by Anne Stevenson

This is the story of a PIH community health worker in Rwanda, Therese Mukukamari, and Uwimana, a boy suffering from mental health issues who Therese and her family have adopted. Uwimana is one of the first success stories to emerge from the Harvard/PIH Family Strengthening Intervention project.

“When we first met ‘Uwimana’ he was 10 or 11. Because he was an orphan living in the Kageyo refugee camp, we still aren’t quite sure how old he is,” recalls Therese Mukukamari from her home in Seka, Rwanda. “He was a delinquent who would roam up and down the streets.”

“Uwimana would seek shelter for a night from someone, and the following morning he would leave without telling anyone,” says Therese. “He would sleep under trees, or next to the home of people in the neighborhood who would offer some food in the morning. When I asked him why he was sleeping outside, I learned that he was hungry and alone.”

Knowing that Uwimana was sleeping outside the home Therese shared with her husband and children, she got up early one morning to ensure that her young guest didn’t run away. She convinced him to come inside and eat breakfast.

An act of generosity quickly took a dangerous turn for the worse. “Uwimana fought with my daughter -- beating her until she became unconscious,” says Therese. “We rushed her to the hospital.”

Therese and FSI Program Manager Anne discuss strategies to help Uwimana continue to grow.

Unloved and without a family

Prior to finding a new home with Therese’s family, Uwimana had been living in Kageyo, a region home to Rwandan refugees – families repatriating to Rwanda from Tanzania after fleeing in the late 1990s. Some of his time had been spent living on and off with a woman from the camp. 

“Instead of providing good parenting, of being motherly, [this woman] beat the child, leaving him to feel like no one ever loved him,” says Therese. In fact, like many orphans living in refugee camps, he had been abused and mistreated for much of his life.

Having worked for two years on PIH/IMB’s Family Strengthening Intervention’s Community Advisory Board (CAB), a project that trains people to recognize and deal with mental illness and depression, Therese realized Uwimana was sick.

At CAB meetings, staff teach local people about mental health and illnesses, explaining what causes them and how they manifest, specifically in children. This includes talking about illnesses caused by violence, mistreatment, poverty and poor care. Staff discuss mental health care at the family level, explaining what CHWs can do to help families with problems, and the role they can play in improving their conditions.

Therese would later learn that Uwimana had no memory of his parents. He had never lived with a family, and even worse, he had never felt loved. Therese was more determined than ever to take Uwimana in.  

“If I had not been trained, I probably would have just shown him pity and provided him with some food,” explains Therese. “Instead, I took the responsibility to accept the child into my home and to become his caregiver.”

With his new mother’s love, Uwimana is reborn

This new journey required patience, but Therese knew what she had to do. “I stayed with him, showed him love, and he started calling me ‘mother.’ I talked with him and I showed him how people live together in harmony. He would show me the scars on his hands, they used to tie his hands. He was so quiet.”

As time passed, so too did Uwimana’s anger. “He began to trust me,” says Therese. “If someone beat him in the community during the day he would resist fighting, Uwimana would come and tell me. He realized that I loved him and whatever I would give to my own children, I would double for him so as to be convinced that someone loved him.” 

“Now Uwimana is a part of our family and works around our home, he takes care of the cows and even builds fires for them at night,” Therese proudly states.“He used to sleep by himself outside with the goats; now he knows I love him and he lives with us. I treat Uwimana the same way I do my own children.”

When asked what Therese sees in his future, the answer comes quickly and with confidence: “He is striving and I plan to take him to school this next year. If Uwimana grows older and is able to look after himself, I would be incredibly pleased.”

“I am grateful for the training I received from FSI,” says an empowered Therese. “Not only has the training helped change the life of this boy, but it has allowed me to help many people in my village through my work as a community health worker.”

“The training opened my mind about mental illness and helped me better understand what children like this experience – as a result I am educating other adults in my village on how harmful physical abuse is.”

Fredrick Kanyanganzi and Anne Stevenson conducted this interview in the summer of 2011. 

Learn more about the Family Strengthening Invention project.
Read about PIH’s work in Rwanda.

by Anne Stevenson

In Rwanda, a group of researchers are mapping the words used by children and teenagers affected by HIV to describe their emotions and experiences. The Family Strengthening Intervention (FSI) project has compiled – and at times helped develop – an incredibly nuanced vocabulary to be used by doctors and social workers addressing the mental health needs of a vulnerable population.

Led by Dr. Theresa Betancourt of the Harvard School of Public Health, Co-Investigator Dr. William Beardslee of Children's Hospital Boston, and Anne Stevenson, Research Manager, the FSI team has interviewed over 600 children and adults in villages throughout southeastern Rwanda’s Kayonza and Kirehe districts since 2007 – a crucial step towards providing culturally appropriate psychosocial care to children affected by HIV.

Read about Uwimana, a 10-year-old boy whose life has improved dramatically as a result of community trainings connected to the Family Strengthening Intervention project.

Victims of genocide and HIV

In Rwanda, the dual effects of the 1994 genocide and the HIV epidemic continue to be felt throughout the country. With hundreds of thousands dead or infected, the HIV epidemic has devastated tens of thousands of families – causing family conflict and economic insecurity. Compounding all of this are the lingering effects of the genocide, which left nearly a million dead and another two million displaced, creating permanent and damaging implications for family and social structures.

As a result, too many of Rwanda’s children are at increased risk for mental health problems and low educational attainment. Yet, the mental health needs of children often receive little attention as families struggle to address immediate medical concerns and the burdens of poverty.

While physicians and social workers can offer young people strategies for dealing with debilitating emotional and socioeconomic situations, these interventions can only work if the entire community is supporting its children. By educating communities and health workers, the FSI project will prevent and treat children affected by mental health problems.

The language of healing

“Previous research has identified locally relevant terms for some mental health constructs among Rwandan adults,” according to Dr. Betancourt and her team, but little formal work has been done with children and adolescents. While all people feel sad or lonely, feelings carry culturally specific meanings. This is doubly true when dealing with young people, say the study’s authors.

The team has identified six local syndrome terms and their associated symptoms, as well as five important local protective processes – strengths that prevent and mitigate problems.

The FSI holds a training with mental health clinicians from Kayonza District and the Ministry of Health.

Symptoms

guhangayika – worry, stress
agahinda kenshi – more severe sadness, sorrow
kwiheba severe – hopelessness
ihahamuka – post-traumatic depression or shock 
uburara – delinquency and high-risk behavior
umushiha  -- annoyance, grouchiness

Protective Processes

kwihangana – perseverance
kwigirira ikizere – self-esteem/confidence
kwizerana family – unity/trust
kurera neza – good parenting
ubufasha abaturage batanga – social support 

Using these terms, the project has been able to “create easy-to-use, understandable, and accurate tools that can be used by providers to assess problems and strengths,” writes the FSI team.

Turning a community initiative into a national project

So far, the mental health measures developed by the FSI are performing well, and have the potential to be used in the future. While compiling research the FSI team was also able to identify and refer a number of at-risk children living near the PIH-supported Rwinkwavu District Hospital.

Dr. Betancourt is proud that this work is helping children today, while at the same time FSI’s research and advocacy are laying the groundwork for stronger local and national mental health responses.

In future phases of the research, the FSI will be completing development of a project adapted from the groundbreaking “Family Talk” intervention developed by Dr. William Beardslee at Children’s Hospital Boston, a co-investigator who will pilot this project among local families.

In the end, FSI hopes that its work will be integrated into Rwanda’s national health care system by the government and available to local community advisors throughout Rwanda, as part of a large-scale effort aimed at preventing mental health problems in children affected by HIV.

Learn more about the FSI's work, read:

"Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS," in AIDS Care.

“Nothing can defeat combined hands (Abashize hamwe ntakibananira): Protective processes and resilience in Rwandan children and families affected by HIV/AIDS” in Social Science & Medicine.

Learn more about PIH’s work in Rwanda.

Work is moving along quickly at the Mirebalais National Teaching Hospital. Hurricane Irene passed by with little more disturbance than rain luckily. The electrical crew has arrived and is making impressive progress.

Wiring in major parts of the new facility is now in place.

This week the crew completed running conduit and pulling wire in the Outpatient, Women’s Clinic, Community Health, Endoscopy and Pharmacy buildings. Furthermore, they have finished the Main Electrical Room switchgear in building 4.1 (mechanical, kitchen and laundry) and have begun running conduit and installing panel boxes in building 2.1 (labor and delivery).

With tiles up, the walls begin to look more like a hospital.

All this was done in less than three weeks. Also, thanks to the National Rural Electric Cooperative Association (NRECA) we will have permanent power to the site within 10 days!

The wall tile in the kitchen is complete and the crew can now start on the floor tile. Once the tile is complete, they will be able to start installing cabinetry and equipment. The tile work is almost complete in multiple bathrooms, including those of Outpatient, Women’s Clinic and Community Health.

In late August, Paul Farmer made a visit to the site. This was a very exciting day for everyone as they were happy to be able to show him the progress that has been made. 

Learn more about Mirebalais Hospital.

“Even in the most remote and challenging settings, providing cancer care is often possible—and the right thing to do,” said Doug Ulman, president and CEO of LIVESTRONG, an organization that collaborates with Partners In Health to fight cancer in poor countries.

LIVESTRONG, a non-profit founded by cyclist Lance Armstrong, released a report yesterday that features a case study on a patient treated for cancer by Partners In Health in Rwanda. The report, Delivering Hope:  Cancer Care in the Developing World, recommends practical, effective and affordable strategies to address cancer prevention and treatment, and describes how existing health systems designed to treat infectious diseases in low-income countries can be strengthened to address cancer.

The case study tells the story of Francine, a girl who came to PIH-supported Rwinkwavu Hospital suffering from a large facial tumor. While cancer was not something the PIH staff were expecting or prepared to treat, Dr. Sara Stulac, the Clinical Director of PIH-Rwanda at the time, worked with colleagues both in Rwanda and the United States to diagnose and treat Francine. As the report explains, 15-year-old Francine is cancer free, and Rwinkwavu Hospital continues to treat cancer patients as well as play a role in contributing to the development of a national cancer plan.

Watch Francine's story:

Cancer alone kills more people than tuberculosis, AIDS and malaria combined, and almost two-thirds of these deaths occur in low- and middle- income countries.

Non-communicable diseases (NCDs) like cancer, diabetes, cardiovascular and chronic respiratory diseases claim the lives of 36 million people around the world each year. These NCDs are responsible for more deaths than from any other cause, according to the World Health Organization. Contrary to prevailing assumption, NCDs significantly impact populations in low- and middle-income countries, where about 80 percent of NCD deaths occur.

“We’ve seen enormous delays because of arguments that it is too difficult, too expensive, that there is not adequate infrastructure, that there were not specialists to deliver services,” says PIH co-founder Paul Farmer, who co-authored a Lancet article calling on the international community to address cancer in poor countries . “Yes there are serious logistic and programmatic challenges, but none of them are insuperable.” 

Read LIVESTRONG's report, Delivering Hope: Cancer Care in the Developing World.

Check out PIH's guide to integrating treatment and prevention of NCDs into a health care system in low-income populations. 

In Boston, a PACT patient talks with her community health worker.

In August, PIH’s Prevention and Access to Care and Treatment (PACT) project received a five-year grant through the Ryan White HIV/AIDS Program, the largest funder of HIV/AIDS care in the US. 

Every year, the Ryan White Program awards $2.1 billion in federal support to HIV/AIDS programs across the country. Historically, community health worker programs like PACT’s have had difficulty competing for government funding against programs with more traditional, social-worker-based models.

This award, which will provide $600,000 over the grant period, marks the first time the organization has funded a CHW program in Massachusetts.

Working in partnership with the Massachusetts Department of Public Health, the Codman Square Health Center in Dorchester, and the Commonwealth Land Trust, PACT will use this funding to continue accompanying Boston’s most vulnerable HIV-positive patients. These patients often suffer from mental illness, substance use, stigma, social isolation, and poverty – all barriers that prevent patients from adhering to treatment.

PACT’s CHWs accompany patients as they reclaim their health, help improve their disease management skills, and become advocates for their patients within the health care system, ensuring their continued adherence. 

In addition to the obvious benefits for patients, the Ryan White funding is an encouraging sign for PACT and CHW programs nationwide – programs that often struggle for national recognition and funding.

“For some people CHWs are a confusing category,” said Rachel Weidenfeld, PACT’s HIV program manager. “They’re not just patient navigators, not just interpreters, and not just case managers.

“People don’t always know about the special set of skills that CHWs bring to patient care, and how important they are in helping connect patients with the resources they need,” continued Rachel. “I think that this grant helps legitimize and validate our work, and shows that we really can compete for these dollars.”

Learn more about PIH’s PACT project.

Dr. Heidi Behforouz (middle, wearing black) surrounded by PACT employees at the organization's Boston office.

PIH’s domestic project will take the stage in front of a global audience on September 20. At this year’s Clinton Global Initiative (CGI) Annual Meeting in New York City, Dr. Heidi Behforouz, founder and executive director of PIH’s Boston-based Prevention and Access to Care and Treatment (PACT) Project, will present a commitment to action that outlines a strategy for integrating community health workers (CHWs) into health systems across the country.

Watch the commitment live starting at noon EST on September 20, 2011. 

The three-day event is an opportunity for participants like Dr. Behforouz to build partnerships with politicians, activists, academics, and other NGOs. Fellow participants at this year’s CGI include Madeleine K. Albright, Tony Blair, Ted Turner and PIH cofounder Dr. Paul Farmer. See a list of featured attendees.

Since 2005, CGI has brought together nearly 150 current and former heads of state, 18 Nobel Prize laureates, and influential people across fields. CGI members have made nearly 2,000 commitments, which have already improved the lives of 300 million people in more than 180 countries. When fully funded and implemented, these commitments will be valued in excess of $63 billion.

A community health worker talks to a patient in her home, she visits twice a day.

Outlining and enacting steps towards change

Both on stage and while talking with fellow participants, Dr. Behforouz will focus on the three points foundational to PACT’s commitment to action.

1. Creating a tool kit (training manual, patient intervention guides, operations manual) that both trains CHWs and provides technical assistance to health care organizations as they incorporate CHWs into their model of care
2. Partnering with health care organizations across the US to pilot and scale an integrated CHW project during the next 3 years
3. Leveraging PIH’s reputation, as well as partnerships with Harvard Medical School, Harvard School of Public Health, and experts throughout Massachusetts to establish cross-disciplinary and rigorous evaluations and analyses of the pilot

These three goals represent a significant change in PACT’s efforts to expand the impact of well-supported and well-integrated CHWs to transform health care delivery for the most vulnerable, complex, and costly patients.

PACT, which is supported by both PIH and the Division of Global Health Equity at Brigham and Women's Hospital, has already had a proven track record in success. Read a New York Times piece by Pulitzer Prize-winning author Tina Rosenberg which chronicles the efforts of a New York-based program modeled after PACT.

A patient talks with her community health worker, together they devise strategies that will allow the patient to move forward.

Lessons learned treating at-risk patients

For the past 15 years PACT has employed CHWs to improve the health outcomes and quality of life for some of Boston’s most vulnerable populations. CHWs work with the hardest-to-reach patients – individuals who suffer from mental illness, substance use, stigma, social isolation, and poverty and who are suffering and dying from despite readily available care and life-saving medication.

CHWs not only save lives, but they streamline health care, reduce redundancies, and save money. One year post-enrollment in PACT’s HIV program, 70 percent of patients witness significant improvement in their health (viral load suppression and CD4 improvements). Analysis of Medicaid claims reveals a 16 percent net savings in total medical expenditure two years after enrollment. This is attributed to a 35 percent reduction in length of stay and inpatient costs.

Meet Mark, an HIV patient receiving care from PACT.

Providing the tools to reform US health care

With health care reforms a major topic in the US, PACT hopes their CHW model will serve as a guide to existing health systems currently treating at-risk patients.

Historically a direct service project, PACT will now focus on providing training and technical assistance to forward-thinking health systems that wish to better accompany their most vulnerable patients to better health and quality of life.

PACT’s new consultancy model will enable broader impact of the CHW model as a solution for the rising disparities in domestic health care outcomes. This new initiative will build clinic capacity for team-based care, data-driven population management, dynamic management skills, and continuous quality improvement prior to integrating the CHW.

PACT is working to identify a community health center for a three-year pilot of its CHW-driven care management model.

Dr. Behforouz’s speech will be streamed live via the CGI website on September 20.

Learn more about the PACT Project.  

With over 23 percent of adults in Lesotho living with HIV, PIH recognizes women living here are at far greater risk of developing cervical cancer. HIV accelerates the progression of pre-cancerous lesions in the cervix — a process that usually takes 10-20 years often takes as little as two. This in a country with less than 1 physician per 10,000 people.

In response, PIH’s sister project in Lesotho has stepped up efforts to identify and treat at-risk women, a necessary step to preventing unnecessary deaths.

Clinicians at PIH-Lesotho’s rural clinics perform pap-smears during routine checkups, three months after giving birth and during menopause — all in an effort to detect cervical cancer. The pap-smear is then analyzed at a lab in Maseru, Lesotho’s capital. 

If a woman tests positive for cervical cancer, she is sent to the main referral hospital in Maseru. Women who require further care would be referred to a hospital in Bloemfontein, South Africa, for services such as radiation treatment and chemotherapy.

The double burden of living with HIV

Women living with HIV are four-times more likely to develop cancerous lesions from HPV. While enrollment on antiretroviral drugs decreases the likelihood that a HIV-positive woman will develop cervical cancer, she is still at greater risk than her HIV-negative peers.

This double burden of communicable and non-communicable diseases (NCDs) impacts poor countries hardest — especially those places that lack universal primary care. While a global consensus to treat diseases like HIV has emerged, we must also treat unrelated NCDs.

PIH-Lesotho provides comprehensive health care to all patients at each of its 7 facilities. For people living with HIV, this includes monitoring for and treating any number of conditions that might result from a weakened immune system — including cervical cancer.

One of the world’s highest rates of cervical cancer

At 179 deaths per 100,000 women each year, Lesotho’s mortality rate from cervical cancer is one of the highest in the world, according to the World Health Organization. Of those 179 deaths, 31 women are between 15 and 44. This highlights the need of a comprehensive screening and treatment program. In comparison, the cervical cancer incidence in North America is only 7.7 per 100,000.

In Lesotho, access to specialized care and oncological expertise is limited. In most cases, patients need to be referred to South Africa to get adequate cancer care; this is out of reach for the majority of Lesotho’s rural women — both geographically and financially. 

Learn more about PIH's work in Lesotho.

More than 5,400 patients were hospitalized at PIH/ZL's 15 cholera treatment facilities in August, confirming that the disease will continue to cause widespread disease and death in Haiti for the foreseeable future despite fluctuations from month to month. 

The bacteria have contaminated the lakes, rivers, and canals that millions of people rely on for water to drink and bathe. Heavy rains or tropical storms could well trigger another spike in cholera cases and deaths before the rainy season ends in November.

PIH/ZL is building CTC's with concrete floors and tin roofs, recognizing that cholera will be in Haiti for the foreseeable future.

Steps necessary to confront a deadly disease

PIH/ZL has continued to implement and advocate for the comprehensive package of prevention and treatment measures needed to combat cholera. At the local level, PIH/ZL has stepped up hiring and training of community health workers to reinforce hygiene education and quickly identify cases in poor and isolated communities. And PIH/ZL's cholera treatment facilities are being moved from tents to solid wooden structures with concrete foundations and sheet-metal roofs.
 
On the national and international scale, PIH/ZL continues to advocate for investment in the municipal water and sanitation systems that are needed to provide reliable access to clean water. PIH/ZL continues working with other organizations to mobilize support and resources for another key element of a comprehensive prevention and treatment strategy — vaccination.
 
A cheap, effective oral cholera vaccine exists. But only a limited number of doses are available. A coalition of international medical and public health experts led by PIH co-founder Paul Farmer has called for development of a two-million-dose stockpile for Haiti and a 10-million-dose global stock to combat cholera around the world. PIH/ZL has teamed up with GHESKIO, a longtime partner based in Port-au-Prince, to plan a 100,000-patient pilot vaccination campaign targeting vulnerable populations in both rural and urban areas.

One of the new cholera-related buildings under construction in Mirebalais.

Tens of thousands continue to suffer

The decline in hospitalizations from 12,649 in July to 5,400 in August at PIH/ZL clinics mirrors the MSPP's updated cholera numbers for the entire country. In August, roughly 20,000 people contracted cholera nationally, compared to the 50,000 new cases seen in July.  

Since the first cholera cases were reported last October, just over 440,000 Haitians have contracted the disease and nearly 6,300 have died.
 
Learn more about PIH's cholera response.

In early September a visiting delegation of US Congressmen toured PIH’s flagship Butaro Hospital, a state-of-the-art facility run in partnership with the Rwandan Ministry of Health.

Congressmen and USAID representatives tour PIH's Butaro Hospital, run in partnership with the Ministry of Health.

PIH's Dr. Peter Drobac walks with Congressman Jim McDermott.

The delegation was in the sub-Saharan country to review Rwanda’s progress in improving maternal and child health. While visiting Butaro Hospital, Antoinette Habinshuti, deputy country director for PIH’s sister organization Inshuti Mu Buzima (IMB), explained how PIH’s community-based interventions have contributed to an 80 percent drop in childhood deaths throughout the region.

“We wanted to show the delegation that preventing maternal and child mortality means building hospitals and health centers—but it also means providing continued education to health professionals,” said Habinshuti. “We explained our community health worker model, which differs from traditional models where patients come to the health facilities.”
 
“This is one of the key factors that increased birth at health facilities, hence reducing maternal and child deaths,” said Habinshuti. “In the past few years, the under-five mortality rate has dropped from 152 per 1,000 children in 2005 to 27 per 1,000.”
 
Congressmen Jim McDermott (D-WA), Donald Payne (D-NJ) and Steve Cohen (D-TN), joined by USAID’s Carla Koppell, also visited an IMB health center and some of the families supported by the organization’s network of community health workers.
 
“I applaud the work that Partners In Health is doing and am encouraged by the positive results I witnessed,” said Congressman Payne after touring the facility.

Read more about Butaro Hospital.

IHSJ Reader     September 2011     Issue 8         

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

NON-COMMUNICABLE DISEASES

Informing the 2011 UN Session on Noncommunicable Diseases: Applying Lessons from the AIDS Response
(Peter Lamptey, Michael Merson, Peter Piot, K. Srinath Reddy, Rebecca Dirks, PLoS, September 6, 2011)
In two weeks, the United Nations (UN) High-Level Meeting on Noncommunicable Diseases will begin, providing the first formal UN opportunity for the international community to raise awareness of the burden of noncommunicable diseases (NCDs). Global advocates are hoping to apply the lessons learned in the global response to HIV to inform the structure of the NCD response.  In order to prevent, diagnose, and treat the dual burden of communicable and noncommunicable diseases that are disproportionately felt among the poorest billion people in the world, plans must focus on strengthening health care from the community to the tertiary care centers.   

Delivering Hope:  Cancer Care in the Developing World 
(Livestrong, September 7, 2011)
Cancer and other noncommunicable diseases NCDs significantly impact populations in low- and middle-income countries, where about 80 percent of NCD deaths occur. In this new report, LIVESTRONG features a case study on a  patient treated for cancer by Partners In Health in Rwanda, where PIH has been advocating for expanded treatment of NCDs like cancer, heart disease, diabetes, and chronic obstructive pulmonary disease. The report recommends practical, effective and affordable strategies to address cancer prevention and treatment, and describes how existing health systems designed to treat infectious diseases in low-income countries can be strengthened to address cancer.

Grappling With the Tensions Around NCDs
(Sir George Alleyne, Alafia Samuels, Karen Sealey, Global Health Magazine, August 2011)
By 2030, the burden of disease from noncommunicable diseases (NCDs) will be three times greater than that of communicable disease and maternal, perinatal, and nutritional conditions combined. The upcoming United Nations High-Level Meeting on NCDs has stirred tensions around global health funding. However, these conflicts could be allayed by redirecting focus to strengthening health systems so they deliver comprehensive, integrated care rather than debating whether communicable or noncommunicable diseases should receive more funding.

HAITI

Haiti’s Needless Cholera Deaths
(New York Times, September 6, 2011)
Nearly one year after cholera’s deadly outbreak in Haiti, more than 6,000 people have died and another 420,000 have been sickened. Cholera is easily preventable and treatable, but resources for building water and sanitation infrastructure, expanding cholera treatment centers, and scaling up antibiotic, Zinc, and vaccination efforts remain insufficient. In this timely piece, the editorial board of the New York Times calls upon the international community and the Haitian Ministry of Health to urgently “wage a more aggressive and effective effort, which should include not only clean water and sanitation systems but more antibiotics and cholera vaccinations.” Controlling the epidemic and preventing unnecessary death will require strengthening the public sector’s capacity to provide comprehensive prevention and care. For more information on the cholera response, see this August United Nations bulletin.

Haiti’s Rise From the Rubble
(Paul Collier, Foreign Affairs, September/October 2011)
Paul Collier, Professor of Economics and Director of the Center for the Study of African Economics at Oxford University, reviews Paul Farmer’s latest book, Haiti After the Earthquake. Though Collier agrees that Haiti’s history of malign foreign intervention has undermined Haiti’s chronically weak institutions, he challenges Farmer’s recommendation that earthquake relief and reconstruction aid be channeled directly to Haitian public institutions and ministerial budgets. Collier views the Interim Haiti Recovery Commission as a necessary solution to the “acute-on chronic” nature of Haiti’s disaster. PIH remains dedicated to accompanying the Haitian government in rebuilding and strengthening public health systems, and views the role of the state as central to ensuring universal and equitable health care.

Nobody Remembers Us: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti
(Human Rights Watch, August 19, 2011)
Despite the billions of dollars pledged in post-earthquake recovery, less than half of the $258 million dedicated to health care has been disbursed. A lack of health care funding results in a lack of access to reproductive and maternal care in Haiti, where the rights of women and girls to health and security are continuously violated. The international community and the Government of Haiti must redouble efforts to ensure that women and girls receive the life-saving care and security they deserve. 

GLOBAL HEALTH FINANCING

Aid Effectiveness: Bringing Country Ownership (and Politics) Back In
(David Booth, Overseas Development Institute, August 2011)
In advance of the Fourth High Level Forum on Aid Effectiveness, David Booth reflects on hidden assumptions shaping the aid effectiveness discourse. For instance, is there good theory linking “aid harmonization” to “country ownership”, or is it possible that “aid harmonization” actually  limits the freedom of recipient governments to choose their own development strategy? And are the concepts of “donor alignment” and “donor accountability” still effective if political leaders are not already committed to good development outcomes? Ultimately, development cooperation involves not only bridging resource gaps and challenging unfair global trade, finance, and military practices, but also helping to overcome obstacles that weaken public institutions and undermine the social and economic rights of citizens.  

Lao PDR: How Free Births are Saving Women’s Lives (The World Bank, August 30, 2011)                                                            In an effort to reach the fifth Millennium Development Goal of reducing maternal deaths by 3/4 by 2015, the government of Laos has implemented an exciting new initiative: free facility-based deliveries in the Nong and Thapanthong districts.  With the help of a $15 million grant from the World Bank, the abolition of user fees has led to an increase in the number of women delivering in health facilities and a decrease in fatal maternal complications. PIH supports the removal of user fees for health and hopes to see more programs like this implemented around the world. 

HIV/AIDS

Deaths Reported As ARV Shortage Continues
(PlusNews, September 5, 2011)
Burundi is experiencing the impact of shortages in HIV treatment, due in part to cuts in foreign assistance. Of the 35,000 people who need ARVs, “Some have died, others have turned to traditional healers, and all of them [HIV-positive people] are discouraged," laments Jeanne Gapiya, President of Burundi's largest HIV NGO, Association Nationale de soutien aux Seropositifs et Sideens (ANSS). The international community must continue advocating for the right to health and refuse to turn back on the enormous progress achieved in the fight against HIV/AIDS.

WOMEN’S HEALTH

Family Planning as a Pro-Life Cause
(Michael Gerson, Washington Post, August 29, 2011)
Family planning plays a crucial role in development. In communities that do not have access to maternal health services, contraceptives save women and children from high risk pregnancies. U.S. global health initiatives should ensure that access to and education around family planning is part of comprehensive health care services.

NEONATAL HEALTH

Neonatal Mortality Levels for 193 Countries in 2009 with Trends Since 1990: A Systematic Analysis of Progress, Projections, and Priorities
(Mikkel Zahle Oestergaard, et. al, PLoS, August 30, 2011)
Between 1990 and 2009, approximately 79 million infants died in the first four weeks of life; most of these deaths occur in developing countries and are caused by preventable or treatable diseases. Though neonatal mortality (deaths occurring during the first 28 days of life) has declined worldwide, progress is substantially slower in poor regions where health systems are weak and underfunded. Many of these neonatal deaths could be prevented by implementing interventions that are commonplace in developed countries.

ADDITIONAL RESOURCES

Global Health Check
(www.globalhealthcheck.org)
Anna Marriott, Health Policy Advisor for Oxfam GB, has launched a new blog to stimulate debate and conversation on health financing and service delivery. Check it out!

The Health Show: Poor sanitation fuels cholera outbreak in Haiti
(BBC News World Radio and TV)
Tune in to a recent episode of this BBC global health series to see Zanmi Lasante’s Dr. Ralph Ternier discuss the devastating impact of cholera in Haiti. 

“It will take a long time to create a basic sanitation system for Haiti, but changing peoples habits through education is also vital to keeping millions of people safe from this highly contagious disease,” says the BBC’s The Health Show.

In an episode focused on cholera in Haiti, the BBC talks with patients receiving care at PIH’s cholera treatment center (CTC) in Mirebalais, Haiti, and interviews Dr. Ralph Ternier. The BBC shows how PIH staff quarantine the sick, treating them with antibiotics and fluids in an effort to save lives and curb transmission rates. 

Watch the BBC’s The Health Show follow PIH patients, doctors at our CTC.

With roughly 440,000 made sick since last October, and well over 6,000 dead, the cholera epidemic continues to ravage the country. Help PIH treat those who are ill, and education communities as we work to stop the spread of cholera.

Learn more about PIH’s cholera response.

By Kate Thanel, PIH’s Haiti Curriculum and Training Specialist

On August 30, Zanmi Lasante’s (ZL) training team conducted a cholera workshop for trainers and health agents from other Haiti-based NGOs. Held in Hinche, the training is a crucial step in the fight against cholera and a reminder that the number of new infections will only be curbed through collaborations such as this.

Nearly a year since entering the country, cholera continues to infect thousands of people each week. As of late August, the Haitian Ministry of Health reports that nearly 440,000 people have been infected to date. In the absence of more permanent structural solutions, community education is one of the most powerful tools we have to confront cholera.

In addition to training thousands of its own community health workers (CHWs), accompagnateurs, and hygiene agents, the ZL National Training Center has opened its doors to all local organizations interested in building training capacity and competence in community-level cholera intervention.

Since June, the ZL training team has worked with staff from six organizations in Haiti’s Plateau and Artibonite regions, preparing them to carry out educational sessions for CHWs over the course of a two-day training. Facilitators return to their organizations with materials in hand, prepared to train new cohorts of CHWs. To assure proper preparation of these facilitators, ZL has also offered to host and guide a first supervised training at the National Training Center for interested NGOs.

For the August 30 event, ZL coordinated a CHW cholera training led by ZL trained facilitators from Mercy Corps, Save the Children and World Vision. ZL training coordinator Vernet Etienne met with the three facilitators in advance to help them prepare the training agenda, divide up tasks and plan logistics. Each organization invited 8 CHWs to participate. 

This collaborative training gives facilitators from each NGO the opportunity to receive guidance and feedback to better prepare them to provide high quality trainings when they return to their communities.

The training materials used in this training are the product of a collaborative effort with the Ministry of Health and the National Department of Potable Water and Hygiene. ZL has been able to provide trainings and materials to other area organizations thanks to a grant from the World Bank.

Learn more about PIH’s efforts to fight cholera.

Watch, listen, and read recent media coverage of PIH co-founder Paul Farmer discussing his new book, Haiti After the Earthquake, in the post below. 

Check out upcoming media coverage and book tour events, and sign up for news and updates about Paul and the book.

Foreign Affairs- September/October 2011

Paul Collier writes, "To his discussion of this receding tragedy, Paul Farmer brings passion, medical expertise, and a long and intimate engagement with Haiti. His account of the year following the earthquake works on three levels: personal, practical, and analytic."

Read the full story.

Minneapolis Star-Tribune- August 13, 2011

The devastating death blow that the Jan. 12, 2010, earthquake delivered to Haiti, and its continuing efforts to recover, have curiously disappeared from the attention of our 24/7 news media. More than 200,000 people were killed and more than 300,000 injured in less than half an hour following the magnitude-7.0 earthquake.

Read the full story.

San Francisco Chronicle- August 10, 2011

It is no secret that before the massive earthquake of Jan. 12, 2010, Haiti was a poverty-stricken, disorganized nation, filled with tales of human misery. With the earthquake killing hundreds of thousands of people, leveling the capital city, destroying numerous towns and upending primitive infrastructure, stating that Haiti is beyond redemption has become common

Read the full story.

The Daily Beast- August 7, 2011

If you ask Dr. Paul Farmer, the deputy U.N. special envoy to Haiti—a man with deep roots in the country who is famous for his extensive work on public health and AIDS treatment before and after the quake—he would grade the relief effort this way: “I would say for humanitarian relief, right after the quake, I’d give a pretty decent grade, like a B,” he tells The Daily Beast. But, he adds, “For reconstruction, I would say we’re lucky if we’re at C- / D+.”

Read the full story.

The Washington Post- August 4, 2011

On Jan. 12, 2010, a group of second-year nursing students in Port-au-Prince, Haiti, felt their world come apart. Phones around the world started ringing. One call went to Paul Farmer, a lifelong advocate for the Haitian people and co-founder of one of the world’s most notable NGOs, Partners in Health.

Read the full story.

The Economist - July 30, 2011

In an overloaded hospital the son of one of the author’s acquaintances recognised “Dr Paul” and greeted him in English, gasping for breath. Dr Farmer got him to an American floating hospital. The next time he saw him was in the morgue.

Read the full story.

PBS Newshour - July 28, 2011

Eighteen months after the massive and devastating earthquake, Haiti is still reeling from the wreckage and a cholera epidemic. Ray Suarez and Dr. Paul Farmer discuss his new book, "Haiti After the Earthquake." Watch on the player below or on the PBS NewsHour website. 

Watch the full episode. See more PBS NewsHour.

Marketplace (Minnesota Public Radio) - July 28, 2011

Dr. Paul Farmer, the U.N.'s deputy special envoy to Haiti, on how the island nation is recovering and whether its aid money is being used wisely.

Read the transcript of the interview.

The Gazette - July 22, 2011

In his new book, Haiti After the Earthquake, doctor and anthropologist Paul Farmer, a professor of public health at Harvard University who has spent nearly 30 years there as the co-founder of the Partners in Health aid organization, the country’s largest supplier of health care, says: “Few would agree that it has been a successful experiment.”

Read the full story.

Power and Politics (CBC) - July 21, 2011

PIH co-founder Paul Farmer discusses his new book with host Evan Solomon. He also discusses the role of NGOs in post-earthquake Haiti, and the importance of supporting the public sector in rebuilding the country.

Watch the interview on the CBC website. (Select the July 21, 2011 episode, and fast forward to about 45:00 in the player.)

BBC News - July 18, 2011

A year and a half since an earthquake destroyed the Haitian capital Port-au-Prince, it is estimated at least 600,000 people still live in settlement camps, many facing a daily struggle for survival. Their story is one which Dr. Paul Farmer - a US anthropologist and physician - tells in his new book Haiti: After the Earthquake.

Watch the full interview.

Financial Times - July 15, 2011

Paul Farmer, doctor and aid worker, offers an inspiring insider’s view of the relief effort. Farmer, a doctor, anthropologist and lecturer began providing medical services in rural Haiti three decades ago through what became the non-governmental organisation Partners in Health. As he stresses in Haiti After the Earthquake, using a medical analogy, the latest horror was “an acute-on-chronic event” that exposed underlying failures.

Read the full story.

Charlie Rose (PBS) - July 14, 2011

Paul Farmer is an American anthropologist and physician. He is currently the Kolokotrones University Professor at Harvard University, formerly the Presley Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medical School, an attending physician and Chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston, Massachusetts. In May 2009 he was named chairman of Harvard Medical School’s Department of Global Health and Social Medicine, succeeding his longtime friend and collaborator Jim Kim.

WNYC - July 14, 2011

Dr. Paul Farmer discusses the massive earthquake that destroyed much of Port-au-Prince, Haiti, in January 2010, killing hundreds of thousands of people. In Haiti After the Earthquake, Farmer describes the suffering and resilience he encountered while treating the injured in Haiti. He explores the social problems that made Haiti so vulnerable to the earthquake—the issues he says make it an "unnatural disaster." Listen to the interview below or on the WNYC website.

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The Capital Times - July 14, 2011

Months after the January 2010 earthquake that flattened the Haitian capital of Port-au-Prince, Haitians would not say the word "earthquake." Instead, they called it "bagay la," roughly translated to "that thing." As author Paul Farmer explains in "Haiti After the Earthquake," for most Haitians an earthquake of that magnitude and destruction was so far outside their experience and comprehension that it simply could not be named.

Read the full book review on the website for The Capital Times of Madison, WI.

Democracy Now - July 14, 2011

Dr. Paul Farmer on Haiti After the Earthquake: “How Can We Do a Better Job of Cleaning Up This Mess?” Eighteen months ago this week, Haiti was devastated by an earthquake that killed as many as 300,000 people, injured hundreds of thousands, and left more than one million homeless. We spend the hour with Dr. Paul Farmer, who has been working in Haiti for nearly three decades, and since 2009 has served as the U.N. deputy special envoy for Haiti working under former President Bill Clinton.

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Download the episode from the Democracy Now website.

The World: Public Radio International- July 13, 2011

Dr. Paul Farmer has worked in Haiti for nearly three decades. He talks with host Marco Werman about how humanitarian aid to Haiti has been spent, and misspent. Here Farmer addresses a question about whether his job as UN Deputy Special Envoy for Haiti in any way compromises his work in humanitarian aid.

The Boston Globe - July 12, 2011

The earthquake that hit Haiti 18 months ago was, in clinical terms, an “acute-on-chronic” event, Partners in Health co-founder Dr. Paul Farmer writes in his book released today, “Haiti After the Earthquake.” In the first two-thirds of the book, Farmer gives an account of Haiti in the decades before the quake and the months after it. His narrative is followed by 11 essays from doctors, humanitarians, and families affected.

Read the full story.

NPR Fresh Air - July 12, 2011

Physician, anthropologist, and PIH co-founder Paul Farmer has spent 30 years treating patients in Haiti. Listen to his interview on NPR's Fresh Air about his new book Haiti After The Earthquake. He details what it was like on the ground in the days after the 2010 quake — and why the country is still struggling to recover.

Listen to the interview on the Fresh Air website. 

Kirkus Reviews- June 15, 2011

From the UN Deputy Special Envoy for Haiti and chair of the Department of Global Health and Social Medicine at Harvard Medical School, and members of his team, a searing firsthand account of the earthquake and its aftermath. Farmer (Partner to the Poor: A Paul Farmer Reader, 2010, etc.) presents consequences of the outrage that U.S. law—e.g., the Foreign Assistance Act of 1961—makes it impossible to do what needs to be done in a country like Haiti.

Read the full story.

Check out upcoming media coverage and book tour events, and sign up for news and updates about Paul and the book. 

By Kate Thanel, PIH's Haiti Curriculum and Training Specialist

In late August, PIH and Dominican Republic Ministry of Health (MOH) staff began training the country's first cohort of accompagnateurs. This group of community health workers (CHWs) will provide medical and psychosocial support to patients coping with HIV, STIs and Tuberculosis. Doctors, nurses, a social worker, a psychologist, and support staff from both Socios En Salud (SES), PIH's project in the Dominican Republic, and the Elias Piña MOH led and organized training exercises. Even the SES IT specialist participated to ensure proper collection and use of pre- and post-test data. 

Using interactive and participatory teaching techniques, this diverse team introduced the new CHWs to the principles of PIH's sister organization in the neighboring country of Haiti, Zanmi Lasante (ZL), and to the model of patient follow up and community work that has improved health outcomes at PIH sites around the world. This collaboration is an example of how PIH draws on all available resources and partners with the public sector at every level of program development to ensure successful and sustainable intervention.

Teams in Boston and the Dominican Republic worked together to adapt the SES training documents used in Peru to the Dominican context, and the Haiti training team has provided materials, topical experts, and on-site logistical support for the training. 

Over the course of the training, the new CHWs have shown impressive advances in knowledge and understanding of HIV, TB and the PIH model. New skills and knowledge combined with an intimate understanding of their communities, prepare them to promote health and improve access to care in the Elias Piña area.  

"The enthusiasm of facilitators from both SES and the MOH has been tangible throughout this training and has inspired this first group of accompagnateurs who are visibly eager to improve awareness and access to treatment in their communities," says Dr. Jennifer Severe, SES's program director.

Finalized training materials updated during the pilot will be available publicly later this year for use by organizations wishing to implement the accompagnateur training in Spanish-speaking areas.

PIH's work in the Dominican Republic is a collaboration between the MOH and staff from Socios En Salud and Zanmi Lasante. As at other PIH sites, this work relies on a network of CHWs to support patients at the community level. These CHWs, of both Dominican and Haitian origin, will serve a border population that is typically vulnerable to lapses in follow up. Coordinating treatment and follow up on both sides of the border with ZL's site in Belladere will create the opportunity to provide consistent care. 

Learn more about PIH's work in the Dominican Republic.

As the summer draws to a close, construction continues at Mirebalais Hospital. Recently, crews have begun painting inside multiple buildings and tiling the walls and floors.

More than ever the various buildings are beginning to look like a hospital, all of which brings PIH/ZL one step closer to opening its state-of-the-art facility in January 2012.

Learn more about Mirebalais Hospital.

"I was very sick and everyone thought I was going to die," says Francine Tuyishime, a  cancer patient from a rural and impoverished village in Rwanda. The 15-year-old had traversed the country looking for a cure for the enormous tumor protruding from her cheek before arriving at Rwinkwavu Hospital, a facility operated by PIH in partnership with the Rwandan Ministry of Health.

But many others are not as fortunate as Francine, as cancer and other non-communicable diseases (NCDs) like diabetes and cardiovascular disease have become major problems in low-income countries like Rwanda.

The World Health Organization (WHO) estimates that NCDs account for about 25 percent of Rwanda's national burden of disease. And NCDs are projected to become an even larger problem in the coming years.

For example, cancer deaths are expected to double over the next 20 years, from 7.6 million deaths worldwide in 2008 to 13.2 million deaths in 2030, according to the International Agency for Research on Cancer. And the WHO estimates that there will be 21.4 million new cancer cases diagnosed worldwide in 2030, with nearly two-thirds of these diagnoses occurring in low- and middle-income countries.

To address this issue, Partners In Health is working with the Dana-Farber Cancer Institute, the Jeff Gordon Childrens Foundation, and the Rwandan Ministry of Health to help poor patients like Francine survive cancer. The need to address NCDs like cancer is also beginning to capture attention on a global scale.

IHSJ Reader     August 2011     Issue 7         

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

HAITI

Not Doing Enough: Unnecessary Sickness and Death from Cholera in Haiti
(Jake Johnston and Keane Bhatt, Center for Economic and Policy Research, August 2011)
A new report from CEPR examines how cholera treatment and prevention efforts in Haiti have not kept pace with the expansion of the epidemic. Since its appearance in Haiti in October 2010, this preventable and easily curable disease has killed more than 6,000 people, making it “the most catastrophic epidemic the hemisphere has seen in decades”. The $175 million UN cholera funding appeal remains underfunded, and resources for building water and sanitation infrastructure, expanding cholera treatment centers, and scaling up antibiotic, Zinc supplement, and vaccination efforts remain insufficient. This paper argues that the international community should redouble efforts to combat cholera.

WOMEN’S HEALTH

Stop Making Excuses: Accountability for Maternal Health Care in South Africa
(Human Rights Watch, August 8, 2011)
Human Rights Watch recently released a report exposing that the maternal mortality rate has more than quadrupled in South Africa over the past decade. The analysis examines health system failures, including patient abuse, administrative and financial mismanagement, and a lack of accountability for these failures, and calls for the government of South Africa to uphold the right to health for all patients. The report concludes that South Africa is unlikely to meet its Millennium Development Goal of reducing maternal deaths by 75 percent by 2015 unless the government focuses attention and resources on the systemic problems that give rise to poor care.

HIV/AIDS

Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from Donor Governments in 2010
(Jennifer Kates, Adam Wexler, Eric Lief, Carlos Avila, Benjamin Gobet, UNAIDS and Kaiser Family Foundation, August 2011)
This report by the Joint United Nations Programme on HIV/AIDS and the Kaiser Family Foundation found that funding for international AIDS assistance from donor governments declined by more than 10 percent over the 2009-2010 time period. Though access to treatment has increased dramatically and new infections have fallen by nearly 25% in the past ten years, recent budget decisions have not prioritized  eliminating the estimated $6 billion resource gap necessary for scaling up HIV treatment, prevention and care.  

 AIDS Divides the Globe
(Michael Sidibé, LA Times, August 3, 2011)
Michael Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS and Under Secretary-General of the United Nations, penned a call to action to address the inequality in HIV treatment that persists throughout the world. Sidibé writes that we must overcome the forces that limit access to treatment in poor countries by moving forward on five key fronts. “If we want to turn scientific successes into progress for the poor... We have to scale up, even as some donors are scaling back, and we have to use innovation to overcome social division and inequity.”

ACCESS TO ESSENTIAL MEDICINES/TUBERCULOSIS

Shortage of Drug-Resistant TB Treatment Looms
(PlusNews, August 16, 2011)
With one of the biggest advances in TB science in decades, scientists have finally identified an effective and accurate diagnostic kit called GeneXpert that will make rapid detection of drug-resistant TB (DR-TB) possible. However, the South African National Department of Health worries that faster diagnosis will result in more patients without access to treatment. Though treating DR-TB has been a global health priority for nearly a decade, medications remain prohibitively expensive. High drug prices are attributed to a variety of market failures, from countries inaccurately forecasting increased demand to pharmaceutical companies experiencing limited access to quality ingredients.

DR-TB Drugs Under the Microscope
(Medecines Sans Frontieres, March 2011)
This MSF report, which has just been translated into Russian, examines two barriers to treatment scale-up for patients suffering from multidrug-resistant tuberculosis (MDR-TB): (1) limited availability, and (2) high cost of quality-assured second-line drugs. Not only are drug supplies limited and unreliable, but prices have actually increased in recent years, with MDR-TB treatment costing nearly 475 times more than treatment for standard TB. Over the last decade, less than 1% of the roughly five million people who developed multidrug-resistant tuberculosis (MDR-TB) had access to appropriate treatment, and 1.5 million died.

Compulsory Licensing of Generic Drugs Remains Mired in Quagmires
(Goldis Chami and Samuel Wasswa-Kintu, Canadian Medical Association Journal, August 9, 2011)
Nearly a decade after the Doha Declaration determined that countries facing public health emergencies have the right to import generic drugs from developed countries, there has only been one instance in which a drug was successfully delivered to a developing country. Though several countries have enacted compulsory licensing legislation, the complicated application process deters low- and middle-income countries from turning to the EU or Canada to access cheaper treatment. Meanwhile, India, which has long served as the “pharmacy to the developing world,” is being forced to comply with international trade law by halting the production of generics patented after 1995.

GLOBAL HEALTH FUNDING

How Will Global Health Programs Fare Post Debt Ceiling Deal?
(Meredith Mazzotta and Christine Lubinski, Science Speaks Blog: Center for Global Health Policy, August 5, 2011)
The debt ceiling legislation passed in early August will result in dramatic cuts to discretionary spending over the next decade. In the agreement, foreign assistance (including global health funding) was grouped under “security”. Exactly what this means for development funding for the next 2 fiscal years is unclear.  Mazzotta and Lubinski offer interesting and concerning predictions.

FOOD SECURITY

Does Global Battle Against Hunger Have a New Hero?
(Associated Press, August 10, 2011)
The recently elected leader of the U.N.’s Food and Agriculture Organization (FAO) says that eradicating hunger is his first priority. Previously, Jose Graziano da Silva was Brazil’s food security minister where he helped create the nation’s “Zero Hunger” social programs. In just six years, these programs have had a dramatic impact by transferring money directly to poor households. Graziano plans to use Brazil’s widely admired system as a model in his work with the FAO.

MULTIMEDIA/ADDITIONAL RESOURCES

Global Health Portal
(TheLancet.com, August, 2011)
The Lancet announced the launch of the Global Health Portal last week. This resource offers free global health content to all users, from World Reports and Perspectives articles, to The Lancet Global Health Series and Regional Reports and Commissions, providing in-depth views for those seeking disease- or region-specific information.

More than two-thirds of all cancer deaths occur in low- and middle-income countries.

PIH and Children's Hospital Boston are working to make sure that Sibo Tuyishimire, a Rwandan boy with a deadly form of Hodgkin's lymphoma, doesn't become part of this dire statistic.

The 13-year-old from a poor village in Rwanda is currently receiving complex medical treatment in Boston.

In an accompanying interview, PIH's Dr. Sara Stulac, Sibo's doctor, also addresses the importance of treating cancer patients like Sibo in countries like Rwanda.

“There’s a lot of [cancer], it’s not being treated, and it can be treated with relatively few resources,” she said.

NPR's Here and Now told his story in a recent segment:

Help PIH advocate for wider attention to and solutions for the growing problem of cancer and other non-communicable diseases in the developing world.

Learn more about PIH's work to fight non-communicable diseases like cancer and diabetes.

By Catriona Spiller, Health Analyst with T&J Meyer Family Foundation

On Rwanda’s Independence Day I flew over the Burundian mountains to Kigali. After a month visiting various East African health care deliverers from small rural clinics to large government hospitals, my perspective on standards of care, staffing, hygiene and aesthetics felt hardened to the realities of low-cost care where resources are scarce.

Driving through the farmed hills of Burera to PIH’s rural flagship hospital in Butaro I discussed the extent of the Ministry of Health partnership and collaboration with country Deputy Director Antoinette and the new initiatives for AAWs – agricultural workers tackling the root causes of malnutrition in the homes of families at risk.

Arriving at Butaro, you are instantly aware that this place was built for patients – the signposts are color coded for the illiterate, inpatients all have a view out the window, the ventilation and space is neutral and light. The labs, equipment, ICU and wards are all professionally maintained and instil confidence. Staff are welcoming and diligent – this is a place that truly cares for those who are sick, a factor taken for granted by so many in the world, but not here in Rwanda.

The resounding message from my trip was not just the achievements in healthcare delivery standards, but what Butaro Hospital means.

Butaro is the tangible creation of an ideal – the strength of capacity and the high quality of services would throw many ‘monitoring and evaluation’ sheets designed for rural Africa into question. 

Butaro stands on top of the hill proving that poor people should not have inferior healthcare because they can’t afford it.

Kamanzi, the Project Manager, told me a story of a patient that had heard of Butaro and travelled from another district to receive treatment here. He was seen, treated and cared for. He vowed that when he went back to his own district he would be asking why they too did not have ‘a Butaro’.

With so many people telling it like it is; the statistics telling us of the brutal inequalities, the rural villagers’ plight in Rwanda, Butaro’s tale of ‘what it could be’ is bringing hope to Rwandans and development analysts alike.

Learn more about Butaro Hospital.

A newly released report from the Center for Economic and Policy Research (CEPR) cites the international community’s failure to adequately address cholera treatment and prevention efforts in Haiti. In fact, Not Doing Enough: Unnecessary Sickness and Death from Cholera in Haiti finds that many NGOs and international organizations stopped providing cholera-related services just as the rainy season set in at the beginning of this summer. Of the 128 aid organizations responding to the outbreak in January 2011, only 48 were still treating patients at the end of July.

In July 2011, PIH/ZL treated over 12,000 patients at 15 cholera treatment centers and units.

Since its appearance in Haiti in October 2010, this preventable and easily curable disease has sickened roughly 420,000 people, killing more than 6,000. These startling statistics make it “the most catastrophic epidemic the hemisphere has seen in decades.”

Still, the $175 million UN cholera funding appeal remains underfunded, and resources for building water infrastructure, expanding cholera treatment centers, and scaling up antibiotic, supplement and vaccination efforts remain insufficient. The CEPR report argues that the international community should redouble efforts to combat cholera.

Read the Center for Economic and Policy Research’s new report.

The New England Regional Council of Carpenters (NERCC) generously offered to donate their resources towards the Mirebalais National Teaching Hospital. Through a class at their Apprenticeship Training Program facility, the NERCC was able to train local carpenters and to retrofit over 200 doors to be used in the National Teaching Hospital in Mirebalais, Haiti. 

The New England Carpenters Apprenticeship and Training Program is a free, 4-year apprenticeship program offered through the NERCC’s Training Fund, in which apprentice carpenters participate in both in-classroom and on the job learning. Every three months, each carpenter attends a one-week class at the training facility in Millbury, MA. The remainder of their school year consists of at least 2,000 hours of work in the field. After 4 years, these apprentices become full journeymen.

Last week, the Millbury training center conducted the last “Doors for Haiti” class in the five-part series. The course required each student to spend 40 hours sanding and prepping the doors. Thanks to the hard work of these apprentices, the doors are now complete and ready to be shipped. Once they arrive in Haiti, volunteer carpenters will install them into each hospital building, including Community Health, Women’s Health , Labor & Delivery, the Emergency Department, and the inpatient medical wards. 

The students had very positive feelings towards this class and were eager to learn more about their handiwork’s final destination. Pat O’Donnell said, “This class has been very rewarding.” Mike Roberston expressed, “it’s a good feeling that you’re doing something to help.”

Mark Erlich, the Secretary-Treasurer of the New England Carpenters Training Fund, initially worked with PIH’s Director of Construction, Jim Ansara, to create this partnership with the Fund and the Carpenters’ Union. Mark believes that the project was very beneficial to the school and its students.

“I have known Jim for a long time, through our strong relationship with Shawmut Design & Construction. To know Jim is to know what a caring and dedicated man he is. We’re pleased we found a way to play a meaningful role in the construction of Mirebalais Hospital because it fits well with the strong culture in the Carpenters’ Union of donating our skills to worthwhile projects in the community. Our apprentices have been able to sharpen their skills while learning that they can apply those skills to help others. It gives our members pride to work on a project that benefits a community that sorely needs it. ”

The Mirebalais Hospital Construction Team and Partners In Health would like to extend our deepest gratitude to the New England Carpenters Training Facility and the New England Regional Council of Carpenters for dedicating their time and energy towards this project, with special thanks to Dave Leonhardi and his August carpentry class, Tom Iacobucci, Catherine Fenton and Lyle Hamm for sharing their thoughts on the project. Mirebalais would not be a success without the help of all of our devoted donors and volunteers.

People Involved

New England Carpenters Training Center
Mark Erlich
Executive Secretary-Treasurer, New England Regional Council of Carpenters Chairman, New England Carpenters Training Fund

Lyle Hamm
Executive Director, New England Carpenters Training Fund

Bert Rousseau
Training Director, New England Carpenters Training Fund

February Cla

Delsin Atwood, Local 1305
Frank Bianco, Local 275
John Carson, Local 33
Kenneth Crawford, Local 94
Justin David, Local 94
Bobby DosSantos, Local 94
Todd Gouthro, Local 424
Michael Jones, Local 40
Michaela MacIntyre, Local 94
Curt Mace, Local 67
Ryan Methot, Local 624
Cedric Mitchell, Local 723

March Class

Melvin Gomez, Local 111
Ryan Homer, Local 275
Christopher Mantia, Local 94
Devin Miranda, Local 1305
Robert Rapino, Local 218
William Anderson, Local 2287
Ronald Bradley, Local 424
Richard Brooks, Local 1305
Creunice Lopes Dacosta, Local 26
Steven DuPont, Local 218
Eric Duling, Local 33
Grady Eason, Local 33
Pedro Flor, Local 94
Bryan Fournier, Local 26
Brian Gardner, Local 275
Bryant Guillemette, Local 1305
Daniel Jacques, Local 107
Gary Jawoski, Local 94
Matthew Kelley, Local 624
Matthew Leone, Local 33

July Class

David Brown, Local 33
Almarie Condry, Local 67
Robert Fuller, Local 67
Daniel Melao, Local 51
David Parlee, Local 94
Michael Smith, Local 94
Anthony Walker, Local 33
Jason Winslow, Local 51

August Class

Evan Briand, Local 108
Raymond Brown, Local 1305
Thomas Flaherty, Local 33
Niall Murphy, Local 33
Patrick O’Donnell, Local 33
Russell Ockerbloom, Local 33
Gregory Price, Local 33
Michael Roberston, Local 40
Robert Tannozzini, Local 33
James VanWie, Local 535

Residents training at Zanmi Lasante facilities shared ideas and input at Monday's launch.

By Donna Barry, PIH Advocacy and Policy Director

On Monday afternoon, August 15, an amalgam of seemingly disconnected partners gathered in St. Marc – a city in Haiti’s lower Artibonite – to lunch and informally celebrate the launch of the new Family Residency and Nursing Professional Development Programs. As recently posted, Partners In Health/Zanmi Lasante (PIH/ZL) are new grant recipients from the Clinton Bush Haiti Fund. This grant will support a new program for family practice medical residents in St Marc, a critically important specialty in Haiti, and education for auxiliary nurses at St. Nicholas Hospital, also located in St. Marc. 

Loune Viaud and Madame Irma Bois watch Monday's ceremony.

Paul Farmer joined the group, which included: Dean Gladys Prosper, State Medical University; Irma Bois, Director of Nursing, Haiti Ministry of Health; Altez Toussaint, Member of Haitian Parliament; Patrick Almazor, Director Clinical Practice, Zanmi Lasante; Loune Viaud, Director of Operations, Zanmi Lasante; Sheila Davis, Director of Nursing, PIH; Esther Boucicault Stanislas, FEBS; and current medical residents at Zanmi Lasante studying community medicine; a surgical team from Boston and North Carolina; representatives from MediShare and several other local NGOs as well as PIH/ZL staff.  

Impromptu speeches focused on the need for more broadly trained doctors and nurses to meet the needs of patients in Haiti. Dr. Patrick Almazor mentioned the importance of family practice physicians in the public health care system as it is only the government that can confer the right to health in Haiti. 

There is a very big difference between learning medicine in a hospital or university setting in Port-au-Prince and going out to communities to see what they need,” said Benjamin Jean Michel, a medical resident at ZL. “This is the first time we have been able to do that and have learned so much. We hope to be the generation of doctors that understands what social medicine is and how to address the social determinants of health.

Drs. Selwyn Rogers and Paul Farmer spoke to PIH/ZL staff, medical residents and nurses.

Dr. Selwyn Rogers from Brigham and Women’s Hospital added that he felt his team was serving as “surgical accompagnateurs” this week in St Marc and that, “… while progress may be slow, we are in this for the long haul.” Madame Bois from Haiti’s MOH highlighted the importance of standardizing nursing training across Haiti and praised the opportunity this grant presents by funding a pilot project on just this topic.

At first it seemed such a strange conglomeration of folks, pulled together last minute by Loune in order to take advantage of so many important people and partners’ presence in St. Marc. But, by the end of the afternoon, as is often the case in Haiti, it seemed the perfect match of talents and personalities had gathered to support this nascent project and to voice their ongoing partnership with the poor in Haiti.

At the end of her internship with PIH’s Right to Health Care project, Sarah Phillips made a short video in which she illustrated one of defining characteristics of PIH’s work: accompaniment. A broad and often difficult to understand term, Sarah beautifully captures its meaning in her short video – in large part because she embodied this approach every day while interacting with patients.

“Sarah’s primary role was accompanying people who have never been to the US, many who have never travelled more than a few miles outside of their local village, to medical appointments here in Boston,” says program assistant Kathryn Oas. “From meeting them where they were staying to going with them to the appointment, Sarah helped patients negotiate the literal and metaphorical mazes associated with the US’s complex hospital care system.”

More than just getting patients from one place to another, “she sat in appointments and took notes on the patient’s care plan – prescriptions, follow up instructions – and then communicated that back to the RTHC team. 

Kathryn says, “Sarah was an integral part of making sure that follow-up care and instructions were implemented correctly.”

“Sarah was enthusiastic, warm, and compassionate,” recounts Kathryn. “She helped us provide a high-level of assistance to patients, while working towards some of our long-term goals.”

As with all of PIH’s 25 summer interns, we will miss Sarah’s energy and commitment. At the same time, we know each of these young social justice warriors will continue advocating for social justice and health equity wherever the world brings them. 

First with the tip of their wheels, and then their whole bodies, the five FACE AIDS riders who spanned the country on their bikes to raise funds and awareness for AIDS marked the final day of their ride Thursday with a celebratory dip in Boston Harbor.

Family and friends greet the five riders at Boston's Long Wharf.

For the 67th and final day of the ride, staff from the Partners In Health Boston office joined the charity riders for the home stretch of the trip, which raised nearly $50,000 for the PIH and Inshuti Mu Buzima (IMB), its sister program in Rwanda. The team of five were the fourth group to complete the ride, which was started by Stanford University students in 2007 and revived by classmates Austin Keeley and Dave Evans in 2009.  

After 67 days together, the end of their journey is more emotional than the riders expected.

In addition to fundraising, the bikers focus on educating the public about issues surrounding HIV/AIDS and access to healthcare, speaking to schools and community groups and spreading the word whenever possible.

The five riders – Michael Henry, Vadim Kogan, Katie Lund, Laura Lynch and Tim Spittle – rode into Boston with nearly double the amount of money they'd planned to raise. They also have a renewed desire to continue finding ways to challenge themselves and fight for social justice and AIDS awareness through personal projects and future FACE AIDS projects.

The group, launched at Standford in 2005, focuses its efforts on AIDS patients in Rwanda and has raised more than $2 million for IMB.

"It feels amazing to be done," said Laura Lynch, a Stanford University junior from Rome, Georgia. "(After 67 days) I'll probably wake up tomorrow ready to bike and realize I have nowhere to go."

Read the FACE AIDS riders blog.
Learn more about PIH’s sister project in Rwanda.

A recent report finds that within days of last year’s earthquake, PIH and its sister organization in Haiti, Zanmi Lasante (PIH/ZL), accounted for and continued to treat more than 95 percent of its existing HIV patients.

Beyond providing continued care and social services, a recent report submitted to PEPFAR (US Government’s President’s Emergency Plan for AIDS Relief) documents the HIV-program’s expansion. In the year after the earthquake, the HIV patient load grew by 20 percent, increasing from roughly 16,500 patients to just over 22,000.

“Despite the earthquake our services were actually strengthened because we were able to provide relief, provide health services for our patients, and ensure that our HIV patients adhered to their drug regimens,” says Dr. Fernet Leandre, director of PIH/ZL’s HIV program in Haiti. “Accompagnateurs and community health workers (CHWs) went out to locate HIV patients displaced by the earthquake. It is remarkable that in such a context we were able to find 95 percent of our patients and ensure they continued to receive immediate treatment.”

This feat was not the product of chance or luck, but the result of a decade-long initiative aimed at expanding and integrating HIV services into existing health systems. This allowed the organization’s HIV-related programs to be back up and running within days and weeks of the earthquake.

While patients living with HIV continued to receive traditional social support services – clean water, food, permanent housing, education, and psychosocial services – the earthquake also required that each of these programs expand significantly.

“One family I know are caring for 15 additional family members, all in their small rural home,” continues Dr. Leandre. “That has a huge impact at the household level.” As tens of thousands of displaced people moved in with extended family, social programs in rural areas were strained.

“Despite the influx, PIH/ZL continues to deliver social benefits to people living with HIV,” says Dr. Leandre.

Part of this effort involved hiring and training cadres of CHWs, ensuring that HIV patients continued to receive daily visits from an accompagnateur – a specially trained community health worker – and monthly meetings with trained HIV/TB physicians and nurses.

Patients waiting outside a pharmacy receive medicine for diseases ranging from asthma to HIV.

Highlighting PIH/ZL’s accomplishments

Between October 1, 2010 and March 31, 2011, roughly 22,000 people received HIV care and counseling across PIH/ZL’s 12 facilities in Haiti’s Lower Artibonite and Central Plateau. In addition, nearly 30,000 family members and children affected by HIV also received various health and social services, all of which was made possible by a PEPFAR grant.*

During that period, staff provided:

• HIV counseling and testing to 48,675 people (excluding pregnant women).
• Clinical care and psychosocial support to 21,679 people affected by HIV.
• Antiretroviral therapy to 6,023 HIV-positive people (excluding pregnant women).
• Antiretroviral therapy to 193 HIV-positive pregnant women, with the goal of reducing mother-to-child transmission of HIV.

Preventing a new outbreak of HIV

These efforts ensured that disruptions in the national health system, and an incredible strain on clinical services, did not reverse a decade-long decline in new HIV infections.

Historically, Haiti’s HIV epidemic peaked in 1994. At that time roughly four percent of Haitians – or 281,000 people – were living with the disease. By 2009, that number had dropped to two percent. Prior to the earthquake, PIH/ZL was monitoring 16,547 of those people, of whom 4,220 were receiving antiretroviral therapy.

Dr. Farmer working with HIV patients in Haiti.

Teaching and advocating after the earthquake

The post-earthquake response by PIH/ZL also utilized education and outreach to prevent new infections. Between October and March, PIH conducted 51 formal HIV and cholera-related training sessions in the Artibonite and Central Plateau – many of which took place at PIH/ZL’s National Training Centers in Cange and Hinche. More than 850 staff members were trained, including 330 doctors, nurses, and social workers, and 477 community health workers.
 
PIH/ZL expanded its public outreach initiatives during the same period, with dozens of awareness and education events taking place in clinics, schools, churches, marketplaces, brothels, public plazas, and people’s homes.

On World AIDS Day (December 1), PIH/ZL organized patient and accompagnateur meetings and testimonies, lectures by the clinical staff, contests, debates, games, singing competitions, skits, and a condom distribution.

Radio spots emphasized important prevention messages and hosted HIV-related call-in games. Listeners who correctly answered HIV-related questions won prizes.

As always, counseling and testing services were provided and nurses were present at all events to provide a safe space for HIV testing. Through these efforts, thousands of people were tested throughout central Haiti. Between October 1, 2010, and March 31, 2011, a total of 398,954 Haitians – about 1 of every 6 people living in the PIH/ZL catchment area – were reached with individual and/or small group level preventive interventions.

* These numbers do not include PIH/ZL’s post-earthquake interventions at the organization’s four Port-au-Prince clinics. At those sites during the same period 22,000 people were tested for HIV. Approximately 4.5 percent – or roughly 1,000 people – tested positive for the disease. These patients were referred to GHESKIO - Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections - an nonprofit working in Port-au-Prince since 1982.

In late July, PIH and the PIH-supported Equipo Tecnico en Educacion y Salud Comunitaria (ETESC) assisted 140 families in Jacaltenango, Guatemala, as they learned to install, use, and maintain improved wood-burning stoves. In a region where wood is the main source of cooking fuel, kitchens are frequently thick with lung-damaging smoke and forests are steadily shrinking from the demand for fuel.

Improved stoves decrease kitchen smoke by as much as 90 percent, significantly reducing both wood consumption and the smoke-related non-communicable diseases (NCDs) – asthma, chronic respiratory disease, lung cancer – affecting people in rural communities like Jacaltenango. This project is one of many PIH initiatives aimed at reducing the burden of NCDs in developing countries.

"Visitors to rural Guatemalan homes are often astounded by the thick smoke filling people’s homes,” says Lindsay Palazuelos, PIH’s project coordinator in Guatemala. Families spend a significant amount of time and money buying, chopping and hauling wood to cook meals and heat water, all of which has to happen multiple times a day.

“Because of this, it’s not uncommon to meet middle-aged women suffering from emphysema or chronic bronchitis, as if they were lifetime smokers,” continues Palazuelos. “But instead of a two pack a day habit, they’ve simply been making beans and tortillas in a smoky kitchen.”

Roughly 90 percent of rural households worldwide still use solid fuels such as wood for cooking. As a result, an estimated 1.5 million people die prematurely from smoke-related NCDs each year, making this the eighth most dangerous contributor to the global burden of disease.

	Each stove includes a combustion chamber, chimney and concrete components that can be assembled by hand, without special tools or adhesives.

	The amount of wood used by a family of four every two months.

Beginning an environmental movement, changing lives

In response to high rates of respiratory illness, PIH invited five communities to form environmental health committees – each consisting of 35 families, with 90 percent of representatives being women. Once the committees had been established, ETESC's ocal Environmental Health Promoters presented each of them with five environmental health projects that PIH could introduce into that community to improve their quality of life.

After receiving training on environmental health themes and analyzing their own communities, all five communities chose to introduce high-energy, low-smoke stoves. 

“I was excited that the community groups chose this project, because indoor smoke is closely associated in children with acute respiratory illnesses like pneumonia, one of the biggest childhood killer,” says Palazuelos. 

The improved ONIL stove, manufactured by HELPS International, will lower families’ wood use by 50-70 percent and decrease kitchen smoke by over 90 percent. As Environmental Health Promoter Francisco Pablo Francisco put it, “If we keep cutting down so many trees, there won’t be forests left to cut.” With the new stoves, he added, “The number of trees being cut is going to decrease, and so is the indoor smoke.”

Participant Catarina Mateo explained that the groups chose stoves because “it’s what we women most use when we work in the kitchen.” She also anticipates that with less smoke she won’t cough so often while cooking.

Combating the root cause of disease

Beyond comfort, these stoves will save lives. Lessening each family's exposure to smoke will result in fewer chronic and often fatal diseases. The closed stove and mesh-protected chimney also prevent accidental burns – a common risk when small children are near open cooking fires. 

The interactive training gave participants a chance to practice assembling the stove’s innovative ceramic combustion chamber, attaching the chimney and – most exciting – starting a cooking fire.

As the flame came to life on the test stove, the participants hovered their fingers an inch above its surface, and smiled approvingly at the temperature.

The stoves arrived and were installed in early August. 

PIH’s three-year environmental health initiative is supported by the Guatemalan nonprofit ETESC – Equipo Tecnico en Educacion y Salud Comunitaria – and funded by Green Mountain Coffee Roasters. 

Addressing NCDs is an integral part of PIH's work.
Learn more about PIH's work in Guatemala.

	In Verrettes, PIH/ZL cared for nearly one thousand cholera patients in July.

	Children with cholera receive care at a dedicated treatment center in Mirebalais.

	A staff member distributes oral rehydration salts to community members.

	At each of our 15 cholera treatment centers and units staff clean the floor with bleach multiple times a day.

Cases of cholera infections in Haiti remained high in July as the rainy season continues to spread the waterborne disease. The most recent numbers show that people treated in PIH/ZL clinics have declined slightly from 14,425 in June to 12,629 in July, but are still nearly triple the 3,932 cases reported in April. This comes as the Haiti's Ministry of Health announced over the weekend that the overall death toll from cholera is steadily approaching 6,000.

Tropical Storm Emily soaked Haiti’s southern peninsula on August 4th causing some flooding on the coast and in and around Port-au-Prince. PIH/ZL tents in the capital city suffered minor damage, but none of our sites in the Central Plateau or Lower Artibonite were affected. PIH/ZL is ready for the hurricane season with a full operational stock and a contingency container of hurricane modules. 

Haiti’s rainy season exacerbates the cholera situation, while stressing and disrupting the country’s woefully inadequate water and sewage systems. 

Of the 12,390 cholera cases treated at PIH/ZL facilities in July, 29 patients died. It is difficult to track the number of Haitians who perish either in their communities or en route to seek treatment at a PIH/ZL facility.

In response to the cholera crisis, PIH/ZL staff continues to build latrines, train hygiene agents, and distribute soap, bleach and water-purification tablets. Additionally, staff continues to conduct research to determine the best treatment practices moving forward.

PIH/ZL caseloads are consistent with those found throughout Haiti. On August 14, Haiti’s Ministry of Health reported that cholera fatalities rose to just short of 6,000 as of July 31. More than 420,000 Haitians have been infected since the outbreak started in October; 600 new cases are registered daily.

Read more about PIH/ZL’s response to the cholera crisis.

By Kaitlin Keane, PIH summer intern
 

Walking the tall, tiled halls of St. Thomas Seminary, Norbert Tibeau looks almost at ease. Having survived a decade of illness and pain, he is finally healthy; and the stone buildings of the serene Connecticut seminary have become a temporary home.

It is a stark contrast to the world he left in Haiti, where the 28-year-old student suffered from a cerebral aneurysm that plagued him for most of his adult life. With debilitating headaches came a constant fear of death, as the weakened blood vessel in Tibeau’s brain ballooned to a staggering two-centimeters – making complicated surgery his best chance for survival. 

The surgery was not an option in Haiti, where health systems do not have the capacity for complex interventions such as brain surgery. But treatment became a reality for Tibeau last year when the Partners In Health’s Right to Health Care (RTHC) team arranged his travel to the United States to have the aneurysm removed. While hopeful, the trip was also shrouded in tragedy – coming months after Tibeau’s life was forever changed by the destruction that befell Haiti in the January 12, 2010 earthquake.

	Right to Health Care patient Norbert Tibeau meets with Dr. Ketan Bulsara before returning to Haiti.

A life-saving illness

Tibeau was 13 when he first knew he wanted to be a priest – just a few years before realizing he was very sick. By the time he entered seminary school in Port-au-Prince at 18, the headaches had become more severe and often left him bedridden for a week at a time.

After his first diagnosis – a Haitian doctor incorrectly told Tibeau he had a brain tumor – he struggled with the decision to tell his mentors in the seminary that he was sick, fearing he would be forced to leave the program. Having a terminal illness, he worried, could make him appear too weak for a life serving the church.

“In Haiti, there is no distinction between diseases like AIDS and cancer,” Tibeau explained with the help of his translator, Matthew Isaac, a fellow Haitian and seminarian at St. Thomas. “If you have a type of serious disease, you have a deadline – you will die.”

But summoning the courage to speak to the priests helped save his life, as one of them reached out to Michael Page, a doctor of emergency medicine from Michigan who was doing work in Haiti with his parish. After hearing Tibeau’s story in 2009, Page pledged to find a way to treat him – sending him for a series brain scans at a clinic in the neighboring Dominican Republic. The images that emerged allowed doctors in the US to make a clear diagnosis of the aneurysm.

In early January 2010, Tibeau was on his final trip to the clinic in the Dominican Republic, when he felt the ground rumble beneath him. He remembers wondering if Haiti had felt the jolt, thinking of his family and fellow seminarians. When he reached a television, he saw scenes of utter destruction in his home city.

It was days before he was certain of the fate of his fellow seminary students – all nine were tragically killed when the structure they were in collapsed. Had Tibeau not required medical care that took him away from Haiti, he would have likely shared the same fate.

Twists and turns to treatment 

Having heard Tibeau’s case, Page vowed to bring him to the US for the lifesaving intervention – and PIH’s Right To Health Care team stepped in to help him keep the promise. Drs. David Walton and Evan Lyon, clinical directors of the program, worked with the RTHC team to find an institution and a doctor that would take Tibeau’s case – a difficult task considering the complexity and cost of the procedure he required. Over the course of two years, RTHC program coordinators Sybill Hyppolite, Naomi Rosenberg, and Anne Beckett searched extensively for a facility to perform the surgery free of major costs – and found a willing participant in Yale-New Haven Hospital and Dr. Ketan R. Bulsara. 

The choice of hospital and surgeon were both vital to Tibeau’s survival, as is condition was not a simple one: the aneurysm had grown to a staggering size and was threatening vital structures and his chance of survival without devastating neurological consequences – including paralysis, an inability to talk, blindness and very likely death, given its size and location. As director of neuroendovascular and skull-based surgery for Yale Medical Group, Bulsara was one of a handful of surgeons in the world capable of the procedure that would save Tibeau’s life.

On April 22, Bulsara threaded a thin catheter through Tibeau’s femoral artery – delicately snaking the instrument up the narrow vessel in his thigh and into his brain to relieve his aneurysm. Hours later, he woke up without the ailment for the first time he could remember.

Life after surgery

Life post-surgery has been calm. Tibeau immediately went back to work on his thesis, writing about The Creation and preparing to present his work to seminary leaders. He returned to Haiti on August 8, with the hope of soon graduating to the priesthood – a path from which he never wavered.

His illness, and the tragic way it saved him from the fate of his fellow seminarians, has strengthened his faith and given him a new purpose among the people of Haiti. The experience has also brought him a new family among the priests at St. Thomas, who have welcomed and protected him as a son.

Leaving Matthew Isaac, who he has come to think of as his Haitian brother in the idyllic grounds of their shared home, will be particularly difficult. But he is ready to go home and use the gifts of health and life to heal others with faith, he said.

“God uses people like instruments to help other people,” Tibeau said. “This time God used Partners In Health to give me life.”

The Mirebalais National Teaching Hospital Construction Team is holding a Volunteer Open House for all those planning to volunteer with us and those thinking about volunteering. The purpose of this meeting is to give us the chance to meet volunteers and discuss the project with them. We will also be presenting about the project and the volunteering process. 

Partners In Health needs skilled tradespeople—carpenters, plumbers, metalworkers,  electricians, medical equipment installers and biomedical technicians—to volunteer to  help build the National Teaching Hospital in Mirebalais, Haiti.  

Join us for a presentation by our Director of Construction, Jim Ansara, at Boston Beer Works to learn what you can do to lend a hand in Haiti. 

September 1, 2011

6 PM - 8 PM

Boston Beer Works (112 Canal St, Boston, MA 02114)

Appetizers will be served. 

To get directions or RSVP, go to the event page.

Disclaimers:

This is an informative session, it will not sign you up for anything. This is for CONSTRUCTION VOLUNTEERS ONLY. This session is not mandatory for those looking to volunteer, but we strongly suggest attendance. 

A new book by PIH co-founder Paul Farmer details the suffering -- and resilience -- that he encountered in Haiti following the 2010 earthquake. Listen to him read an excerpt from Haiti After the Earthquake on the player below.

Download the MP3 file.

To give readers a sense of what it was like in those first few days after the quake, at least for some of the doctors and nurses and patients, let me describe the events of a single afternoon and evening at the General Hospital. At least I believe it was a single night, a very long one...

-Paul Farmer, Haiti After the Earthquake

Inside a medical tent in Port-au-Prince, shortly after the January 2010 earthquake.

The USNS Comfort arrived in the Bay of Port-au-Prince to offer its medical services to earthquake victims.

A team loads a patient onto a helicopter for transport to the USNS Comfort.

Patients filled the courtyard at the General Hospital in Port-au-Prince.

Volunteer surgery teams worked frantically to set up operating rooms to treat injured patients.

A patient in Port-au-Prince.

A patient at the General Hospital in Port-au-Prince.

The destroyed National Palace in Port-au-Prince.

IHSJ Reader     August 2011     Issue 6         

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

NON-COMMUNICABLE DISEASES

***A World of Chronic Disease (Sara Reardon, Science, July 29, 2011)

Non-communicable diseases (NCDs) like cardiovascular disease, cancer, diabetes, and asthma now kill more people worldwide than all other causes combined, with 80% of these deaths occurring in low- and middle-income countries. The United Nations will convene a high level meeting in September to address this global NCD epidemic with a focus on four major risk factors that affect large populations (tobacco, alcohol abuse, lack of physical activity and poor diets). However, cardiologist Gene Bukhman warns that by lumping NCDs together, the poorest billion who struggle with poverty-related risk factors are further marginalized from the global response to prevent and treat non-communicable diseases.

HEALTH SYSTEMS STRENGTHENING

Partners In Help: Assisting the Poor Over the Long Term (Paul Farmer, Foreign Affairs, July 29, 2011)

Adapted from his May 2011 commencement speech at the Harvard Kennedy School of Government, in this article Paul Farmer further defines the practice of “accompaniment”.  True accompaniment, Farmer argues, “does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges.” Instead, accompaniment “requires cooperation, openness and teamwork… sticking with a task until it is deemed completed by the person being accompanied.” In a time of renewed focus on aid effectiveness, PIH’s longstanding approach which is human rights-based and which prioritizes the accompaniment of government and local partners, serves as an important guide for international actors committed to an equitable future in Haiti and beyond. The article is adapted from his May 2011 commencement speech at the Harvard Kennedy School of Government

Improving Sanitation, Still a Long Way to Go (Aimable Twahirwa, Inter Press Service News Agency, July 22, 2011) 

Nearly half of the world’s population lacks access to basic sanitation, and 1.9 million people die every year from diarrhea. In Africa, Rwanda is one of only four countries that are on track to achieve Millennium Development Goal 7, which includes halving the population that doesn’t have access to safe drinking water and basic sanitation. By addressing the issue of sanitation through local initiatives, 61% of Rwanda’s rural population has improved access to potable water and 20% has improved access to sanitation. The Rwandan government’s strong vision and leadership has helped galvanize sustainable solutions for hygiene and sanitation.
 

WOMEN’S HEALTH

Maternal Deaths Focus Harsh Light on Uganda (Celia Dugger, The New York Times, July 29, 2011)

The recent deaths of two Ugandan women while seeking delivery care at public hospitals have received widespread criticism within Uganda and have led to a lawsuit against the government for violating these women’s right to life. This tragedy reflects the larger crisis of maternal mortality within Uganda: approximately 5,200 maternal deaths occurred in the country in 2008 alone, making Uganda one of the twenty-one countries in the world in which 80% of maternal mortalities occur. With aid narrowly focused on disease-specific programs, broader health systems remain weak and underfunded. The result is drastic shortages of health workers such as midwives and obstetricians, equipment and supplies. 
 

FOREIGN AID REFORM

The United States Development Assistance Committee: 2011 Peer Review (Organization for Economic Co-operation and Development, July 2011)
In addition to increasing the total amount of foreign assistance available to fight hunger, disease and poverty, the U.S. could maximize contributions by implementing reforms laid out by the OECD. Key recommendations include improving coordination amongst the 25 U.S. agencies involved in development to avoid duplication and strengthening the role of USAID.  Though the U.S. has made progress in increasing resources for development assistance, from 0.1% of gross national income (GNI) in 2001 to 0.21% in 2010, the U.S. is far from meeting the U.N. target of allocating 0.7% of its GNI to aid.

Modernizing the Foreign Assistance Act of 1961 (Rep. Howard Berman, Modernizing Foreign Assistance Network, July 2011)

In this post, Congressman Berman, former Chairman and now Ranking Member of the House Foreign Affairs Committee  (D-CA), calls upon the U.S. Congress to overhaul the Cold War-era Foreign Assistance Act of 1961. Foreign aid is a critical tool in the fight against global hunger, poverty and disease, but in the 21^st century we need to evaluate how well aid projects are implemented and ensure that they are coordinated with national plans and other donors. Partners In Health has provided feedback on Rep. Berman’s previous  draft legislation and continues advocating for a rights-based approach to development that prioritizes local public sector capacity-building and results-based, pro-poor development assistance.
 

FOOD SECURITY

Escaping from Somalia's Famine into a Perilous Refuge (Samuel Loewenberg, TIME, August 03, 2011)

Journalist Sam Loewenberg reports on the heart-wrenching humanitarian situation at a refugee camp in Kenya where hundreds of thousands of Somalis have relocated and are arriving daily to escape the drought and famine in their own strife-torn country.  Over 29,000 children under 5 years old have perished in just the past few months. The current situation, with extremely high levels of acute malnutrition and mortality, represents the worst nutrition crisis in Africa since the 1991--1992 famine in Somalia.

GHI targets chronic malnutrition in Guatemala (Lomi Kriel, Global Post, July 18, 2011)

Though Guatemala has the highest GDP in Central America, it simultaneously suffers from the greatest prevalence of chronic malnutrition in the western hemisphere, and the third highest rate of chronically malnourished children in the world. In the short term, U.S. foreign assistance is critical to fighting some of the highest rates of stunting in the world. Aid channeled through the Global Health Initiative and Feed the Future have begun targeting food insecure regions such as El Quiche, where seventy percent of children under five are chronically malnourished. Long-term measures including land reform and improved conditions for the historically subjugated Mayan population will be critical to overcoming centuries of mistreatment.

International Food Assistance: Funding Development Projects through the Purchase, Shipment, and Sale of U.S. Commodities Is Inefficient and Can Cause Adverse Market Impacts (GAO, June 23, 2011)

This GAO report finds that monetization—or the process of using foreign aid to purchase U.S. agricultural commodities for NGOs to sell on local markets to fund their development work—diverted $219 million from the U.S. food aid budget over a three year period. Not only is monetization inherently inefficient, but it often forces NGOs to undermine local livelihoods by driving down prices and/or underselling local farmers with highly subsidized U.S. commodities. Legal requirements that 75 percent of food aid be shipped on U.S. maritime vessels were also found to divert critical resources necessary to address food security.  GAO findings only reinforce PIH’s position that food aid must be untied from U.S. procurement and shipping, as other donor countries have done. For more concrete recommendations from PIH and our colleagues, please see  “Sak Vid Pa Kanpe: The Impact of U.S. Food Aid on Human Rights in Haiti.” 

Agriculture Accountability: Holding Donors to their L’Aquila Promises (ONE International, July 11, 2011) 

In the wake of the 2007-08 global food crisis, the G8 and five other donors responded by committing to deliver $22 billion in financing for agriculture and food security within three years. This report investigates the promises made by the G8 and the European Commission, and finds that donors remain severely below their promised donations. Two years into the pledge, only 22% of funds have been disbursed. In addition to calling for donors to fulfill their pledges, the G20 and developing countries themselves need to play a central role in strengthening development and food security.

Empty Promises, Empty Stomachs (Roger Thurow, Global Food for Thought, July 15, 2011) 

In response to the release of ONE’s report on the failing commitment of L’Aquila pledges, Roger Thurow ties these unfulfilled pledges to the food crisis devastating the horn of Africa. In the two years since the G8 promised $22 billion in financing for agriculture and food security, the number of people in Somalia, Kenya, Ethiopia, Djibouti and Uganda in dire need of emergency food aid has nearly doubled from 6.3 million to 10 million. This dramatic increase cannot be ignored and should be an impetus for wealthy countries to disburse their pledges without further delay.
 

U.S. HEALTH DISPARITIES

***Estimated Deaths Attributable to Social Factors in the United States (Sandro Galea, Melissa Tracy, Katherine Hoggatt, Charles DiMaggio, Adam Karpati, American Journal of Public Health, June 16, 2011)

A recent study on the underlying social determinants of health in the U.S. calculated the number of adult deaths attributable to “big social factors” such as poverty and inequality. The analysis quantified the relative risk of mortality for six social factors with astounding results: “245,000 deaths… attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to neighborhood poverty.”  The results are comparable to those for the leading pathophysiological causes—such as 193,000 deaths a year due to heart attack—and behavioral causes—such as 400,000 deaths a year due to smoking. Though public health campaigns and biomedical interventions are critical to the prevention and treatment of disease, they must be accompanied with political and economic interventions to curb the gross disparities in national health outcomes.

A Worker with No ID and Great Medical Need (Sanjay Basu, New York Times, August 1, 2011)

Access to health care is a basic right for all people. It is also one of the rights most frequently stripped from the marginalized poor, particularly within immigrant populations. In this telling New York Times post, Dr. Sanjay Basu, co-founder of Nyaya Health, recounts the story of one of his patients, Carlos. Carlos was an undocumented, uninsured migrant laborer from Mexico whom Dr. Basu treated regularly in his mobile clinic. When Carlos developed a growth in his neck, Dr. Basu struggled but was ultimately unable to connect him with a timely biopsy and proper medical care. This narrative illustrates the injustices in healthcare that persist in the United States. 

On Thursday, August 4, Partners In Health hosted a live chat with Dr. Evan Lyon and Sybill Hyppolite.

They talked about the work they do with our Right to Health Care (RTHC) program. Dr. Lyon is a contributing author to Dr. Paul Farmer’s new book Haiti After the Earthquake and Medical Director of the RTHC program, which helps bring patients to the United States and other countries for surgeries and treatment that is unavailable in their home countries.

You can listen to their chat here:

On August 3, 2011, El Comercio, the largest newspaper in Peru’s capital city of Lima, published an in-depth story about Socios En Salud’s ongoing multidrug-resistant tuberculosis (MDR-TB) research project, called the EPI project.

The yearlong study is spread among 124 heath centers, and involves 4,000 patients, 20,000 contacts and hundreds of staff. In partnership with Brigham and Women's Hospital and Harvard Medical School, SES’s project is one of the world’s largest MDR-TB research initiatives.

“It has taken many years and much investment by many, and it really represents so much of what PIH’s work has been about and what is possible by our transnational team,” says project researcher Dr. Mercedes Becerra, associate professor of social medicine at Harvard Medical School. “This project has been possible by building on our deep roots in one place over time, identifying a priority medical problem for poor patients there, building close technical collaborations with the public health services at all levels, bringing to bear a systematic approach to answering an important research question, finding and administering the funds, , and recruiting a world-class local team that is more skilled every day.”

“I am just exceedingly proud to be part of this team and to witness the energy and enthusiasm the local team is investing,” continues Dr. Becerra. “I hope we can continue to build on this experience to work on improving access to effective TB treatment in Lima and beyond.”

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US [GOVERNMENT] SPONSORS AMBITIOUS STUDY OF TB TRANSMISSION IN PERU

Researcher Leonid Lecca states this is the largest TB study ever conducted anywhere in the world, with $6 million in funding.

Socios En Salud Perú, an affiliate of the highly regarded medical organization Partners In Health, has for a year been conducting an ambitious study that aims to determine precisely how tuberculosis is transmitted. Although it is well-established that overcrowding and poor diet contribute to TB transmission, particularly in poor neighborhoods, the study “Epidemiology of Multidrug-Resistant Tuberculosis in Peru (The EPI Project) examines a broader question and seeks to ascertain why some people have greater resistance to infection than others. 

Read the article in its entirety (Spanish version).
For an English translation, click here.

	Ti Jean works with Haitians living with disabilities to prevent cholera from spreading.

	The rehabilitation team distributes water purification tablets.

On August 3, 2011, Megan Brock, PIH’s new Haiti-based rehabilitation program coordinator, sent us a unique cholera update – one we’d like to share. Megan and PIH/ZL’s rehab team are working to ensure that disabled Haitians avoid contracting cholera and know what to do should symptoms present themselves.
 

I recently started working on the ground with the Rehabilitation Team in Haiti and have enjoyed a whirlwind first week. I’ve spent time getting to know the team and learning the needs of individual Haitians living with disabilities in the Central Plateau and Lower Artibonite. In many ways it was a flurry of excitement, planning for future activities and learning about the important work completed since the earthquake. While we continue planning future endeavors, Jean Louis Ernst (or “Ti Jean” as we call him), PIH/ZL’s Rehabilitation Educator, reminds us that cholera is the most pressing issue for all Haitians, including those with disabilities.

People living with disabilities in these communities are uniquely vulnerable to many health conditions, including cholera. As the second wave of cholera surged in Haiti, Ti Jean and the team took swift action to ensure that we had the necessary knowledge and supplies to help our patients avoid this disease. As Ti Jean reminds us: Our rehabilitation, advocacy and education work is about human rights. Those rights include clean water, access to the community and health care – rights we protect each day.

With our partners at the Disabled Person’s Organization (DPO) in Lascahobas, Ti Jean organized distributions of cholera prevention supplies to individuals with disabilities, their families and community leaders – including water purification tablets, oral rehydration solution to prevent excessive dehydration if someone becomes ill, and bars of soap for sanitation. He commanded the attention of the room, as he explained how to use each item and circulated to make sure everyone had what was needed and understood how to use each item. Distributions continued throughout the week as we visited patients in their homes.

The example that Ti Jean set this week is inspirational and in many ways speaks to the Rehab Team’s broader goals. While the team responds to the ongoing rehabilitative needs and chronic medical conditions of our patients, we also have to be aware of the acute concerns that arise and often have a great impact on individuals with disabilities. We react to the unique needs of this population through various mechanisms including accompaniment of individuals in the community and support for organizations like the Lascahobas DPO. 

As I looked back on this week, Ti Jean’s work really stood out to me. It exemplifies the critical role community health workers like the Rehab Educators play in accompanying patients and guiding teams’ priorities in response to the needs of the community. As PIH/ZL and our partner organizations respond to this second wave of cholera, I am glad to know that the rehabilitation team is able to react at this critical time, reaching out to those with disabilities to ensure that they have access to the knowledge and tools necessary to fight cholera.

Learn more about PIH's cholera-related work.

As construction moves along and our team navigates through the inherent challenges of building in resource-constrained Haiti, there has been no decline in donor interest and very generous in-kind donations of materials continue to come in. These donations include Organogensis, Inc. of Canton, MA, who has generously donated 133 wood doors, frames and hardware that will be used in the staff housing, adjacent to the main Hospital. Additionally, Honeywell International’s Fire Systems Group and the J & M Brown Company of Boston teamed up to donate engineering services and all the materials for a much needed fire alarm detection and notification system for the hospital. Although there is no fire department to respond to an alarm, this is still an important donation, as the size of the hospital complex would make it difficult to notify all staff and patients of an emergency. 

Also on a special note, we would like to recognize and thank David Wilson of the Boston law firm Corwin & Corwin, for donating countless hours of his time over the past six months to give PIH construction legal advice and draft many different contracts with suppliers and contractors in four different countries, and in three languages. Assisting David and doing much of the English to Spanish translation is a very dedicated volunteer, Maria Concha Hein, who has also made five trips to the DR and Haiti over the past year to help nail down many of the details of these contracts. Their help has been invaluable to the building of the hospital. 

We’d also like to thank the Massachusetts Laborer’s District Council for their generous contribution towards the hospital. Furthermore, a special thanks goes out to Joseph Bonfiglio, the business manager of the laborers, and Martin Walsh of the MA Building Trades Council for their time and energy in recruiting construction volunteers.

If you are or know anyone who is skilled and experienced in the building trades and is interested in volunteering to help with the construction of the New National Teaching Hospital at Mirebalais, Haiti, we want to hear from you! You can learn more at www.pih.org/mirebalais or contact our Volunteer Coordinator at hburgess@pih.org. 

Welcome to week three of PIH’s Summer Reading Series.

On Thursday, we’ll be hosting a live chat with Dr. Evan Lyon and Sybill Hyppolite. We'll be talking about the work they do with our Right to Health Care (RTHC) program. Dr. Lyon is a contributing author to Dr. Paul Farmer’s new book Haiti After the Earthquake and Medical Director of the RTHC program, which helps bring patients to the United States and other countries for surgeries and treatment that is unavailable in their home countries.

During last week’s live event, we had a great discussion with Haiti Procurement Manager Jon Lascher. Jon answered questions submitted by supporters, and spoke about his experiences coordinating supply shipments for earthquake relief, as well as the current work PIH is doing battling cholera in Haiti.

In case you missed Jon's talk, listen in here:

Join us this Thursday, August 4 at 7pm EDT for a live online chat with RTHC Program Director Dr. Evan Lyon and Sybill Hyppolite. Dr. Lyon will be answering questions about the work of the RTHC team. Make sure to submit your question for Dr. Lyon below, and call in on Thursday to participate!

Live chat: Thursday, August 4, 2011 – 7 p.m. EDT
Submit a question & RSVP

As Tropical Storm Emily approaches Haiti, Partners In Health and its sister organization Zanmi Lasante are keeping a close watch on potential flooding and its impact on a recent resurgence of cholera cases.

According to the Associated Press, forecasters said the center of the storm was expected to pass over the southwestern corner of the Dominican Republic late Wednesday and was likely to weaken somewhat in the high mountains that divide the country from Haiti. But intense rain still poses a threat, with possible mudslides or flash floods.

Read the entire AP story, Tropical Storm Emily nears Dominican coast, Haiti.

Flooding could play a significant role in the spread of cholera, which is a water-borne disease. Already Partners In Health and Zanme Lasante have been responding to a second wave of cases, working tirelessly to scale up the availability of treatments including, oral rehydration salts antibiotics and IV fluids. In just three months, patients treated and hospitalized at PIH cholera clinics have nearly quadrupled from 3,932 in April to 14,425 in June.

Now, according to PBS NewHour, Tropical Storm Emily could compound the problem, bringing 10 inches of rain to Haiti. Talea Miller writes, “A tropical storm is dangerous for many reasons in Haiti, where tens of thousands of people are still living in tent camps more than a year and a half after a massive earthquake on July 12, 2010. The rainy conditions make containing sewage to specific areas very difficult, and cholera bacteria thrive in poor sanitation conditions.”

Read the entire PBS NewsHour story, Haiti Braces for Storm, Cholera Surge.

The United Nations has mobilized in response to the threat of Emily. A news alert released late Wednesday indicated nearly 12,000 UN peacekeepers are on emergency standby as the tropical storm approaches. “Last November, Hurricane Tomas caused widespread flooding, unleashing a cholera epidemic that killed hundreds and infected some 20,000 people,” the alert states, reflecting the gravity of another natural disaster striking a country still reeling from past and current disasters.

According the alert food stocks, medical kits, cholera treatment kits, tents and tarpaulins have already been pre-positioned throughout the country in preparation for the hurricane season.

Read the entire alert, UN forces on standby for emergency relief as tropical storm nears. 

To learn more about cholera in Haiti, and how Partners In Health is advocating for the construction of sewage treatment facilities and the use of an oral cholera vaccine, visit http://www.pih.org/pages/cholera.

PIH co-founder Paul Farmer reflects on aid, the importance of "accompaniment," and Haiti following the January 2010 earthquake. Read an excerpt of "Partners in Help: Assisting the Poor Over the Long Term" below, and check out the full article in Foreign Affairs. 
 

	PIH co-founder Paul Farmer

The road from policy development to implementation is usually long and rocky, one that must be trod with companions. When travelers have diverged as dramatically as Haiti and the United States, communication between them becomes difficult. About ten years ago, one of my colleagues was examining a patient, a five-year-old girl named Maveline, and found a tumor in her abdomen. It turned out to be cancer on her right kidney, curable if removed before it spread elsewhere. That procedure, a nephrectomy, could be performed right there in rural Haiti — at one of the hospitals we built, an investment that had been regarded by some policy experts as foolish. The procedure went smoothly enough, but an X-ray suggested that the cancer had already spread to Maveline's lungs, and she needed chemotherapy and radiation, which could not be performed in Haiti. Since I was then living in a faculty apartment in a Harvard dorm but often absent, my wife and I thought that the child and her mother might stay there for a month or two while receiving treatment in Boston.

The two months or so turned into a year, and we got pretty close to Maveline and her family. When in Boston working at the Brigham and Women's Hospital, I would come home at about nine o'clock at night, tired but looking forward to seeing Maveline. Her mother, who had never before left central Haiti, would make me dinner, and we would all sit and watch cartoons or whatever Maveline wanted.

One night, well after nine, I was eating a home-cooked meal and sitting with Maveline and her mother, and there was a rap on the door. In came two students: one from Harvard and one from MIT. The Harvard student, Emilio, was from Miami, and although he had never once traveled to Haiti, he'd mastered Haitian Creole with a touching fluency that said a lot about him (he has since become a Jesuit priest and has dedicated himself to the poor in Haiti and Brazil). I'd never seen the MIT student before, but he was Haitian, and the conversation — completely in Creole — went something like this:

MIT student: "You're Dr. Paul Farmer?"

Me (suppressed thought): "No, I killed him and took his apartment."

Me (actual words): "Yes, nice to meet you."

MIT student: "You wrote The Uses of Haiti?"

Emilio, somewhat proudly: "Yes, and he's written other books as well."

Maveline's mother (hands on hips, mildly offended): "Dr. Paul, you never told me you knew how to read and write!"

I tell this story to amuse, sure, but also to illustrate how inequality works in the modern world and thus what an accompaniment approach needs to address. Maveline is still alive and well, but I'm not confident her mother knows how to read and write.

Haiti needs and deserves proper cancer and surgical care facilities and new and better health systems. But for this to happen, we will have to move from aid to accompaniment. Maveline needed an open-ended commitment; her care did not last for a couple of months but for years. An accompagnateur would not say, "Sorry, Maveline, we can help with your surgery but not your chemo." Seeing Maveline through to a cure involved a great many people. And her disease uncovered gaps in local infrastructure: If she'd been seen earlier and her tumor had been found before it spread to her lungs, much needless suffering could have been avoided. If her mother had been able to attend school, she would have been able to read and write, and chances are that Maveline would not have been born to poverty, and so on. It is not a bad thing to think systemically; if you want to solve problems, do not fear so-called mission creep. If the biggest failures in the policy world concern implementation or delivery, the second-biggest cause of failure is that programs are too often stovepiped, even though the problems they seek to address — health and illiteracy, for example — are tightly interwoven.

Read Paul Farmer's full article in Foreign Affairs. 

	A cholera patient in Haiti. PIH representatives recently traveled to Washington, DC, to update members of Congress on the epidemic.

On July 28, 2011, US Congressman Donald Payne, Chairman of the Subcommittee on Africa and Global Health on the Committee for Foreign Affairs and the Congressional Black Caucus Foundation convened an Emergency Haiti Cholera Summit on Capitol Hill. With cholera numbers in Haiti surging this past June, the roundtable discussion — including representatives from the US Congress and Partners In Health — discussed the new and renewed cholera interventions that need to be taken.

During the meeting, Dr. Louise Ivers, PIH's Senior Health and Policy Advisor, and Dr. Ralph Ternier, PIH’s Director of Community Health in Haiti, advocated for continued focus on the cholera epidemic in Haiti and described the extent of the problem in the areas where PIH works. Ivers said, “Attending this meeting is an important opportunity to directly inform Congressional members and others about the resurgence of cholera in Haiti. We’re thankful that Congressman Payne and the other Congressional members who attend today are so committed to continuing to support Haiti, even amidst the budget battles in Washington.”

Nine months after the outbreak began, the international community must now work with the Haitian government to address the second phase of the epidemic — curbing cholera deaths while laying the foundation for a broader nationwide health system that can handle future waves of the disease. Efforts must now place the bulk of resources directly with Haitian workers and infrastructures — in contrast with the first phase, which was carried out largely by foreign workers.

Representatives Payne (NJ), Jackson Lee (TX) Lee (CA), Waters (CA), Wilson (FL) attended the meeting as well as a staff member from NY Representative Clarke’s office.

Other attendees include officials from the State Department, USAID, CDC, Project MediShare, the University of Maryland and Johns Hopkins University.

The summit was held in the Rayburn House Office Building.

Learn more about PIH’s response to the cholera epidemic.

PIH's Cate Oswald spoke with Free Speech Radio News about the rise in new cases of cholera infections in Haiti. The number of patients treated at cholera clinics supported by PIH almost quadrupled from April to June — from nearly 4,000 to more than 14,000. And the Haitian Health Ministry reported that there were 1,000 new cases of the disease each day last month. Listen to the interview on the player below.