and mentorship, nurses at Butaro will begin providing chemotherapy on a regular basis.
 
One of IMB’s District Clinical Advisors, Dr. Lydia Pace, has been working closely with Anne Elperin and the newly designated oncology team at Butaro on these efforts. 

On May 18, Dr. Pace sent us the following email update. We want to share her thoughts with all of our supporters.

--- 
From: Lydia Pace
Sent: Friday, May 18, 2012 4:33 PM
Subject: Chemo at Butaro

Dear all,

I wanted to share with you a brief report on our first week of administering chemotherapy at Butaro Hospital in anticipation of opening the Cancer Center of Excellence this summer. Even though we’ve been treating cancer with chemotherapy at the PIH-supported Rwinkwavu Hospital since 2007, this week was our first formal introduction of chemo to patients at Butaro Hospital, and it felt like the real thing!

Vedaste, our new Oncology Nurse Coordinator at Butaro, worked closely all week with Anne Elperin, our Oncology Nurse Fellow from Dana Farber Cancer Institute. The two mixed chemotherapy and administered the medication to patients while also teaching oncology-trained and non-oncology-trained nurses.

Vedaste did a fantastic job, was extremely meticulous, and is now "signed off" with chemotherapy administration. Anne and Di Longson, our General Nurse Educator, carefully guided Vedaste and other oncology-trained nurses as they learned dose calculations, the mixing and administration process, and how to address some unexpected – but inevitable – challenges, such as suboptimal IV systems and leaky dextrose bottles, and staff shortages.

Our biggest challenge was that everything we did took a long time, but the processes will speed up as we get more practice. And, it feels great to be able to offer a full spectrum of cancer care here at Butaro.

We gave chemotherapy to five patients: one with rectal cancer, one with cervical cancer, and three with breast cancer. I think they all received excellent care, and they were very appreciative. Daily hugs from Anne also helped.

We learned a LOT! For example, in the future, we’ll plan on giving chemotherapy on pre-specified days to cut down on pulling staff away from other parts of the hospital. We will also work on scheduling issues to ensure that enough oncology-trained nurses are available on specified days, and that the Internal Medicine ward remains well staffed.

Since this is the first time that non-oncology nurses have worked with chemotherapy, some of them felt alarmed seeing the chemo team in their bright blue protective gear.  People were concerned about whether the chemo is dangerous.

To address their concerns, Dr. Egide, who runs Non-Communicable Disease (NCD) program, has joined us for follow-up meetings with nurses to discuss their concerns about chemotherapy safety. It is a challenge to present this information in a way that is clear and honest, yet not anxiety-provoking. But I think that these discussions have gone well so far.

This kind of dialogue will be essential to making sure that the NCD/Oncology program is successful for both patients and providers, and that we all feel pride in and ownership of this exciting initiative. 

Several of our maternity nurses are interested in learning how to administer chemotherapy safely to our two young women with cancer on the maternity ward, one of whom has nearly completed her therapy and is doing well. That patient has been a source of inspiration to us all, demonstrating the potential of cancer care in saving lives.

I wanted to extend a huge thank you to Anne for her expertise, flexibility, patience, dedication and good humor, and thank you to the Dana Farber Cancer Institute for sharing her and others who will rotate into service in the future.

We feel enormously grateful!

All the best,
Lydia

Learn more about PIH's work in Rwanda.

Maggie Sullivan (right) recently returned from a training trip in Guatemala.

Maggie Sullivan provides ongoing clinical mentorship to nurses working with the PIH-supported nonprofit ETESC, Equipo Técnico de Educación en Salud Comunitaria, in Guatemala. Upon returning from a recent trip, Sullivan shared some of her reflections. 

Sullivan is an accomplished family nurse practitioner who has long worked for the Boston Health Care for the Homeless. She co-moderates the Global Health Delivery Project’s online forum, and is a board member for the Global Nursing Caucus and the nonprofit Found in Translation.

Clinical mentorship is the foundation of any clinical practice, be it nursing or medicine. Good clinical mentorship, especially during one’s education and early in one’s career, is essential to sound practice. 

It makes the difference between getting by in clinic and effecting positive health outcomes in the lives of your patients. When I was in nursing school, I remember a neonatal nursing instructor teaching us how to do newborn exams. She started by saying, “if you want to see a healthy baby, you’ll see a healthy baby.”

Maggie Sullivan (second from left) with ETESC health workers in Guatemala.

This phrase has stuck with me ever since and, even though I no longer see newborns, it reminds me to slow down, pay close attention to my patients and focus on my clinical skills. It was not written down in any pathophysiology text book, yet I think about it nearly every day in clinic as I’m examining patients.

It’s true, sometimes if we’re not careful, we see what we want to see, not what’s actually there. It would have taken me many years (and many mistakes) to learn this, but instead I learned it from a clinical mentor when I was still in school. 

The clinical mentorship I provide in Guatemala is outside of any academic setting and with nurses who’ve already been practicing for some years. Because of this, for me clinical mentorship is a collaborative process between peers.

I ask questions of them, they ask questions of me. I am taught how to make some of my own clinical supplies, how clinical practice changes when we don’t have enough of something in stock, how to have conversations about health and illness with patients who might have a fairly different understanding of what health or illness is, and much more. 

I think this is why I keep going back.

There is profound reciprocity and relationship building in clinical mentorship outside this country. Not to say that it doesn’t exist in my practice here in Boston, but I am reminded in Guatemala that if I don’t step outside of what’s familiar, I am more likely to see what I want to see. 

Learn more about PIH’s work in Guatemala.

Beatrice Romela and Miss Amazan headed up events at Mirebalais Hospital on International Nurses Day.

On Sunday, May 13, nurses from each of Zanmi Lasante’s 12 clinics and hospitals gathered to celebrate International Nurses Day.

The cadre of health workers held a one day conference at Mirebalais National Teaching Hospital, a new facility built by Zanmi Lasante – Partners In Health’s sister organization in Haiti – and the Haitian Ministry of Health. Though the hospital is still under construction and won't be complete until the end of the summer, the location was chosen because it embodies PIH/ZL's emphasis on quality health care.

Nursing care will be critical to the success of the new hospital and, in turn, the hospital will be part of the Ministry of Health's strategy to strengthening nursing education and nursing country throughout the island nation.
 
The day began with a Mass lead by representatives from Cange – home to PIH/ZL’s medical and education complex – and ZL's long-standing Nurse Educator Miss Amazan. Following Mass, everyone convened in one of the large conference rooms where various talks took place: Madam Lucile Charles Presidente spoke on behalf of the National Nurses Association of Haiti, motivating young nurses to understand the importance and value of their profession. Minister August reflected on her work providing care in inner-city Carrefour Feille. Madam Myrtha Marescot spoke of her experience as a mental health nurse. Madam Leonida Emmeline from the University of Notre Dame nursing program spoke of importance of nurse training and research around nursing care.

Lastly, Head Nurse Beatrice Romela gave a moving speech about the central role nurses play in health care delivery. We found Ms. Romela's words so moving that we would like to share with all of our supporters. 

Today, I cannot hide the emotion and honor I feel at speaking on behalf of Zanmi Lasante’s Nursing Department as we commemorate International Nurses Day.

This day is dedicated to all nurses, but let me remind you that it was not chosen by chance, since it is the birthday of Florence Nightingale, an extraordinary nurse who greatly impacted the world around her by brining compassionate care to the poorest and most isolated of those suffering from disease and hunger.

Today, as during Nightingale’s time, nurses must not only listen to our patients and care for their needs, but we must learn and integrate sophisticated technologies and rapid advances in the science behind what we know. Our workplace is in constant motion, it is constantly evolving, and these improvements help our patients. 

Nurses are important in their role and responsibilities. We are constantly pushing ourselves to improve and become more competent. Traditional models of working and learning seem less and less able to meet the current exigencies in terms of performance of health systems. 

Too often, employers feel that nursing graduates are not trained to meet the demands of our work. They say we lack the skills needed to function properly in health institutions.

This finding is not surprising because nursing education too often lacks proper funding, guidance, and supervision. The situation in rural and remote settings is even worse.

In addition, the shortage of resources is keenly felt as nurses and auxiliary nurses are often the only providers of care. Unfortunately, we are often the most neglected, left to fend for ourselves, all of which leaves us unable to properly manage our patients. 

Today, we call on the nation’s nursing schools and hospitals to strengthen in-service training for all nursing personnel, to strengthen the supervision of care in remote areas, to train educators for teachers, instructors, and hospital management. 

We must loudly advocate for nurses, and shape a future that befits our society. We must create a future that provides quality services for all communities.

We can pave the way for the nurses that will come after us. 

Today, like yesterday, the nursing profession requires qualities of selflessness and infatigable compassion.

We must believe that great nurses are the result of good schools, training, and practice. We must commit to move in all environments, with all patients regardless of their race or social level. 

I am strongly encouraged by all my sisters who have chosen to invest in this profession, to help the profession move forward.

The study reviewed the records of over 1,000 patients and found that 92 percent of them were still taking their ART medications regularly, two years after they were enrolled in treatment at clinics supported by PIH’s Rwandan partner organization, Inshuti Mu Buzima (IMB). 

This retention rate far exceeds the average of 70 percent reported in a review of 39 published studies that looked at a combined 225,000 HIV patients across sub-Saharan Africa. And retention rates in North America were even lower, averaging just 55 percent, according to a review of 31 studies published in the Journal of the American Medical Association.

“This study reinforces published evidence demonstrating that HIV treatment outcomes in resource-limited setting can match or exceed those in wealthy countries,” write coauthors Michael Rich, MD, Ann Miller, PhD, and their colleagues from Partners In Health, Harvard Medical School, and the Rwanda Ministry of Health.

What makes IMB’s program different is the added support provided to patients. In addition to daily home visits from health workers, patients enrolled in the program received nutritional assistance for 10 months, a travel allowance for routine clinic visits, and comprehensive integrated medical care. They were also enrolled in support groups and HIV education programs.

“Excellent Clinical Outcomes and High Retention in Care Among Adults in a Community-Based HIV Treatment Program in Rural Rwanda” was published in the Journal of Acquired Immune Deficiency Syndromes in March 2012.

The costs and benefits of community health workers

Over the past decade, the number of people who receive antiretroviral therapy in low- and middle-income countries has increased from 200,000 to more than 6.5 million. However, one of the largest challenges facing patients who do have access to HIV/AIDS drugs – especially those living in extreme poverty – is their ability to take ART each day. Inconsistency can cause the virus to become resistant to medication, ultimately putting the patient’s life at risk.

Because HIV programs in poor countries are often based in health clinics, patients are forced to travel long distances for check-ups, blood tests, and medication refills. Patients who cannot afford to travel outside of their rural villages, to buy food, or to pay for out-of-pocket health care costs are less likely to take medications or make follow up visits to these difficult-to-reach clinics.

As part of its effort to break this cycle, the Government of Rwanda has been committed to universal free access to HIV care and has backed that commitment with increased investment in the health system since 2004.

The program has achieved impressive results. Nationally, Rwanda’s HIV program has a retention rate of 86 percent, with only 4.9 percent of patients being lost to follow-up care, according to a 2009 article in the Journal of Acquired Immune Deficiency Syndromes.

“While Rwanda has incredible retention rates, a difference of 5 percent in retention numbers still means that 5 more people of every 100 infected could still be receiving care,” continued Rich.

The daily visits from community health workers and other social supports provided in the IMB program cost an extra U.S. $630 per patient per year for the first year, and then U.S. $340 per year thereafter. Providing 10 months of nutritional support was the primary cost driver in the first year of treatment. The daily accompaniment component costs approximately U.S. $128 per patient per year.

“With PEPFAR [the U.S. President’s Emergency Plan For AIDS Relief] cutting back funding in Africa, we have to show the world that we need more investment in these programs,” concluded Rich. 

And with that increased investment, Rich believes, the international community can set and achieve a long-term retention goal of 90 percent for patients with HIV throughout sub-Saharan Africa. 

Read “Excellent Clinical Outcomes and High Retention in Care Among Adults in a Community-Based HIV Treatment Program in Rural Rwanda” in its entirety.
Learn more about PIH’s efforts to fight HIV.
Learn more about PIH’s program in Rwanda.

IHSJ Reader     May 2012     Issue 24         
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FOOD SECURITY
Investing in Nutrition Security is Key to Sustainable Development (Anthony Lake, UNICEF, May 2012)
Anthony Lake, Executive Director of UNICEF, calls on world leaders to make the fight against childhood hunger a global priority. More than 180 million children around the world suffer from stunting – the result of chronic malnutrition in the first 1,000 days of life. Stunted children are not only shorter than average; studies demonstrate that they also suffer from impaired brain development and lower economic productivity over the lifetime, and are nearly five times more likely to die from disease than a non-stunted peer. Curbing chronic malnutrition will require an enormous surge in resources and political will for nutrition interventions, as well as strategies to address the structural drivers of hunger including the magnitude of inequity within and between countries. 

Africa Human Development Report 2012: Towards a Food Secure Future (United Nations Development Program, May 15, 2012)
The first-ever UNDP Africa Human Development Report is dedicated to the critical issue of food security on the African continent. The persistence of undernutrition in many African countries is due in part to decades-long neglect of the rural sector and international practices which have contributed to high levels of inequality, skewed control over resources, and limited access to essential services. Authors recommend a series of food security interventions aimed at agricultural productivity, nutrition policies, community resilience, and empowerment among marginalized groups.

TUBERCULOSIS
No More TB Suspects: Time To Change the Way We Talk About TB (Stop TB Partnership, May 15, 2012)
In this compelling article, international tuberculosis experts call upon the TB community to replace words such as “defaulter”, “suspect”, and “control” with more dignified, patient-centered terms. Instead of reflecting widely-held assumptions that drive stigma and inequality, the terminology used by health service providers and authorities must acknowledge the inherent worth and dignity of all persons affected by TB. The World Health Organization is in the process of updating its recommended definitions and will issue final recommendations before the end of 2012.

NURSING
Why Nurses Are the Unsung Heroes of Global Health (Sheila Davis, Huffington Post, May 8, 2012)
Sheila Davis, Global Nursing Director of Partners In Health, discusses the critical role of nurses in global health delivery. Nurses constitute 60-80 percent of the global health workforce and provide 90 percent of health care services worldwide. Yet they are largely absent from policy-making processes in the national and international health arenas. With coordinated investments in training, mentorship, and leadership, international partners can help the current and future generations of nurses to strengthen health systems and improve the quality of health care for millions of people in the poorest parts of the world.

HEALTH CARE REFORM
Realigning Health with Care: Lessons in Delivering More with Less (Rebecca Onie, Paul Farmer, Heidi Behforouz, Stanford Social Innovation Review, May 2012)
A new article co-authored by PIH’s Paul Farmer and Heidi Behforouz identifies three ways to address the bloated health care spending in the US: incorporate the root causes of disease into treatment; deliver health services in homes and communities; and include nontraditional health workers in health care provision. The authors highlight three organizations that have improved health outcomes and lowered expenditures by pursuing a comprehensive definition of “health” that encompasses the relationship between health and poverty.

MATERNAL HEALTH
Another Blow Against Women – House Appropriations Committee Votes to Defund UNFPA (Valerie Phillipo, Huffington Post. May 17, 2012)
The day after the World Health Organization, United Nations Population Fund (UNFPA), and several other UN bodies released a report heralding the sharp decline in maternal mortality over the past decade, the United States House of Representatives Appropriations Committee voted to remove $39 million in funding for the UNFPA. US funding is critical to UNFPA’s ability to deliver life-saving health care to women and girls in developing countries. The decision by the House Appropriations Committee to jeopardize access to critical health services such as contraceptive supplies and emergency obstetric care is an affront to the health and dignity of women and girls everywhere.

Maternal Deaths Continue to Decline but More Progress Needed (UN News Centre, May 16, 2012) + Trends in Maternal Mortality: 1990 to 2010 (UNFPA, UNICEF, WHO, World Bank, May 2012)
Last week, the United Nations Population Fund, the United Nations Children’s Fund, the World Health Organization, and the World Bank released an updated report focusing on the progress that has been made in reducing maternal mortality over the past decade. Between 1990 and 2010, the annual number of maternal deaths has reportedly dropped 47 percent. This decline is a result of concentrated efforts to address preventable pregnancy-related complications and improve access to family planning. Despite the progress, 99 percent of maternal deaths occur in developing countries. Reducing maternal mortality must remain a priority .Even with the decreases in mortality over the past decade, most regions will still fail to reach the Millennium Development Goal target of reducing maternal deaths by 75 percent by 2015. 

Mothers’ Health Worth the Investment (Ophelia Dahl, GlobalPost, May 13, 2012)
On Mother’s Day, Ophelia Dahl, Executive Director and Co-founder of Partners In Health, called for increased investment in mothers across the world. Despite medical advances over the past several decades, nearly 300,000 women still die every year in developing countries because they cannot afford or cannot access the care that they need to prevent most of these deaths. Partners In Health is committed to reducing maternal mortality by providing proven interventions such as prenatal care, family planning services, access to safe delivery with skilled attendants, and emergency obstetrical care including Cesarean sections with local partners in some of the poorest communities in the world. 

Saving Mothers (Sarah Palermo, Concord Monitor, May 13, 2012)
With the third highest HIV infection rate in the world, one of the highest TB infection rates, and limited access to health services, Lesotho is one of few countries where the maternal mortality rate actually increased between 1990 and 2008. In partnership with village leaders and the Government of Lesotho, Partners In Health trains community health workers to identify and accompany pregnant women to clinics for prenatal exams, delivery, and post-partum care. The death of a mother causes ripple effects from one family to entire communities to a country. Decreasing maternal deaths by providing access to high quality healthcare is critical to slowing these ripple effects.

HAITI
Funding Dries Up Even As Rains Worsen Cholera Deaths (Jane Regan, IPS Network, May 18, 2012)
Despite the well-known fact that this year’s rainy season would bring increased cholera infections, many humanitarian actors have remained absent. Cholera cases have increased dramatically, with some cholera centers reporting a three-fold rise in the number of patients in April. The Pan American Health Organization predicts that between 200,000 and 250,000 more people will contract the disease during 2012. The government of Haiti lacks the necessary funding to expand prevention and treatment services and rebuild the water and sanitation infrastructure that is needed to end the cholera epidemic. This is a crucial time for donors to address the funding gap by making resources available for comprehensive cholera treatment and prevention.

Haiti: Where Has All the Money Gone? (Vijaya Ramachandran, Julie Walz, Center for Global Development, May 2012)
This new report from the Center for Global Development finds that improved reporting and accountability mechanisms are needed to monitor the activities of non-governmental organizations (NGOs) operating in Haiti. However, instead of relying solely on private contractors and international charities to deliver essential services, Partners In Health recommends specific benchmarks for strengthening public institutions and community systems. This may include targets for: increasing local participation, contracting, hiring, procurement, and consultation; channeling resources directly through Haitian institutions and ministerial budgets; and supporting the development of robust plans, systems, and staff structures necessary to carry out daily activities of public ministries.

MULTIMEDIA
Lessons from Rwanda: Improving Maternal and Child Outcomes through Health System Strengthening (Toni Habinshuti, COREGroup, May 14, 2012)
Toni Habinshuti, Country Director of Inshuti Mu Buzima (IMB), Partners In Health’s Rwandan sister organization, presents the impact of strengthening health systems on the health of women and girls. In partnership with the Rwandan Ministry of Health, IMB has worked to strengthen health systems in three rural districts by expanding comprehensive health care and integrating services at the community, clinic, and hospital level. 

The Robin Hood Tax Campaign (Robin Hood Tax, May 17, 2012)
Activists around the globe are calling for governments to support a financial transaction tax (FTT) that could raise hundreds of billions of dollars to tackle poverty and inequality. In Chicago, hundreds of nurses demonstrated alongside other global health, labor, religious, climate change, and community activists as part of the May 15-22 Global Week of Action for the FTT, or Robin Hood Tax. Learn more and join the Robin Hood Tax Campaign.

Earlier this spring, Partners In Health gained a new ally, Nick Filippo. As part of a project for school, the fifth-grader decided to do a report about PIH co-founder and future World Bank President Jim Yong Kim. Beyond just learning about Kim, Filippo embodied the energy and mission of the new World Bank president by both dressing as him and running a fundraising campaign.

His goal: raise $100 for PIH’s health care work around the world.

On May 21, Nick reached his goal!

In fact, to date he has raised $165 – surpassing his goal of $100.

All of us at Partners In Health are incredibly proud of Nick and hope that this is just the beginning of a long career dedicated to fighting for the poor.

Earlier this week, we asked Nick and his mom, Elizabeth, to tell us a little more about Nick’s project and his hopes in starting a fundraising campaign.

How did you learn about Partners In Health?

For my 5th grade Wax Museum project, I am doing a report on Jim Yong Kim, the newly elected President of the World Bank. The Wax Museum is a presentation where all of the 5th graders choose someone who has changed the world, and they pretend to be them during the designated period.

They also make a poster board and table presentation and tell visitors to their table about their famous person. I chose Jim Yong Kim because he is an important Korean-American who is working really hard to reduce poverty and make the world a better place.

One of Dr. Kim's accomplishments is co-founding Partners In Health, an organization that provides medical care and fights poverty in poor countries. I first learned about Partners In Health by reading Dr. Kim's Wikipedia page.

What motivated you to raise money and awareness for PIH?

When I was researching Drs. Jim Kim and Paul Farmer, I learned more about what PIH does for poor countries and I wanted to help.

I notice from some videos that kids only got to eat small portions only once a day and couldn’t go to the doctor, while I’m lucky enough that my mom can support my family so we can eat three times a day and even have snacks. It made me feel good that the money that I am raising can go towards more meals and medical care for the kids in need.

 

What do you want to be when you grow up?

I take Dr. Jim Yong Kim as a role model. I am also a Korean American. I was adopted from South Korea when I was a baby. One day I would like to be like him and have kids look up to me for doing great things.

It makes me want to do well in school and makes me think about how I want to change the world in my own way someday. Maybe a kid might do me for the wax museum when I grow up!  

I want to be an engineer because I am good at math and science and I would like to help other people build things, so I could walk in Dr. Kim’s footsteps and be as successful as him someday. Maybe even meet him someday and shake his hand! 

View Nick’s campaign.
Start your own fundraising campaign.
Read more about PIH's supporters of the week.

Jon Lascher, PIH – Artibonite Region, Haiti

We've completed the planned vaccination -- doses 1 and 2 -- for the current phase of the project.

We are very pleased with the results thus far, but we know there are still people we can reach.

We proposed to the teams today that we continue vaccinating for 1-2 days of “attrapage” or continued case finding. We are sensitive to the long hours the teams have already been working and we want to ensure that they have enough rest for the next leg -- dosing children 9 and under -- but given the option this evening, they said they wanted to continue working.

Jon Lascher, PIH – Artibonite Region, Haiti

It rained most of the day today limiting our ability to vaccinate large numbers of people. Teams were deployed at different intervals throughout the day in the hopes of vaccinating farmers returning home from the fields in the evening. 

Tomorrow teams will be going door-to-door again.

The country’s coat of arms, which is placed in the flag’s center, depicts a trophy of weapons ready to defend the people’s freedom, and a royal palm, a symbolic representation of Haiti’s political independence. On top of the palm is a Phrygian cap—often call the liberty cap—which has been used to signify freedom and the pursuit of liberty since the time of the Romans. A banner underneath the palm tree reads, "L'Union Fait La Force"—Through Unity there is Strength.

On May 18, 1803, the newly independent Republic of Haiti officially adopted one of today’s most recognizable symbols of Haitian freedom—the Haitian flag. Since then, Haitians have recognized May 18 as Haitian Flag Day.

Each year, at Zanmi Lasante's (ZL) socio-medical complex in Cange, thousands of people from across the Central Plateau proudly celebrate the Haitian flag.

Festivities focus on the importance of standing together with pride as Haiti continues to rebuild. Hope permeates the air as students from 29 ZL-supported schools recite poems, sing songs, and perform dances and plays, all to honor the history and optimism that Haiti’s flag represents.

The history of Haiti’s flag

The story of Haiti’s flag begins during the Haitian Revolution—more specifically with the battle of Cul-du-Sac, which took place outside Port-au-Prince on December 1, 1802. On that day, Haitian General Alexandre Pétion led his men into battle against the French army; not only did the Haitian forces lose, but they lost their tricolor flag during their retreat.

A teacher from Cange, dressed as Jean Jaques Dessalines—the father of Haitian independence—initiates activities.

That flag was quickly seized by the French and heralded as a symbol of their victory. European newspapers ridiculed the Haitian army not only for losing this battle, but also for carrying the French flag in a battle against the French. This was seen as a sign of the rebels’ chaotic disorganization.

The French press interpreted the use of the French flag to mean that Haiti’s people were not fighting for succession, rather they were merely making a proclamation. The spin: the Haitian army’s use of the French flag during battle was proof that the insurgents were not fighting for their independence, but were simply expressing their desire for greater liberties under French rule.

After hearing these stories, Haiti’s revolutionary leaders knew they needed their own flag. 

Jean-Jacques Dessalines, a leading figure in Haiti’s struggle for independence, was so enraged upon reading these stories that he grabbed the tricolor French flag, and with a sharp jerk, ripped the white stripe to pieces. He turned the flag on its side and rejoined the blue and red strips of fabric—symbolic of the union of mulattoes and blacks against the French. In doing so, he also made Haiti’s flag. 

Haitian soldiers went on to win their independence against the French under the new bicolor flag.

Skyrocketing spending, a shortage of primary care doctors, and rising poverty all contribute to the crisis facing the U.S. health care system. But there is good news, write Rebecca Onie, Paul Farmer, and Heidi Behforouz in “Realigning Health with Care: Lessons in Delivering More with Less”. We can provide better health care, expand access to services, and cut costs—by using solutions that already exist.

The key is to learn from successful programs, many of them in developing countries, that have pioneered ways to deliver quality care despite extreme resource constraints, too few doctors, and overwhelming poverty. A prime example of this “reverse innovation” cited in the article is PIH’s Boston-based Prevention and Access to Care and Treatment (PACT) project. Under Heidi Behforouz's leadership, PACT has adapted the model of accompaniment by community health workers PIH developed in Haiti to simultaneously improve health outcomes and reduce the costs of care for high-risk patients with HIV, diabetes, and other chronic diseases.

Published in the Stanford Social Innovation Review’s Summer 2012 issue, the article urges U.S. policy makers to broaden the definitions of product, place, and provider in health care.

“Realigning Health with Care” highlights three U.S.-based organizations that pull from successful models in resource-poor countries that have addressed the undeniable link between poverty and illness. In addition to PACT, the organizations include Health Leads and the Special Care Center. Health Leads, which was founded and led by Rebecca Onie, deploys a corps of 1,000 college volunteers to help doctors, nurses, and other health providers write and fill “prescriptions” for food, housing, heating assistance, and other basic resources. The Special Care Center, based in Atlantic City, N.J., uses community health workers as “health coaches” to help patients achieve healthier lifestyles and manage chronic disease. 

All three of these organizations offer lessons that should be integrated into the U.S. health care system.

First, health care can go beyond simply providing medicine to include learning about and addressing a patient’s environment and access to resources. Will she have safe water to with which to take her medicine? Will he have transportation money for his follow-up visit? Enlarging the definition of the healthcare “product” in this way can open the door to tackling the structural causes of poor health, reducing a patient’s repeated visits and thus lowering costs. 

Second, broaden the “place” where health resources are delivered so that patients can access them easily—in their homes and communities. The reverse is also true. Bringing economic and social resources that patients need into or near hospitals and clinics can help make medical care more effective. For example, PIH operates farms next to clinics so that malnourished patients have ready access to nutritious foods.

Third, expand the definition of “health care providers” to include nonmedical staff—people who know the patient’s culture and community. For example, trained community health workers can distribute food, deliver medicine, and identify illnesses, allowing more specialized staff to concentrate on what they’re trained to do.

The bottom line is that alternative models work: It is possible to deliver high-quality health care at low cost.

Can we apply these solutions to the U.S. health care system? Yes, say the authors. With investments from the private, public, and philanthropic sectors, we can realign “health” with “care”—and transform U.S. health care in the process. 

Read “Realigning Health with Care: Lessons in Delivering More with Less”.
Read an article about "Realigning Health with Care" posted by Boston's NPR affiliate WBUR. 

"This is not an easy time to join the profession or further your studies in health care," PIH's Chief Medical Officer Joia Mukherjee told the graduating class of the Massachusetts General Hospital Insitute of Health Professions on May 10. "The landscape here in the U.S. and abroad is mired in a fight about who should fund health care and how much it should cost and who should have access."

“The lack of access, in my view, is about the silos we have created — between rich and poor, black and white, nurses and doctors, patients and providers," Dr. Mukherjee continued. "What is needed to break these silos and to bring the best of our collective strength, competencies, and passion is a movement for health as a basic human right.” 

Dr. Mukherjee urged the 400 graduates and the more than 2,000 family and friends who packed the Hynes Convention Center in Boston to dedicate themselves to building that movement. 

“We despearately need all of you on the TEAM for CHANGE," she said. "My greatest hope is that you realize and act on the weight of your responsibility as one of the privileged few with a degree in higher education — whether it is in nursing, physical therapy, speech-language pathology, or medical imaging — to liberate yourself from conventional wisdom and liberate others from suffering.”

Watch video of Dr. Mukherjee's keynote address. (the speech starts at 29:01)
Read Dr. Mukherjee's address in its entirety.  

Clinicians from Harvard and Rwanda work side-by-side at clinics run by PIH and the Rwandan Ministry of Health.

The Rwandan Ministry of Health, Partners In Health, and Harvard Medical School have joined forces to launch a Global Health Delivery course for clinicians in Rwanda. The weeklong course encourages students to consider the ways that politics, economics, and other social factors affect health in resource-poor countries. Previously taught only on Harvard's campus, the course now brings Harvard faculty to Rwinkwavu.

In her article, “Hands-On Medical Education in Rwanda," published by The New York Times on May 13, Stephanie Novak writes that "visits to Rwandan clinics and hospitals allow students to see health care in action, and give them the opportunity to collaborate with other professionals to discuss solutions.”

When not meeting in Rwinkwavu, students, faculty, and partners stay in contact via an online portal called Global Health Delivery online.

GHDonline is a platform where health care implementers consult with each other, post information, and access services and content to improve the delivery of health care, according to Sophie Beauvais, web manager for the Global Health Delivery Project. Participants also learn by sharing and responding to a series of case studies that are the core of the GHD course curriculum and are now available for free online.

Whether online or in the field, this course provides a powerful bridge between professionals across the globe.  

"We hope to have students come from around the world and learn from them as well, and also have the students learning from each other, because they are all coming from countries where there are things ongoing," Dr. Agnes Binagwaho was quoted saying in the New York Times.

Dr. Binagwaho is both the Rwandan Minister of Health and a Harvard faculty member. And it was she who took the initiative to bring the course to Rwanda, where it will now be held twice a year.

Read “Hands-On Medical Education in Rwanda” in its entirety.

Learn more about Partners In Health’s work in Rwanda.

Ophelia Dahl visits with young women receiving care at a PIH-supported clinic in Malawi.

"For as long as I can remember, I have been aware that pregnancy and childbirth can be dangerous," writes PIH co-founder Ophelia Dahl, in a commentary published by GlobalPost on Mother's Day, May 13. "My mother, Patricia Neal, was five months pregnant with my sister Lucy when she suffered a massive stroke in February 1965. She and my sister didn’t die — and I wasn’t left motherless at the age of one — because she was in a place where she could receive the best that medical science had to offer: Los Angeles."

"But that is hardly the case on the other side of the economic and geographical great divide where I have been working for the past 25 years as a co-founder of Partners In Health," continues Dahl. "In poor countries like Haiti, Lesotho and Malawi, women routinely and obscenely die because they do not have access to basic healthcare services that we in the United States take for granted — family planning, pre- and post-natal care, delivery assisted by a doctor or midwife, and access to C-sections or blood transfusions in an emergency."

Read "Mothers' health worth the investment" in its entirety.

Jon Lascher, PIH – Artibonite Region, Haiti

We are pleased to report that during the first two days of delivering the second dose of Shanchol, we vaccinated over 8,000 people. Thanks to Amanda, Jessica and the Majella team for working on a fast solution to a few problems we had yesterday with the tablets. 

Some challenges faced today:

• Due to the seasonal rains, water levels in some Artibonite communities are rising. Anecdotally, we are hearing reports that people are busy tending to their farms, mitigating the water levels. Also in some communities the water is so high that people would have to swim to a post to receive the vaccine.
• We believe many people are waiting at their homes until we change our strategy (again) to vaccinate door-to-door.

IHSJ Reader     May 2012     Issue 22         
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HEALTHCARE FINANCING

Cash Transfer Schemes and the Health Sector: Making the Case for Greater Involvement (Ian Forde, Kumanan Rasanathan, Rudiger Krech, Bulletin of the World Health Organization, April 11, 2012)
Cash transfer schemes are widely recognized as important contributors to human development. Though they impact health systems and health sector priorities, health officials are rarely involved in their design or implementation. Furthermore, Ministries of Health seldom consider cash transfers as a core policy option for advancing health equity.  In this publication, authors make the case for more substantive collaboration across the health, development, social protection, and education sectors in the design, delivery, and monitoring of cash transfer schemes.

The Free Health Care Initiative is Making a Difference in Sierra Leone (President Ernest Bai Karoma, Huffington Post, May 5, 2012)
Two years ago, facing one of the highest rates of infant and maternal mortality in the world, the government of Sierra Leone eliminated user fees for pregnant women, new mothers, and children under five years old.  The successes of the Free Health Care Initiative include a 214% increase in children receiving clinic-based care and a 61% decrease in the number of women dying from pregnancy-related complications at health facilities.  In this article, President Ernest Bai Karoma calls upon the G8 and other international donors to prioritize initiatives aimed at reaching the poorest and most vulnerable people. Sierra Leone is an example of how to provide free health care with good planning and financial backing from political leaders and international donors.

HAITI

Haiti’s Fight for Transparency (Jake Johnston, Caribbean Journal, May 3, 2012)
More than two years after the earthquake flattened much of Port-au-Prince and surrounding communities, less than half of the donor pledges have been disbursed. Specifically, the author focuses on aid delivered by the United States Agency for International Development (USAID) and challenges its transparency. Of the over one billion dollars disbursed by USAID, only 0.02 percent of contracts have been awarded to Haitian firms. The author and PIH recommend that USAID and other donors focus on increasing local procurement as a sustainable way to improve the Haitian economy and health and development outcomes.

CDC Study Shows Haiti Cholera Has Changed, Experts Say It Suggests Disease Becoming Endemic (Associated Press/Washington Post, May, 3, 2012) + CDC study   
Over 530,000 Haitians have been sickened by the cholera epidemic during the past 18 months. A recent report released by the US Centers for Disease Control and Prevention indicates that the current strain of cholera has adapted that the disease is becoming endemic to the country.  Those who were previously infected with cholera will no longer have full immunity to the new strain. Fortunately, the vaccine that is being administered to 100,000 Haitians by Partners In Health and Gheskio provides protection to both strains of cholera.

HIV/AIDS

A Controlled Study of Funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as Resource Capacity Building in the Health System in Rwanda (Donal Shepard, Wu Zeng, et. al, The American Journal of Tropical Medicine and Hygiene, May 2012) 
This six-year investigation in rural Rwanda brings fresh evidence to the debate over whether donor investments in the fight against HIV/AIDS have strengthened broader health systems. In the 25 rural health centers randomly selected for the study, the expansion of HIV/AIDS services did not divert resources from other disease programs, and in fact helped spur improvements in overall preventative care including delivery of childhood vaccinations. By providing robust support for HIV/AIDS programs, donors and host governments can help diagnose, treat, and prevent HIV/AIDS—an infectious disease which killed 1.8 million people in 2010 alone—while simultaneously strengthening weak health systems.

Don’t Stop Now: How Underfunding the Global Fund Impacts on the HIV Response (International HIV/AIDS Alliance, May 2012)
This recent publication by the International HIV/AIDS Alliance draws on data collected from numerous countries to illustrate why the Global Fund to Fight AIDS, Tuberculosis, and Malaria must act urgently to replenish funding. The report specifically provides three recommendations to the Global Fund and its donors to help maintain critical HIV services and scale up treatment and support for key populations at higher risk of HIV infection.

Excellent Clinical Outcomes and High Retention in Care Among Adults in a Community-based HIV Treatment Program in Rural Rwanda (M. Rich, A. Miller, A. Niyigena, et. al, Journal of Acquired Immune Deficiency Syndromes, March 2012) 
This study from Partners In Health, Inshuti Mu Buzima, and Rwandan Ministry of Health colleagues demonstrates that incorporating both community health worker accompaniment and social supports into HIV programs helps keep patients healthy and alive. Instead of requiring patients to travel long distances for care, PIH/IMB/MOH trains and compensates community health workers to monitor health problems, identify potential barriers to treatment adherence, provide social supports such as food, accompany patients as they take their medications, and attend clinic visits for the first four months of treatment and as needed after that period. Patients who received community health worker accompaniment in addition to facility-based care were less likely to die and drop out of treatment when compared to patients who received facility-based care only. PIH/IMB will use this evidence to advocate that community health workers and social support be integrated more widely in HIV/AIDS treatment programs.

NON-COMMUNICABLE DISEASES

Insight: Cancer in Africa: Fighting a Nameless Enemy (Reuters, May 1, 2012)
Cancer kills the poor too. Unfortunately the burden of disease is disproportionally felt in developing countries where access to oncologists is extremely limited. By 2030, the World Health Organization predicts that 70 percent of the world’s cancer burden will be in poor countries such as Ghana where there are currently only six trained oncologists to serve 24 million people. The types of cancer that are pervasive in developing countries are those caused by infections that are largely preventable including Human Papillomavirus. Focusing efforts on preventing these infections is critical to tackling the looming cancer epidemic.

FOOD SECURITY

Three Years After L’Aquila: Are the G-8 on Track to Fight Hunger?(ActionAid, May 2012)
At the 2009 G8 Summit in L’Aquila, Italy, G8 countries agreed to “act with the scale and urgency needed to achieve sustainable global food security.” In advance of the 2012 G8 Summit, Action Aid calls upon leaders to sustain and expand efforts to combat hunger by: (1) expanding financial pledges with a goal to enable 50 million people to rise out of poverty over the next three years; (2) investing in national agricultural development plans, such as those developed through the Comprehensive Africa Agriculture Development Program (CAADP); and (3) a focusing on local participation by farmers and civil society. 

Food Aid in the Farm Bill: One Step Closer to Reform (Eric Munoz, Oxfam, April 30, 2012) 
The 2012 Farm Bill recently passed out of the US Senate Agricultural Committee with modest reforms for US food aid programs. Key improvements include increased funding for local and regional purchase and efforts to reduce the “monetization” of food aid which is both inefficient and often harmful to local farmers. Though insufficient in scope or scale, even incremental reforms to Title II food aid programs are an important step towards aligning US food assistance programs with human rights and aid effectiveness principles.  

MULTIMEDIA

No Mother’s Day (Every Mother Counts, May 2012)
Ninety percent of the deaths caused from pregnancy and childbirth complications are preventable. Every Mother Counts launched their second annual Mother’s Day campaign to raise awareness about women who die each year during pregnancy and childbirth. This video invites mothers to participate in “No Mother’s Day” and disappear on Mother’s Day in an act of solidarity with mothers around the world. 

Two Years On: Celebrating the Success of the Free Healthcare Initiative (Save the Children, YouTube, April 30, 2012)
This moving video looks at the impact of user fee abolition in Sierra Leone, illustrating how women’s and children’s lives change for the better after accessing life-saving care free of charge. For more information on removing user fees from health care, please see PIH fact sheets.

Global Child Survival Efforts: Every Child Deserves a Fifth Birthday (Kaiser Family Foundation, April 23, 2012)
This Kaiser Family Foundation briefing on ending child death coincided with USAID’s kick-off of the “Every Child Deserves a Fifth Birthday” campaign. In June, the US Government, in partnership with India, Ethiopia, and UNICEF, will launch a global call to action for a new way forward to eliminate preventable child deaths. 

[Just over a year ago, on April 21, 2011, an arson attack on a Zanmi Lasante (ZL) staff residence in Belladère killed two beloved members of the PIH/ZL family -- head laboratory technician Phyzeme Isly and Olivier, the three-year-old son of senior midwife Claudine Jean Gilles, who also suffered serious injuries herself, along with her 10-month-old daughter. The attack on ZL and government facilities came in the immediate aftermath of the announcement of final election results for local officials in Belladère. ZL was forced to withdraw temporarily from Belladère but has since resumed working at the Ministry of Health's Hôpital de la Nativité. On April 20, 2012, ZL and the community gathered together to mourn and remember the victims on the anniversary of the attack, as recounted by Dr. Nixon Eustache of Zanmi Lasante.]

WE REMEMBER ... APRIL 20, 2011 - APRIL 20, 2012

By Nixon Eustache, Zanmi Lasante, Haiti

	Phyzeme Isly
	Hôpital de la Nativité in Belladère.

As a native of Belladère and the medical director for the county, I was very honored to see the community gather at the hospital to observe a moment of silence in memory of our colleague, Phyzeme Isly, and to pray for Claudine and her family. We thought about little Olivier who innocently lost his life in this terrible event.

Patients, staff, and local leaders were in attendance. They offered words of peace and gratitude, and some of them shared very moving memories of their experiences with Phyzeme and Claudine.

Members of the community also expressed words of gratitude to the members of the staff who returned and continued delivering care to the community. They remember how they suffered a year ago, during the time we had to stop our work in the area. 

I want to take this opportunity to thank my coworkers and Zanmi Lasante/Partners In Health’s family for their courage and their support. While we are asking for justice for Phyzeme and Olivier and the many who died in the violence, we will continue our work. We know that we have a mission to deliver quality health care to the poorest of the poor, “whatever it takes.” This is Zanmi Lasante/Partners in Health.

By Anne Stevenson

Just over a year ago, the Family Strengthening Intervention research team at Partners In Health-Rwanda encountered a depressed teenage boy during the course of its research. Since then, the boy’s life has been transformed thanks to follow up by the Family Strengthening Intervention team and the Social Work department at PIH.

	FSI mental health clinicians Christina Mushashi and Charles Ingabire discuss Placide's care.

Placide* was only 13 years old when his mother abandoned the family in 2010, leaving him as the head of the household and sole caretaker for his five younger siblings. In April 2011, team members from the Family Strengthening Intervention (FSI) project—a mental health research initiative conducted by the Harvard School of Public Health/FXB Center in collaboration with Inshuti Mu Buzima (IMB), Partner’s in Health’s sister organization in Rwanda—happened to interview Placide during the course of their research. At the time, the project was using structured diagnostic interviews and local measurement tools to assess mental health problems in the children in the community. When they encountered Placide, the staff was alarmed by the boy’s critical levels of depression, loneliness, and hopelessness.

Despite his dire need for mental health services, Placide refused to visit the hospital’s mental health team for additional follow-up. And when FSI staff and IMB social workers tried to visit him at home, he ran away.  

But FSI and IMB staff persisted. Finally, after many attempts to contact him, Placide agreed to speak with the concerned team. He shared that he had been abandoned by his mother one year earlier. The children were struggling to eat, and none of them was in school.

	IMB Social Worker Virginie Mukakayijuka gives a food packet to a child near Rwinkwavu Hospital.

The IMB social work team and FSI took Placide’s case in hand. They enrolled the family in IMB’s supplemental food program, which supplies regular food packages of sugar, beans, cooking oil, and cereal. And Placide began seeing a mental health clinician at the hospital.

In December 2011, several months after services for Placide’s family were initiated, a social worker, community health worker, and FSI team member drove to Placide’s house to check up on him and to deliver a donated mattress to the family.

When they arrived, Placide’s sister called him in from the field. The young man had changed. Instead of running away, Placide came over and gave each of the visitors a hug. When they asked him how he was doing, Placide laughed and smiled and said that things were better. He shared that IMB had helped enroll three of his younger siblings into a boarding school nearby and that the school would provide for all of the siblings’ needs going forward. IMB had also enrolled his 11 year-old sister in primary school. And they helped Placide and his sister enroll in vocational school.

“I helped follow up on Placide’s care and I saw his life changing day by day," says Christina Mushashi, a mental health clinician and one of the Program Coordinators on the FSI project. "He is smiling much more than before and I can see the impact of our work on the family. All of the children are now in school and the burden on Placide has been reduced.” 

Placide and his family continue to receive food packages from IMB and to check in with the social work department in Rwinkwavu. 

Placide’s story is a powerful example of how research and services work together at IMB. Innovative projects like FSI are pioneering new strategies and tools for assessing unmet needs in the community, and strong services systems at IMB are able to provide comprehensive support to new referrals.

In Placide’s case, channels existed to provide the family with food, education, mental health care, and social support. With all of these systems working well and in coordination with one another, and with the dedicated perseverance of research and services staff, a boy’s life and the lives of his siblings were dramatically transformed for the better.

“By being in this study, the boy’s family was able to benefit from services that PIH can offer," Christina Mushashi adds. "The family members are no longer isolated and they have hope for the future.”

* The boy’s name has been changed to preserve confidentiality.

Anne Stevenson is a Program Manager at the Harvard School of Public Health. She is currently working with PIH’s sister organization Inshuti Mu Buzima (IMB) in Rwanda.

Dr. Max Raymond Jr., PIH - Artibonite Region, Haiti

Phase 1, dose 1 of the project is completed and may be considered a success.

Phase 1, dose 2 will begin on Sunday 13th and run through until May 20-22th. Then we'll double back to vaccinate children.

We will start vaccinating children 9 years old and under starting on May 27th. The timeline for all of this has changed a bit because the national government is running a National Polio Vaccine Campaign in the Artibonite region right now. The vaccines cannot be delivered at the same time, so we've had to adjust our schedule. I am keeping in close contact with government health officials about the timing of all vaccine administration to avoid overlap.

A blog featured in the Huffington Post

We are in the midst of celebrating International Nurses Week, which culminates on May 12 with the birthday of Florence Nightingale. Although our founding mother of modern nursing would be impressed with the health technology of today, I am sure she would be sorely disappointed by the ongoing invisibility of nurses, which she fought so hard to overcome during her lifetime.

Everyone knows someone who is a nurse. In addition to health clinics and hospitals, we work in your children's schools, at your workplace, in all branches of military service and in your places of worship. There are more than 3 million registered nurses in the United States alone. But the vast majority of nurses -- over 32 million of them -- work in other parts of the world.

Read "Why Nurses are the Unsung Heroes of Global Health" in its entirety.

The field of Global Health is a good example of nurse “pack” behavior. Although there is sometimes competition in global health for funding and for collaborations amongst other groups or disciplines, global health nurses seek each other out, feed each other information, provide support, and look for areas to collaborate. Nurses provide the vast majority of health care globally, yet we are disproportionately underrepresented in leadership positions. It is a collective “win” when one of our own moves into a global leadership position, with congratulatory emails flooding in from all around the globe.

Nursing has found its way onto the global stage. It feels like a slow process sometimes, but I believe that we are making progress and the momentum is increasing. But a major obstacle remains: Recognized in-country nurse leaders do not have a voice in the poor countries where global health programs are implimented. This must change.

There has been an unwritten rule in global health nursing: You bring to the table a nurse leader from the country in which you are working—that is the beauty of our “pack”. It is our shared responsibility now to advocate, cajole, insist, and convince those in Global Health leadership positions to recognize and abide by that rule, to include in-country nurses in the decision-making arena.

May 6 starts International Nurses Week, a week of celebration that culminates on May 12, which is the birthday of the founder of modern nursing, Florence Nightingale. This is a time when nurses around the world take the time to pause and recognize each other and our contributions to global health. We provide care for the sick and the well, help bring babies into the world and also ease the suffering of those who are dying. Thirty-five million strong, we are everywhere. The time is now to rally each other, our patients, and our supporters to recognize and value the role that nurses play in providing health care globally. 

What is most challenging about your work?

Marina Bogdanova, Nurse
PIH-Russia

I want to develop a relationship of trust with each patient and really identify the problems at hand. Doing this depends on my ability to communicate. I have to be able to hear people. I have to make contact and help people no matter where they are in their lives.

IHSJ Reader     April 2012     Issue 22         
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WORLD BANK

US Candidate Is Chosen to Lead the World Bank (Annie Lowrey, The New York Times, April 16, 2012)
On Monday, April 16^th, the World Bank selected its next president: Dr. Jim Yong Kim, co-founder of Partners In Health and president of Dartmouth College.  As the president of the World Bank, Dr. Jim Yong Kim will be instrumental in advancing pro-poor strategies for achieving the broad mandate of the World Bank—including reducing global poverty.

GLOBAL HEALTH FUNDING

Global Health Funding and Economic Development (Greg Martin, Alexandrea Grant, Mark D’Agostino, Globalization and Health, April 10, 2012)
Despite consisting of predominantly caring individuals, society as a whole fails to translate individual empathy into the collective action necessary to stop millions from dying of preventable and treatable diseases.  This editorial argues that in order to increase investments in global health commensurate with the need, global health must be acknowledged not only as a moral imperative, but as an engine of economic growth in four ways. First, healthier populations are more economically productive; second, strong public health systems save costs associated with lack of care; third, improved health itself represents an economic end; and fourth, investments in health care have an economic multiplier effect by increasing demand across the economy.

CHOLERA

Vaccination Against Cholera Finally Begins In Haiti (Richard Knox, NPR, April 12, 2012)
Haiti’s National Ethics Committee approved the launch of a cholera vaccination campaign in mid-April. Partners In Health has started vaccinating 50,000 people living in a rural community in the Artibonite River Valley; the other 50,000 vaccines will be delivered by GHESKIO in Port-au-Prince. Since cholera was first detected in Haiti eighteen months ago, the Ministry of Health has documented 530,000 cases and more than 7,000 deaths from this curable disease. This vaccine will serve as one step in a comprehensive approach to ending the cholera epidemic that includes dramatic improvements in water and sanitation infrastructure.

NON-COMMUNICABLE DISEASE

A New Resolution for Global Mental Health (Rebecca Hock, Flora Or, Kavitha Kolappa, Matthew Burkey, Pamela Surkan, William Eaton, The Lancet, April 14, 2012)
The authors of this comment applaud the World Health Organization for adopting a resolution calling for a response to the global burden of mental illness, while encouraging all actors, including the WHO, UN member states, caregivers, and civil society groups to increase investments in mental health. Currently, one fifth of all nations allocate less than 1% of their health budgets to mental health care despite the fact that mental illness is the most common cause of disability globally.

ACCESS TO MEDICINE

Judgment on Generic Medicines – Kenya’s First Victory on the Right to Health (Kenya Legal and Ethical Issues Network on HIV & AIDS, April 23, 2012)
In 2008, the Kenyan government passed the Anti-Counterfeit Act in response to the importation of counterfeit medicines. Unfortunately, the language of the Act confused counterfeiting with patent infringement, so also threatened the importation of generic medicines.  Three people filed suit shortly after this law was passed, arguing that inhibiting the flow of generic medications, including antiretroviral therapy for people living with HIV/AIDS, was a violation of their right to life, human dignity, and health. Last week the Kenyan High Court ruled that sections of the Anti-Counterfeit Act of 2008 will not apply to generics.

WHO Says Give AIDS Drugs Earlier to Check the Spread of HIV (Sarah Boseley, The Guardian, April 19, 2012) 
Guidance on couples HIV testing and counseling, including antiretroviral therapy for treatment and prevention in serodiscordant couples
Groundbreaking research in 2011 showed that antiretroviral treatment not only saves lives, but also reduces the chance of transmitting HIV to an uninfected sexual partner by 96%. The World Health Organization released new guidelines recommending that anyone living with HIV who has an uninfected partner be started on treatment as soon as possible. Continued advocacy is needed to pressure donors to increase support for HIV/AIDS treatment programs in order to implement these recommendations.

MALAWI

How Malawi Fed Its Own People (Jeffrey Sachs, The New York Times, April 19, 2012)
Following the death of President Bingu wa Mutharika of Malawi earlier this month, development economist Jeffrey Sachs reflects on one positive legacy: the agricultural input subsidy program. Mutharika’s government pioneered a national subsidy program to help millions of smallholder farmers buy the seeds and fertilizer necessary to improve agricultural yields. Not only did the program defy free market economic prescriptions, but it has been credited with spurring wider economic growth, poverty reduction, and increased food availability for the nation’s poor—the majority of whom depend on agriculture for their livelihoods. This success story demonstrates why country governments must have the policy space to make deliberate investments where they see potential for sustainable development.

Malawi’s First Female President: A Quiet and Earth Shaking Victory (Joia Mukherjee and Jonas Rigodon, The Huffington Post, April 13, 2012)
Sometimes the lives and experiences of leaders serve as rays of hope. President Joyce Banda is one such leader. Her dedication to advancing women’s rights and the right to health and education has already helped reduce the structural causes of poverty and premature death in some of Malawi’s hardest-to-reach communities. In this op-ed, Joia Mukherjee, Chief Medical Officer, Partners In Health, and Jonas Rigodon, Malawi Country Director, Partners In Health/Abwenzi Pa Za Umoyo, commend President Banda’s commitment to civil society and government engagement on human rights and look forward to continuing to work with the Government of Malawi to strengthen the health sector in the rural district of Neno and improve TB care nationwide.

WOMEN’S HEALTH

Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention (John Meara, Paul Farmer, et al., PLoS One, April 25, 2012)
The major causes of maternal mortality—hemorrhage, sepsis, hypertensive disorders, and obstructed labor—cannot always be predicted, but they can be effectively treated if facilities are accessible, well-equipped, and appropriately staffed.  Yet each year, nearly 275,000 women die from complications during pregnancy and childbirth. This new study from Harvard Medical School calculates the economic benefit of providing Caesarean deliveries in cases of obstructed labor. Across a sample size of 49 developing countries, every $1 invested in this surgical procedure generated an average of $6 in productivity gained from preventing death and disability. These findings confirm that investing in the training, staffing, and infrastructure needed to provide surgical interventions such as Caesarean delivery not only saves lives, but is highly cost-effective.

Family Planning: Making the Fundamental Human Right a Reality (Babatunde Osotimehin, The Huffington Post, April 9, 2012)
Executive Director of the United Nations Population Fund applauds David Cameron and the Bill and Melinda Gates Foundation on their announcement of a summit in July dedicated to raising funds for voluntary family planning. When women are counseled, educated, and provided with contraceptive options, they are more likely to delay childbearing, have fewer children, and reduce their risk for obstetrical complications. However, an estimated 215 million women in developing countries lack access to modern contraceptives, contributing to more than 100,000 maternal deaths every year. The outcomes from this summit in July will hopefully address this unmet need by expanding the availability of family planning services. 

MULTIMEDIA

No Woman, No Cry Trailer (Christy Turlington Burns, Every Mother Counts)
Every 90 seconds a woman dies from preventable causes related to pregnancy and childbirth; 99% of these deaths occur in developing countries. Learn more by watching the trailer to “No Woman, No Cry,” a powerful movie dedicated to sharing the stories of pregnant women in Tanzania, Bangladesh, Guatemala, and the United States.  Every Mother Counts has multiple opportunities for those committed to reducing maternal mortality to raise awareness and funding to eliminate maternal deaths.

Congressional Briefing on Cholera in Haiti (Georgetown University Law School O'Neill Institute for National and Global Health Law and Center for Economic and Policy Research, April 18 2012)
Watch a videotaped recording of the April 18, 2012 briefing on Capitol Hill. Representatives John Conyers and Maxine Waters share their concern about the epidemic and panel members address the health, infrastructure, legal, and aid policy implications of the outbreak and response to it. 

Just before 7 p.m. on Wednesday, April 25, the last concrete block at the main complex of Mirebalais National Teaching Hospital was put into place.

When it opens its doors in Autumn 2012, the 180,000-square foot, 320-bed hospital will offer a level of care never before available at a public facility in Haiti. 

As can be seen in the pictures below, the hospital incorporates a great deal of green technology. The facility will use 400kW of high efficiency photovoltaic roof-mounted solar collectors to supply electrical power.

The massive solar array will be one of, if not the, largest in Haiti, and may even allow the hospital to return extra capacity back to the power grid.

Learn more about Mirebalais National Teaching Hospital.

As usual, nurses are on the frontline of the battle against this killer.

They coax oral rehydration into patients. They start IVs for those already dangerously dehydrated. They give antibiotics to the most seriously ill. They perform the less glamorous, but critical, duty of keeping patients as clean as possible while suffering through horrific vomiting and diarrhea. 

Zanmi Lasante Nurse Miss Tulmé participates in a water hygiene and supply distribution session.

Miss Ketty and Miss Tulmé are two nursing heroes who are on the frontline treating cholera at Zanmi Lasante (PIH’s sister organization in Haiti). Both are very experienced, long-time, community health nurses who have mobilized community health workers, launched community education efforts about water hygiene, and kept the word out in rural communities that cholera is deadly. 

I have learned so much from the committed nurses at Zanmi Lasante. 

They don’t wear white uniforms or scrubs. They don’t have high-tech equipment to do their jobs. They serve where nurses usually serve: on the ground, blending in, taking care of their community. 

Our cholera vaccination campaign is underway, and we are hoping that vaccination efforts—for at least one rural community—will help hold back the tide of cholera cases and deaths this rainy season.

But we know that, no matter what cholera throws at them, the nurses of Zanmi Lasante will continue to provide compassionate, lifesaving care.

You can follow all of the work of Zanmi Lasante’s cholera campaign here.  

Each year, nearly 273,000 women die from complications during pregnancy and childbirth. Ninety-nine percent of these deaths take place in the developing world and nearly all of them are preventable.

A new study published on April 25, 2012, in the medical journal PLoS One, finds that investing in the training and infrastructure needed to provide simple surgery such as Caesarean delivery can not only save lives, but is a highly cost-effective and economically viable tool for improving global health. 

“Of course, those of us whose patients have died for want of this basic surgical intervention have long known of the terrible cost—not just to the women and their families, but to the communities and whole countries which bear the greatest burden of preventable death and illness,” said Paul Farmer, PIH co-founder, and co-author of the study.

The study, “Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention,” was led by John Meara, director of Harvard Medical School’s Program in Global Surgery and Social Change and chief of the Department of Plastic and Oral Surgery at Children's Hospital Boston.

By performing 2.8 million additional Caesarean deliveries for obstructed labor in 49 of the worlds poorest countries, Meara projected that 16,800 mother’s lives would be saved. Many other women would be spared lives with chronic disabilities such as obstetric fistula, an abnormal communication between the vagina and the rectum following difficult labor. 

According to the study, the median cost of each surgery is $141, and the median cost to avert the loss of a healthy year of life is $304. On average, for every $1 invested in providing the surgery, $6 of economic value are earned by preventing deaths and disabilities.

“Although one might arrive at this position solely based on human rights theory, our study suggests that surgery can also be highly cost-effective and a good economic proposition,” said Meara. 

“The conclusion is straightforward: surgery, or more specifically in this case, Caesarean delivery, is not a luxury that should be reserved for the developed world,” said Blake Alkire, co-author and clinical fellow in surgery at Brigham and Women’s Hospital.

Paul Farmer goes on to point out that, although surgical disease remains a ranking killer of the world’s poor, surgery is “the neglected stepchild of global health.”

“As this study makes clear, these are not only ‘stupid deaths,’ as is said in Haiti (which has the highest maternal mortality rate in our hemisphere), not just tragedies, but tragic misallocations of resources, ” continued Farmer.

Other co-authors include Christy Turlington Burns, founder of Every Mother Counts, Ian Metzler, co-author and fourth-year medical student at Harvard Medical School, and Jeffrey Vincent, Clarence F. Korstian Professor of Forest Economics and Management at Duke University.

Read “Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention” in its entirety.

In the first two days after eliminating user fees at the PIH-supported clinic in Mamohau, Lesotho, patient visits more than tripled.

Health is a human right that must be free from discrimination. Yet throughout the Global South, user fees continue to prevent the poor from accessing life-saving health services.

User fees for essential services were widely imposed as part of structural adjustment programs in the 1980s and 1990s. Today they act as an unjust rationing system by excluding the poorest and most marginalized members of society from accessing health care.

Countries such as Sierra Leone have demonstrated that with robust support from international partners, removing user fees for health care can improve health outcomes for the poor. But too few partners are stepping up to the plate. Donor support for user fee abolition and concurrent reforms - including hiring, training, and fairly compensating public health workers, procuring additional medicines and supplies, and increasing financial flows to front line services - is requisite to ensuring effective and equitable health services in low-resource settings.

It is time bilateral and multilateral donors answer this call to action by acknowledging: (1) the negative impacts of user fees on poor people’s access to health care, and (2) their commitment to working with countries to eliminate these fees without requiring specific pre-conditions. 

Download a two-page overview on removing user fees for health care.
Download talking points on removing user fees for health care.

Wednesday, April 25, is World Malaria Day. A number of Partners In Health's projects are located in malaria-endemic regions of the world, and our clinicians frequently treat patients suffering from this disease.

Though preventable and easily treated, malaria killed 655,000 people in 2010. Ninety-one percent of malaria-related deaths occur in Africa, the majority of those affected are children under 5 years of age.

The photo gallery below shows some of these sites and our work to treat and prevent the disease, including the use of bednets — a low-cost and effective way of sheltering families from the mosquitoes that carry the disease. 

For example, each year, Malawi’s people endure millions of cases of malaria and mourn the death of thousands — most of whom are women and young children. To help fight malaria in Neno District, Partners In Health has teamed up with TAMTAM and Project 7 to provide long-lasting insecticide-treated bed nets to pregnant women, new mothers, and their newborn children.

These nets offer important advantages over nets traditionally available in Malawi, as they last up to five years and do not require recipients to treat them again with insecticides. Provided at the district’s prenatal clinics, ART centers and maternity wards, the nets encourage women to seek primary healthcare services and complement our existing work with the Ministry of Health to distribute nets at the community level.

To date, over 400 women and newborns have benefited from the program. 

Listen to Joia Mukherjee, PIH’s medical director, discuss the need to fight malaria in an NPR interview from 2011.
Learn more about malaria from the USAID and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Visit Malaria No More.