In Kazakhstan, roughly one in seven inmates living in the state’s prison system is infected with tuberculosis (TB). For years, the rampant spread of TB has put prisoners at risk of debilitating infection, with many dying from a preventable and treatable disease. At the Kazakh government’s request, PIH is working to curb that trend. Earlier this year, PIH began offering technical and medical assistance to each of the Central Asian country’s estimated 5,000 prisoners living with TB.

A prisoner living with TB is examined by his doctor.

“This is a miniature reform of the country’s penal system,” said Dr. Askar Yedilbayev,
Program Director for PIH-Kazakhstan (PIH-KZ). From training prison personnel in better techniques for treating the disease, to advocating for changing outdated laws, PIH’s project aims to prevent infection and death in the six prisons housing TB patients.

With nearly 15 percent of the prison population living with this highly contagious and potentially fatal disease, the need for an intervention could not be greater. TB spreads between people in enclosed spaces with incredible ease. A condition that primarily affects the lungs, the bacteria that cause TB move into the air when an infected person coughs or sneezes. Kazakh’s outdated prisons are ideal conditions for new TB infections.

As if these numbers were not bad enough, roughly 20 percent of the 5,000 prisoners living with TB have developed the more debilitating multidrug-resistant TB (MDR-TB) – a dangerous strain of the disease resistant to treatment. And of those patients, an unknown number are living with extremely drug-resistant TB (XDR-TB).

Chest x-rays from prisoners infected with TB dry in a room near the prison's lab.

A system needing reform

Just north of Kazakhstan in neighboring Siberia, PIH has been working to combat TB in Russia since 1998. Within a few years, PIH-Russia was seeing treatment adherence and reinfection rates significantly below international averages. Impressed by these accomplishments, Kazakh health officials invited PIH-Russia to help overhaul its own prison facilities. In late 2010, PIH-KZ was created, and began formulating a plan based on the Russian model.

In Kazakhstan, PIH found a Soviet-era prison system unequipped to fully meet the needs of patients infected with TB and MDR-TB. Fewer than half of infected prisoners were being effectively treated. Consequently, strains of TB became dangerously resistant to more and more drugs, and prisoners continued to spread the bacteria through the wards. Prison staff simply lacked the knowledge, resources, and motivation to treat the disease.

The PIH-KZ team quickly began implementing its plan.“We visit patients at each prison, we look at treatment files, go through regimens, check everything – we fix prescriptions and create consistency,” said Dr. Yedilbayev.

A patient living with TB receives medication from a trained nurse.

A simple solution: isolate infectious prisoners

After realizing the extent of the problem, PIH-KZ devised a plan. They recommended that each prison be divided into three wards, separated by levels of contagion – red for highly infectious patients, yellow for those on treatment and green for prisoners free of the disease. These stringent infection control measures curb re-infection rates by separating the sickest patients from prisoners free of the disease.

According to World Health Organization standards, all prisoners undergo careful bacteriological monitoring – receiving smears and sputum cultures. These tests detect new infections as well as monitor the treatment progress of infected patients. When prisoners fall ill, or if those in treatment respond well to their therapy, the patient is transferred to a demarcated zone.

Breaking the chain of transmission

“In addition to separation, effective treatment is one of the most important tools to break the chain of transmission,” said Dr. Yedilbayev.

Prisons with TB wards are broken into wards, a necessary step to controlling the spread of the airborne disease.

While PIH-KZ does not provide medicine directly to the prisoners, its nine clinicians and support staff are advising the government and prison officials on how to treat this vulnerable patient population. In addition, PIH-KZ is training prison staff to diagnosis TB and MDR-TB as early as possible.

“We believe in early identification of drug-resistance and timely start of treatment with aggressive and effective regimens under direct observation,” said Dr. Yedilbayev. While PIH-KZ does not provide medicine directly to patients, its 9 clinicians and support staff are advising the government and prison officials on how to separate and treat this vulnerable patient population.

Help support PIH’s efforts to combat tuberculosis.
Learn more about PIH-Kazakhstan.

From Jim Ansara, Heidi Burgess, Andrew Johnston and David Walton 

As the year comes to a close, we’d like to take some time to reflect on all those that have volunteered their time and energy for the construction of the National Teaching Hospital at Mirebalais, Haiti. Each volunteer went above and beyond the call of duty, putting in numerous hours of hard work and completing many projects in a short amount of time. Everyone adjusted well to living and working in Haiti, everyone got along with each other on site, and many of us forged long-term friendships.  All in all, we could not have asked for a better group of volunteers.

From all of us on the Mirebalais Construction Team and everyone at Partners In Health, thank you for the incredible contribution you have made towards the project.

*A special thanks to Chuck, Larry and Hugh from SullyMac for putting together so many teams of electrical volunteers. 
 

A message from your volunteer coordinator:

I could not have asked for a better group of people to work with. You know you have a great job when you look forward to work in the morning and I have you all to thank for that. I have heard only positive responses from our on site team about the work you completed. It has been a joy to work with each and every one of you. I wish you the best of luck in the future!
Best, Heidi  

A message from the project coordinator: 

It’s been a privilege and an honor to work with you in Mirebalais this year!  I deeply appreciate the effort and experience that you have brought to the project as well as the friendships and good humor. I look forward to seeing you in the coming year as we work together to finish construction of the Mirebalais Hospital!  
Happy Holidays, Andrew

Learn more about Mirebalais Hospital.

A holiday message from Maggie Gyllenhaal and Peter Sarsgaard.

By Maggie Gyllenhaal

Every family celebrates the holiday season in a different way -- sometimes with traditions that go back generations, sometimes with traditions that are just a few years old.

Last year, my family and I started something new. Instead of just giving conventional holiday gifts, we made donations to Partners In Health in honor of our loved ones. We decided that these were the most meaningful gifts we could give, because they reach those most in need around the world with lifesaving care.

We'll be continuing the tradition this year by sending PIH holiday e-cards. Here's part of the message that my husband Peter and I are sending to our friends and our whole family this holiday season:

Over the past year, we have continued learning about PIH's work, and we are all the more compelled by their mission. This year we are giving in your honor again, because we can't think of a more meaningful way to show our appreciation of your presence in our lives. We have so much to be thankful for, and we are grateful for the opportunity to give back. Together, we can make a true difference in the lives of those less fortunate around the world.

We're asking others to join us in this new holiday tradition. Give a gift that gives twice: first, to show your appreciation for someone special in your life and, second, to help provide medical care to thousands of people in need.

Maggie Gyllenhaal is an Academy Award-Nominated actress. 

In Rwanda, PIH helps a young genocide survivor overcome poverty and his past.

Above photo: Private accepts the keys to his new home from PIH/IMB staff.

By Aubrey Davis, PIH/IMB External Relations Coordinator, Rwanda

Private Njyenawe was 12 years old when the genocide took his family, his home, and his childhood. He witnessed unspeakable acts and unfathomable violence. And in order to survive, he found the courage to handle himself in situations that no child should ever be in.

After the violence passed, Private was alive but alone and without a home. So he left his village of Rwinkwavu and joined the army, which was absorbing many of the orphaned boys left in the genocide’s aftermath. After spending years as a child soldier, Private participated in the massive demobilization effort that traded guns for education — for him, some vocational training in electrical engineering.

Private tried to find work in the capital city of Kigali, but life there was difficult, and he wasn’t able to earn enough to support himself.  Ashamed of his failures, he eventually decided to return to Rwinkwavu. He didn’t know where else to go.

A difficult homecoming 

Private returned only to find that most of his family’s land had been given to another family. A common occurrence after the war, the government often gave away land to returning refugees when they believed the land had no surviving titleholders.

	Private had been living in the crumbling remains of his childhood home.

With no money and no job, Private’s only choice was to take shelter in the crumbling ruins of his childhood home. Over time, the building had deteriorated so badly that there was only one small room with four walls remaining, and no roof.

Every day, Private woke up and stepped outside his room wondering how he would afford food. Looking across his yard, he would see a nice, big house on the land where he grew up, but he couldn’t sleep there. He could see the orange tree that his father planted, but he couldn’t eat from it. Occasionally, he would get work digging in a nearby mine — the same mine where his family and thousands of others were slaughtered.

Struggling to cope with his memories and his daily suffering, Private would often wish that he had died with his family.

Addressing poverty through preventative medicine 

In April 2011, Private gave his testimony at a genocide commemoration in Rwinkwavu.  A number of staff from PIH’s Rwandan sister organization, Inshuti Mu Buzima (IMB), were present, and heard his story. They knew that they had to help this member of their community — a man in misery no more than a mile from their hospital headquarters.

Although Private wasn’t an IMB patient, the poor conditions he lived in threatened his health daily, and he could have very quickly become one of IMB’s sickest patients. Good health systems are made up of more than doctors and hospitals and patients, and IMB believes that building houses for people like Private is a form of preventative medicine. Standing in solidarity with the poor isn’t limited to the poor who happen to walk through the doors of our hospitals or clinics.

With this in mind, IMB acted quickly, resolving the very next day to intervene. They worked with Private and the local government to get some of his land back, and began constructing a new modest but sturdy house — with a roof.  

Chasing mice together

	Private in front of his new home.

In the local language of Kinyarwanda, the word for housewarming is “Kwirukana imbeba.” Translated literally, it means “chasing mice,” which signifies helping to make the new home comfortable and clean. In October, with the new house complete, IMB staff, local government representatives, neighbors, and community members all came out to help Private chase the mice out of his new home.

Proudly holding the keys to his house, Private told those gathered, “It’s beyond what I expected. At first I thought it would be impossible to have a house. But now, because I have a vision for the future, I have a lot of hope.” He feels strongly that it’s his job to find a direction for his life, a direction guided by his heart and desire to help others like him. With his new house, he plans to provide shelter to people who don’t have a place to live, and to sick travelers on their way to the hospital.

Recently, IMB received a generous donation for Private to further his vocational training and hone his art skills. And he says with all the space he has in his new home, he hopes to fill it with a big family. In a way, it’s only fitting. After all, his last name, Njyenawe, literally means “me and you.”

By Tricia O’Donohue, RN
December 7, 2011

Saint Marc, Haiti – Nursing staff at the PIH-supported l’Hôpital Saint Nicholas (HSN) recently pioneered a program for nurses that has proven to improve patient care, while fostering employee education. After weeks of training and scenarios, the new initiative can officially be called a success, with nurse and auxiliaries’ test scores improving by 30 percent.

American and Haitian nurses and auxiliaries update CPR skills in Saint Marc, Haiti.

The new program is just one way PIH is bringing the facility closer to becoming a site of nursing excellence. Since the program’s inception, six classes have been taught across the Pediatric, Emergency and Internal Medicine wards. Licensed nurses as well as auxiliaries, staff who support nurses, learned the latest cardiopulmonary resuscitation (CPR) techniques for neonate, pediatric and adult patients, and discussed skills for improving bedside manner. Volunteer health care professionals from the U.S. traveled to the costal town of Saint Marc to launch the program. Two Haitian clinical nurse educators will manage the initiative as it moves forward.

Beyond improved test scores, the overall response to the trainings was excellent, and nurses have already begun applying new lessons at the hospital. Hospital management reports that morale and motivation have also improved, a less tangible but necessary step in making HSN a site of nursing excellence.

The successful project was designed at the request of nurses and auxiliaries who identified continuing education as one of largest barriers to high-quality patient care. In a survey taken earlier this year, staff also identified other barriers to care: limited supplies, lack of accountability, extremely high nurse/patient ratios, and burnout. The goal of PIH is to improve the overall nursing system in Haiti by providing ongoing education AND tangible support, making way for improved patient care.

HSN’s program is part of PIH’s Family Practice Residency Program, and is funded by the Clinton Bush Haiti Fund.

Prior to surgery, Medjine rarely ate. Here, just days after her operation, she is hungrily eating up her lunch.

On January 30, four Haitian children living with debilitating heart defects travelled nearly 1300 miles to Guatemala City’s UNICAR Hospital (Unidad de Cirugia Cardiovascular de Guatemala, the Cardiovascular Surgery Unit of Guatemala). It is there that the newest patients of PIH’s Right to Health Care program (RTHC) – Rosaica, Marconi, Medjine, and Michelda – will receive livesaving cardiac surgery.

Separated from their homes and Haiti for the first time, the four children and their mothers (or in one case, grandmother) have embarked on a life-changing journey. Over the coming months this makeshift family will support each other as the three girls and one boy undergo complex heart surgeries. To help facilitate a sense of community, the entire group is living in a Ronald McDonald House located just two blocks from the hospital.

Learn a bit more about each of the four children who travelled to Guatemala. Moving clockwise from top left: Medjine, Rosaica, Michelda, and Marconi.

“So far, two of the kids have received successful surgeries. They went well,” said PIH’s Sybill Hyppolite, RTHC’s program coordinator. “Both are in recovery. They’re spending time with their moms, and other children in the hospital, while they get better.”

The other two children will undergo their procedures in the coming weeks.

Each year the RTHC program connects dozens of Haitian children in desperate need of medical care with hospitals in the U.S. and Guatemala. For the past decade, physicians at Guatemala’s UNICAR Hospital have donated their services to RTHC patients suffering from severe, but treatable, heart conditions. 

“We help our patients travel long distances to access one-time, lifesaving interventions that are not yet available in Haiti,” explained Sybill. “When PIH’s Mirebalais Hospital opens in late 2012 we will hopeful be able to provide these cardiac treatments in Haiti. Until then, we will continue to work with outside hospitals like UNICAR to save these kids’ lives.” 

UNICAR Hospital’s unique cardiac surgery program was started in 1997 by Aldo Castaneda, world-renowned cardiologist and former director of surgery at Children’s Hospital Boston. Since then, the facility has performed operations on 2,000 children with congenital cardiac disease.

The resources necessary for these surgeries – everything from hospital rooms to supplies, rehabilitation to food and lodging – were generously donated by UNICAR and the Rotary Club’s Gift Of Life Foundation.

“We are very grateful to be able to work with such generous and kind partners,” said Sybill.

PIH co-founder Paul Farmer reflects on Mirebalais and meliorism.

On January 25, 2012, Paul Farmer shared his thoughts on our efforts in Haiti two years after the earthquake. In his insightful essay, Dr. Farner reflects back on the enormous achievements gained and the gaps that still need to be addressed as the poorest nation in the Western Hemisphere continues its long journey of recovery.  
 

HAITI: TWO YEARS LATER

I’ve just returned from two brief trips to Haiti. Conditions there are harsh, but improving, and that’s cause for some joy. I wish to translate my own uplift into a New Year’s message of gratitude and determination. Because the backdrop is admittedly stark, it’s only fair to acknowledge the possibility that I am writing this to give myself hope and to spur all of us to launch, continue, or finish some ambitious and urgently needed projects.

On Saturday, January 21, the CBS Evening News's Jon LaPook sat down with Paul Farmer in the new Mirebalais National Teaching Hospital, the state-of-the-art medical complex being built by PIH and Haiti’s Ministry of Health.

You know the phrase: hope is not a plan. But hope is, in our line of work, a necessary ingredient and sometimes the “secret sauce.”

My time in Mirebalais, Cange, and Saint-Marc, our meetings with Haitian officials in the tiny trailer that now serves as the office of the country’s leading public health experts, and even yesterday’s commemorations of the two-year anniversary of the quake, gave me hope—hope worth sharing with all those who support a vision of building back better in Haiti.

To see, in Mirebalais, a lovely and gleaming hospital and medical campus taking shape across what was once a bit of broken terrain running from steep conical hills down to an unproductive rice paddy—more of a swamp, really—is a stirring image for any visitor.

Read "Two Years After the Quake" in its entirety.
Download a PDF of Paul Farmer's essay, "Two Years After the Quake".
Learn more about Mirebalais Hospital.

Marconi (8) suffers from severe subvalvular and valvular pulmonic stenosis – a condition where lesions in the heart valves disrupt the blood flow. He is also epileptic.

In the past few years, Marconi has been admitted to the hospital six times – the last time for more than 3 weeks. 

Marconi lives with his mother, his father and his 10-year-old brother in a town near Port-au-Prince, Haiti. 

Rosaica (3) lives with patent ductus arteriosus and pulmonary hypertension – a heart problem that affects some babies soon after birth, where abnormal blood flow occurs between two of the major arteries connected to the heart. 

Though she has spent little time in inpatient care for her heart condition, she is in need of life-saving cardiac surgery. 

After the 2010 earthquake, Rosaica spent two days under rubble before her family was able to find her. She and her mother live with extended family outside Port-au-Prince.

Medjine (4) is living with severe tetralogy of fallot – a congenital heart defect that keeps blood and oxygen from mixing.

At two months old, Medjine was abandoned by her mother. Her paternal grandmother Marie stepped in to care for the infant and has been by her side ever since.

Medjine was a patient in the pediatric ward of the PIH’s hospital in Cange from February 2010 - April 2011, ensuring she had continual access to oxygen. Her grandmother lived in her room throughout the 14-month stay. 

Despite tremendous strides in its public health sector, the country of Rwanda does not have a single trained pediatric oncologist. In the article, "Harvard Professors Partner in Unique Approach," the Harvard Gazette explores a new program initiated by PIH's Sara Stulac to bring together or “twin” Rwanda physicians with Boston-based pediatric oncologists.

The strategy has cured at least five of 10 children at a Rwinkwavu Hospital in Eastern Rwanda which PIH operates in conjunction with the country’s Ministry of Health. The article goes on to explain that the program has been further developed and formalized through a partnership with several other Boston-based specialists, including pediatric oncologist Leslie Lehmann, a Harvard Medical School assistant professor of pediatrics.

In the article, published December 13, 2011, Dr. Lehmann addresses how the “twinning” approach utilizes and strengthens in-country resources by adding long-distance supervision and treatment-planning. “We show that we can safely deliver care using this model — an American-trained pediatrician supervising a Rwandan-trained generalist — who are together supervised through phone calls from a U.S-based pediatric oncologist,” says Lehmann, who is clinical director of the pediatric stem cell transplant program at Dana-Farber/Children’s Hospital Cancer Center.

Lehmann is expected to present the project's results at the American Society of Hematology’s 2011 annual meeting in San Diego.

Read the full article.

Sonia Pierre (right), Kerry Kennedy (President, RFK Center for Justice) with an elderly Haitian couple who emigrated to the Dominican Republic as children to harvest sugar cane.

As a 13-year-old girl, Sonia Pierre was arrested for organizing a five-day protest that would mark the beginning of her life’s work as a social activist for the rights of Haitians living in the Dominican Republic. Pierre's parents were Haitian sugarcane workers and she was born and grew up in the cane culture of the Dominican Republic. Their community was impoverished and basic human rights were often denied.

After devoting her adulthood to bringing dignity to the bateyes – Dominican sugarcane towns where workers live in barracks – Pierre died December 4, 2011 near the village where she was born, Villa Altagracia, Dominican Republic. She was 48 years old and leaves behind a legacy of advocacy that her family, friends and colleagues at the Robert F. Kennedy Center for Justice will carry ahead. PIH’s Loune Viaud and award winning novelist Edwidge Danticat have written tributes to Sonia Pierre.

In a Philadelphia convention hall packed with scientists, clinicians, and advocates specializing in the prevention of infectious diseases in poor settings, Dr. Louise Ivers was honored by the American Society of Tropical Medicine and Hygiene as the 2011 recipient of the Bailey K. Ashford medal. The award, which recognizes distinguished work in tropical medicine, was presented by PIH co-founder Dr. Paul Farmer.

“For more than eight years, Dr. Ivers has worked in Haiti, leading efforts to implement health and social justice programs, expand clinical services, conduct pioneering research, and respond to the 2010 earthquake and ongoing cholera outbreak,” wrote Farmer in his nominating letter. “To say that she has distinguished herself in the field of tropical medicine does not begin to do justice to her extraordinary skill as a clinician, researcher, educator, and mentor.” Farmer drew parallels between Ivers' career and that of Dr. Bailey K. Ashford, the clinician for whom one of the awards is named. Ashford was deeply involved in organizing the medical response to a devastating hurricane that struck in Puerto Rico in 1899.

The award was presented at the ASTMH 60^th annual convention.

Farmer’s keynote: investments and health equity

In his keynote address, Farmer spoke about the innovative thinking and structural changes needed for advancements in health equity in resource-poor settings.

“Think of the impact we can have when we link our understanding of improvements in people’s lives to policy endeavors that can change the lives of millions,” said Farmer. “The question is how we can build consensus in the scientific community and among our allies, and how we can build coalitions to pull those policy levers more effectively.”

More than treating instances of infection, international organizations must partner with governments to address the root causes of disease, continued Farmer. “If we do not invest in municipal water systems, there will be major outbreaks of waterborne disease.” The cholera epidemic in Haiti stands as one grim example. As of November 24, there had been almost 514,000 cases and nearly 7,000 deaths attributed to the cholera outbreak in Haiti.

Even before the 2010 earthquake, the lack of investment in municipal water systems foreshadowed disaster. In fact, Haiti is the most water-insecure country in the hemisphere if not the world, he added. This is in part due to the “cynical manipulation of foreign aid,” which derailed water projects in 2002 and 2003.

“How long does it take to build public water systems with governments? It takes a long time. We don’t have a long time.”

Dr. Farmer also discussed a 100,000 patient (200,000 dose) pilot cholera vaccination campaign targeting vulnerable populations in both Port-au-Prince and rural communities near the town of St. Marc, where the outbreak first began. The project, slated to begin in early 2012, is a collaborative effort of PIH, the Haitian nonprofit GHESKIO, and Haiti’s Ministry of Health.

Read Katherine Harmon's article from the conference, "Paul Farmer's Prescription for Restoring Health in Haiti--and Beyond," published on Scientific American's website. 

Farmer’s talk was also covered by John Donnelly in his article, “Farmer: It’s all about health equity,” and Meredith Mazzotta’s article, “Paul Farmer on building up Haiti – a long-term investment”.

How new official guidelines for treating HIV are affecting patients in rural Malawi.

By Robbie Flick, Health Programs Coordinator, Malawi

In 2010, the World Health Organization issued bold new guidelines for the management of HIV in poor settings. Two were particularly groundbreaking: initiating anti-retroviral therapy (ART) to patients at earlier stages of the disease, and providing ART to all HIV-positive mothers who are breastfeeding their children.

The first specified starting ART when a patient’s CD4 count (a measure of immune system strength) drops to 350 of the previously recommended 200.  This means that patients begin life saving ART to fight HIV when their immune system is stronger which has been shown to greatly reduce disease burden and mortality. The second guideline virtually eliminates the chance of mother-to-child transmission of HIV. 

Five months ago here in Malawi, the Ministry of Health not only adopted this agenda, but went one step further by providing ART for HIV-positive pregnant mothers for life, helping to protect future children from HIV while providing a plethora of health benefits to the mother.

This agenda filled my thoughts as I traveled down the bumpy, intermittently passable road to Nsambe village. Nsambe is remote and beautiful, surrounded by domes of striated rock, with gently rolling hills punctuated by terraced plots of tilled land extending to the horizon’s blue fog. It is also viscerally poor. Tucked away in the southwest corner of Malawi against the Mozambique border, it feels forgotten by both countries.

I came to Nsambe to understand the real-world impact of ART and the new guidelines by attending an ART clinic conducted in partnership by PIH’s sister organization in Malawi, Abwenzi Pa Za Umoyo (APZU), and the Malawian Ministry of Health. We arrived at the health center and found the long, simple brick structure buzzing with activity.  ART clerks took height and weight measurements for each patients, while Ministry of Health officials organized treatment regimens of brightly colored pills into ziplock bags, with dosing and timing information clearly indicated in black permanent marker.  Staff dressed in sterile white uniform ferried boxes of drugs, food, and paperwork between departments. Exam room doors periodically squeak open and shut as clinicians examine their patients.  I was struck by the harmony of all the different parts working together to bring dignity and care to people living with HIV in this underserved area.

I spent my day with Maggie, an ART clinician with an intense gaze that conveys both her deep passion and compassion for this work and these patients. I noticed how her compassion influences her work—a gentle question, a comforting touch, and a look of concern that immediately put her patients at ease.

I quickly realized the profound impact of ART care directed by the new guidelines through the stories of Maggie’s patients. The first patient we saw tested positive for HIV earlier this year, but her CD4 count was too high to initiate ART. Now pregnant, the old guidelines would have put her on ART monotherapy in her third trimester, but only until the birth of her child. Under the new guidelines, Maggie was able to immediately start her on a robust triple therapy drug-regimen, allowing her to begin fighting the infection early in her pregnancy and dramatically reducing the chance of transmission to her child.  Further, she will continue ART for life, providing greater protection to her child while breastfeeding and even further reducing the chance of transmission for future children. Maggie also wasted no time in arranging for her to attend group therapy to help address the psychological burden of the disease.

Later we saw Janet, a community health worker for APZU. Several years ago, she was sick from a co-infection of both tuberculosis and HIV. APZU’s outreach ensured that she received the drugs she needed, and she has been on ART ever since. Today, she is fit, healthy, and capable of working the long days required of health workers. In fact, she had come to the clinic with another woman who was seven months pregnant. Maggie prescribed the life-saving drugs for her that day.

These patient stories were echoed in the stories of other patients I met throughout the day. The bold new guidelines and PIH’s partnership with the Ministry of Health to implement them in underserved areas are truly helping patients receive the life-saving treatment they need to remain healthy, and to dramatically reduce the chance of transmitting the virus to their children.

By necessity, guidelines like those impacting the patients I saw at Nsambe are formulated in hermetic conference rooms insulated from the gritty reality of the patients suffering from complex diseases. Yet, the human stories I’ve heard here in rural Malawi boldly underscore the value of ambitious government guidelines and PIH’s human rights-based approach in delivering services to the district’s most vulnerable individuals.  Without these two components, patients are needlessly denied access to the only intervention that will prolong life, reduce the burden of disease, and protect their children from transmission.

For the past 18 months, construction crews have worked tirelessly to build Mirebalais National Teaching Hospital, an impressive 180,000 sq. ft. complex that will soon be home to Haiti’s largest public teaching and referral hospital. Scheduled to open in 2012, the project is the cornerstone of PIH's efforts to help the country rebuild following the devastating 2010 earthquake. At a time when Haiti desperately needs skilled professionals, the facility will provide high-quality education for the next generation of Haitian nurses, medical students, and resident physicians.

Before a massive earthquake struck Haiti on January 12, 2010, PIH had been planning to build a new community hospital in Mirebalais, a city just 30 miles north of Port-au-Prince. Then the earthquake struck, leaving most of the health facilities in and around Haiti’s capital in ruins. Responding to an urgent appeal from the Haitian Ministry of Public Health and Population (MSPP), PIH quickly scaled up its plans.

Just two years after the earthquake, Mirebalais Hospital is only months away from opening its doors to patients seeking outpatient health services. When complete, the 320-bed hospital will accommodate an estimated 500 ambulatory visits each day and require the services of hundreds Haitians employees — becoming the largest single source of employment in the area.

By the close of 2012, PIH will roll out expanded services like maternal and child health, radiology, CT scans, and surgical care. In early- to mid-2013, special services will begin, including neonatal intensive care and expanded surgical operations. In mid-2013, advanced medical and nursing education and training will begin at the hospital, with Haitian students receiving training in comprehensive and innovative care.

Once the hospital is running at full capacity, it will have over 30 outpatient consultation rooms, six operating rooms, and space to host trainings with over 200 participants. It will offer innovative technology — some of which was previously unavailable in Haiti — including digital radiography, a full-body CT scanner, teleconferencing capabilities, solar panels that will fully power the hospital during the day, on-site waste water treatment, and wall-mounted oxygen for over 60 percent of inpatient beds. The hospital is also designed to withstand earthquakes and high-winds from tropical storms. 

The hospital will be operated in partnership with the national government. Over time, financial responsibility for the hospital will gradually transition from PIH to the government, with the government assuming control of most of the facility by 2021. 

Read more stories about the construction of Mirebalais Hospital.
Learn more about Mirebalais Hospital.

PIH's training team presents how they train community health workers and develop training materials at the American Public Health Association annual meeting.

By Kate Thanel and Jenny Lee Utech, PIH Training Team

Last month, PIH’s Training Team joined thousands of public health practitioners in Washington DC at the American Public Health Association (APHA) annual meeting. We were excited to meet others who worked with community health workers (CHWs), but we were a bit overwhelmed by the size of the conference – 12,000 people! Fortunately, we presented our work at a roundtable—a small, informal session where we could talk directly with groups who work with CHWs across the US and abroad.

At this session, we explained how CHWs are the backbone of PIH’s community-based approach to delivering health care. The work they do at PIH-supported sites around the world is varied and wide-ranging: educating the community, households, and individuals; connecting far flung rural communities with the health center or hospital; working with patients to help them adhere to drug regimens; responding to patient and family concerns; and providing psychosocial support.

Our trainings must prepare PIH CHWs to handle all of these roles and responsibilities, and also master basic clinical content. How do we manage to do this when the local situations and the CHWs themselves, can be very different from one site to another? It’s a long process! We communicate and collaborate with the clinical and community health program staff and the Ministry of Health officials at each site. These local partners define what CHWs need to be able to know and do, and we develop training materials to teach these skill that utilize learning activities that can be adapted to suit each specific context. The review process continues back and forth until all partners are satisfied that the materials are accurate, comprehensive, and relevant.

Learn about the PIH's Accompagnateurs Curriculum for CHWs.

During the APHA roundtable, we also explained how we pilot CHW training materials once they have been written, reviewed, and finalized. We want to find out how the CHWs respond not only to the particular training materials, but also to the training program as a whole. The pilot trainings help us test the program and structure at our sites in Rwanda, Lesotho, Malawi, and Haiti. First, we hold a Training of Trainers (TOT) for clinical staff, usually nurses, who will be the ones that train the CHWs. The TOT strengthens the teaching and facilitation skills of the clinicians, as well as their and knowledge base. It also helps to build the structure and on-the-ground skills needed to support a strong and on-going training program.

	Preparing oral rehydration solution during a cholera training at Zanmi Lasante, Haiti.

During the TOT, trainers get the chance to practice role plays, case scenarios, and other activities –all participatory methods that have been proven to be the most effective with adult learners. We’ve seen TOT participants respond very positively when they try out these methods themselves. They’re able to draw on their own experience and expertise as they practice new skills and information. They also practice giving demonstrations ranging from mixing baby formula, to using condoms correctly, to preparing oral rehydration solution, all while the other participants observe them and provide feedback.

We’ve found that the lessons learned from these experiences stick with the training participants long after the training is over. As one participant from a TOT at Zanmi Lasante said, “I see myself as a different trainer now. I now have the knack and the necessary basics for training adults and to plan better all around.”

After the TOT, the new trainers deliver the training to CHWs over several sessions. During the training sessions we evaluate the materials, the trainers’ delivery, how well the training is organized, and how all the planning and logistics required before and during the training affect training delivery. We designate observers to provide us with daily feedback, we also arrange focus groups for participants and trainers, and we give pre-and post-tests to participants. These tools help us to see what’s feasible and what needs to be changed.

We shared these pilot testing experiences with roundtable participants at the APHA conference, who all asked us the same question: How could they get all those involved in a CHW program—clinical staff, administrators, program managers, government officials—to support the piloting of CHW training? We pointed to the success of the very first pilot of the CHW curriculum at our site in the Dominican Republic. The local program director invested time and effort meeting with key decision makers in the community, hospital, and government to plan the pilot and to follow-up afterward. She also made sure there was adequate preparation time for trainers, and sufficient budget and time to run the TOT and CHW training sessions. These strategies are part of a checklist of questions we devised to help trainers plan and carry out a successful training pilot. 

Our CHWs are dedicated to their work. Conducting a thorough pilot helps us to improve the training programs that CHWs rely on to do their jobs well. As one CHW from Zanmi Lasante put it during a recent pilot training, “During this training, we learned new information that fortified our will, our determination, and our competence to better treat our patients.”

Kate Thanel is the Curriculum and Training Specialist for Zanmi Lasante, PIH's sister organization in Haiti. Jenny Lee Utech is PIH's Curriculum and Training Manager. 

On December 1, World AIDS Day, thousands of Peruvians attended an HIV health fair held in one of Lima’s central parks. Participating Peruvian organizations working in human rights, stigma and discrimination, family planning and sexual health set up informational booths, organized games and distributed tools needed to curb HIV.

PIH’s sister organization in Peru, Socios En Salud (SES), filled its booths with games and contests aimed at teaching people about HIV in a dynamic and participatory way. Many of the outreach efforts were geared towards young people. Staff was incredibly pleased with the high student turnout.

Focusing their efforts a bit more, SES also conducted an awareness campaign at the National Police Force Technical School. About 400 first and third year cadets participated in the lecture, which focused on HIV prevention. The activity exceeded expectations as the National Police Force authorities expressed interest in continuing prevention-promotion work for tuberculosis and HIV/AIDS.

The day’s events were organized by the Ministry of Health, SES, municipal districts and the grassroots collaborative COSACA, a coalition of community organizations and health promoters from the region.

View more images from the day’s events.
Learn more about PIH’s work in Peru.

Sonia Pierre and Loune Viaud, both winners of the RFK Human Rights Award.

Greetings Dear Sonia,

I am writing you this letter although I know very well it will not reach you as I witnessed your burial this afternoon at 2pm, at Villa Altagracia, San Cristobal’s cemetery.

Pierre and Viaud share time with friends in Haiti.

But, it doesn’t matter because you are not "dead" for us… You are living in our hearts and souls. When we are with your mother Delcam and the children Manuela, Carlos, Leticia, Humberto, Gaël, Israel and everyone at MUDHA, we see you in them.

Lots of people showed up and talked at your funeral. Lots of words of admiration and praise for you for which we are grateful and very appreciative BUT the only way to honor you, the only way to keep you alive is to continue the work! You showed us the way; we need to reach the destination.

In this letter which you are not going to read but a letter to myself to share with others, I want to say that I am committed to work with Marisol, Sirana, Lily, Ninaj, Jocelyne, Nancy, Lody, Colette, Marshela, Kerry, Lynn and team at RFK Center to find ways in which the work can go on.

I am so grateful that I had a chance to share a quality moment with you in Léogâne this past summer at MUDHA’ s graduation ceremony for the first class of young professionals. Unfortunately, you left us in a hurry, too fast and too soon.

Everyone I had a chance to talk to at the funeral told me that they want to continue the journey with great hope that your spirit will guide us.

As Lody said in her note upon hearing of your death: "a solid woman like Sonia can’t disappear with death."

With much respect,

Loune Viaud, RFK Laureate 2002

San Cristobal, 12/7/2011

--

Bonswa Sonia,

Mwen ap ekri w lèt sa byen ke m konnen ou pap li l paske mwen fèk sot temwen ke ou  antere nan Villa Altagracia, San Cristobal.

Men sa pa fè anyen paske ou pa mouri pou nou… ou toujou ap viv nan kè nou. Lè nou wè manman w Delcam, timoun yo Manuela, Carlos, Leticia, Humberto, Gaël, Israël ak tout ekip MUDHA a, se ou menm nou wè.

Anpil temwayaj jou sa yo sou ki lit ke w te ap mennen. Anpil bèl pawòl ke nou apresye men sèl fason pou nou onore memwa ou, sèl fason pou w pa mouri, sèl fason pou moun pa bliye w, se kontinye travay la, swiv chimen ke w te trase pou nou an.

Nan lèt sa a, ke w pap li men ki se yon lèt pou tèt mwen ke mwen vle pataje ak tout moun, mwen vle di w ke mwen pran angajman pou chita ak Marisol, Sirana, Lily, Ninaj, Jocelyne, Nancy, Rose-Anne, Colette, Marshela, Kerry, Lynn ak tout ekip Robert F Kennedy Center a pou nou gade kijan pou nou kontinye batay la.

Mwen te kontan gen chans pataje seremoni gradyasyon leogane nan ak ou. Men ou kite nou twò vit, twò bonè.  Tout moun mwen gen chans pale di ke yo ap kontinye wout la ak lespwa ke w va gide nou.

Jan Lody di a «Fanm solid kou Sonia pa ka disparèt ak lanmò ».

Ak anpil respè.

Loune Viaud, RFK Laureate 2002

San Cristobal, 7 desanm 2011

By Benjamin Ndovi, IT Coordinator, Malawi

	Benjamin Ndovi at work in Malawi.

The majority of the focus related to the modernization of medical records is placed on developed countries. However, developing countries are also progressing from paper-based records to electronic records. The requirements of their systems can be dramatically different from those of the developed world.

Malawi, one of the developing countries, has shown quite a remarkable focus and determination in the application and usage of the electronic medical records (EMR). With a case study of the rural Neno District of Malawi (the place where I am working), it was shown that almost every service -- from medical to physical, from the hospitals to the households -- depends on quality input and measurable, quantified accurate outcomes. This data can be used for monitoring and evaluation, future reference, continuity guide, and community sensitization toolkits. The need for sending data electronically has  been a major priority in Neno. In January, 2010, we had about 20 computers using our internet/network. Just one year later, the population has increased by approximately 112 percent. This growth has taken us into the need for bandwidth/traffic control measurements and a larger field of computer management.

This shows that there are lot of people, not just the health workers, but also people in the community who are utilizing the system, which has been a priority for communication and data processing, as well as for entertainment and social interaction. One effect that has caused this development is lack of communication facilities in this part of the country. The second is the initiative by Partners In Health to share with the community a passion for real-time, accurate information in order to sustain better health care in the homes of local families. This has enhanced the use of computer-generated reports, such as reports that track patients who default on drug regimens, and basic demographic information of local households.

Getting a view from a local community member’s perspective, most of the information we acquire is what we think is necessary. So when the information is used and processed, how does the each individual gain? This is one of the problems that developing countries have faced while working to enhance the use of technology on health care development -- in addition to resistance and lack of knowledge. Addressing these issues brings in a concrete understanding between the specialists and the community themselves.

Therefore, in addition to data entry, review, analysis and reporting, EMR offers a wide range of pillars for decision-making in order to come up with timely and effective health care.

This piece was originally posted on the Global Health Corps blog. Benjamin Ndovi is the IT Coordinator for PIH's sister organization in Malawi, Abwenzi Pa Za Umoyo. He is a Global Health Corps Fellow. 

IHSJ Reader     December 2011     Issue 13         

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

HIV/AIDS

Decline in AIDS Funding Risks Jeopardizing Recent Gains Made By Countries (UNAIDS, November, 27, 2011)
The past decade has seen incredible gains in the treatment and prevention of HIV/AIDS, but this progress is facing severe threats from a decline in resources available for HIV/AIDS programs in low- and middle-income countries. In response to financial challenges, the Executive Director of the Joint United Nations Program on HIV/AIDS (UNAIDS) argues that new sources of funding are necessary to maintain the life-saving momentum of the AIDS response, including the implementation of a financial transaction tax and reprioritizing AIDS investment.

Board Cancels Round 11 and Introduces Tough New Rules for Grant Renewals (Global Fund Observer, November 23, 2011)
The Global Fund to Fight AIDS, TB and Malaria (GFATM)—the most successful global health funding mechanism to date—has been forced to indefinitely suspend the financing of new grants. The cause is clear: both government and private sector donors have broken their financial promises to fund the fight against the world’s leading infectious killers.  Yet, in just ten years, the GFATM has saved more than seven million lives and fortified health systems in many of the world’s most impoverished nations. Partners In Health strongly urges the U.S. Congress to protect life-saving global health investments, including at least $6 billion for HIV/AIDS and PEPFAR with $1 billion for the GFATM in the 2012 State and Foreign Operations Bill.

How to Get to Zero: Faster. Smarter. Better.  (UNAIDS World AIDS Day Report, 2011) +
Nearly 50 percent of People Who Are Eligible for Antiretroviral Therapy Now Have Access to Lifesaving Treatment (Press Release, UNAIDS, November 21, 2011)
The Joint United Nations Program on HIV/AIDS released the 2011 World AIDS Day report last week. It presents the remarkable successes that have been made in the HIV/AIDS response over the past year. Between declines in HIV/AIDS related deaths and new infection rates, gains in the number of eligible people accessing treatment (6.6 million total or 47 percent) and research revealing that AIDS treatment reduces HIV transmission by 96 percent, the world is on the verge of a significant breakthrough in the AIDS response. Continuing this momentum and reaching ambitious targets, like zero new HIV infections, will be possible only if innovative partnership and investment continue.

HIV-Free Survival and Morbidity Among Formula-Fed Infants In a Prevention of Mother-to-Child Transmission of HIV Programs in Rural Haiti (Louise Ivers, Sasha Appleton, Bingxia Wang, et al., AIDS Research and Therapy, October 12, 2011)
The results from this study highlight the success and feasibility of using breast milk substitution for prevention of mother-to-child transmission (PMTCT) for non-breastfeeding mothers with HIV living in rural Haiti. Worldwide, an estimated 2.5 million children are living with HIV; most were infected through mother-to-child transmission either during pregnancy or through breastfeeding. But we have the tools to eliminate new infections among children. PIH and our sister organization Zanmi Lasante previously supported mothers enrolled in the PMTCT program who chose not to breastfeed with the tools necessary to exclusively formula feed during the first nine month of life—including infant  formula, food support, clean water, education and accompaniment. This report acknowledges that the feasibility of success in similar programs depends on access to clean water and the existence of strong health systems that are able to provide integrated health services, including community education.  Our programs in Haiti now offer women the option to use formula or take antiretroviral therapy according to new Ministry of Health protocols to avoid infecting their infants.

HAITI

 Haiti Reconstruction: Factors Contributing to Delays in USAID Infrastructure Construction (United States Government Accountability Office, November 2011)
This new GAO report analyzes delays in USAID and State Department reconstruction projects across multiple sectors in Haiti. Most alarmingly, the report finds that USAID has expended a mere $3 million of the $412 million allocated for infrastructure projects due to perilous delays in the hiring and deployment of technical and program staff.  Partners In Health recommends increased transparency and reporting so civil society partners can work with USAID and other funding partners to help identify and pursue strategies to rectify implementation gaps.

FOOD SECURITY

The Famine Next Time (Samuel Loewenberg, The New York Times, November 26, 2011)
Drought has been plaguing the Horn of Africa for over a year, but media and donors failed to act until it was too late for many. When attention finally shifted to the casualties of the hunger crisis, international actors ignored the root of the problem—poverty—and attempted to treat the hunger by simply providing food supplies. These food packages cut the value of food aid in half, according to the U.S. Government Accountability Office, and ignore the medium- and long-term needs of affected communities. Instead of dropping food packages, investment should be made in sending cash for local purchase and developing local agriculture and infrastructure. 

WOMEN’S HEALTH

The Other Half of the Story: The HPV Vaccine in Rwanda(Patrick Adams, Dowser, November 23, 2011)
When Dr. Agnes Binagwaho, Rwanda’s Minister of Health, was asked if she was concerned about whether vaccinating preadolescent girls against human papillomavirus (HPV) might lead to promiscuity as social conservatives in the U.S. have warned, she responded “You believe that the day we have a vaccine for HIV, we are going to fight it? In Rwanda, people don’t link this vaccine with sex; they link it with a cancer that kills women.” This article highlights Rwanda’s roll-out of the third and final phase of the nationwide HPV vaccination for 12-15 year old girls. The progress that has been made in Rwanda since the 1994 genocide is remarkable and the success of this vaccination program reflects the dramatic improvements in access to comprehensive health services.

NON-COMMUNICABLE DISEASES

PEPFAR Opens the Door: Integrating HIV/AIDS with an NCD (Jeff Meer, Dialogue4Health, November 21, 2011)
Though the U.N. High Level Meeting on Prevention and Control of Non-communicable Diseases held in September provided an opportunity to unite governments, activists, and experts, it failed to secure meaningful financial commitments. The Obama administration has recently stepped up to this task by agreeing to expand the President’s Emergency Plan for AIDS Relief (PEPFAR), in collaboration with the George W. Bush Institute, to incorporate cervical and breast cancer screening and treatment. This new public-private partnership, known as Pink Ribbon Red Ribbon, presents a good example of building upon successful global health platforms to integrate additional health services and provide comprehensive care to patients.

How the UN Can Undo Damage From Chronic Disease (Jean-Luc Butel, Fox News November 18, 2011)
Eighty percent of the 36 million deaths each year from non-communicable diseases (NCDs) are felt in low- and middle-income countries. Such endemic diseases cannot be addressed by government and non-governmental organization action alone; rather they must join forces with multilateral agencies and private sector actors to foster partnerships that encourage innovative approaches to combating NCDs. Integrating NCD care into existing primary health care programs requires these diverse partners to work together to develop strong health systems and encourage the development of local infrastructure.

IDF’s Advocacy Guide to the Political Declaration From the 2011 UN High-Level Summit on NCDs (International Diabetes Federation, November 2011)
The International Diabetes Federation developed this Advocacy Guide following the September United Nations High-level Meeting on non-communicable diseases. It provides a detailed analysis of the promises made by governments in the U.N. Political Declaration, as well as guidance on how to advocate for expanded NCD programs at the national, regional and global levels. Partners In Health remains engaged in service and advocacy efforts aimed at increasing access to comprehensive health care for the poor, including the prevention and treatment of non-communicable diseases.

Images to commemorate World AIDS Day and PIH's efforts around the world to help end AIDS.

In Haiti, communities pull together to honor the International Day Against Gender-Based Violence on November 25.

On Friday, November 25th, across the Central Plateau and throughout all of Haiti, women and men and boys and girls came together to educate each other and publicly decry gender-based violence in Haiti. In Belladère and Lascahobas, hundreds of high school students gathered in large community centers to listen to PIH/Zanmi Lasante community educators and clinicians as well as their peers, community theater groups, and public officials share about types of gender-based violence (GBV), ways to prevent GBV, and resources available in case of emergency. In honor of International Day Against Gender-based Violence, this year’s slogan, supported by the Haitian Ministry of Women’s Conditions and the National Coalition against GBV, “Konbat vyolans sou fanm ak ti fi yo se zafe nou tout. Ann pote kole!” (Combating violence against women and girls is all of our jobs. Let’s work together!), encouraged everyone from all sectors of society to rally around the cause and not keep silent.

	Honoring International Day Against Gender-Based Violence in Belladere, Haiti.

In Belladère, a community theater group, Kumbaya, performed a skit depicting a wealthy man raping his young servant girl, only to end up in jail after thinking that he could bribe his way out. Psychosocial support and a medical exam and certificate were quickly arranged for her, and justice was pursued. Hundreds of women from organized women’s groups later joined forces with the high school students, accompanied by two prominent female senators, Hugette L’Amour and Cémephise Gilles, to continue the day-long conference focused on a call for justice and education.

In Hinche, women’s groups organized a ceremony of reflection with representatives from both the public and private sectors (the Ministry of Women’s Conditions representative for the Central Plateau, local representatives, the police chief for the region, the justice system, mayor’s office, the UN, the press, and Zanmi Lasante), calling for a collective, organized effort to end gender-based violence. Ernst Origene, psychosocial team coordinator for Zanmi Lasante’s GBV work, called for the inclusion of religious leaders, schools and universities, youth groups, the press, and the private sector in the fight.

	Speaking out against violence against women in Lascahobas, Haiti.

In Lascahobas, Zanmi Lasante community educators along with the Medical Director, Dr. Wakendy Mirthyl, spoke about the importance of getting to medical care within 72 hours after an act of sexual violence has occurred, to not only prevent STIs and unwanted pregnancy, but also to help facilitate the judicial process. A teenage girl shared about her experience with gender-based violence, and the fact that it can’t be combated in isolation. Having social workers, physicians, psychologists, the justice system, human rights organizations, the police, and community members all working together for prevention and treatment in a concerted effort is unprecedented and is encouraged to continue. In addition, in Lascahobas and Mirebalais, women’s groups organized rallies and marches to bring attention to violence that exists in society and call for ongoing efforts to pursue justice.

Zanmi Lasante teams focusing on women’s health, psychosocial, and prevention projects worked together to make this day a success, with funding support from the UNFPA and the U.S. Department of State. This day is just one in a series of hundreds of activities and trainings organized by Zanmi Lasante teams in the border regions with the Dominican Republic—an area where there are notoriously high rates of sexual violence—over the past months as part of a larger project to increase prevention and education efforts around issues of GBV.

Iguenson Joseph stands on the roof of Mirebalais Hospital, set to open in early 2012.

By Andrew Johnston

­Mirebalais, Haiti – On a team of hard workers, Iguenson Joseph, 27, is a standout performer. Although Iguenson had no construction experience when he joined the project in early 2011, he has become a very important member of the team.

Iguenson brings energy to Mirebalais Hospital construction team in two senses of the word. From the start, he has had a strong and resonant sense of team spirit. Iguensen joined the project as a laborer and security guard. During his first weeks on the project, some of the workers called him “Ti Chèn” or “little chain” because he opened and closed the chain at the main gate. 

Iguensen Joseph working on an electrical pole outside Mirebalais Hospital.

Enthusiastic and personable, he soon got to know many members of the team. Through a casual conversation, John Chew, a PIH staffer, learned that Iguensen spoke English and had some electrical training. Iguensen was then reassigned to the electrical team. Through hard work, eagerness to learn, and enthusiasm, Iguensen soon distinguished himself on the challenging task of building the electrical system for the Mirebalais hospital.  

“You never know who you have around you,” says John Chew. “If you never take time to ask people how they are and what they do, you can miss out on big opportunities.” 

Over the past months, Iguenson has worked closely with a series of experienced electricians from the U.S. who donate their time to the project. He has installed switches, breakers, lights, and fans. In the process, Iguenson and others learn skills that are crucial for the reconstruction of Haiti.

Sound construction skills and experience are particularly important for this generation of Haitians, because construction skills are in demand now and improper construction was a main cause of injury and death during the January 12, 2010 earthquake.

It’s an exciting time for the electrical team as lights and fans have just been installed and are now running in much of the hospital. It’s difficult to pull Iguenson away from wiring the Women’s Outpatient Ward, but I sit him down for a short break on 4:30 on a Friday evening. Brucely Joseph, a Haitian American engineer assigned to a PIH agriculture and livelihoods project provides Creole translation. 

Although Iguenson has been working hard since 6:00 AM, he has an easy smile and the relaxed, upbeat demeanor of someone who likes what he does and is good at it. In a few minutes, he will be back to his work amid wires, switches, and conduits. He will finish after dusk and start again with the rest of the Mirebalais team early Saturday morning.

Andrew: Thank you for taking a break to speak with me. How long have you worked on this project?

Iguenson: For about eight months.

Andrew: Why did you choose to work here?

Iguenson: For me, it’s important, there are not many hospitals [in Haiti]. For me, this work is a pleasure. I give all my wishes for this work to be a success.

Bringing power inside Mirebalais Hospital.

Andrew: What do you do here?

Iguenson: I do all but especially electricity – electrical technician. I also help out by translating between Creole and English for workers on the site.

I do this to help my country. I do this to help my family too. I have two kids. My daughter, Truerlie, is two years old and my son, Tomson, is two and a half months. 

Andrew: What does your family think? 

Iguenson: My family likes it very much that I am doing this work. Before this project, I worked as a teacher and I did not earn as much. As a teacher, I could not provide much for my family.

Andrew: What do you want for your children?

Iguenson: I want them to go to school and take the hard subjects, and to continue on to university. I was studying physics but had to stop before graduation. I want them to be able to finish. 

When I was two, my father died. We did not know if I would ever go to school. My cousin paid my tuition to school on condition that I do well. I did, I never repeated a single class. I have five sisters and one brother. One is married, the rest are in school in Mirebalais.

I want to give my children what I don’t have – even a laptop. That’s development.

Andrew: What are your future plans? 

Iguenson: Even after construction is finished, I would want to keep working here. I have gained a lot of experience, great project work with the volunteers who have come down from the states. I have installed large safety switches and panel breakers; this is rare in Haiti. I want to keep working and study electricity.

Andrew: What about working on such a large, diverse team?

Iguenson: We work very well together, the Haitians and the American volunteers. Tom, a volunteer, was very important to me. He encouraged me. He often said that he liked my work. He supported me. He trusted me. We still talk on the phone every weekend. I do not like it when foreigners give only money. I also want respect and opportunities to work and learn. When my son was born, I named him Tomson, to remember my friend in the U.S. I met people who I would never have expected or hoped to meet. 

Andrew: How has Mirebalais changed since the earthquake?

Iguenson: People are moving here from Port-au-Prince. More foreigners have come.

The Hospital will be a big change in Mirebalais. Lots of people die when there is not a hospital.

I wish a change for Haiti and the world. More honesty, less insecurity. Much less economic stress. The way the economy is now here, you can’t afford health care. More economic opportunities are necessary. Many other towns in Haiti need hospitals. We must work to develop our country.

“We must work together and collaborate to make this project a success for us and because of all of the support,” Iguenson proudly declares. “We work harder and harder every day to make it a success.”

And with that, Iguensen gets up and heads back to Women’s Health to return to his work with wires, switches, and electrical conduits.

Andrew Johnston works on the Mirebalais Hospital project in Haiti.

Read more about Mirebalais Hospital. 

Just yards away from Rwinkwavu Hospital on a softly sloping hill, a series of well-irrigated and fertilized gardens burst with healthy pineapple plants, rows of cabbages, and avocado trees. These gardens represent the hard work and vision of Sebu Gaston, the director of the Agriculture Assistance Program supported by Partners In Health and its Rwandan sister organization, Inshuti Mu Buzima (IMB).

Sebu Gaston, Director of PIH's agriculture program in Rwanda, points to rows of vegetables. 

Malnutrition in Rwanda 

• 43% of child deaths are attributed to malnutrition

Agricultural Assistance Program Making a Difference

• Of 66 families surveyed, average food security increased from 39% to 62%

Goals for 2012 

• Expand Kirehe and Burera agricultural programs
• Expand to 3 health centers
• Expand animal distribution program

Gaston and his team of 22 Agriculture Assistance Workers (AAWs) form the modest but growing agriculture program, designed to combat malnutrition among patients at PIH-supported hospitals in Rwinkwavu, Kirehe, and Butaro. Food insecurity is a severe problem in Rwanda. “Chronic undernutrition and stunting remains stubbornly high at 45 percent nationwide,” said Dr. Peter Drobac, IMB Program Director. The stark reality is children who are chronically hungry become far more vulnerable to diarrheal illness, bacterial infections, physical stunting, intellectual impairment, and death. In Rwanda, 43 percent of child deaths are attributed to malnutrition. 

Gaston and his AAWs work most frequently with the mothers of children being treated for malnutrition in Rwinkwavu Hospital’s pediatric ward. Mothers receive training in the gardens twice a week on best practices for creating compost, planting vegetables, raising livestock, and cooking well-balanced meals for their families. During the initial three months of training, the mothers receive food packages for their children. Training then continues for at least nine months, with home visits from AAWs to advise and check on their progress. 

PIH/IMB’s agriculture program features a homestead on a small plot of land, representing the average space Rwandan families have for gardening. Gaston points out that soil, especially in southern Rwanda, is shallow. This prevents roots from spreading. To tackle this problem, his program teaches women to build tiered gardens, and to fill tires or sacks with a combination of soil and compost. The small compact gardens can bear some very vitamin-rich vegetables including cabbages, onions, carrots eggplants, and beets.

Agricultural Assistance Workers create a tiered garden to allow vegetables' roots to spread. 

Women who complete the agricultural program training can reap lasting rewards. After completing one year of training, they are given seeds, small grafted plants, and farming tools. After two years, some become eligible to receive livestock -- either a pig or goat -- and a rabbit that produces manure to help with composting.

Already, the Agricultural Assistance Program is bearing fruit. A survey based on 66 families found that after 12 months of training and education, their food security increased from 39% to 62%. And within the last two years, the malnutrition rate in the community of Kirehe has dropped nearly eight-fold. “This is where we believe our agriculture program can make a real and lasting difference,” said Dr. Drobac.

Read more about PIH’s efforts to battle poverty and illness by providing access to food, clean water, and adequate housing.

Drive down any road in Rwanda and you’ll find children walking — some for miles to the nearest water pump, some carrying tinder for their mother’s cooking fires and others on a journey by foot to school.

Most children walk in dust covered plastic sandals which in most cases, are the only shoes they’ll come to own during their growing years.

	In this Rwandan community, most children only have dust-covered plastic sandals to wear during their growing years.
	The Mayor of Kayonza in Rwanda joined a TOMS Shoes distribution at a local school in his community.

On November 10th and 11th, PIH staff distributed new TOMS Shoes to thousands of school children in Rwanda’s southern Kayonza and Kirehe Districts. “We are so happy that TOMS Shoes are supporting school children here in Rwanda because we think they make up the next generation of leaders,” said TOMS Shoes Senior Giving Accountant Manager, Jenise Steverding who joined PIH staff for the distribution.

PIH began its two-day shoe distribution at a rural school which serves nearly 1,000 children from grades one through six. Before the shoes were distributed, the children gathered for a ceremony with the Mayor of Kyonza who used the opportunity to remind the eager children to practice good hygiene, stay in school and to hold tight to their brand new shoes.

TOMS Shoes, based in California, was founded on a One for One model. The company gives a pair of shoes to a child in need for every pair of shoes they sell . PIH has partnered with TOMS to ensure healthy, well protected feet for children in Haiti and Malawi. This was the first shoe distribution in Rwanda PIH has done.

“Our goal isn’t simply to give shoes one time, but to continue to provide shoes to PIH for these children as they grow, so together we can truly have an impact on the health and well-being of this community,” said Steverding.

Children in Malawi also received new TOMS Shoes. Learn more. 

IHSJ Reader     November 2011     Issue 12         

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

GLOBAL HEALTH FINANCING

How We Can Save Millions of Lives (Paul Farmer, Washington Post, November 17, 2011)
Partners In Health exists to provide a preferential option for the poor in health care, because every year, nearly ten million people die of entirely preventable and treatable diseases. The vast majority of the world’s poor still lack access to the medicine, food, and water that would prevent these “stupid” deaths. Still, public health victories are possible. In only ten years, antiretroviral therapy (ART) for AIDS has gone from being virtually unavailable in developing nations to being provided for more than 6 million people. Initiatives like the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) have made many global public health advances possible, but this progress can only be sustained through robust political and financial support for global health programs.

Innovation with Impact: Financing 21^st Century Development (Bill Gates, November 2011) +
Bill Gates’s Plan to Assist the World’s Poor (Bill Gates, Washington Post, November 1, 2011)
Bill Gates’ report to the G20 heads of state calls on global leaders to fundamentally shift the way we think about financing development. In addition to the vital role of official development assistance (ODA), Gates argues that a financial transaction tax is feasible and could generate substantial resources--to the tune of $48 billion annually. Other opportunities for revenue include: legally binding measures to enforce transparency in the oil, gas and mining sector; advanced market commitments for new products; innovative partnerships with emerging economies such as China and Brazil; taxes on tobacco and shipping; and minimal transaction costs on remittances. Meanwhile, wealthy countries such as the US should take steps to invest 0.7% of GNP in poverty-focused ODA and improve the effectiveness of aid.

HAITI

Making Nutrition a Sustainable Business in Haiti (Duff Wilson, New York Times, November 1, 2011)
Ready-to-Use Therapeutic Food (RUTF) is a vital tool in the fight against child malnutrition.  In 2007, PIH and our Haitian sister organizations began manufacturing RUTF locally. In 2010, Zanmi Agrikol (Haitian Creole for “Partners In Agriculture") manufactured 56 tons of Nourimanba and Zanmi Lasante (“Partners In Health”) effectively treated thousands of severely malnourished Haitian children. Partners In Health believes that high quality RUTF should be produced locally wherever possible to increase access to treatment and strengthen local economies. This partnership with Abbott Laboratories will increase the quality and quantity of Nourimanba production in Haiti.

Over 5,000 Haitian Cholera Victims Sue UN, Seeking Justice (Press Release, Institute for Justice & Democracy in Haiti, November 8, 2011)
On November 3^rd, over 5,000 Haitians affected by the devastating cholera epidemic submitted claims to the United Nations (UN) and the United Nations Stabilization Mission in Haiti (MINUSTAH). In addition to seeking a public apology for MINUSTAH’s introduction of cholera into Haiti, the victims’ claims demand individual financial compensation, in some cases, for loss of family members. These claims are based on the UN and MINUSTAH’s liability in failing to screen and treat peacekeeping soldiers, dumping untreated wastes into a tributary of the Artibonite River, and failing to adequately respond to the epidemic that has killed over 6,600 Haitians.

New Haiti Cholera Campaign Faces Tough Questions (Trenton Daniel, The Guardian, November 9, 2011)
Partners In Health and GHESKIO will be rolling out a cholera vaccination campaign in January 2012 as part of a comprehensive approach to slowing cholera in Haiti. Complementary interventions include continuing to educate communities on prevention measures, providing access to clean water and latrines, treating infected patients, and advocating to build water and sanitation systems. Representatives from the WHO and other organizations have expressed doubt as to the success of the vaccination program because of the purported complexities that surround it (each patient must receive two doses and the vaccine must be stored at a refrigerated facility). However, strong community connections and the extensive community health worker network will make it possible for PIH and our partners to successfully reach and retain patients.

TUBERCULOSIS

 A TB Breakthrough: The “Espresso” Machine (John Donnelly, GlobalPost, November 13, 2011)
In this GlobalPost article, John Donnelly explores the opportunities and challenges surrounding the GeneXpert tuberculosis (TB) diagnostic (aka “espresso”) machine in the Philippines. The standard way of diagnosing TB typically takes weeks in low-resource settings--and depends on technology that has been around for more than half a century. With the introduction of DNA-based rapid diagnosis, patients with access to GeneXpert technology can receive test results for TB and multidrug-resistant TB in just two hours. Robust contributions to the Global Fund as well as long-term bilateral and local government funding will be vital to ensuring an equitable distribution of GeneXpert in poor countries and driving down costs for public health systems.   

Out of the Dark: Meeting the Needs of Children with TB (Medecins Sans Frontieres, October 26, 2011)
TB in children remains a neglected issue and receives insufficient funding for research and appropriate pediatric drug formulations. The World Health Organization’s (WHO) main strategy for identifying and managing cases of TB is largely ineffective for children under the age of ten who tend to have smear-negative forms of TB.  Equally alarming, pediatric drug formulations which correspond to WHO dosage guidelines are not being produced. Despite the current state of pediatric TB prevention, diagnosis, and treatment, awareness is on the rise, and advocates should continue pushing donors and the international community to achieve zero TB deaths among children.

NON-COMMUNICABLE DISEASES

Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries (Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, November 4, 2011)
More than two-thirds of cancer deaths occur in low- and middle-income countries where the poor largely lack access to health care. Yet the expansion of cancer care into low-resource settings is impeded by myths about the burden of disease and the affordability and feasibility of treatment. Most pernicious is the notion that treating cancer is inappropriate because it would reapportion funding reserved for communicable diseases.  This report identifies a series of interventions to dispel these harmful myths, and makes the case for expanding access to cancer care in low- and middle-income countries.

HEALTH TECHNOLOGY

Call to Action on Global eHealth Evaluation (Hamish Fraser, GHDonline, October 20, 2011)
With funding from various development agencies, many eHealth projects have sprung up over the past decade, but the value of these systems has yet to be determined. Several months ago, a group of eHealth experts convened to address the crucial need for comprehensive evaluation; this statement is their first call to action. As a learning organization, Partners In Health emphasizes the importance of feedback loops, and prioritizes the sharing of information across sites to improve the quality of care.

MULTIMEDIA AND ADDITIONAL RESOURCES

Creating and AIDS-Free Generation (Secretary Clinton, National Institutes of Health, November 8, 2011)
In this highly-anticipated address, Secretary Clinton announces the Obama Administration’s new policy priority of “creating an AIDS-free generation”. The rhetorical shift marks a major advancement in the Administration’s commitment to scale up AIDS antiretroviral treatment (which has been shown to reduce transmission by 96% among discordant couples), eliminate mother-to-child transmission of HIV, and strengthen health systems. Strong leadership from the White House is critical to protecting life-saving global health and foreign assistance programs from Congressional budget cuts. If President Obama builds upon Secretary Clinton’s announcement with bold new treatment targets, the vision of an AIDS-free generation could become reality.

Re-imagining Accompaniment in Global Health: Global Health and Liberation Theology (Paul Farmer, Gustavo Gutierrez, Kellogg Institute, Nov, 7, 2011)
Listen to Paul Farmer and the acclaimed father of liberation theology, Gustavo Gutierrez, discuss the structural drivers of poverty and the importance of “accompaniment”. This video offers a unique chance to hear Dr. Farmer and Father Gutierrez ruminate on the issues that have driven much of the philosophy behind the work of PIH. 

Through a partnership with TOMS Shoes, thousands of new shoes distributed to children in poor communities.

By Robbie Flick, Health Programs Coordinator, Malawi

Hundreds of jubilant voices in unison merged into an excited cacophony as our truck pulled up at the Malimba Primary School in southern Malawi. Children danced around the truck until the head teacher, a sharply dressed older man with an air of authority, began organizing the students. A quick order and the first graders were in line, laughing, pushing, and singing. Older students began offloading dozens of brown cardboard boxes, each filled with new TOMS black canvas slip-on shoes.

It was the first day of a 10-day TOMS Shoe distribution coordinated by Partners In Health’s Malawian sister organization, APZU. In the impoverished rural Neno District of Malawi, most children have never owned a new pair of shoes, and many have never owned any shoes.

“[The shoes] make me feel happy and that everything will be OK,” beamed Alfred Benson, a student whose parents are both subsistence farmers. He told us that his new black shoes were the first pair of shoes he’s ever owned. 

Bare feet carry a number of ramifications in these communities. For example, children without shoes are at a greater risk of becoming infected with soil-transmitted parasites, such as hookworm. These common infections can have debilitating effects on a child’s health and long-term development, including cognitive development. In addition, bare feet are at a higher risk of injury and resulting infections. Many students walk several kilometers each way to school, a journey that often takes them across huge stretches of scorching sands and rocky river beds, sometimes even discouraging students from attending school.

With smooth efficiency, the members of APZU’s Department of Community Programs (DCP) began the arduous process of sizing and putting shoes on the feet of every child enrolled at the school, along with hundreds of students in the community who are either too young for school or have dropped out. Using a laminated sizing chart stapled to a plank of cardboard, our team quickly measured each child’s feet. The children then walked over to the distribution area to receive their properly-sized shoes. As the hot dry season’s sun traced a lazy arc across the cloudless sky, the pace continued unbroken, child by child, grade by grade. As the sun set behind the rounded western mountaintops; the APZU team brandished headlamps and lanterns — we had promised the children of Neno that we would give a new pair of shoes to every child who needed them.

Over the 10 long days of the shoe distribution in late September and early October, we witnessed an overwhelming demand for a resource that I had taken for granted for much of my life. We held distributions at the Lisungwi Primary School, with their concrete school buildings surrounding a soccer field, right off the main road; and at the Mphitsa Primary School, whose region is effectively cut off from the outside world during the rainy season. We distributed thousands of pairs at Community Based Organizations — M’sambe and Chiyembekezo — to ensure the region’s most vulnerable children were impacted by the program. The team also distributed hundreds of shoes right at APZU’s pediatric clinic.

At the end of those ten days, thousands of children in Neno had received a pair of new shoes. The APZU team immediately began discussing how to address the ongoing need for shoes going forward. Victor Kanyema, APZU’s Director of the Program for Social and Economic Rights, expressed a simple goal: to put shoes on the feet of every child in Neno District. With the help of TOMS Shoes, we are getting closer to making that vision a reality.

PIH also recently distributed news TOMS Shoes to children in Rwanda. Learn more. 

Children pose, showing off their new TOMS shoes.

	PIH co-founder Paul Farmer.

In his recent op-ed in the Washington Post, PIH co-founder Paul Farmer highlights the success of both the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV, TB and Malaria, urging the international community to scale up these projects and others like them.

How we can save millions of lives argues that “Redoubling treatment efforts for leading causes of morbidity and mortality is not only the right thing to do, but it also must be a cornerstone of any effort to redress the inequitable burden of disease on the poor.” Read an excerpt below: 

Ten million people — many of them young and most of them poor — will die around the world this year from diseases for which safe, effective and affordable treatments exist. In Haiti, these are known as “stupid deaths.” What’s more, inadequate health services predominate precisely where the burden of disease is heaviest, keeping a billion souls from leading full lives in good health.

In recent years, initiatives such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria have helped rein in some of the biggest scourges. We’d be hard-pressed to point to a more inspiring achievement in global public health since the eradication of smallpox in 1977. Massive efforts have been made to address the “delivery challenge”: getting the medicines to those who need them. Citing evidence that, in addition to saving lives, treatment for AIDS also reduces the transmission rate by 96 percent, Secretary of State Hillary Rodham Clinton this month proposed more investment in PEPFAR, even calling for “an AIDS-free generation.”

Read “How we can save lives” by Paul Farmer in its entirety.  

PIH's mental health team holds community services for Haitians affected by cholera.

This year, Partners In Health begins an exciting new initiative in global mental health delivery. Dr. David Grelotti and Dr. Stephanie Smith are the recipients of the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery, which provides PIH an opportunity to more formally integrate psychiatric and community-based mental health services at project sites. Dr. Grelotti will work with PIH's sister organization in Haiti, Zanmi Lasante; and Dr. Smith will work with Inshuti Mu Buzima, PIH's Rwandan sister organization. Both fellows say their focus will be on improving mental health care through training and capacity building over the next year.

We had a chance to sit down with PIH’s first Pagenel Fellows as they prepared to begin their new roles. 

Q: What goals do you have in mind as you prepare to head to Haiti and Rwanda?

Both David and Stephanie say that their focus will be on improving mental health care through training and capacity-building over this next year.

Dr. Grelotti: In much the same way PIH has revolutionized the treatment of HIV and TB in low-income countries through primary care, one of my goals is to expand access to mental health services through primary care and consultation-based psychiatry in the Zanmi Lasante and MOH hospitals. ZL has a growing mental health team, and I hope to accompany them clinically in addition to working with them behind the scenes to help Haitians in need. There is much concern for stigma related to mental illness – also similar to HIV and TB and cholera for that matter. Whereas stigma is probably as much of an issue as it is in the US, a bigger difference is access. When I went to Petite Riviere for the first time in March to do a clinic with the psychologist there, we had 30 patients lining up for us before I got there. If there is stigma, it’s certainly not keeping many patients away.

Dr. Smith: Mental health is a key component of overall well-being, and mental health needs must be addressed in order to fulfill the right to health. One important goal for achieving the right to health is to provide community-based services for people with mental disorders and to integrate mental health care into primary care. People with mental disorders do best when they are treated in their communities and are not excluded from everyday life. The Rwandan government has prioritized mental health care with a goal of integrating it into the primary care system. This includes establishing an infrastructure for mental health services which includes helping physicians and nurses learn how to identify and treat patients with mental disorders.

Q: Both Haiti and Rwanda have experienced catastrophic and traumatic events; do you expect to see similarities in their impacts on mental health?

Dr. Smith: Catastrophic events certainly always have a context, which can mediate the reaction people have to those events. It’s also possible to see differing patterns in emotional and behavioral responses across cultures. Traumatic events can cause a range of reactions, and whether you’re in Haiti or Rwanda, it’s important not to assume one standard set of feelings following an event. One important component of a good mental health system is to ensure that many different types of mental health needs and presentations of emotional distress can be addressed.

Dr. Grelotti: Traumatic events have likely impacted many Haitians and Rwandans, but everyone handles trauma differently. People in Haiti have shown remarkable resilience. But if someone is having difficulties – no matter what the difficulties – they should be able to access help. The goal should be to build a mental health care system that is always there to aid those who are suffering and that can respond effectively to things that affect individuals and groups.

Q: What role do you believe medication can play in treating mental illnesses in Haiti and Rwanda?

Dr. Grelotti: Medication is one important tool, part of a toolbox for treating psychiatric and neurologic illness that includes both pharmacologic and non-pharmacologic strategies. These can be both psychosocial and psychotherapeutic. However, there can be biological reasons for the illnesses that we treat, and medications can be helpful. PIH has made some of the most important medications in treating psychiatric and neurologic illness available to Haitians free of charge, and one of my most important responsibilities as a psychiatrist will be to transfer knowledge of how to safely and effectively use these medications to ZL doctors and psychologists.

We often talk about the disability caused by mental illness from the context of the person. This is true, but it is also true that medication can free up resources and reduce the burden on the family. One of the patients with schizophrenia who I met in Hinche was so disorganized that he needed constant supervision. It is my hope that with medication he will do better and his family will not need to be by his side all the time.

Most patients we are treating with medication have not been on psychiatric medication before, and for medication to be most effective we have to be mindful of adherence. Much like HIV and TB, we need to make sure that people start and stop medications under close supervision and not because they feel better or seem to be doing better. For example, the mother of one little boy with epilepsy from St. Marc had not refilled his medication because his seizures had stopped. She came to see us because his seizures came back. Medications are important, but so is regular follow up and education about the illness and its treatment.

Dr. Smith: Medications are important for treating the symptoms of mental illness such as anxiety, insomnia or psychosis. There are a number of psychiatric medications on the WHO essential medicines list, and to fulfill the right to health for people with mental disorders, it’s very important to ensure access to these medications. It’s also important to make sure that medication management is combined with community support in order to best treat severe mental disorders. 

Q: How do you offer therapy to patients if you don’t speak the same language?

Dr. Grelotti: Stephanie’s and my role will be primarily to support our local colleagues in the provision of care, with them as the main point of contact with patients and families. I learned from the many dedicated PIH staff who work in Haiti that it’s possible to learn a new language as an adult, and I’m committed to improving my Creole! However, one of the most important aspects of any therapy is creating what we call a therapeutic alliance. It’s important that the patient feel that you understand them and are on their side. I probably won’t be doing a lot of therapy myself, but if I’m sitting in on a session I’ll be listening and reacting to body language and hope that even in these small ways will make the talk as therapeutic as possible.

Dr. Smith: Without a firm grasp of the language, therapy can work well when you have a trusted interpreter, although it’s important to take into account that there are three people in the room and incorporate this difference into the psychotherapeutic work. Our primary goal as clinician-teachers is to accompany Rwandan clinicians and healthcare workers to care for people with mental disorders using the most sound treatment for the clinical situation. This also includes an ongoing dialogue with the clinician about their training, and the cultural context.

Q: Is there more stigma in Rwanda around mental health than other countries?

Dr. Smith: There is stigma around mental illness in many places. Treating patients in their communities helps to reduce this stigma. People with mental disorders can then continue to have relationships, work, and participate in community life. It also helps others to see that mental disorders can be treated and that people can recover from them.

Q: What are the largest challenges facing these countries as they integrate psychiatric care?

Dr. Smith: One of the largest challenges will be to integrate mental health services into the current health system and to provide appropriate diagnosis and treatment for those with mental health disorders, including ensuring the rights and dignity of people with mental disorders.

Dr. Grelotti: First, probably sustainability. We can’t just go in, start treatment, and leave. Any intervention needs to be part of a long-term commitment, and we need to be thoughtful in our approach. Another challenge is the integration of mental health services into existing medical service infrastructure. People with mental disorders may have medical problems that contribute to their psychiatric difficulties and certainly need primary care, but often they do not or cannot access services. All patients will benefit if mental health care is valued in the healthcare system. I think other challenges might also present opportunities to do things better than in the U.S., including actively trying to identify people at risk for mental illness through the involvement of community health workers, educational programs, and other partnerships.

About the Pagenel Fellows

Dr. David Grelotti

Dr. David Grelotti will be accompanying our Haitian colleagues in identifying core challenges to the delivery of quality mental health care and help to devise collaborative plans for providing hospital-based, public sector mental health services.

During an earlier trip to Haiti with PIH, David administered improvised neurological exams to patients using office supplies, scraps of paper, and a cell phone – an experience that inspired him to develop and strengthen methods of delivering specialty care in resource-poor areas in Haiti and beyond. 

With a background in anthropology, David’s work aims to collapse the barriers too often separating mental health care and local cultures. Prior to joining PIH’s sister project in Haiti, David worked to improve mental health systems in Singapore and Australia.

David completed residencies in both adult psychiatry and child and adolescent psychiatry at Massachusetts General Hospital and McLean Hospital. He holds an MD from Johns Hopkins, and graduated from Dartmouth College with honors in anthropology and government.

Dr. Stephanie Smith

Dr. Stephanie Smith will be working with PIH’s sister organization in Rwanda, Inshuti Mu Buzima. Her work seeks to enhance IMB’s capacity to develop practitioner skills in hospital settings, particularly at the new teaching hospital at Butaro. Beyond her work with IMB, she will support Rwanda’s Ministry of Health as it integrates mental health services nationwide.

Stephanie champions a rights-based approach to mental health care, one that upholds human dignity by removing barriers to treatment. She has worked alongside health practitioners throughout Africa and Latin America.

A passionate advocate for human rights and health policy change, Stephanie has worked with victims of torture and political violence in Zimbabwe. In her role as a researcher, she monitors the impact World Bank health policies have in aid-dependent countries. 

Stephanie completed her residency in psychiatry at Boston Medical Center. She holds an MD from the University of Minnesota – where she co-founded and chaired a chapter of Physicians for Human Rights. While there she also completed a medical ethics fellowship at Harvard Medical School. She graduated, with honors, from Cornell University, where she studied philosophy.

About Dr. Mario Pagenel

Among the hundreds of thousands of victims of the January 12, 2010 earthquake in Haiti was a beloved doctor, Dr. Mario Pagenel, from PIH’s sister organization Zanmi Lasante. Dr. Pagenel was the ZL Director for Training and Medical Education and the Director of the Caribbean HIV/AIDS Regional Training Center — a collaboration between ZL, the University of the West Indies in Jamaica, the U.S. Centers for Disease Control, and the University of Washington I-TECH program. Dr. Pagenel had advanced training in Family Practice at the Justinian Hospital program in Cap Haitian and had studied community health in Montreal, Canada. With these credentials, he returned to Haiti in 2007 to work in Haiti’s rural, isolated Central Plateau to serve the poor and raise the academic standards of medicine within ZL's programs. “Dr. Pagenel truly lived the term preferential option for the poor,” said Dr. Louise Ivers, Senior Health and Policy Advisor to PIH. “He could have worked anywhere but he decided to work in one of the most isolated parts of Haiti to serve his people."

A discussion about challenges and accomplishments over the past year, recorded live on Tuesday, November 15, 2011. 

Speakers:

Ophelia Dahl
PIH Executive Director

Manzi Anatole, RN
Director of Clinical Mentorship, Partners In Health Rwanda

Dr. Joia Mukherjee
PIH Chief Medical Officer

New collaborative initiative provides tutoring and education opportunities to primary school students and teachers in rural Rwanda.

By Celia Reddick

Little feet in brightly colored plastic sandals patter back and forth at the Rwinkwavu Center for Training and Operational Research in rural eastern Rwanda each Sunday afternoon. The feet belong to 6th grade students from Nkondo Primary School, and they’re heading to math and science enrichment classes offered by doctors from the nearby Rwinkwavu Hospital.

The doctors, moonlighting as volunteer teachers, arrive at 2:30pm each Sunday. Some come straight from morning call at the hospital, still wearing scrubs; others dismount motorcycle taxis, returning from a weekend trip to the capital city. Together, they congregate at the Training Center in an effort to address the relationship between poor schools and poor health which they see in their daily work.

	A student works on his math skills during a Sunday class in Rwinkwavu, Rwanda.
	A doctor discusses scientific concepts with a small group of 6th grade students.

“We do this because the kids need extra support,” Alain Uwumugambi, Director of Internal Medicine at Rwinkwavu Hospital, explains. “Education is needed as much as health care, if not more. Health care targets the sickest kids, but education determines the future of far more children. And, of course, if we provide quality education to all children, this will improve the Rwandan healthcare system.”

This initiative began as a collaboration between PIH’s Department of Medical Education and Training and the Rwandan Ministry of Health doctors at the hospital. It has subsequently grown to include a number of other local community members, including local teachers, as well as international staff from the Global Health Corps and Harvard’s Global Health Equity program.

The need is clear, and the work shows immediate results, as students begin using academic English and shouting out answers to basic questions about math. However, the students, aging from 11 to 15 years old, have a long way to go, as they have long been educated in overburdened schools. In addition, although they’ve only ever been taught in French and Kinyarwanda, according to national policy, they’re now being taught in the new language of instruction — English — by teachers who are still struggling to learn the language themselves. 

Working in small groups scattered between two large rooms at the Training Center, the students practice math and science. One group draws insects that they have collected, labeling the parts of the body and counting the number of legs. Another group practices multiplication tables, tossing a neon green tennis ball around a circle and calling out answers. A third group learns about heat conduction, comparing the temperature of water in a plastic and a metal cup.

For students and teachers, this is just the beginning. Soon, students will take their promotional exams, and find out whether they will gain entry to more rigorous secondary schools elsewhere, or continue for three more years of basic education at their local school.

The initiative is also working to improve the local education system itself. As the students depart for their winter holidays, the teachers of Nkondo Primary will take their places at the Training Center on Sundays for instruction in English. When the students return to school in January, they will be met with teachers who are better equipped to teach them. Next year, 5th and 6th grade students will participate in the Sunday school sessions as hospital and PIH staff continue to work hand in hand with the local school to tackle the root causes of poverty and disease.

Celia Reddick serves as the Curriculum and Training Specialist for Partners In Health in Rwanda.

Learn more about PIH's work in Rwanda. 

Students take a stretch break at a Sunday science class in Rwinkwavu.

With only a few months until Mirebalais Hospital opens, workers strive to complete the entrance to the new hospital. Roughly 500 patients a day will soon find health care through these doors.

Some will come seek life-saving emergency treatment, others will arrive for routine care and check-ups. All will receive the highest-level of care at this state-of-the-art hospital, run in partnership with Haiti's Ministry of Health.

See some of this week's highlights. 

Learn more about Mirebalais Hospital.

How the PIH Program Management Guide is helping a young non-profit organization in Rwanda.

By Aaron Shapiro, Gardens for Health International

Just five months after college graduation I found myself standing at a health center in Rwanda, anxiously waiting for thirty mothers of malnourished children to arrive for their first training on improved nutrition. After two hours of waiting, I finally accepted that no one was going to show. And so began my humble introduction to the challenging world of program management.

	Aaron Shapiro works for Gardens for Health International in Rwanda.
	Participants in a Gardens for Health project.
	A cooking class organized by Gardens for Health.

I moved to Rwanda three months ago and immediately began setting up a monitoring and evaluation system, training field staff, overseeing procurements, and collaborating with our health center partners over program design and sustainable exit strategies. I work for Gardens for Health International (GHI), a non-profit organization that partners with local health centers to create long-term solutions to malnutrition by helping families grow more nutritious food and providing training on the diverse causes and solutions to malnutrition. I’m here through a Global Health Corps (GHC) Fellowship, a program that matches young professionals from around the world with health-related organizations (currently operating in Rwanda, Burundi, Malawi, Uganda, and the United States) in an effort to strengthen and build the movement for global health equity.

I’m finding more and more people my age applying for jobs in international development and global health. However, global health work was always something of an enigma to me until I experienced it first hand when I started volunteering with an orphanage for HIV positive children in Tanzania four years ago. We can all be inspired by an international NGO’s website or promotional video, but when a website says that they successfully ran a women’s empowerment program in Malawi, what does that actually mean? How many people, how much money, and how much time does it actually take to complete a water sanitation project in Congo? And how do you actually get it done?

I can tell you first hand that managing a program isn’t easy. Every day, I work through language barriers, cross-cultural miscommunications, and new regulations that need to be fully understood before any implementation takes place.  The new PIH Program Management Guide took many of the complexities I work with on a day-to-day basis and pulled them together into one document.

For me, this manual not only gives a glimpse into health programming for anyone interested, but also serves as a practical guide for those of us working with these complex challenges every day. It sheds light on ways to accurately collect data, efficiently train community members, and demonstrates the critical importance and value of working collaboratively with host governments.

PIH, GHI, and GHC all strongly hold quality healthcare as a human right. Many of us working to reduce the healthcare gap are in this line of work for similar reasons. But actual change comes down to quality program implementation.

PIH, and young non-profits developing in PIH’s wake, are setting the bar for information sharing and collaboration. It’s the only way to learn from past mistakes and move forward to better serve those in need. Plain and simple: the guide helps me do my job better. 

Thank you, PIH team, for sharing such a valuable document with the rest of us. We here at GHI have already started putting together a program management guide of our own in hopes of continuing the momentum that you’ve started.

Take a look at the PIH Program Management Guide.

Some of the participants of the Gardens for Health International project in Rwanda.

This week – two months before the second anniversary of Haiti’s devastating January 2010 earthquake – the vision of a dignified and productive life for Haitians living with disabilities reached a major milestone as construction began on the Center for Rehabilitation and Excellence in St. Marc.

When it opens next year, the 6,700-square-foot facility will transform immediate and long-term delivery of rehabilitation services in central Haiti while dignifying and normalizing the daily lives of people living with disabilities. 

The center will establish new national standards for rehabilitative care in a country where 10 percent of the population has some form of disability, a figure that increased dramatically following the quake. It will also house a program to train rehabilitation technicians, serving as a model of disability-centered design, construction, education, and services within the public sector.

“For me the most powerful aspect of the Center for Rehabilitation and Excellence is the dignity it will create for people in Haiti,” said Koji Nakashima MD, Director of Rehabilitation Services for Partners In Health. “The ability to move freely – or to simply bathe when you choose – is incredibly empowering.”

The pro bono project is a collaborative effort that brings together the expertise and vision of Partners In Health, Partners HealthCare, Shepley Bulfinch, MASS Design Group, and Spaulding Rehabilitation Network, working closely with senior Haitian officials. 

A gymnasium for physical therapy is the facility’s centerpiece. An integrated ramp wraps the building on three sides, making patients’ rehabilitation progress visible to one another while providing access to offices and training facilities on the second floor. A culturally appropriate simulated home environment incorporates local cooking and bathing practices. The building is designed to be earthquake and hurricane resistant. MASS Design Group is overseeing construction of the center, which was designed by Shepley Bulfinch architects.

The center will also focus on educating and training a cohort of locally based Haitian paraprofessionals to work with the population with disabilities. While construction is underway, Spaulding Rehabilitation Network in Boston, under the direction of Dr. Andree LeRoy, is developing a nine-month program with a curriculum that builds on materials developed by Health Volunteers Overseas. These training programs will be an ongoing part of the center's mission.

Plans for the Center for Rehabilitation and Excellence were announced by Partners In Health co-founder Dr. Paul Farmer at an event in Boston in June 2011. At that event, Dr. Farmer called the project the “fruit of the partnership model” from which Partners In Health takes its name.

The Center is scheduled for completion in late April 2012.

"Real service to the poor means understanding global poverty," said PIH co-founder Dr. Paul Farmer at an October event with Rev. Gustavo Gutierrez, hosted by the Kellogg Institute for International Studies at Notre Dame University.

Farmer and Gutierrez focused their 90-minute discussion on "Re-imagining Accompaniment: Global Health and Liberation Theology." 

Gutierrez is known around the world as the founder of liberation theology, which interprets Christianity in terms of a liberation from unjust economic, political, or social conditions. “Fr. Gustavo is one of my heroes and has inspired much of my own work in global health with a preferential option for the poor,” said Farmer. 

"Poverty is not fate, it is a condition; it is not a misfortune, it is an injustice," Gutierrez is known for saying. "It is the result of social structures and mental and cultural categories, it is linked to the way in which society has been built, in its various manifestations."

"Poverty is not an act of nature…but a historically driven by social and economic factors," added Farmer. "Real service to the poor...requires listening to those most affected by poverty."

Peruvian-born Gutierrez is the John Cardinal O'Hara Professor of Theology at Notre Dame University and a Kellogg Institute Faculty Fellow.

A medical anthropologist and physician, Farmer is Kolokotrones University Professor at Harvard University, chair of the Department of Global Health and Social Medicine at Harvard Medical School, and UN Deputy Special Envoy for Haiti.

In October, PIH's mental health staff led activities for community members across Haiti.

October 10th was World Mental Health Day, and for the second year PIH/Zanmi Lasante mental health and psychosocial staff spent the day, and the entire month, raising awareness of mental health services available at PIH/ZL clinics and educating communities about signs and symptoms of common mental disorders.

From radio shows to trainings with school teachers, key community leaders, youth and community health workers, to large mass-mobilization events complete with music, sports events and question-and-answer contests, to community meetings and debates in schools and churches, events took place throughout October at each of PIH/ZL’s clinics and hospitals.

This year's theme, selected by the Haitian Ministry of Health and the national mental health working group, focused on "having a clear mind for ensuring a strong body" – "Ak tet klè kò a pi djanm" in Haitian Creole. In countries with small health budgets, like Haiti, roughly 2 percent of financial and human resources are allocated to mental health, according to the WHO, despite a global disability burden of approximately 13 percent.

Mental health in Haiti since the 2010 earthquake

Since the 2010 earthquake, PIH’s Mental Health program has been dedicated to finding, supporting and treating both psychosocial and acute mental health needs in the communities we serve. Following the earthquake the Haitian Ministry of Health asked PIH/ZL to support the Ministry's leadership in developing a national mental health response to the disaster. PIH/ZL proposed a two-pronged approach. First, mental health services must be decentralized. A key component of this includes training community health workers and nurses to find and refer people suffering from mental disorders.

PIH/ZL mental health staff gather after a day of events recently in Haiti.

Second, mental health services much be integrated into larger, comprehensive health systems. Since 1987, PIH/ZL has successfully introduced programs to prevent and treat infectious diseases such as HIV/AIDS and tuberculosis. These programs integrate the treatment for specific diseases into comprehensive health programs. Today, PIH/ZL is working to doing the same with mental health services.

The PIH Mental Health program has worked to link training and education, research and advocacy missions to the delivery of critical mental health services in collaboration with the Program in Global Mental Health and Social Change at Harvard Medical School. This has included the awarding of a US NIMH grant focused on the development of a school-based mental health intervention for youth in Haiti's Central Plateau, led by ZL Mental Health and Psychosocial Services Director Father Eddy Eustache, and Dr. Anne Becker of Harvard Medical School. Also this year, PIH and Harvard Medical School launched the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery.

Treating those in need

The program is also working to integrate mental health services at PIH/ZL sites. Sixteen months after the earthquake, PIH/ZL staff had documented 20,000 individual and group appointments for mental health and psychosocial needs across Port-au-Prince and PIH/ZL’s 12 clinics and hospitals.

Whether injured in the earthquake, suffering from cholera or affected by longstanding mental illness, people have been able to reintegrate into their communities – returning to jobs, church, choir and school – after receiving mental health care from PIH/ZL. These efforts have had the added effect of reducing stigma and changing perceptions around mental health. As a result, there is growing awareness and enthusiasm about the need for these services in the community and the medical system.

To keep this momentum going, PIH/ZL is expanding its education services while continuing to find and treat men, women and children requiring mental health services – all free of charge.

Proving that mental health care can be delivered in developing countries

In October, PIH advocated for mental health in developing countries in the medical journal Lancet. In the commentary PIH Mental Health Director Giuseppe Raviola and PIH co-founder Paul Farmer, with Dr. Becker, underline the need for greater inclusion of mental health into the global health agenda, reflecting a truly “global scope for global health.”

A support group in Rwanda tends to the mental health needs of patients.

This past July, Dr. David Grelotti and Dr. Stephanie Smith became PIH’s first Pagenel Fellows. Dr. Grelotti will spend the 1-2 year long fellowship working with Zanmi Lasante, PIH's sister organization in Haiti, while Dr. Smith will work with Inshuti Mu Buzima, PIH's sister organization in Rwanda.

	Dr. Mario Pagenel

Established in 2011, the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery provides psychiatrists and graduating senior psychiatric residents with the opportunity to develop service and academic career interests in global mental health, and support mental health training programs at PIH sites.

The Fellowship celebrates the life and work of Dr. Mario Pagenel, who died in Haiti's 2010 earthquake. Dok Pagenel – director of training and medical education at Zamni Lasante – had a special interest in mental health and health equity. 

Co-sponsored with Harvard Medical School, the Pagenel Fellowship is designed to facilitate training in mental health services for local health care providers in the places where PIH works, as well as for US-trained clinicians interested in global mental health.

Treating those in need, training the next generation of health care professionals

	A training for mental health clinicians in Rwanda.
	Health workers in Haiti discuss mental health issues at a recent training.

The Pagenel Fellows will share clinical expertise at the bedside and through didactic teaching, accompanying local health care providers in developing their skills in implementing clinical mental health interventions. Fellows will work side by side with Haitian and Rwandan clinicians who are the primary providers of mental health services. This program aims to facilitate opportunities for Haitian and Rwandan health care providers distinguished as leaders in mental health to develop their skills and careers, promoting their desire to practice and serve in their home communities. In turn, the Pagenel Fellows will directly experience the challenges that their colleagues experience in providing mental health care to the poor. 

In Haiti and Rwanda, the Pagenel Fellows will provide training to a range of health care workers (physicians, nurses, psychologists, psychiatric nurses, social workers, and community health workers). Cooperating closely with the Haitian and Rwandan Ministries of Health, they also will support efforts to strengthen mental health services nationally.

PIH's mental health strategy is coordinated with the construction of Butaro Hospital in Rwanda, and of Mirebalais Hosptial in Haiti. The Fellows will serve as expert clinician-teachers at these teaching hospitals, and will be instrumental in supporting expert multidisciplinary teams in mental health care and training at these facilities.

Integrating mental health care into local health systems

Ultimately, the Pagenel Fellowship is part of an overarching strategy focused on integrating mental health into every level of health care. Mental health care will be integrated along with psychosocial care into home visits, appointments at health clinics and care at district hospitals.

In order to meet patients' needs, all levels of health workers will eventually participate in mental health care to some degree. For instance, a community health worker might identify a potential patient, a physician might determine the appropriate course of treatment, and a nurse might manage treatment over time. Each health worker will know how to support decentralized mental health systems. This is a system where community health workers and social workers deliver the bulk of the care. Psychologists and physicians oversee care and take responsibility for treatment of the most severe cases.

Consistent with WHO guidelines, this care structure aims to maximize the efficient use of expertise in resource-limited settings. By supporting capacity building efforts, the Pagenel Fellows will facilitate the development of this "continuum" of mental health care.

In July 2011, the Fellows participated in the Harvard Global Health Effectiveness Program – an intensive program that trains people how to manage health care in resource-poor settings. They will spend most of their fellowship year in Haiti and Rwanda, while also developing an area of academic focus in global health related to mental health service delivery.

Meet this year’s Pagenel Fellows.

October 10 was World Mental Health Day, learn how PIH staff and patients in Haiti commemorated the day.

IHSJ Reader     November 2011     Issue 11         

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

SOCIAL DETERMINANTS OF HEALTH

Rio Political Declaration on Social Determinants of Health (World Health Organization, October 21, 2011)
At the World Conference on Social Determinants of Health in October, the World Health Organization convened Heads of State and representatives from over 100 governments to discuss how social, economic, and environmental conditions could be improved to reduce the health inequities within and between countries. The Rio Political Declaration illustrates five key action areas that are critical to addressing health inequities, including implementing the “Health In All Policies” framework to integrate health priorities across all sectors of society. Though the Declaration reaffirms official commitments to addressing the social determinants of health, some civil society members  have criticized the Declaration for not identifying what policies need to be changed and who is accountable for health inequities, especially in the context of the global financial crisis, increasing food insecurity, neo-liberal policies, and challenges posed by climate change.

Protecting the Right to Health Through Action on the Social Determinants of Health (Declaration, Public Interest Civil Society Organizations and Social Movements, October 18, 2011) 
The People’s Health Movement issued an “Alternative Declaration by Public Interest Civil Society Organisations and Social Movements” in conjunction with the World Conference on Social Determinants of Health. The Alternative Declaration identifies specific political and economic interventions that are needed to reduce the unequal distribution of wealth and power in the world, as well as policies that could mobilize public resources for robust, equity-oriented health systems. Action areas include: progressive domestic and international tax mechanisms such as the financial transaction tax, equity-based social protection systems, and health impact assessments to document the ways international trade and unregulated corporate activity violate the right to health.

Social Protection Floor for a Fair and Inclusive Globalization (Advisory Group, chaired by Michelle Bachelet, International Labor Organization, October 2011)
A new report released by the International Labor Organization (ILO) advocates for the implementation of social protection floors worldwide. The social protection floor, a concept developed by the ILO and endorsed by Heads of State and Government in the 2010 Millennium Development Summit, is an integrated set of policies that guarantee social services and income security to all, paying particular attention to vulnerable populations. A social protection floor is not only critical to guaranteeing the right to health for all, but is also a key driver of economic growth and stability.

Social Justice in the OECD – How Do the Member States Compare? (Bertelsmann Stiftung Foundation, October 27, 2011)
In a recent report by the Bertelsmann Stiftung Foundation of Germany about social justice in those countries which constitute the Organization for Economic Cooperation (OECD), the USA ranked among the bottom five countries for basic fairness and equality. Taking into consideration various social justice metrics, including poverty prevention, access to education, health, social cohesion and nondiscrimination, intergenerational justice, and labor market inclusion, the authors found that there is considerable variation among the OECD countries.

TUBERCULOSIS 

Time for Zero Deaths From Tuberculosis (Salmaan Keshavjee, Mark Harrington, Gregg Gonsalves, Lucy Chesire, Paul Farmer, The Lancet, October 22, 2011)
Almost 130 years after the tuberculosis bacillus was identified, TB remains the world’s leading curable infectious killer, taking more than 1.7 million lives each year.  More and better coordinated advocacy from the multilateral agencies as well as civil society is necessary to garner more resources to reduce deaths from TB to zero. In addition, better leadership and more ambitious vision and goal-setting are needed from the agencies leading the efforts including the WHO, GFATM and others.

Global Funding for Infectious Diseases: TB or not TB? (The Lancet, October 22, 2011)
Progress made in TB treatment over the past few decades, such as China’s achievement of reducing tuberculosis mortality rates by 78% in the past 20 years, will slow if global funding does not increase. At least $2 billion is needed in 2011 to meet the goal of halving TB prevalence and deaths by 2015--but only $600 million is expected to be funded. More than 80% of donor funding for TB control comes from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which is itself facing a severe funding shortfall. Success, as in China, is possible, but international donors and communities must take action to address TB in the most challenging settings and close the enormous gap between what is needed and what is actually available to fight TB.

HAITI

After A Half-Million Cholera Cases, Vaccination Will Begin In Haiti (Richard Knox, National Public Radio, October 20, 2011)
It’s been over a year since the first cases of cholera were detected in Haiti and since then, the epidemic has afflicted nearly half a million people. Partners In Health plans to introduce a cholera vaccine early next year to slow the illness. Despite the $4.6 billion that the international community pledged after the earthquake in January 2010, funding for cholera vaccination, treatment, and prevention has been slow to come. The vaccine will alleviate the suffering of hundreds of thousands of Haitians as part of a comprehensive approach to the cholera response that includes strengthening water and sanitation infrastructure and increasing access to safe drinking water.

GLOBAL HEALTH FINANCING

User Fee Removal in Low-Income Countries: Sharing Knowledge to Support Managed Implementation (Bruno Meessen, Lucy Gilson, Abdelmajid Tibouti, Health Policy and Planning, September 20, 2011)
User Fee Removal in the Health Sector in Low-Income Countries: Lessons from Recent National Initiatives (Health Policy and Planning Supplement, November 2011)
The Health Policy & Planning journal dedicated a supplemental publication to the issue of user fees for health. Though there is a growing consensus that user fees for essential health care in developing countries discriminate against the poor, the broader package of health financing reforms necessary for achieving universal access to free care remains controversial. These articles draw from diverse perspectives to explore challenges related to the design and implementation of user fee removal policies. The Meeesen et al. editorial finds that “policies aiming to reduce financial barriers can be very effective in improving health service utilization, provided they are well designed, funded and implemented”. Partners In Health supports the removal of user fees for health and is committed to expanding access to high quality health care to the poor.

Five Lives: How a Financial Transaction Tax Could Support Global Health (Médecins Sans Frontieres, October 2011)
In this issue brief, MSF argues that the financial transaction tax (FTT) could save millions of lives if a percentage were allocated to global health. The European Commission has proposed a Europe-wide FTT on bond and stock trades that could raise hundreds of billions of dollars a year to help address poverty, fund sustainable job policies and strengthen public services.  The MSF report highlights successful global health programs which could save millions more lives if a portion of the FTT were directed to global health.

Gender Equality and Social Justice: Why Foreign Assistance Matters (Representative Jim Moran, Huffington Post, October 28, 2011)
In October, the Nobel Peace Prize was awarded to three women leaders from Liberia and Yemen. Representative Moran (D-VA) calls on Americans to recognize the importance of these awards in the midst of foreign assistance budget discussions. He writes that these women and the communities and countries they are from are proof that foreign aid works by saving lives, fostering stronger communities, and expanding economic opportunities. Most importantly, Rep. Moran argues, foreign assistance is moral and that Congress must continue its obligation to be part of the solution to poverty, discrimination, and oppression everywhere. 

H.R. 3159 - Foreign Aid Transparency and Accountability Act of 2012 (Rep. Poe, October 12, 2011)
Poe and Kolbe: Shedding More Light on U.S. Foreign Aid (Rep. Ted Poe and former Rep. Jim Kolbe, Roll Call, October 20, 2011)
Congressman Ted Poe (R-TX) introduced the Foreign Aid Transparency and Accountability Act of 2012 with a lengthy list of bipartisan co-sponsors. The legislation calls for creating guidelines and requiring comprehensive reporting to measure the impact of U.S. foreign assistance programs and to ensure that this increased transparency is accessible to the public.

NON-COMMUNICABLE DISEASES

***A Global Scope for Global Health – Including Mental Health (Bepi Raviola, Anne Becker, Paul Farmer, The Lancet, October 17, 2011)
The past few decades have seen remarkable advances in treating chronic diseases, from HIV/AIDS to cancer, and health systems improvements that have encouraged poor countries to develop the infrastructure capable of treating these disorders. Unfortunately, mental health services have been absent from these advances with 75% of patients in low-resource communities left untreated. The barriers that prevent patients from seeking treatment, where it’s available, are pervasive, and range from structural obstacles to social stigma. But, other health movements have surpassed similar barriers. Instead of creating a competing vertical system, current health care systems could be strengthened by integrating quality mental health care.

GLOBAL HEALTH INITIATIVE

The U.S. Global Health Initiative and Sexual Reproductive Health and Rights: Integration (Center for Health and Gender Equity, October 2011)
Sexual and Reproductive Health and Rights and the U.S. Global Health Initiative (Center for Health and Gender Equity, October 2011)
CHANGE launched a series of policy briefs examining the strengths of the Global Health Initiative (GHI), and recommendations for tangible policy and program change. The most recent brief focuses on the critical need for the integration of women’s health and HIV programs worldwide. Key recommendations for the Obama Administration and GHI country teams include: operationalizing a rights-based approach that addresses the needs of all populations, especially marginalized and hard to reach youth; addressing gender inequality and other socio-economic barriers to health, investing in health worker training, and eliminating harmful policy restrictions such as the Helms amendment and the Anti-Prostitution Loyalty Oath.

MULTIMEDIA AND ADDITIONAL RESOURCES

Haiti Grapples With Highest Cholera Rate In World (Tell Me More, NPR News, October 24, 2011)
In this episode of Tell Me More, Michel Martin examines the cholera epidemic in Haiti, highlighting what cholera is, the upcoming vaccine campaign, and the efforts that should be taken by Haiti’s new government to educate communities and strengthen the public health system. 

Treating Pulane, MDR-TB Treatment, PIH Lesotho (Partners In Health, October 2011)
This video introduces the specialized tuberculosis work done at Botsabelo Hospital in Lesotho, as Pulane, a young girl, is examined and treated for life-threatening multidrug-resistant TB. IHSJ Reader, October 21, 2011.

Reflect with Dr. Fernet Leandre, co-executive director of Zanmi Lasante, on how much has changed in his 15 years of service with our Haitian sister organization.

Read New York Times coverage of our innovative collaboration with Abbott Laboratories to fight malnutrition and create jobs in Haiti.

See the latest images from the construction of Mirebalais Hospital.

Read more about Zanmi Lasante's efforts to fight cholera with vaccinations.