In central Haiti, PIH now provides regular clinics to screen women for cervical and breast cancer

This year, thousands more women living in poverty will have access to cervical and breast cancer screenings and treatment because of a recent PIH initiative.

	In Guatemala, a patient is screened for cervical cancer using Visual Inspection with Acetic Acid.

In August 2010, Dr. Paul Farmer announced that PIH would integrate cancer care across several of its sites. In partnership with Boston’s Brigham and Women’s Hospital, the Jeff Gordon Children’s Foundation, the Avon Foundation for Women and the Lance Armstrong Foundation, PIH began testing women and girls for various types of cancer in Guatemala, Haiti, Lesotho, Malawi and Rwanda. In the past 18 months, thousands of women have been screened and hundreds treated.

To ramp up these projects, PIH is training local health care workers to test for cervical and breast cancer and building the infrastructure needed to offer both prevention and treatment in places where they’ve never existed.

A simple swab to detect cervical cancer

Since 2010, PIH clinicians and nurses in Haiti, Lesotho, Malawi, and Rwanda, and at ETESC (the PIH-supported project in Guatemala) have used Visual Inspection with Acetic Acid (VIA) to test women for cervical cancer. The procedure is incredibly simple. Clinicians swab a small amount of acetic acid – common vinegar – across the cervix. Normal cervical tissue remains unaffected by the solution, but damaged tissue found in pre-cancerous or cancerous lesions turns white.

	In Haiti, young girls receive doses of Gardasil.

To treat these pre-cancerous lesions – which could develop into cervical cancer – clinicians learned how to use cryotherapy, which removes the lesions by freezing them with liquid carbon dioxide or nitrous oxide. 

"We have screened thousands of women since last year and even found some with advanced cases of cervical cancer,” said Dr. Jacklin St Fleur, PIH’s director of women's health in Rwanda. “We sent seven women for radiotherapy in Uganda and we've so far put over seventy others on treatment.”

Hundreds of women have also been tested at facilities in Guatemala, Lesotho and Haiti.

In early 2010, PIH completed a pilot project aimed at guarding young women against human papillomavirus (HPV)—the primary cause of cervical cancer – with Gardasil, the HPV vaccine. The project succeeded in vaccinating 2,884 girls between the ages of 10 and 13. More than 75 percent of the girls enrolled in the program received all three required doses of the vaccine -- a completion rate higher than those recorded in the US and other developed countries -- even though the devastating earthquake struck Haiti between their second and third doses.

Addressing breast cancer in Haiti

Since starting a weekly breast cancer clinic in June 2012, PIH staff has diagnosed some strikingly advanced cases of breast cancer – an arresting reminder of the work that remains to be done, from basic education to health care access.

	In Haiti, PIH clinicians learn how to give breast exams at a training.

With generous support from the Avon and Lance Armstrong Foundations, PIH initiated a weekly breast cancer clinic at Clinique Bon Sauveur in Cange in the Central Plateau of Haiti in June 2011. Since then, PIH’s Dr. Damuse has performed about 12 to 15 exams each week. Of the women tested, three to four women are diagnosed with cancer weekly. 

Women who have early forms of cancer are offered care at PIH’s hospital in Cange, Haiti. Women with more advanced forms of the disease are sent to the Dominican Republic for care.

Though the challenge is a big one, this is only the beginning of ZL’s cancer initiative. Beginning in late 2011, Dr. Damuse began assembling a team of nurses and a social worker to help provide psychological support to patients with cancer, organizing surgeries, and coordinating care outside of the clinic.

The broader situation

The toll of death and suffering from cancer in developing countries has increased sharply in recent decades. So has the disparity in the allocation of resources for cancer care and control between rich and poor countries.

More than 4 million of the 7.6 million cancer deaths in the world each year now occur in developing countries – and more than half are preventable. The result is a drastic "5/80 disequilibrium" in which only 5 percent of the global resources allocated for cancer go to the developing countries that bear more than 80 percent of the burden of disease.  

Read more in Paul Farmer’s call-to-action in the medical journal The Lancet.
Watch a video of Francine Tuyishime, a young woman treated for cancer at a PIH hospital in Rwanda.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

ELDA'S STORY:
A woman learns to live with epilepsy, becomes health worker, in Chiapas.

	Elda, left, works with a patient from a neighboring community.

Elda first started suffering from epilepsy when she was 13 years old. Soon, her violent and unpredictable seizures forced her to drop out of school. Handicapped by her condition, she more or less became confined to her home – a marginalizing situation for someone living in one of the small villages scattered across the mountains of Chiapas, Mexico.

Largely isolated by the rugged terrain and often-eroded dirt roads, Elda – like many people in the region – initially turned to “doctors unqualified to handle the disease,” recalled Dr. Hugo Navarro, a physician working with PIH's project in Mexico, Compañeros En Salud. “Sometimes they are just deceived by charlatans who sell them miracle products. Sometimes they are told that they will never be able to heal.”

Elda’s family brought her to many of these local healers throughout the years but nobody was able to help. Despite the fact that epilepsy can be easily treated when people have access to quality health care and basic resources, “living with a non-communicable disease like epilepsy in an environment where people do not know about the physiopathology of the disease can be very impairing’” said Hugo.

Confronting a chronic disease in rural Chiapas

With as much as one-percent of the population suffering from the disease, people in Chiapas living with epilepsy are weighed down by the social stigma. They often lack work and rely on their families to survive. “They are unable to marry because people would not want to be with them,” stated Hugo. “Some people in their villages may even think they are cursed.”

	Elda talks to Dona Chus, a neighbor living with epilepsy.

While people suffering from epilepsy certainly are not cursed, the exact causes of the condition are not totally understood. What is known is that epilepsy results from the generation of abnormal or excessive electrical signals inside the brain, which causes recurring seizures. And symptoms vary wildly: some people simply stare blankly for a few seconds, while others have full-fledged convulsions.

While death or permanent brain damage from seizures is rare, those lasting for a long time or two or more seizures that occur close together may cause permanent harm. The greatest risk stems from the suddenness of the episode, causing people to fall onto hard surfaces or into water and cooking fires.

“Outcomes are especially bad in remote areas because appropriate care and treatment is not available for most people,” according to Hugo.

After finding help, Elda becomes a health advocate

“A few years ago Elda finally heard about the health promoter network in the area, and came in for a visit,” said Hugo. “She started taking carbamazepine, which helped her stop having seizures. After that, she started coming to training workshops run by CES and its longtime partner EAPSEC. As soon as the second workshop a few weeks later, Elda was able to walk to the meeting from her village, something she had not done in years.”

	Elda, once housebound because of her epilepsy, is a community health worker with PIH/EAPSEC.

In March 2012, the team celebrated Elda’s 29th birthday, and the fact that she has lived seizure-free for four years. That’s not all. “She is a health promoter in her village and helps other people who have this same disease in her community,” said Hugo.

Elda spends her days bringing medicine to people once like her, while also working to educate people in the region about the disease.

According to physicians at the Mayo Clinic, most people living with epilepsy can become seizure-free by using a single anti-epileptic drug, such as carbamazepine. More than half of people on these drugs can discontinue using them after two years without risk of future seizures.

“Many epilepsy patients have told me that they thought about committing suicide,” reflected Hugo. “This is why we have must reach out as many patients with epilepsy as possible and help them make a significant change in their lives and fate.”

Elda, Hugo, and the rest of the Compañeros En Salud and EAPSEC teams are bringing hope and relief to people living with epilepsy in Chiapas one person at a time.

Read more about Compañeros En Salud.

The new GeneXpert machine just installed in Tomsk, Russia cuts the time needed to test people for tuberculosis (TB) from weeks to just two hours. In a region with an especially high rate of TB, the system enables medical providers to identify and treat TB and multidrug-resistant TB (MDR-TB) early and fast. This in turn improves patients' quality of life and curbs the spread of disease.

A patient's sputum sample is placed in the GeneXpert machine.
Credit: Alex Golubkov, PIH

Each patient's sample is electronically tracked throughout the procedure.
Credit: Alex Golubkov, PIH

The launching of the new rapid TB detection system was a joint effort of Russia’s Tomsk regional tuberculosis services and Partners In Health.

"Without a GeneXpert, it takes 1 day to read the smear sputum and up to 3 months to do a conventional drug susceptibility test on a solid culture", says Alex Golubkov, PIH Medical Director for Russia and Kazakhstan. "With the  GeneXpert it should take two hours to determine if the sample is positive for MBT (micro bacteria tuberculosis) and identify Rifampicin resistance [the key indicator in diagnosing multidrug-resistant TB]."

While the speed of these new tests will still be dependent on the patient’s distance from the laboratory and any potential backups once there, it is a significant improvement -- one that will reshape the face of TB care in the Siberian region.

In addition, the GeneXpert is better able to detect TB in sputum samples from people living with HIV/AIDS. Microscope tests on samples from patient's suffering from complex medical conditions are often difficult to read. The new machine reads samples at the molecular level, sidestepping the limitations of the human eye.

The two machines in Tomsk, Russia are now up and running – one in the civilian TB service and another one in the penitentiary institution for TB treatment. Roughly 1,300 new TB patients will be diagnosed in this Siberian region in 2012. 300 of those people will be prisoners.

GeneXpert was created by Cepheid and endorsed by the World Health Organization in early 2011.

Learn more about PIH’s work in Russia.

At just 15-years old, PIH Right to Health Care patient Samantha Cadet underwent open-heart surgery at Upstate Golisano Children’s Hospital in Syracuse, New York. Partners In Health flew Samantha from Haiti in late January and accompanied her through the lifesaving process.

Samantha’s story and the work of PIH and medical staff at Golisano Children's Hospital captured the attention of local TV news stations in Syracuse.

“She was a sickly child. She was a young girl and her mother took her to a Haitian doctor who said she had a life-threatening condition and said there’s nothing you can do about it in Haiti,” Owen Robinson of Partners in Health told WSYR-TV.

After four hours of extensive surgery and seven days of recovery, Samantha is on her way to visit friends at the Partners In Health Boston office, before heading home to Haiti.

Click below to watch the full news stories of Samantha Cadet:

"Teen gets lifesaving surgery in Syracuse"
"Haitian teen receives life-saving surgery at Golisano Children's Hospital"
"Haitian teen returns home with a new heart and a new love for Central New York"

Stay involved: Sign up now for updates

IHSJ Reader     February 2012     Issue 18         

Note: Triple asterisk (***) indicates subscription-only sources.

FOREIGN AID REFORM

USAID Now Free To Buy Goods From Companies In Poor Countries (Claire Provost, The Guardian, February 6, 2012)
In January, the US Agency for International Development (USAID) revised its procurement regulations to allow for more local and regional purchase of goods and services in developing countries. The simplified and streamlined policy sets a target of procuring 30% of goods and services through local governments, businesses, and NGOs. Though new procurement rules do not extend to US food aid, they represent an important step towards making aid more sustainable, cost-effective, and relevant to local country-driven development priorities.

The FY2013 Budget Request: Presidential Priorities for Development Face Uncertain Outcome (Connie Veillette, Center for Global Development, February 14, 2012)
The President’s budget for fiscal year 2013 was released amidst a political process dominated by budget austerity.  Though the overall funding request for the international affairs account reflects last year’s appropriations, bilateral global health programs may experience cuts if Congressional budgets do not restore funding. Multilateral health aid fared better, including a request to fully fund the US contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Partners In Health is committed to preventing cuts to poverty-focused foreign assistance programs in the months and years to come.

We Quantified the Quality of Health Aid! (So What?) (Amanda Glassman, Center for Global Development, February 8, 2012)
In this Center for Global Development study, researchers use quantitative analysis to rank 30 donors across four dimensions of health aid effectiveness. Though results vary by donor, the United States ranks high on “transparency and learning”, average on “maximizing efficiency”, and below average on “reducing burden” and “fostering local institutions”. The US can improve the effectiveness of its health aid by channeling more resources through multilateral agencies and allocating more health assistance to well-governed countries with national health plans.

NON-COMMUNICABLE DISEASES

Closing the Global Cancer Divide: Together It Is Possible (Jonathan Quick, Felicia Knaul, The Huffington Post, February 4, 2012)
On World Cancer Day, Dr. Jonathan Quick and Dr. Felicia Knaul review the progress that has been made in cancer treatment in high income countries while highlighting four myths that have delayed cancer care and control in developing countries.  Cancer causes more death in low- and middle-income countries than AIDS, tuberculosis, and malaria combined, yet only 5% of global spending on cancer is spent in the developing world. This burden cannot be alleviated without addressing the need to invest in stronger national health systems in developing countries.  

Community Workers Help to Bridge Treatment Gap in Mental Health (Rosalind Miller, Poverty Matters, February 16, 2012)
In India, there are only 4,000 psychiatrists serving a population of 1.3 billion people. This article provides a short introduction to the Manas intervention, a randomized controlled trial conducted to assess the impact of training community mental health workers in India. Results suggest that the large gap in access to mental health professionals can be addressed by integrating mental health care into primary care services. Training lay health workers to provide mental health care in primary care clinics helps ensure patients receive the health services they need and the dignity they deserve.        

FOOD SECURITY

A Life Free From Hunger (Save the Children, February 2012)
A new report by Save the Children calls on world leaders to put chronic malnutrition back on the global agenda in 2012. Malnutrition is an underlying cause of 2.6 million child deaths every year and is considered the single gravest threat to global public health. Social protection systems including cash transfers and food packages have the potential to save millions of lives. The US G8 and the Mexican G20 meetings in 2012 offer critical opportunities for galvanizing the political will and financial resources necessary to reverse global hunger.

HAITI

Yon Je Louvri: Reducing Vulnerability to Sexual Violence in Haiti’s IDP Camps (NYU Law School Center for Human Rights and Global Justice, February 2012)
The Center for Human Rights and Global Justice and the Global Justice Clinic at New York University School of Law released this report examining the prevalence of sexual violence in internally displaced persons (IDP) settlements in Haiti. Two years after the devastating earthquake struck Haiti, more than half a million people in Port-au-Prince remain living in IDP settlements where living conditions are grim, with limited access to food, water, and sanitation, and continued reports of rape and sexual violence. This report offers five key recommendations for improving the lives and reducing the vulnerability of young women in Haiti’s IDP camps.

RWANDA

Poverty Down By 12% - Survey (The New Times, February 7, 2012)
Impressive results from the third Integrated Household Living Conditions Survey released earlier this month show that poverty in Rwanda has dropped 11.8% since 2006, with 45% of the country’s 10.7 million people now living under the poverty line. The survey, conducted by the Ministry of Finance and Economic Planning and the National Institute of Statistics Rwanda, was released in conjunction with the fourth Demographic and Health Survey which indicated that both infant and maternal mortality rates have declined by 41% and 35% respectively.

MULTIMEDIA/ADDITIONAL RESOURCES

Fixing the Delivery of Humanitarian Aid: Ed Cairns Explains Oxfam’s Report “Crisis In a New World Order” (Oxfam, February 8, 2012)
A Senior Policy Advisor to Oxfam calls for humanitarian aid to shift from its “Western-dominated past” in order to meet the challenges of the 21^st century. Oxfam’s new report calls for donors and NGOs to work more closely with local civil society, governments, and others on the ground to deliver more effective aid.

	PIH co-founder Paul Farmer

In a matter of weeks, Haiti's cholera epidemic, which has already killed some 7,000 people and sickened more than half a million, will surge -- causing thousands of new cases and claiming many lives.

That's not a guess. It's a predictable outcome: April marks the beginning of Haiti's rainy season. Daily downpours create conditions in which cholera can tear through destitute communities without access to clean water.

Flooding, no stranger to Haiti, makes the situation worse.

Help us get the word out. Share this information with your family and friends now.

When the rains came last year, the number of cholera cases nearly tripled from 18,908 in April to 50,405 in June. This year could be worse, but it doesn't need to be.

When cholera broke out in Haiti in October 2010, we called for a comprehensive response using all the tools for treatment and prevention available: Aggressive case-finding and treatment (usually simple rehydration will suffice to save lives; antibiotics are needed in severe cases), major investments in water and sanitation systems, education about how to prevent and treat cholera, and oral vaccination.

In the United States, we drink from the tap without worrying about contracting cholera or the many other waterborne diseases that stalk the poor. Haitians deserve the same standard: Clean water and modern sanitation. But building water and sewage treatment systems takes time, and Haiti's cholera epidemic is already the world's largest in recent history. We can't afford to wait. And we need to roll out a safe, effective oral cholera vaccine that would help buy the time necessary to build (or rebuild) much-needed municipal water systems.

Help us tell the world that cholera is coming back in force and that we can fight it.

In a few days, we will launch a program to vaccinate an entire flood-prone rural commune. Our goal is threefold: To protect some of Haiti's most vulnerable people, to prove that vaccination can be effectively integrated into the ongoing response to cholera in Haiti, and to help the Haitian Ministry of Health develop and strengthen an immunization program capable of protecting all Haitians against cholera and other vaccine-preventable diseases for years to come.

We need to get the word out, and you can help. Share the news and encourage your friends and family to help us slow -- and someday stop -- the spread of cholera in Haiti. 

Thank you,

Paul Farmer
PIH co-founder

Learn more about PIH's efforts to fight cholera.

On February 17, NBC's Connecticut affiliate interviewed Smysshell Delva, PIH's Right to Health Care program's newest patient. We're happy to report that Mr. Delva is doing well, and recovering with a host family in Cambridge, MA. 

Eighteen-year-old Smysshell Delva is taking his first steps across a personal finish line.  The young man from Haiti has just undergone hip replacement surgery at Saint Francis Hospital.  It’s one of the first times he’s walking without pain in more than two years, after the deadly 2010 earthquake that devastated his country.

"One of the walls of the school is collapsing down, hits him on the back and throws him,” described his father Louicito Delva. 

According to his father, Smysshell was practicing with his basketball team after school when the quake struck.  Out of his teammates with him on the court that day, Smysshell was the only one who made it—albeit badly injured in his right leg.

Read "Haitian Man Gets New Start in CT".
Learn more about PIH's Right to Health Care program.

An expert panel to discuss managing second line drugs for multidrug-resistant tuberculosis, February 20-24.

By Sophie Beauvais, GHDonline

In the fight against multidrug-resistant tuberculosis (MDR-TB), second line drugs are among the last options for treating MDR-TB patients. Therefore, program administrators and health workers operating with limited resources in high-burden areas have to get it right when it comes to managing second line drugs (SLD). 

However, they are faced with many challenges such as difficulties in procurement and supply management of SLD; price regulations; and the selection of approved manufacturers. They also struggle with limited funding and political will, despite the global threat caused by increased drug resistance.

	Dr. Masoud Dara will moderate an online panel discussion on MDR-TB drugs.

“For some of us who have been working in Eastern Europe, TB cases with strains resistant to all drugs tested are unfortunately not a new phenomenon,” notes Dr. Masoud Dara, Team Leader of the Tuberculosis Programme in the Division of Communicable Diseases, Health Security & Environment at the World Health Organization Europe. According to a Medecins Sans Frontieres recently press release, barely 10 percent of the global annual estimate of 440,000 new MDR-TB patients receive treatment.

Dr. Dara will moderate an expert panel discussion on GHDonline.org  from February 20 - 24 to discuss MDR-TB treatment and prevention, focusing on managing second line drugs. He will be joined by Ernestor Jaramilo, Paul Nunn, and Malgosia Grzemska from the WHO; by Dr. Kaspars Lunte, Team Leader MDR-TB supply at the WHO Global Drug Facility, and by Andrei Zagorski, Senior Technical Manager for TB at Management Sciences for Health to answer questions and share experiences with health care professionals. 

Join the MDR-TB Treatment & Prevention community today (it’s free) to participate in this online discussion! Please consider joining the conversation by answering these questions on GHDonline:

• What issues do you face with the supply of SLD? Are there big time lags between order and delivery for example?
• Have you been affected by price increases of SLD and what is the impact on your work?
• How are you funding drug procurement for MDR-TB?
• What does the cancellation of Round 11 mean to you, your program, and for the population you care for?
• Are you applying to the TFM and if so how do you prioritize funding request?

Jon Lascher, PIH – Artibonite Region, Haiti

Once the vaccine arrives it needs to be kept cold.

The cold container where the vaccine will be stored is running, but Max and staff are having trouble regulating the temperature. I don’t quite understand all of the issues, but Max set the temp to 5 degrees and the thermometer that we installed is reading 1.7 degrees – Max reset the temp and visited a couple of hours later and the temp is now set at 2 degrees.

We're experimenting with the temperature control panel in the back of the container. The thermostat inside the container is difficult to regulate. I will look into this more tomorrow.

The vaccine will arrive in Haiti any day now.

“I was coming back from a trip with an arts organization in Jacmel, Haiti, when I first met Paul Farmer in the Miami airport,” says Laurel True, artist and owner of True Mosaic Studio. “A friend introduced us, and I showed him pictures of the project I was working on in Haiti. He suggested that I do something in Mirebalais. This is how the seeds were planted.”

Since that initial meeting, Laurel has dedicated much of her time to creating beautiful and lasting pieces of artwork at the Mirebalais National Teaching Hospital. Laurel and her team recently finished the installation of the welcome mural and the Partners In Health logo.

We sat down with Laurel as she explained her project and discussed her time at the hospital.

What was your inspiration for the mural’s design?
LT: I had several conversations with PIH staff about the content ideas. We wanted something that was colorful and had an overall good vibe. It had to be a design that everyone could relate to and access conceptually. The natural scene is a great way to hit all of this. I came up with a couple of versions and sent them around. The final design was the one we went with.

We’ve heard all the tile was donated. Can you tell us a little about that?
LT: Yes, most of the tile and supplies needed for the project was donated. About 80% of the tile came from Heath Ceramics. My company, True Mosaic Studio, donated the super bright colored tiles.

What was the process for installing the mural? How long did it take from the beginning plans to the end product?
LT: Well, it all began about a year ago with the initial fundraising and conceptual designs. Design development was all done in the US over a time period of about a few months. I then spent six weeks in Haiti completing the project. When I first arrived I gathered all the drawings together and taped them to wall. I then unpacked all the tile, spent a few days coding it and then put together a team. After the New Year we began setting the mosaic sections that we had set onto fiberglass mesh. It was intense work, but it went fast.

You worked with a team of Haitians to complete the mural. Were any already good tile workers? Did you have to do much training?
LT: Pretty intensive training had to be done. There were two Haitians that worked with me throughout the entire project and neither had any training. Some of my trainees from Jacmel came up, so I could train a larger class at once. We then added a mason and a tile setter to the team. For the most part it was ground up training. I really loved everyone that was on my team, as one member said to me, “I got to build beauty.”

Did you run into any problems while working in Haiti?
LT: I can’t believe that I’m going to say no, but I really had no problems. There were some small problems while doing the logo with the grout, but no major problems at all.

What is your favorite memory from working at the Mirebalais Hospital site?
LT: Honestly, the sense of camaraderie from everyone who helped of the project. The best moments for me were seeing people who worked on the project being so happy and proud of their work. One night we stayed up past dark to work on the logo, and we had to really work as a team to get it done.

What do you hope patients will take away from the mural?
LT: I really love that when you walk up to the entrance of the hospital you see this flash of color. I hope it gives everyone a positive, uplifting feeling. Having art in a healing space is a really important thing to help fortify people, and I hope that it continues to do that into the future.

PIH knows this beautiful mural will have a lasting effect on each patient that passes through the door of Mirebalais Hospital. We are very grateful to Laurel for her hard work and dedication. Laurel is now back at Mirebalais working on more projects in the Community Health outdoor waiting area.

Laurel True and PIH would like to thank everyone that generously donated to the mural project. Through the Facebook page, numerous donations ranging from $10 to $1,000. 

To learn more about this and Laurel’s other project please visit the Mosaic Artwork Fund for Mirebalais Hospital Facebook page and Laurel’s website, www.truemosaics.com.

A training specialist travels from Rwanda to Haiti to foster a cross-site collaboration.

A training session in Haiti, organized by Zanmi Lasante.

by Celia Reddick with Vernet Etienne

It is 6:00am, and I am in search of Vernet Etienne, the Training Coordinator at Zanmi Lasante, PIH’s sister organization in Haiti.

I work for the Department of Medical Education and Training of Inshuti Mu Buzima (IMB), PIH’s sister organization in Rwanda. I’m in Haiti to shadow, collaborate with, and learn from our colleagues in the Training Department here at Zanmi Lasante (ZL).  I’m eager to chat with Vernet about his work, but I have to be quick -- he’s leaving in an hour to facilitate one of many cholera trainings the ZL training team has designed and implemented this past year in response to the cholera outbreak.

	Zanmi Lasante Training Coordinator Vernet Etienne at a recent training.
	Bad roads are one of the many challenges faced by the training team in Haiti.

When I find him, he’s eating breakfast, his suitcase packed for the journey and propped next to the door, but he welcomes me to join him.

I ask him to tell me about his work, and he smiles. “Well,” he says, taking a deep breath, “there are so many projects.” He describes his responsibilities: planning, implementing, and reporting on training initiatives to support ZL’s community health worker program. “It’s the planning that is the hardest,” he explains. “There are so many factors which can get in the way of training. I do my best to make sure everything is set and scheduled, but sometimes, there are things I can’t control.” He lists some of the challenges of working in a rural environment with an unstable infrastructure: rutted dirt roads, unreliable vehicles, sporadic training supplies. I note that the hurdles in Haiti sound similar to the ones the training team faces in Rwanda.

Vernet is animated as he discusses his work. With formal training as a secondary school language teacher before coming to ZL, his presentations skills are excellent. He is now working toward a BA in anthropology and sociology, and hopes to bring this interest to ZL’s fieldwork. In many ways, he already does so. “When you are working with the community, you have to understand the cultural reality of a place,” he explains. “We are working in rural communities where this cultural reality has a big impact on our work.” 

One aspect of this cultural reality has to do with perceptions of training. Vernet and his department support Ministry of Health training initiatives, but often, they come second to participants’ expectations, or to various other ministry or clinical priorities. In Haiti and Rwanda, to implement effective trainings the team must develop thoughtful activities using participatory methods; mentor trainers to use supportive and engaging training styles; and design and print clinically accurate and engaging materials. For most participants, however, training has always been a didactic experience and participants frequently arrive late or choose not to attend because of past experiences with ineffective teaching styles. Vernet compensates with some healthy hounding; as he explains: “Sometimes I send a text, then I call with a reminder, then I call on the day, and then I am there to welcome the trainers to the training site,” he says. “With this strategy I make sure the trainings happen.”

Vernet’s role requires that he maneuver through many political and social levels—many cultural realities—to make sure that ZL implements training to support the Ministry of Health. He communicates with high-level officials from the Haitian Ministry of Health and international funding organizations, local and expatriate staff from ZL and partner non-governmental organizations (NGOs), and community health workers from rural villages. Across all these contexts, he must make a case for participatory learning. His ability to articulate the importance of ongoing education for low-literate adults, and to form bridges between these many worlds have led to his success. 

My colleagues at IMB in Rwanda and I have a lot to learn from Vernet and his team. IMB’s Department of Medical Education and Training is growing to accommodate ever-more ambitious goals from the Rwandan Ministry of Health. As we hire new Training Coordinators in Rwanda, we will benefit from Vernet’s work and experience, and the training implementation systems the Haitian team has developed.

Vernet’s car is waiting for him outside, and he quickly swallows the rest of his breakfast of spaghetti, eggs, and bananas. As he heads outside, we commit to ongoing collaboration between our teams in Haiti and Rwanda. I look forward to sharing our experiences across sites so that the educational initiatives we undertake reflect the nuances of our particular communities, as well as the larger goal of improving health outcomes through capacity building.

Celia Reddick serves as the Curriculum and Training Specialist for Partners In Health in Rwanda. Vernet Etienne serves as the Training Coordinator at Zanmi Lasante, Haiti.

On January 25, Global Post reporter John Donnelly highlighted the work on PIH's sister project Socios En Salud in "A determined TB nurse, and the impact on a young mother". In it, he follows a nurse as she finds and treats a woman living with multidrug-resistant tuberculosis in the shantytowns of northern Lima.

The young mother wanted to die.

Melissa Vargas, 23, a mother of two, came down with multi-drug resistant TB last year. Soon after beginning treatment, she lost her will to live. But thanks to continuing treatment and the actions of a nurse, Ruth Espinoza, she has regained her health and now is thinking of going back to school. (Riccardo Venturi/Courtesy).

She had multi-drug resistant tuberculosis, or MDR-TB. The TB drugs made her sick and depressed in a way she had never experienced. She couldn’t sleep. She had no energy. 

And she was just a few months into two years of taking this awful medication every day.

Ruth Espinoza, a nurse, had other thoughts. She weighed the situation carefully. She believed that the deep depression felt by the mother, Melissa Vargas, 23, was partially a byproduct of the TB medicine. She made an appointment for Vargas to see a psychiatrist.

The next morning, the nurse appeared at the young mother’s house. She said she was there to take her to a psychiatrist. The mother refused. The nurse demanded it. The mother went.

Today, the mother wants to live.

Read "A determined TB nurse, and the impact on a young mother" in its entirety.

Sir Richard’s Condom Company announced its donation of 500,000 condoms to Haiti. The donation will be made available for free at Partners In Health’s clinics throughout Haiti, including the Mirebalais National Teaching Hospital.

Scheduled to arrive in late spring, the condom donation marks Sir Richard’s first step in helping address the global shortage of condoms in developing countries by donating one condom for every one purchased in the U.S.

In addition to helping bridge the need gap for condoms, Sir Richard’s aims to deliver a product and brand that is culturally relevant to Haitians, thus promoting usage. The organization worked with Marc Baptiste, the company’s creative director to Haiti, a Port-au-Prince native, and acclaimed artists, to create the brand KORE, (pronounced kȯr-ā) which is a slang term that translates as “I have your back.” The packaging also incorporates Haitian Kréyòl messaging and visual instructions.

“At the heart of Sir Richard’s is our belief that the power of business can not only deliver a quality product, but can also help serve the global community,” said Jim Moscou, CEO of Sir Richard’s. “Delivering KORE is the first step in seeing that vision come to fruition.”

The KORE condoms will be distributed through PIH and its Haitian sister organization Zanmi Lasante.

“Within the last year, PIH has treated more than 6,300 HIV-positive patients in Haiti. Reinforcing the importance of condom use and ensuring that condoms are available and accessible is key in our battle against the spread of HIV/AIDS. PIH is deeply grateful for Sir Richard’s partnership in this mission,” said PIH’s Christopher Hamon.

Inspired by Partners In Health’s work and taking into account various economic and social factors, Sir Richard’s identified Haiti as its first donation site. 

About Sir Richard’s Condom Company

Sir Richard’s Condom Company launched in 2010 with the goal of helping address the global condom shortage by donating a condom to a developing country for every one purchased.  Exceeding FDA requirements, Sir Richard’s condoms are of the highest quality and made with 100% natural latex, without casein (making them vegan-friendly), and with lubricant free of spermicide, glycerin and parabens. Sir Richard’s condoms can be purchased nationwide at Whole Foods Market, natural markets, and pharmacies, as well as online at Drugstore.com, and SirRichards.com

Djencia Eresa Augustin, PIH – Artibonite Region, Haiti
February 12, 2012

From everything I’ve seen, there is no one who was eligible for the vaccine who didn’t want it. It’s really great. I did see one case where a 26 year old woman was pregnant and therefore she was ineligible, I felt sad, but I told her that it wasn’t good for pregnant women. All other folks seemed very eager to receive their cards.

Jessica Teng, PIH – Artibonite Region, Haiti

February 11, 2012

Long day. Good though, I think.

Amanda and I trekked with Miss Poulen for 40 minutes into a remote village, which turned out to be an incorrect location. It was a glorious little hike and we enjoyed it immensely (aside from sunburn). Then we went to the correct locality, where Djencia was one of the two surveyors in that team and she was kicking serious butt. Her spiel on the vaccine was 100% spot on: vaccine isn’t going to save us, it’s going to help us. Just like washing our hands, eating hot food, and covering your toilet after you fè bezwen ou. She demonstrated how to use hand sanitizer. Then she explained that when you shake someone’s hand, it means your hands aren’t clean anymore so you shouldn’t eat without washing your hands again. I was incredibly impressed. Then we watched her work through a household and it was smooth as silk.

6:30 a.m. start tomorrow. Our supply distribution is streamlining and soon it will take less than an hour to do both morning and night.

IHSJ Reader     February 2012     Issue 17         

Note: Triple asterisk (***) indicates subscription-only sources.

FOREIGN AID REFORM

Why the Global Fund Matters (Paul Farmer, New York Times, February 1, 2012)
In this powerful op-ed, Dr. Paul Farmer highlights the importance of sustaining support for the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Dr. Farmer outlines four reasons for ensuring the existence of the Global Fund, including its vital role in: reducing the intolerable burden of preventable and treatable diseases and expanding access to health care, strengthening and building local health systems, and promoting multilateralism. Farmer concludes by arguing that the economic recession cannot be used as an excuse to cut off support to millions of people around the world who depend on the Global Fund for survival.

10 Years On, Funding Crisis Threatens the Global Fund’s Effort to End AIDS (Joanne Carter, Huffington Post, January 30, 2012)
The Global Fund’s achievements in providing prevention, treatment, and care for diseases of poverty have been extraordinary. However, the entities that finance the Fund have not kept their promises and a few months ago, the Global Fund announced that it would be suspending new grants due to lack of funds. Former Global Fund Board Member and Executive Director of RESULTS, Joanne Carter, argues that such funding shortfalls are unconscionable. The U.S. should convene an emergency donor conference in advance of the International AIDS Conference in July 2012 to garner the funding needed to continue the critical work of the Global Fund into the next decade.

RIGHT TO HEALTH

The Rockefeller Foundation's Heather Grady On Politics, Policy-making, And The Implementation Of Health Financing And Delivery Mechanisms (Heather Grady, UHC Forward, February 1, 2012)
In this Rockefeller Foundation blog post, Heather Grady discusses what it takes to drive progress towards universal health coverage. A number of lessons have recently emerged from Thailand, Ghana, Rwanda, India, and other countries committed to improving health outcomes for the poor. First, health financing should be considered a key contributor—not cost—to development and economic growth. Second, from a rights-based approach, expanding access to essential health services can enable historically marginalized people to experience and claim their basic right to health. Finally, it takes pressure from domestic interests, civil society organizations, and international donors to catalyze the political will necessary to fundamentally shift health systems towards universal health coverage.

FOOD SECURITY

Resolving the Food Crisis: Assessing Global Policy Reforms Since 2007 (Timothy Wise and Sophia Murphy, Global Development and Environmental Institute and Institute for Agriculture and Trade Policy, January 2012)
The global food crisis of 2007-2008 helped shift donor attention back to agriculture, nutrition, and rural development. But beyond modest increases in development assistance, this report finds that governments of rich countries have been unwilling to tackle the structural causes of rising food prices—including biofuels expansion, price volatility, and land grabs. Wealthy countries should not only give more, but they must take less if we are to prevent the next food crisis from erupting.  “Giving more” includes more policy space for developing country governments to advance local solutions such as national and regional food reserves.  “Taking less” includes regulating corporate profiteering in the financial, trade and foreign investment arenas.  With one billion people vulnerable to food insecurity, humanitarian assistance alone cannot sustainably reverse widespread suffering and death from hunger and malnutrition.

NON-COMMUNICABLE DISEASES

***Momentum to Tackle Non-Communicable Diseases Must Be Maintained (Matthew Limb, British Medical Journal, January 25, 2012)
At the Cambridge Post-UN Summit Conference on Non-Communicable Diseases and Mental Health in Developing Countries last month, experts on NCDs presented a challenge and a call to action for the international community: keep up momentum around treating diseases that cause 63% of deaths worldwide. Conference participants agreed that the 2011 UN Declaration on NCDs is far too weak and public and political action is needed to halt the growing NCD epidemic.

MULTIMEDIA/ADDITIONAL RESOURCES 

Tectonic Shifts: What Haiti’s Massive Earthquake Exposed About the Country’s Past – And Tells Us About the Present (Mark Schuller and Pablo Morales, Kumarian Press, January 2012) 
This new book draws upon the diverse perspectives of 59 scholars, journalists, activists, and allies to illuminate the “structural vulnerability” facing Haiti before and after the earthquake.  The firsthand accounts explore institutional failures and their impact on the Haitian people, as well as the myriad ways in which communities are organizing to influence the social, political, and economic terrain. Partners In Health physicians Louise Ivers and David Walton are both contributing authors.

Helping The Disabled in Post-Earthquake Haiti (Whit Johnson, CBS News, February 5, 2012)
After the devastating earthquake two years ago, few programs offering prosthetic support were available to those with disabilities. Now, with the help of Shelove Julmiste and a team of physical therapists, technicians, and community health workers, Partners In Health and Zanmi Lasante are running an organized rehabilitation program. Shelove had both legs amputated after the earthquake and now accompanies other Haitians with disabilities on how to live with prosthetics.

Haiti: Where Did the Money Go? [Episode 1] [Episode 2] [Episode 3] [Episode 4] [Episode 5]
This U.S. public television series examines the impact of NGO relief efforts after the devastating January 2010 earthquake in Haiti.  The documentary awakens viewers to the inhumane living conditions that more than half a million displaced Haitians continue to endure across hundreds of camps. Unless donor assistance is used to strengthen local institutions and increase access to public services such as sanitation, water, housing, health, and education, what should be life-saving assistance will continue to bypass those most in need.

Jessica Teng, PIH – Artibonite Region, Haiti

February 8, 2012

Hi ekip,

Training day 1 went really well today! We were split into two groups so I wasn’t present at both, obviously, but I thought ours was great and heard the other one was as well. I presented with Miss Ketty, Joe and Almazor, and Amanda, Max, and Miss Tulmy (and Ralph but he had to duck out for a conf call) were at the other one. 

At each training session, there were 25 enumerators and 5 supervisors—many of whom were our previous ANLaP enumerators (which made me swell with pride and joy). The morning was spent going over training/project values (respect, etc), census in general (background, purpose), how to number houses (Sekte, Kay, Menaj, strung together to make unique numbers).

After lunch, we had a couple hours to introduce the hardware, the software, and go through both the household and individual forms, question by question. Some folks did look confused, but by the end, during pair practice, everyone seemed really into it, helping each other out, giving each other tips, role playing, etc. I think I got some good photos from our session, tried to attach one but Outlook keeps on freezing.

Training Day 2 planned for tomorrow—communication styles in the morning, how to talk to participants, and then review of technology + field practice in the afternoon. Still scheduled to go live with registration later this week.

I think the generator problem is fixed (knock on wood). Seems to be electricity tonight, but no wifi yet for the tablets. One step at a time!

Dr. Daniel Mantuani trains nurses at Mamohau Hospital.

Ultrasound imaging has long served as an invaluable diagnostic tool for clinicians in the United States and other wealthy countries, not to mention a routine way for expectant parents to get a first glimpse of their babies. Now, following a two-week training offensive in late January, ultrasound is being used for the first time to save lives and assist nurses and doctors at health centers high in the mountains of Lesotho.

“Today we found a set of twins in one woman who didn't know she was pregnant, and another with a placenta previa (potentially life threatening if it bleeds later in pregnancy)," Dr. Sachita Shah reported in an email from one of the remote mountain clinics. Shah is a specialist in emergency medicine and ultrasound at the University of Washington and the lead author of the PIH Manual of Ultrasound for Resource-Limited Settings. She conducted the training in Lesotho along with her colleague Dr. Daniel Mantuani, a fellow in emergency ultrasound at Alameda County Hospital in Oakland, CA.

During their two weeks in Lesotho, Shah and Mantuani hopscotched by single-engine plane from one isolated mountain clinic to another, training nurses at six of the seven rural health centers operated by PIH. At each clinic, they made sure that the portable ultrasound machine provided at a steeply discounted price by Sonosite was working properly and that there was at least one person trained to use it. In several cases, as Shah reported, the nurses put their training to use immediately to provide lifesaving care.

PIH-Lesotho nurses Mabathoana Phaila (rear) and Mohloki Chere (foreground) put their ultrasound training to use.

“Just wanted to let you know that we had a great ultrasound save case today at Bobete health center in the mountains," Shah wrote in another email. "A 32-year-old woman presented to our clinic, supposed to be in her first trimester sometime, with bleeding and lower abdominal pain. She was pale and dizzy with standing, with a heart rate well above normal. Our nurses grabbed the Sonosite Titan ultrasound machine and me, and started scanning her. They realized her uterus was empty and she was bleeding from a ruptured ectopic pregnancy, which can be life-threatening.

"We were able to transport her in the single car to the nearest operating room an hour away but she remained stable. Right after she left, we realized we forgot her chart, and so the nurse ran off into the hills to chase down a horse-riding local, who rode off, chart in hand, to cut the ambulance-car off at the next crossing to give them the chart…It was a rapid diagnosis of a life-threatening disease by our newly ultrasound-trained maternity nurses here! So exciting….."

Shah and Mantuani also trained clinicians at the two hospitals where PIH works in Lesotho. At Mamohau Hospital in the mountains, they trained a total of 14 nurses, focusing on use of ultrasound to assist in pregnancy, labor, and delivery. The course brought together nurses who work in the hospital's maternity ward and others who administer PIH's Maternal Mortality Reduction Program and five health centers. And at Botsabelo Hospital, the national referral center for treatment of drug-resistant tuberculosis, they taught doctors how to use ultrasound to detect fluid that can accumulate around the heart and in the lungs of TB patients.

On February 4, CBS Evening News correspondent Whit Johnson reported on PIH's rehabilitiation efforts in post-earthquake Haiti. 

"There is a common perception that disability is something that's permanent," said PIH Rehab Coordinator Dr. Koji Nakashima. "You become disabled, and once you are given that marker of disability, you become less of a person." In his story, Johnson shows how PIH's rehabilitation team is combatting that misperception by providing care to thousands. 

Learn more about PIH's rehabilitation work in Haiti. 

PIH co-founder Paul Farmer explains in an op-ed posted on the New York Times website why it is vital to fund the Global Fund to Fight AIDS, TB, and Malaria.

Why does the Global Fund to Fight AIDS, TB and Malaria matter? PIH co-founder Paul Farmer penned an op-ed laying out four reasons in the International Herald Tribune published on February 2. The piece was also featured on the New York Times website.

Ten years ago, the Global Fund to Fight AIDS, Tuberculosis and Malaria was created to be a funding mechanism that increased resources available to fight preventable, treatable diseases stalking the poor and depleting developing economies around the globe, Dr. Farmer explains.

	The impact of the Global Fund. View more

"In 2001, very few people — almost none, really — living with H.I.V. in Africa had access to antiretroviral medicines," writes Dr. Farmer. "Today, more than 3.3 million people — more than half of those on treatment worldwide — are on treatment supported by the Global Fund: A true victory for the global community."

Today, the Global Fund is facing a serious financial shortfall, and the fund’s board voted recently not to accept new grant requests until at least 2014, writes Dr. Farmer. He adds that Bill Gates’ announcement of a $750 million contribution to the fund in Davos last week was welcome news, but will not change the board’s decision, as they knew of Gates’ donation before they canceled the current round of grant-making.

"This funding deficit hit right when the end of AIDS became plausible: Last year, scientific breakthroughs provided conclusive evidence that putting more people on treatment earlier can significantly reduce incidence of H.I.V. Treatment is prevention," writes Dr. Farmer

In addition to HIV/AIDS, the Global Fund is also the largest donor in the world for tuberculosis and malaria programs. Overall, it has saved an estimated 8.6 million lives over the past ten years. "The question is not whether the Global Fund works, but how to ensure it keeps working for years to come," writes Dr. Farmer.

He explains that there are four reasons this is imperative:

1. The world needs to expand, not contract, access to health care because of the sheer burden of disease.
2. The Fund doesn’t simply give handouts; it takes the longer road of investing in and working with health ministries.
3. The Global Fund proves how much multilateral organizations can accomplish.
4. A recession is a lousy excuse to starve one of the best (and only) instruments we have for helping people who live on a few dollars a day.

"Simply put, if we allow the fund to fail, many people will die, and we will forfeit the chance at the 'AIDS-free generation' that U.S. Secretary of State Hillary Clinton called for in November," Dr. Farmer conclundes. "This is no time to step back."

Read the full text of Dr. Farmer's op-ed, which was published on the New York Times website and in the International Herald Tribune.

See why PIH believes that the Global Fund matters.

Adolescence is a difficult time for girls everywhere, but coming of age in a developing country carries even greater risk. Teenage girls living with HIV struggle to come to terms with their condition. As girls mature, they face contracting sexually transmitted infections such as HIV and human papillomavirus.

ADOLESCENT SUCCESS STORIES

Gardasil Vaccination: In Haiti, thousands of girls are vaccinated against HPV, the disease that can lead to cervical cancer

Carmen's Story (VIDEO):After losing her legs as a result of Haiti's 2010 earthquake, a young woman devotes herself to helping others

Marie's Story: In Rwanda, a young woman gains access to an education

Pulane's Story (VIDEO): In Lesotho, a young girl receives treatment for multidrug-resistant tuberculosis

GARDASIL VACCINATION:

In Haiti, thousands of girls are vaccinated against HPV, a disease that can cause cervical cancer.

Each year nearly 3,000 women in Haiti develop cervical cancer. Just over half of those women will die as a result of the disease. 

In an effort to combat these preventable deaths, Partners In Health’s sister organization in Haiti, Zanmi Lasante, partnered with the country’s Ministry of Health in late 2009 to pilot the country’s first vaccination project for human papillomavirus (HPV)—the primary cause of cervical cancer.

The project aimed to vaccinate 3,800 girls, between the ages of 10 and 13.

Cervical cancer is overwhelmingly a disease of the poor. For example, the annual mortality rate for the disease in poor countries like Haiti is 54 deaths for every 100,000 women—more than 30 times higher than in the United States. Nearly 80 percent of women who develop cervical cancer live in developing countries, with roughly 275,000 dying as a result of the disease each year. Almost all of these deaths are preventable. 

Introducing a Gardasil campaign in rural Haiti

Gardasil, the HPV vaccine, can save many women’s lives. But delivering it in developing countries—especially post-earthquake Haiti—is not without obstacles.

Gardasil must be administered in three doses over a period of six months. Delivering multiple doses of a vaccine can be difficult because patients face barriers in making follow-up visits. Although studies have established a connection between HPV and cervical cancer and the vaccination is widely available in the U.S., most rural Haitians know little about the virus and the vaccine.

The large number of girls who volunteered to receive the first doses of Gardasil in December 2009 reflected the success of PIH/ZL’s education campaign throughout Haiti’s Central Plateau. In cooperation with schools, community leaders, educators, and local health teams, PIH/ZL raised awareness about cervical cancer, HPV, and the Gardasil vaccine in rural villages and larger towns alike.

In post-earthquake Haiti, PIH/ZL delivers HPV vaccine

After the devastating earthquake on January 12, 2010, ZL staff realized it would be even more challenging to locate the 3,806 girls who had received the first dose of Gardasil and administer the second and third doses. The earthquake strained all medical resources, some of the girls had been displaced, and schools that had hosted the vaccine program were closed or overwhelmed by displaced children.

But project leaders decided to proceed. Radio messages and community criers were used to encourage girls who had moved following the earthquake to return to their schools to complete the vaccination regimen. In late February and early March, 2010, Zanmi Lasante launched the outreach effort.

The team administered the third and last dose throughout June, even though the process was delayed by problems with shipping the vaccine and changes to school schedules. As an extra incentive to the girls, ZL staff gave small gifts at the completion of all three doses. 

Of the 3,806 girls who received the first dose, 2,884 girls—over 75 percent—received all three doses of Gardasil. This percentage is higher than rates reported in countries with far more resources, including the U.S.

This pilot program demonstrates that implementation of HPV vaccine is possible in rural Haiti, where cervical cancer affects a disproportionate number of women.

Learn more about PIH/ZL’s Gardasil campaign in Haiti.
Learn more about PIH cervical and breast cancer work across its sites.

Childhood brings threats such as diarrheal disease and malnutrition to girls in poor countries. A lack of clean water and proper nutrition weaken their immune systems and invite infectious diseases, leading to health problems that can last a lifetime and into the next generation.

CHILDHOOD SUCCESS STORIES

Taisha's Story: A young girl avoids cholera because of a water project in Haiti

Rachel's Story: In Malawi, PIH's Nutritional Rehabilitation Unit allows for rapid and dramatic recoveries

Mother to Child (VIDEO): Slowing the spread of HIV through transmission from mother to child

Louise's Story: In Rwanda, a young girl receives lifesaving treatment for rheumatic heart disease

LOUISE'S STORY:
In Rwanda, a young girl receives lifesaving surgery for rheumatic heart disease.

Louise (right) at her desk with a classmate.

In 2007, Partners In Health followed the story of two young girls suffered from rheumatic heart disease (RHD) – an all too common diagnosis in Rwanda. Both girls were treated through a unique partnership formed by PIH's Rwandan partner organization Inshuti Mu Buzima, the Salam Center for Cardiac Surgery in Sudan, and the Italian humanitarian organization Emergency.

One of those girls is Louise. This is her story.

A child made sick by an easily prevented disease

Five years ago, Louise’s small body was painfully swollen and wracked by recurrent asthma-like spasms in her lungs. She coughed throughout the day. Her heart – weakened and scarred from an infection – could not effectively pump blood to the rest of her body. Louise was slowly suffocating.

The bedridden 8-year-old suffered from rheumatic heart disease (RHD), a grim and all too common diagnosis in her Rwandan community, and one that could have been easily prevented by access to basic medical care, says Dr. Gene Bukhman, a PIH cardiologist who works at the Brigham & Women's Hospital in Boston and the Department of Social Medicine at Harvard Medical School.

RHD results from untreated streptococcal infections. These bacteria, which commonly cause strep throat and skin infections like impetigo, can be cleared up with a simple course of antibiotics like penicillin. If left untreated, however, the body’s immune system can start to attack its own heart valves in a mistaken attempt at self-defense, leading to RHD.

In countries like the U.S., children with sore throats and skin infections are usually quickly diagnosed and treated. But in poor countries, like Rwanda, medicine and diagnostic tools are not readily available, hospitals are often far away, and quality medical care is usually too expensive for most citizens. So when children like Louise catch a sore throat, there are no services to prevent this simple infection from progressing to RHD.

As a result, nearly half of the 16 to 20 million people affected by the disease worldwide live in poverty-stricken sub-Saharan Africa. A disproportionate number of these children are girls.

Finding care far from home

Louise faced almost certain death without heart surgery.

Access to care presented a barrier – no medical facility in Rwanda could safely provide the surgery Louise needed. In 2012, more than a half-decade later, this is still the case.

So PIH and Emergency, and Italian humanitarian organization, arranged for her to travel to Sudan, where the Salam Center for Cardiac Surgery had just opened in the city of Khartoum. 

At the Salam Center, doctors struggled to fix Louise’s damaged valve, but the tissue had already been scarred beyond repair. So they replaced the valve, and Louise quickly and dramatically began to recover.

Within weeks, she was well enough to return to her family in Rwanda. 

“It’s very amazing to see how she has improved,” said Eric Kamanayo, a nurse who accompanied Louise to Sudan. Just a few months after the surgery, she was able to run, and even carry her little brother around on her back. “This is unbelievable but true!” added Kamanayo.

Checking in five years later

Louise in her classroom with her peers (last row, center)

Today, a very healthy Louise is in the fourth grade. “She is doing well in school and is happy to be there,” said the headmaster of Louise’s school. “Her performance is satisfactory in all subjects, but she does particularly well in math.”

Although she excels at math, English and social studies are her favorite subjects. She is popular with the other kids and enjoys playing handball and jump rope. She sings in her church choir.
 
One day she hopes to be a doctor.

“I recently asked Louise how she feels since her surgery 5 years ago,” said PIH’s Aubrey Davis. “She says she feels good now, although sometimes with physical exercise, she gets winded. But she says there’s a big difference between how she was before the surgery. Before, she says, it was terrible. Today, she’s had no problems since the surgery, and she takes her medication every day. She says she no longer worries about her health.”

Today, Partners In Health continues working with local partners in Rwanda to help bring the access to care to Louise’s community – ranging from basic care that can prevent simple strep infections from deteriorating into RHD, as well as surgical capacity for treating advanced cases.

Partners include the Rwandan Ministry of Health, King Faisal Hospital in Rwanda’s capital city of Kigali, and Team Heart, a team of cardiac surgery volunteers from Boston-based hospitals who are working to strengthen Rwanda’s surgical infrastructure.  

Read a story about Louise published on PIH’s website in 2007.
Learn more about PIH’s efforts to combat non-communicable diseases like RHD.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

BETANIA'S STORY:
A mother learns to live with HIV in the Dominican Republic.

Socios En Salud patient Betania and her daughter Jennifer.

“I saw my mother hang herself! I cut the rope," cried 9-year-old Jennifer. She had just run from her home to find her mother’s social worker. It was the third time she had interrupted her mother’s suicide attempt.

Three years ago Jennifer’s mother, Betania, tested positive for HIV. Only 26 years old at the time, Betania knew little about HIV, but believed it was “a disease that removes people from the society.” As an illegal immigrant and her young daughter’s only caregiver, separation from her family was not an option. With no financial support from her new husband, Betania recalls her exhaustion and despair: “I wanted to die." she said. 

She was afraid that if she sought medical treatment, her husband would find out she was sick and leave her.

Instead, she kept her secret. And she became increasingly sick.

An emergency intervention

When staff from Partners In Health’s sister project in the Dominican Republic, Socios En Salud, began treating Betania in 2011, she was near death. Treatment for HIV is recommended if a patient’s viral load—the measurement of the amount of HIV virus in the blood—is greater than 100,000 instances per milliliter of blood. Betania’s viral load was an unimaginable 10 times higher, at over 1,000,000.

The HIV virus was storming Betania’s body; her immune system had collapsed. She was underweight, had several infections, including pulmonary tuberculosis (a contagious form of TB that affects the lungs), a cellulitis skin infection in one leg, and herpes. 

The medical team at Socios En Salud knew they needed to act quickly. Betania was immediately put on an intensive drug regimen and enrolled in the organization’s psychosocial program. She was assigned a community health worker—called an accompagnateur—who began visiting her house each day.

A much healthier Betania and her daughter Jennifer.

Life as an illegal immigrant

For Haitians living with HIV in the Dominican Republic, the stigma around the disease is only part of the problem. Betania lives with the constant threat of deportation. Though she has lived in the Dominican Republic for 14 years, and despite being married to a Dominican, Betania is considered an illegal immigrant. This status transfers to her daughter, Jennifer, despite having a Dominican father. Because of this, Jennifer will have to leave school after she turns 10 later this year.

Today, SES staff are working with a lawyer to help Betania fill out the paperwork necessary to stay in the country, and her whole family is enrolled a support group for Haitians living in the Dominican who are also affected by HIV—a double stigma. She is currently in the process of seeking legalized status for her daughter.

In its first year, SES provided 33,900 people with the same kind of medical care and social support Betania received.

Taking control 

“When this project started, I was given all the orientation I need to live better. They gave me medications for free, besides the ARV, food, and legal and health advisement,” recounts Betania. “I can finally look after my daughter again after all of this.”

Betania received more information about her illness and received psychological and nutritional support. Within six months she had gained 51 pounds, and was back to a healthy weight. She felt strong enough again to start working.

Recently, she decided that it was finally time to disclose her HIV status to her husband. But she did not have to maneuver this stressful, risky situation alone. SES staff were with her as the family worked through the issue. Betania’s husband was tested, and discovered that he too is HIV positive. He has also been enrolled in SES’s HIV program. The family is meeting regularly with a psychologist.

New patients receive social support outside SES's clinic in Elias Piña.

PIH’s successes in the Dominican Republic

In late 2010, Partners In Health and its sister organization in Haiti, Zanmi Lasante, launched SES. The project specifically focuses on HIV/AIDS prevention and treatment in the Dominican Republic border town of Elias Piña. SES targets migrant farm workers from both the DR and Haiti who live in the region.

While still a small and very new program, Socios En Salud has tested over 4,000 people for HIV and educated nearly 35,000 about the disease. Today, 131 women living with HIV receive care from SES. Of these women, half are Haitians living illegally in the Dominican. Like Betania, they largely fear seeking health care.

Adolescence is a difficult time for girls everywhere, but coming of age in a developing country carries even greater risk. Teenage girls living with HIV struggle to come to terms with their condition. As girls mature, they face contracting sexually transmitted infections such as HIV and human papillomavirus.

ADOLESCENT SUCCESS STORIES

Gardasil Vaccination: In Haiti, thousands of girls are vaccinated against HPV, the disease that can lead to cervical cancer

Carmen's Story (VIDEO): After losing her legs as a result of Haiti's 2010 earthquake, a young woman devotes herself to helping others

Marie's Story: In Rwanda, a young woman gains access to an education

Pulane's Story (VIDEO): In Lesotho, a young girl receives treatment for multidrug-resistant tuberculosis

CARMEN'S STORY:
After losing her legs after Haiti's 2010 earthquake, a young woman devotes herself to helping others.

Learn more about PIH's work in Haiti.

Adolescence is a difficult time for girls everywhere, but coming of age in a developing country carries even greater risk. Teenage girls living with HIV struggle to come to terms with their condition. As girls mature, they face contracting sexually transmitted infections such as HIV and human papillomavirus.

ADOLESCENT SUCCESS STORIES

Gardasil Vaccination: In Haiti, thousands of girls are vaccinated against HPV, the disease that can lead to cervical cancer

Carmen's Story (VIDEO): After losing her legs as a result of Haiti's 2010 earthquake, a young woman devotes herself to helping others

Marie's Story: In Rwanda, a young woman gains access to an education

Pulane's Story (VIDEO): In Lesotho, a young girl receives treatment for multidrug-resistant tuberculosis

PULANE'S STORY:
In Lesotho, multidrug-resistant tuberculosis kills thousands of children each year. 

Learn more about PIH's work in Lesotho.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

SORI'S STORY:
In Boston, a community health worker accompanies women living with HIV.

Sori Santana, right, visits a PACT patient in her home.

Every week, Sori Santana travels to the homes of more than a dozen patients living with HIV. As a community health worker with PIH’s Prevention and Access to Care and Treatment (PACT) program, Santana is one of nine health workers who provide daily home visits to 85 of Boston’s most vulnerable HIV patients.

Like Sori herself, the patients she cares for live and work in Boston’s predominantly black and Hispanic Dorchester neighborhood. In a poor, disenfranchised community, people living with HIV often carry the double burden of stigma associated with the disease and with mental illness, substance abuse, and poverty.

Santana helps these patients stick with their complex drug regimen. At the same time, she empowers them through education, advocates for their needs during doctors’ visits, and provides much-needed friendship.

But her job is not to force patients to take their medicine. Santana’s long-term goal is to make herself obsolete, “to empower clients to know that they can do this on their own, they don’t need us.” She is there to listen, to understand, and to provide emotional and practical support.

Empowering the city’s most vulnerable

In Boston, over 15,000 people live with HIV. While this number is relatively low compared to cities like New York, where at least 240,000 people live with the disease, the demographics of those affected reflect a troubling national trend. 

Watch a short video outlining PACT’s mission.

African Americans comprise only six percent of greater Boston’s population but account for 28 percent of those living with HIV. Women in the black community are impacted hardest. A shocking 83 percent of women diagnosed with HIV in Boston are African American.

In Boston's Haitian and Dominican immigrant communities, Santana and her colleagues often contend with a harmful level of misinformation about HIV. Some widely believe that HIV is transmitted by sharing eating utensils and toilets and through mosquito bites. People infected are often stigmatized as sexually promiscuous or homosexual. The cultural weight of these assumptions forces many people to stay quiet about their status.

For many, this isolation can be unbearable. Often it leads to self-destructive behaviors. This is when Santana and PACT’s other community health workers step in.

Sori’s story

As a young mother with three small children, Sori Santana decided to go back to school in order to get off welfare, become independent, and support her family. “I wanted to do something that I felt good about. I always loved helping people... and I found PACT.”

Sori Santana, left, and a fellow PACT health worker, center, talk with a PACT patient as she organizes her weekly medications.

Now, as a directly observed therapy (DOT) specialist, she helps people in her community who are struggling to help themselves. She accompanies patients as they follow complex daily drug regimens, and she connects them to health care and social support programs. 

With a smile, she describes the progress of one of her clients. “Sometimes when I walk in, she says, ‘I don’t feel that I can take my meds today. My stomach’s grumbling and I don’t want to do it. I don’t want to do it!’”

“Then we just start talking about her issues with her daughters, with her mom, with her job, or whatever. I’m just sitting down listening to her,” continued Santana. “And she gets up, grabs her meds, swallows them. And as she’s swallowing them, she says, ‘Oh... I just took my pills! Didn’t I just say I didn’t want to take my pills! Why didn’t you stop me?’”

“So I say, ‘Why should I stop you? I want you to take your pills; I want you to get healthy,’” said Santana. “The client said, ‘You just sat here and kept on talking. You are good.’ And we sit back and laugh about it.”

In 2011, Santana and her eight colleagues at PACT logged 5,160 home visits.

Saving patients, relieving stress on the medical system

Since 1997, PACT has recruited and trained community health workers (CHWs) to accompany Boston’s most vulnerable patients living with chronic diseases like HIV and diabetes. CHWs don't only accompany patients as they reclaim their health and improve their disease-management skills. They also facilitate better relationships between patients and the healthcare system, leading to reductions in costly emergency room visits and hospitalizations.

An analysis of Medicaid claims revealed a 16 percent savings in total medical expenditures two years after patients enroll with PACT. This is attributed to a 35 percent reduction in length of hospital stays and a 60 percent reduction in inpatient costs.

This kind of cost saving is linked to PACT’s focus on integrating CHWs into high-risk patients’ primary care teams. The partnership allows clinics to develop the infrastructure and culture necessary to support interventions for the most vulnerable and high-cost patients.

Enhancing health care delivery for vulnerable patients

Working in a half-dozen sites across the nation, PACT trains organizations to integrate PACT’s CHW delivery model into existing health systems in order to improve the health outcomes of vulnerable populations across the United States.

In 2011, PACT’s small staff trained more than 300 nurses and CHWs.

Learn more about the PACT project.

Childhood brings threats such as diarrheal disease and malnutrition to girls in poor countries. A lack of clean water and proper nutrition weaken their immune systems and invite infectious diseases, leading to health problems that can last a lifetime and into the next generation.

CHILDHOOD SUCCESS STORIES

Taisha's Story: A young girl avoids cholera because of a water project in Haiti

Rachel's Story: In Malawi, PIH's Nutritional Rehabilitation Unit allows for rapid and dramatic recoveries

Mother to Child (VIDEO): Slowing the spread of HIV through transmission from mother to child

TAISHA'S STORY:
A young girl avoids cholera because of a water project in Haiti.

At 4 years old, Taisha walked barefoot down dirt roads carrying heavy, plastic jugs of water. Her hair was tinged orange, an unmistakable sign of malnutrition. For Taisha and her family, limited access to food and virtually no access to clean drinking water and sanitation posed a deadly combination. 

Taisha and her brother used to walk alone down a dirt road to collect water.

This story is not unusual. In fact, Taisha and her family represent a majority of Haitians. A staggering 70 percent of the entire population lacks direct access to clean water. And fetching and carrying water in Haiti is mostly the work of women and children, who typically walk 10 to 30 minutes each trip carrying heavy buckets of water.

Lack of access to clean water and sanitation leaves millions susceptible to waterborne diseases, including the deadly cholera epidemic that has sickened over 530,000 people and killed more than 7,000 since October 2010. The village of Mosambe, where Taisha and her family live, was not spared. In an isolated community of 2,000 people, nearly 10 percent of the population—at least 185 people—required medical attention after falling sick with cholera.

Children like Taisha and her siblings who live in poverty are especially vulnerable because malnutrition and frequent bouts of illness often leave their bodies and immune systems too weak to combat deadly waterborne diseases.

Across the world, at least 2,700 children die of water-related diarrheal illnesses each day. One million children die each year, nearly all of them under the age of five. The UN predicts that unclean water and insufficient sanitation will account for roughly 10 percent of the world’s disease burden and 6.3 percent of all deaths in 2012.

Working with communities to filter water

In response to this crisis, Partners In Health and the nonprofit charity: water are bringing filtered water and sanitation facilities to poor communities across Haiti. Their goals: keep people—particularly vulnerable children like Taisha—from becoming sick and reduce the workload and risks of injury faced by children and women carrying water long distances.

One of the large water kiosks placed in the center of the small village of Mosambe.

In late 2011, the community of Mosambe went from having no access to clean water to having four community kiosks—large facilities that house both fountains and showers. The partnership has also delivered eight stand-alone showers and 40 biosand filters to individual households that allow them to filter their own water. PIH and charity: water are also working to improve sanitation by building 50 dry latrines.

Taisha and her family can now obtain clean water both from the community kiosks and with a biosand filter in their home. Partners In Health also built a dry latrine behind the family home, which converts dangerous waste into valuable fertilizer that can be deposited without the threat of contaminating the local water supply.

Water projects are one of the most effective ways of saving lives and one of the most cost-effective investments in disease prevention. Potable water projects typically reduce diarrheal disease by more than 50 percent.

The health and safety benefits of clean water

Beyond the effort of collecting water and the likelihood of it being contaminated, time spent walking and resulting injuries and diseases keep mothers and children from school, work, and taking care of their families.

Along their long walk, girls like Taisha are at a greater risk of harassment and sexual assault.

Hauling cans of water for long distances takes a toll on the spine and many women experience back pain early in life.

In providing access to clean water, Partners In Health and charity: water create opportunities for women to pursue new projects and improve their families’ lives and for children like Taisha to earn their education and build the future of their communities.

Learn more about PIH’s water projects.

Around the world, nearly 800 women die every day in childbirth – and 99% of these deaths occur in developing countries. Delivering a baby can be dangerous where women must hike hours in labor to reach a health facility, if one even exists.

PREGNANCY & CHILDBIRTH SUCCESS STORIES

Peruth's Story: A mother in Rwanda receives an emergency cesarean section

Gertrude's Story: In Malawi, a woman living with HIV dedicates her life to helping new mothers after losing her infant to that disease

Maternal Health (VIDEO): In Lesotho, women with HIV learn to care for themselves and their newborns

Maternal Health (VIDEO): Providing emergency obstetric care in post-earthquake Haiti

MATERNAL HEALTH:
Providing emergency obstetric care in post-earthquake Haiti.

The massive 2010 earthquake overwhelmed a country already struggling mightily with malnutrition, HIV, and infant mortality. Few safe childbirth options and substandard healthcare facilities have left many of Haiti's expectant mothers facing grave circumstances upon delivery.

Learn more about PIH's work in Haiti.

Childhood brings threats such as diarrheal disease and malnutrition to girls in poor countries. A lack of clean water and proper nutrition weaken their immune systems and invite infectious diseases, leading to health problems that can last a lifetime and into the next generation.

CHILDHOOD SUCCESS STORIES

Taisha's Story: A young girl avoids cholera because of a water project in Haiti

Rachel's Story: In Malawi, PIH's Nutritional Rehabilitation Unit allows for rapid and dramatic recoveries

Mother to Child (VIDEO): Slowing the spread of HIV through transmission from mother to child

MOTHER TO CHILD:
Slowing the transmission of HIV from mother to child is a key focus for Partners In Health, Haiti.

Learn more about PIH's work in Haiti.

Around the world, nearly 800 women die every day in childbirth – and 99% of these deaths occur in developing countries. Delivering a baby can be dangerous where women must hike hours in labor to reach a health facility, if one even exists.

PREGNANCY & CHILDBIRTH SUCCESS STORIES

Peruth's Story: A mother in Rwanda receives an emergency cesarean section

Gertrude's Story: In Malawi, a woman living with HIV dedicates her life to helping new mothers after losing her infant to that disease

Maternal Health (VIDEO): In Lesotho, women with HIV learn to care for themselves and their newborns

Maternal Health (VIDEO): Providing emergency obstetric care in post-earthquake Haiti

MATERNAL HEALTH:
Women living with HIV in Lesotho learn to care for themselves and their newborns. 

Learn more about PIH's work in Lesotho.

Women often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by. Partners In Health helps women find dignified work and the social support they need to be healthy and economically productive.

MORE ADULT SUCCESS STORIES

Jelen's Story: In Peru, a mother survives multidrug-resistant tuberculosis, starts a small business, and saves her family

Lomile's Story (VIDEO): In Lesotho, a mother adopts five orphans after her own children are grown

Dr. Ruth's Story: In Haiti, PIH's breast cancer clinic is now open

Sori's Story: In the U.S., a community health worker accompanies women living with HIV

Elda's Story: In Mexico, a woman controls her epilepsy 

Stella's Story: Former sex workers living with HIV start a restaurant in Malawi

Ilrick's Story: In Haiti, a woman living with HIV learns to control her disease while becoming a small business owner 

Betania's Story: A mother learns to live with HIV in the Dominican Republic

Family Planning: Recent trainings give health workers new tools to bring family planning services to their communities.

ILRICK'S STORY:
A mother living with HIV enrolls in Fonkoze’s program for the poorest of the poor in Haiti.

Women who receive microfinance loans enter the local marketplace and earn money to support their families.

If you are walking through the small Haitian village of Bento and find yourself hungry for some bread or cookies, or maybe just some fresh fruit, you may find yourself in front of the home of Ilrick Louis-Fils.

Ilrick sells goods in front of her home.

For just over a year now, Ilrick has sold food and refreshments from a small basket in front of her house. Because she lives on the main path to the nearby market, Ilrick has had no trouble finding customers. During that time she has watched her profits steadily grow. In fact, today she buys food for her two children and pays for them to go to school.

All of this would have seemed unimaginable just a few years ago.

In 2009, Partners In Health’s network of community health workers found an emaciated and sick Ilrick. She was referred to the organization’s nearest medical clinic in Boucan Carré. Tests revealed that she was living with HIV. Within days, Ilrick began taking antiretroviral therapy drugs (ART) and receiving comprehensive care.

As with all PIH patients living with HIV, Ilrick is visited daily by a community health worker. This health worker, a woman from Ilrick’s village, keeps track of the family’s health and works to connect them with psychosocial support programs.

A unique microfinance institution lifts women out of poverty

Thanks to Partners In Health's close partnership with Fonkoze, Ilrick had access to more than just health care. Soon she was a client in the microfinance institution's program for the extremely poor. The largest such organization in Haiti, Fonkoze serves more than 56,000 women borrowers and more than 250,000 savers—all of them poor and all living in rural villages. As of early 2012, Fonkoze’s network of 46 branches cover every region of Haiti. 

A busy market flourishes in Boucan Carré near the new Fonkoze bank (left), the new hospital (center), and the old clinic (right).

Ilrick was enrolled in Fonkoze's Chemen Lavi Miyò program, which translates as Pathway to a Better Life. Chemen Lavi Miyò Director Gauthier Dieudonne describes the women selected for the program as utterly hopeless. They are the outcasts of their communities, often indebted to their neighbors, living in shacks with mud floors and leaking roofs, and without a sanitary place to go to the bathroom. They cannot afford to send their children to school, and they go hungry for days.

"Where they live—some people would not put their animals there. They only live to eat for that day. All their efforts are put into one thing, just to getting the meal for that day."

Born out of a conversation between Paul Farmer and Anne Hastings, CEO of Fonkoze, the program searches out the most destitute women in poor, rural communities and provides them with income-generating assets such as livestock and a stipend to help stabilize their income. It also helps them to start a small business.

Throughout their 18 months in the program, participants receive weekly visits from case managers who accompany them on their journey out of extreme poverty. They counsel the women on family problems, give business advice, and connect them to the health services of Zanmi Lasante, Partners In Health’s name in Haitian Creole.

After participating in the program, they can re-connect with their communities and participate in the economy.

"The transformation is unbelievable," Dieudonne said. "It's not that we provide them with some assets, or provide them a stipend so they can eat better. It's how they feel about themselves. There is this hope in their face. They feel like they are no longer alone. They finally feel like they are somebody."

The birth of an entrepreneur

With money from Fonkoze's Chemen Lavi Miyò program, Ilrick began selling groceries from her home. The program also gave her family three goats. 

She worked as hard as her strength would allow her. Soon she was making a small profit.

Working together, PIH and Fonkoze help patients overcome illness by helping them break the cycle of poverty that keeps them sick. While PIH provides medical care to Ilrick and other women like her, Fonkoze accompanies these women as they enter the local economy, earning money to support themselves and their families.

In fact, two of PIH’s hospitals are located right next to Fonkoze branches. Paul Farmer once explained the partnership by saying that he was tired of watching people recover from illness only to have them suffer from poverty that medicines alone cannot cure. “Good public health requires more than just medical treatment,” said Farmer. “It takes economic development, too.”

From a shaky start, a solid businesswoman emerges

The turning point for Ilrick’s business came when she was able to save 2,000 Haitian gourdes (US $50) and buy a small horse. The horse allows her to make weekly trips to the nearby city of Domon, where she can buy food and liquor for her store at a cheaper price.

Ilrick and her new horse.

Today her weekly sales average about 600 gourdes (US $15), at least half of that is profit. In 2010, the World Bank estimated that the average Haitian family earned US $671. With a yearly takeaway of roughly US $390, Ilrick’s earnings are still far below the national average. But she is thriving. 

"I used to have to beg for something to feed my children every day," said Ilrick. "I had nothing. We didn't even have a dry place to sleep at night." With the help of PIH and Fonkoze, Ilrick has put a tin roof on her wooden house. Healthy and making money, she has a new lease on life.

Ilrick is now planning for the future. She is expanding the number of items she sells. Two of her three goats are pregnant. And she would like to buy a cow. In addition to the milk and the calves it could provide, it would also serve as an insurance policy, an asset that gives her greater leverage in the local economy.

Learn more about Fonkoze.
Learn more about PIH’s work providing microfinance loans in Peru and Malawi.

As women age, they often battle chronic diseases while playing an important role in the care of their families. Partners In Health is working to address chronic diseases through regular visits and accompaniment of community health workers.

OLDER ADULT SUCCESS STORIES

New Stoves Curb Disease: Reducing kitchen smoke in rural Guatemala

Non-communicable Diseases (VIDEO): Controlling asthma and diabetes in rural Rwanda.

Gulmira's Story: In Kazakhstan, a family survives MDR-TB

GULMIRA'S STORY:
A grandmother survives multidrug-resistant tuberculosis in Kazakhstan.

Gulmira Shunshaliyeva signs a log to affirm that she has completed the day's drug regimen for drug-resistant tuberculosis.

In December 2012, Gulmira Shunshaliyeva and her family will finally be free of drug-resistant tuberculosis (DR-TB), a disease that has ravaged the family for the past three years. The battle has been difficult, the challenges overwhelming. With support from Partners In Health’s program in Kazakhstan, run in partnership with the country’s Ministry of Health, Gulmira defeated the disease and is now caring for her family as they, too, fight for their health.

Gulmira and her family left their small home in the seemingly endless grasslands that cover much of central Kazakhstan in 2009. In search of work, they moved east to Karagandy, an industrial coal-mining city and regional capital of Karagandinskaya Oblast.

The adobe hut that Gulmira and her family call home.

Traveling with her husband, their two daughters, a son-in-law, and three grandchildren, the family found themselves renting a small adobe hut in a remote, poor region of the city. The hut lacked both a toilet and heating system. Despite living in a city of a half-million people, the family spent their days scavenging the streets for firewood. in a region where temperatures regularly drop to -5 F on winter nights, they spent what little money they had to buy coal in a desperate attempt at heating their makeshift shelter.

Unable to find permanent employment, Gulmira and her two adult daughters spent their days moving between various temporary jobs.

And then the family’s difficult life got worse.

Gulmira became sick with drug-resistant tuberculosis (DR-TB), a deadly strain of TB that takes upwards of two years to cure. An intensive, daily-dose drug regimen and unpleasant side effects make completion difficult.

Surviving a deadly disease

Around this same time, in mid-2010, Partners In Health launched a new partnership to combat drug-resistant tuberculosis in Kazakhstan. Because of PIH’s track record of curing and curbing the spread of drug-resistant tuberculosis in Russia, the Kazakhstan Ministry of Health invited PIH to help fight one of the highest rates of drug-resistant TB in the world.

Gulmira was one of the new team’s first patients.

In Kazakhstan, most TB patients must travel to regional dispensaries to receive their medication. Too often the poorest and most isolated patients, like Gulmira, are unable to afford the cost of travel. As a result, many of these patients do not complete treatment. Many die needless deaths. And failure to complete courses of antibiotics fuels increased drug-resistance.

This is where PIH steps in. Working with the local government, PIH trains nurses to accompany patients through treatment. These nurses visit patients in their homes multiple times a week, ensuring that they take their drugs and connecting them with valuable social services. Most importantly, they treat them like family. As a result of this practical and emotional support, patients are significantly more likely to complete their drug regimen. 

Gulmira was lucky not only to have been diagnosed early, but also to have been accompanied throughout her treatment. In a country with one of the world’s highest TB infection rates, only 82 percent of cases are diagnosed. And only three of every five people whose cases are diagnosed complete treatment for this deadly disease. The numbers are even worse for the country’s poor, people like Gulmira and her family.

Gulmira takes her daily does of medicine for DR-TB.

From patient to caregiver

Early in 2011, as Gulmira was entering the second year of her own treatment, her two adult daughters also became ill with DR-TB. A health worker noted the symptoms during a home visit. Soon Gulmira’s daughters were also on treatment. 

The same team of nurses and health workers continues to visit the family, providing care, food packages, and warm winter clothes.

Yet it is Gulmira who has shouldered the brunt of her family’s burden. Having been in treatment for nearly two years, she helps her daughters as they move through the most painful phases of the drug regimen. She has also taken an active role in ensuring that the rest of her family does not contract this potentially fatal disease.

“All three women are responding well to the treatment and are expected to make a full recovery,” said Dr. Askar Yedilbayev, program director for PIH-Kazakhstan. PIH is working with the local government to find them permanent employment and better living conditions.

As of April 2012, Partners In Health’s project in Kazakhstan was providing technical assistance to 511 people living with drug-resistant tuberculosis.

Learn more about PIH’s work in Kazakhstan.

Across Mexico this week, medical students are receiving their diplomas, and entering a required one-year social service assignment. These new physicians typically work in ministry of health clinics in rural or underserved areas.

Building on PIH's tradition of investing in health care provider training, this month PIH's sister organization in Mexico, Compañeros En Salud (CES), will debut a groundbreaking curriculum geared towards physicians in their social service year.  

"This year is crucial to young doctors' development,” said Dr. Daniel Palazuelos, CES Clinical Director. “But they often lack the mentorship and support to be successful. CES will make those elements a centerpiece of our program, to help build a new generation of social medicine physicians.”

To do this, CES teamed up with Dr. Andrew Ellner of the Harvard Medical School Center for Primary Care. In addition, Brigham and Women's Hospital residents Dr. Andrew Van Wieren and Dr. Carlos Gonzalez Quesada were awarded a Martin P. Solomon Primary Care Scholarship that allows them to collaborate in the curriculum's develop and implementation on the ground. The team envisions that the curriculum will reinforce clinical skills, while also fostering analysis of how to improve global health delivery.

Speaking of the new project, Dr. Van Wieren said, "This is a wonderful opportunity to help new physicians understand how the community, health system, and they themselves each play a role in high quality primary care."

Through CES the social service physicians will take part in monthly seminars, as well as receive on-site mentorship, logistical support and access to needed supplies.

"In order to attract clinicians to rural areas, it has to be a rewarding experience, in which they can develop professionally, and have tools they need to do their jobs well,” said Dr. Hugo Flores, CES On Site Director.

The team hopes this curriculum will serve as a model that can be replicated at other rural sites in Mexico.

Learn more about PIH’s newest project, Compañeros En Salud.

Looking out at the villages lining the mountains of Chiapas.

PIH is officially launching its newest sister project in a rural, mountainous region of Chiapas, one of Mexico’s poorest states. The new organization is called Compañeros En Salud (CES), which translates as “friends in health.” 

Chiapas is Mexico's southernmost state.

Beginning February 1, 2012, CES staff and recent graduates of Mexico’s top medical school, Tecnológico de Monterrey, will begin providing high-quality health care in an area encompassing thousands of people in nearly a dozen isolated communities. The physicians will be based in two rural government medical facilities that have been underutilized and understaffed. 

As with other PIH projects around the world, CES is partnering with local communities and the regional government in order to strengthen Chiapas’s public health system. “This approach is based on what we’ve learned from local people through several years of operating a mobile clinic unit in these isolated towns,” said Project Coordinator Lindsay Palazuelos. “Our goal is that community members will be involved in raising standards in every aspect of their health care.”

Listening to local communities, building customized health systems

While CES is a new entity on paper, PIH has a long history in Mexico’s southernmost state. Since 1989, PIH has partnered with the Chiapas-based nonprofit EAPSEC – Equipo de Apoyo en Salud y Educación Comunitaria, Spanish for “Team for the Support of Community Health and Education” – with the aim of organizing communities to improve health care and the determinants of health.

One of the previously shuttered government-built clinics that CES will staff, supply and reopen.

For two decades PIH accompanied that organization with clinical and program staff, financial support, and strategic planning. Working together, the organizations staffed a mobile health unit and trained dozens of community health workers. 

CES will focus on providing medical care and training, while PIH will also continue supporting EAPSEC as it concentrates on programs in food security, women’s empowerment, and access to credit. PIH has long recognized the intimate connection between socioeconomics and health. The best health care does little good if a patient goes home to a makeshift home or lacks access to food and clean water.

PIH’s work in Mexico is made possible by a generous donation from Green Mountain Coffee Roasters, which donates a percentage of its profits to helping develop the communities where it sources coffee. This year Green Mountain will fund projects through roughly 1,200 nonprofit organizations throughout Latin America and beyond.

A region blessed with riches, but desperately poor

Despite being home to world-class organic coffee farms and incredible biodiversity, the people of Chiapas are largely marginalized. Too many households still lack electricity and water. Schools are inadequate and illiteracy rates high. Unsurprisingly, access to health care also lags behind needs, meaning that too many people suffer from preventable or treatable conditions.

By working with local communities and hiring and training a team of local community health workers, CES will take key steps towards establishing a sustainable public health system.

Attracting physicians to rural Chiapas, expanding partnership opportunities

CES's Drs. Dan Palazuelos and Hugo Flores Navarro.

“In rural areas, attracting medical staff is a key challenge that we wanted to find innovative ways to address,” said CES’s Dr. Hugo Flores. A central component of the new organization’s strategy aims to address this problem.

When medical students graduate in Mexico, they enter a one year required social service assignment before receiving their medical license. Too often residents spend this year with little mentorship or guidance in underequipped rural clinics. For many, the experience can feel discouraging.

CES aims to transform the social service year into a meaningful training experience that helps build the next generation of social medicine physicians. CES is partnering with Brigham and Women’s hospital residents to provide a unique package of training and support that includes global health seminars, supervision on site, and supplementary supplies, that has already attracted many interested medical students and recent graduates from Mexico’s top universities, including Tecnológico de Monterrey.

These measures help ensure that physicians have the tools needed to provide high-quality care in poor communities.

The CES core team possesses several years of experience working in Chiapas. Dr. Palazuelos began work in the area as a Doris and Howard Hiatt Global Health Equity and Internal Medicine resident at Brigham and Women’s Hospital in 2005, and helped launch the mobile health unit in 2007. Ms. Palazuelos began as coordinator in 2008, and Dr. Flores began serving patients in the area in early 2010. 

Just weeks before PIH launched the Haiti cholera vacciation project, NPR's Jason Beaubien visited our cholera treatment centers in order to understand the scope of what's being done. With more than 525,000 Haitians infected and 7,000 killed, Haiti's cholera epidemic is now the world's largest. 

Partners in Health, a Boston-based nonprofit, is planning to launch an unprecedented cholera vaccination campaign to try to curb the outbreak — but it faces many challenges, including a shortage of the vaccine.

For decades, Haiti had been considered a potential cholera flash point. Even before the 2010 earthquake, roughly 50 percent of Haitians lacked access to clean water, and 80 percent didn't have adequate sewage systems, according to the World Health Organization.

Read more of Jason Beaubien's "Can Vaccines Break Cholera's Deadly Hold On Haiti?"

IHSJ Reader     January 2012     Issue 16         

Note: Triple asterisk (***) indicates subscription-only sources.

FOREIGN AID REFORM

The MLI Model for Advancing Country Ownership (Ministerial Leadership Initiative, January 12, 2012) +
US Officials Pledge To Let Health Aid Recipients Decide (John Donnelly, Global Post, January 13, 2012)
Over the past five years, the ground-breaking Ministerial Leadership Initiative (MLI) has been working to change the way that foreign aid is delivered. Instead of building parallel health structures based on donor priorities, the MLI model enhances authentic country ownership of health planning and implementation. Lessons learned from the Gates Foundation-funded initiative include the benefits of South-South government exchanges, demand-driven technical assistance, and a focus on country leadership at all stages of planning and implementation. The MLI approach provides a helpful roadmap as the Obama Administration’s Global Health Initiative seeks to turn aid effectiveness rhetoric into reality.

HAITI

***Elimination of Cholera Transmission in Haiti and the Dominican Republic (Mirta Roses Periago, Thomas Frieden, Jordan Tappero, Kevin De Cock, Bernt Aasen, Jon Andrus, The Lancet, January 11, 2012)
On January 11, the Governments of Haiti and the Dominican Republic, in collaboration with the Pan American Health Organization, the Centers for Disease Control and Prevention, and UNICEF, launched a call to action for major investment in water and sanitation infrastructure on the island of Hispaniola. Fifteen months after the outbreak of cholera in Haiti, over 500,000 cases have been reported in Haiti and over 20,000 cases have been reported in the Dominican Republic. Despite the multiple intervention efforts, Hispaniola will not see the elimination of cholera until existing water and sanitation infrastructure is strengthened and expanded. International donors should support local government efforts to build, operate, and maintain water and sanitation infrastructure over the long term. To watch the press briefing, see: Call to Action: A Cholera-Free Hispaniola .

TUBERCULOSIS

India reports cases of totally drug-resistant tuberculosis (Samuel Loewenberg, The Lancet, January 21, 2012)
The emergence of totally drug-resistant tuberculosis (TDR-TB) in Mumbai, India raises burning questions for the international community: Why has TDR-TB emerged? Why do so many people lack access to quality, second-line TB drugs in countries like India? And what can be done to stop it? For decades, TB departments and programs have been underfunded, resulting in weak delivery systems of treatment and prevention, and unregulated private sector delivery of care. High-quality second-line TB medications remain prohibitively expensive and less than 1% of MDR-TB patients access treatment worldwide. The international community must step up to the plate.  Prices must be lowered on TB diagnosis and treatment tools, and resources must be mobilized to bring the Global Fund to Fight AIDS, Tuberculosis, and Malaria—which contributes 80% of international funding for TB control—out of its financial crisis.

SEXUAL HEALTH 

Applying New Technologies For Diagnosing Sexually Transmitted Infections in Resource-Poor Settings (Rosanna Peeling, British Medical Journal, January 20, 2012)
Bacterial sexually transmitted infections (STI) impose a disproportionate burden on the developing world, especially among women and children. Though STIs are curable and treatment is affordable, the sensitive diagnostic tests that play a crucial role in early detection require laboratory capacity—something that is frequently missing in resource-poor settings. This paper analyzes recent technological advancements that have made such diagnostics available, while simultaneously urging readers that increased investments in technological innovations must be balanced with investments to strengthen health systems.

FOOD SECURITY

Effectiveness of Agricultural Interventions That Aim to Improve Nutritional Status of Children: Systematic Review (Edoardo Masset, Lawrence Haddad, Alexander Cornelius, Jairo Isaza-Castro, British Medical Journal, January 17, 2012)
Researchers conducted a literature review of 23 studies to examine the impact of agricultural interventions on the nutritional status of children. Though initiatives such as home gardens were found to increase production and consumption of nutrient-rich foods, methodological constraints made it difficult to assess their impact on child nutrition. These findings are a useful reminder that agriculture programs should be rigorously evaluated and refined to meet the nutritional needs of children. Today, malnutrition contributes to more than 3.5 million deaths of children annually and more than one billion people—nearly one-sixth of the world's population—suffer from chronic hunger. It is critical that agricultural interventions be designed to increase access, availability, and utilization of food, and ultimately improve child health outcomes.

NON-COMMUNICABLE DISEASES

New Mindset Needed to Tackle Non-Communicable Diseases, Says UN Official (UN News Centre, January 16, 2012)
Dr. Margaret Chan, Director-General of the World Health Organization (WHO), announced this week that tackling non-communicable diseases (NCDs) will require a change to the traditional mindset that focuses public health efforts on controlling and preventing infectious disease. Dr. Chan reiterated the WHO’s commitment to making prevention and treatment of NCDs a priority and cautioned that new approaches will not be easy, but are necessary to control the NCD epidemic that disproportionately impacts the world’s billion poorest people.

A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come (Judith Bass, Thomas Bornemann, Matthew Burkey, Sonia Chehil, Lenis Chen, John R.M. Copeland, William Eaton, Vijay Ganju, Erin Hayward, Rebecca Hock, Rubeena Kidwai, Kavitha Kolappa, Patrick Lee, Harry Minas, Flora Or, Guiseppe Raviola, Benedetto Saraceno, Vikram Patel, PLoS Medicine, January 17, 2012)
In this recent essay, international health experts call for a special session of the United Nations to focus on mental, neurological, and substance use (MNS) disorders. The authors outline three broad areas of action needed globally: enhancing access to treatment of MNS disorders, ensuring that people living with mental health disabilities have full access to their basic right to live a life with dignity, and expanding knowledge about MNS disorders. A special session of the UN General Assembly would provide recognition of the urgent need for a global strategy to address the burden of MNS disorders. 

MULTIMEDIA/ADDITIONAL RESOURCES 

Haiti Builds State-Of-The-Art Teaching Hospital (CBS News, January 21, 2012)
Dr. Jon LaPook of CBS News interviews Dr. Paul Farmer about the state-of-the-art teaching hospital in Mirebalais, two years after the devastating earthquake. Built in collaboration with the Haitian government, this facility will ensure that high-quality health services are accessible to poor people regardless of ability to pay. The hospital will also serve as a teaching facility for a new generation of Haitian doctors and nurses.

With EU and UNICEF Support, Lesotho Puts in Place a Social Protection Programme for the Most Vulnerable (Tsitsi Singizi, UNICEF, January 18, 2012)
This short video provides a look into the social cash transfer program, Lesotho Child Grants Programme, which operates in rural communities in Lesotho and is supported by the European Union and UNICEF. The program was implemented in 2007 to serve as a social safety net for children affected by HIV/AIDS. In addition to the comprehensive support offered by the program, participation also increases access to health and education services for vulnerable children.

Famine, War, and Corruption: The British Media’s Portrayal of the Global South (Institute for Development Studies, January 11, 2012)
This new short film discusses how media coverage tends to focus on the violence and victims of disasters in the Global South, while ignoring the structural causes at the root of global poverty.

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Driving up to Mirebalais National Teaching Hospital, the largest reconstruction project in Haiti since the 2010 earthquake.

On January 25, NPR's Jason Beaubien reported on the role Mirebalais National Teaching Hospital, a collaborative project between PIH and the Government of Haiti, plays in Haiti's recovery. Listen to this compelling story, "State-Of-The-Art Hospital Offers Hope For Haiti", which played on Morning Edition.
 

A view inside the new 320-bed, 180,000 square foot medical complex, the largest in Haiti.

Even before the devastating earthquake in 2010, Haiti's public health care system was perhaps the worst in the Western Hemisphere. Then the quake knocked down clinics, killed medical workers and severely damaged the General Hospital in Port-au-Prince, the capital.

Now, the Boston-based group Partners in Health has set out to build a world-class teaching hospital in what used to be a rice field in the Haitian countryside.

Amid much talk about the slow pace of recovery, the hospital is a concrete sign of progress. The project is also being touted as a possible model for international aid in the developing world.

Listen to Jason Beaubien's piece "State-Of-The-Art Hospital Offers Hope For Haiti" in its entirety.

Learn more about Mirebalais Hospital.

Elise Garrity, PIH – Boston
January 26, 2012

We had one week to find 50 supporters around Boston to help with a ‘mystery project’ – Didn’t advertise details, just that it was an urgent task for our Haiti team. Although we’d hosted a few “Volunteer Nights” at the office before, this was the first time that the night’s task would lead so directly into our work on the ground.

Sure enough our mix of 50 volunteers arrived. Students, long-time supporters, friends of PIH supporters, and newcomers too. Dr. Ivers appeared over Skype to greet our eager volunteers and fill them in on the importance of this task, one of a series of events which would lead to our cholera vaccine roll-out in Haiti.

The 50,000 blue vaccine cards that our volunteers were about to assemble – each marked by a unique barcode sticker – would be distributed to patients upon receiving their first dose of the vaccine, and later used to track follow-up and outcome.

For the next two hours, our volunteers began to ‘stick and stack’. Working in pairs around the office, their barcodes ribboned across the floor. Our staff gathered all completed stacks of 500 cards in a side office, and soon enough had covered every surface with finished blue stacks.

When 8pm rolled around, we made the obligatory announcement that our time had ended. “…And you’re welcome to stay,” we hinted, explaining that all 50,000 cards would have to be packed by the end of the night. That’s when nobody seemed to move from their seats.

Naturally, some volunteers were unable to stay. Nektarios left only to recruit his fiancée, and then returned for another good hour of work. Jimi earned several papercuts by the time he left around 10:30. At last we had ‘stuck’ and ‘stacked’ all 50,000 cards.

Our handful of remaining staff lined up 8 open suitcases to fill with cards. In the hallway we knelt over the luggage with packing tape, and soon enough the stacks of cards were ready for travel. Written on the wall above us was a Haitian proverb, Men Anpil Chay Pa Lou, which means “Many hands lighten the load.”