When the power goes out in a hospital, the lights aren’t the only thing that could shut off.

A power outage could disrupt surgeries and disable lifesaving medical equipment, including oxygen concentrators keeping patients alive.

In Peru, where power outages are common in impoverished areas, many hospitals and health centers face the daunting task of delivering care amid unstable electricity. Most are powered by generators, which run on fuel that can be costly and in short supply.

Stable electricity is essential in care delivery, enabling health workers to run medical devices like heart monitors, quickly heat water to disinfect surgical tools, refrigerate medication and vaccines, and carry out countless other tasks.

To tackle these challenges, Socios En Salud, as Partners In Health is known in Peru, plans to install solar panels at four health centers across the country. These solar panels come as part of Socios En Salud’s ongoing work to strengthen Peru’s health system in partnership with the Ministry of Health.

The first solar panels were installed in March at a health center in the southern Arequipa region. More panels will be installed in June and July at health centers in Ucayali, a region in the Amazon rainforest, and Cuzco, a city in the Andes mountains.

Renewable Energy

Peru is one of the most biologically diverse countries in the world, with climate zones ranging from the Andes mountains to the Amazon rainforest. But that biodiversity has come under threat in recent years due to climate change—a global phenomenon of long-term shifts in temperatures and weather patterns due to human activity, primarily the burning of fossil fuels.

In the last 15 years, Peru has lost 22% of its glaciers. Last year, it was among the 10 countries with the most tropical primary forest loss. As ice melts, forests dwindle, and sea levels rise, communities already living on the margins—including Peru’s indigenous peoples, who have cared for the environment for millennia—are most at risk of displacement, impoverishment, and lack of access to health care.

But there are ways to counter the effects of climate change.

Renewable energy such as solar, which currently accounts for just 1.1% of the world’s energy, will be crucial in responding to climate change and correcting global inequities in energy access, according to the United Nations. More than 80% of the world’s energy comes from fossil fuels, which emit greenhouse gases that contribute to global warming.

Solar panels work by converting sunlight into electrical energy. Some panels, like those installed by Socios En Salud, store this energy in a battery, which can be used when sunlight isn’t available. As a form of renewable energy, solar panels are more sustainable than traditional energy sources like a generator, which runs on fuel and emits greenhouse gases. They’re also more cost-effective in the long-term.

Powering Care

Peru is among the countries with the highest potential for solar energy, which relies on direct sunlight. But few health centers in Peru have solar panels due to the upfront costs of installation and technical expertise required.

Socios En Salud began working with the Ministry of Health earlier this year to buy solar panels at a low-cost and fund installations at four health centers across the country, as well as providing training on use and maintenance. The first solar panels were installed in March at a health center in Yura, a rural district in the southern Arequipa region.

At the Ciudad de Dios health center, 48 solar panels now bolster the electricity from the grid, which on its own was unreliable and lacked a backup source of energy to support medical devices like oxygen concentrators during a power outage. Some oxygen concentrators use more electricity than a refrigerator.

In addition to supplying more reliable electricity, the solar panels will also help the health center save money in the long run.

“This renewable energy will reduce the high costs of electricity, representing sustainable and economic development in the region,” says Dr. Leonid Lecca, executive director of Socios En Salud.

Annual savings from the solar panels are projected to be 26,000 soles ($6,995), with average monthly savings of 2,167 soles ($583).

Building Capacity

Access to electricity has dramatically increased in Peru over the past 15 years, with 96% of the country’s rural population having electricity. But the quality of that electricity varies widely, and the most rural and impoverished areas continue to lack reliable electricity, sometimes even lacking access to the national grid.

Before the solar panels were installed, Masisea Health Center in Ucayali did not have access to reliable electricity. Ucayali, a region in the Amazon rainforest, is home to 18 indigenous groups and has a poverty rate as high as 14%; the region has also been affected by drug trafficking and guerilla warfare.

During emergencies, the health center there used a generator, which was expensive and ran on fuel. The solar panels, installed by Socios En Salud in early June, now provide electricity that is reliable and sustainable, ultimately saving lives.

“One of the great health problems in Peru is access to health,” says Dr. Alvaro Lujan, who is coordinating Socios En Salud’s solar energy work. “The use of solar panels eliminates this gap…By having adequate electricity, we expand the capacity of the health system, allowing doctors to use the necessary equipment for patient care.”

COVID-19 has been devastating all around, but a new study evaluates its toll on new mothers in six countries where Partners In Health works.  

A report by an international team of academic and on-the-ground researchers, published in BMJ Global Health, found that across 37 PIH-supported health facilities, almost all experienced significant disruptions in the use of maternal health services. Specifically, the researchers identified declines in expectant mothers’ first prenatal appointments as well as deliveries at health facilities during the start of the pandemic in 2020.  

“That kind of drop really happened everywhere,” said Nurse Midwife Isata Dumbuya, a study author and director of reproductive, maternal, and newborn health at PIH in Sierra Leone, one of the countries studied, along with Liberia, Haiti, Malawi, Mexico, and Lesotho.  “People were scared. No one knew with COVID what it was, so their first reaction was to stay away until it’s all clear.” 

Overall, the study found significant declines in expectant mothers’ first prenatal care visits in Haiti (18% drop) and Sierra Leone (32% drop) and facility-based deliveries in all countries, except Malawi, from March to December 2020.  Presumably, more women gave birth at home, though that data was not collected in the research. Nor did the study compare the PIH-backed facility numbers with national rates of maternal health service use. 

In addition to analyzing expectant mothers’ use of hospitals and clinics, the study also assessed the strategies used in various countries to mitigate the pandemic’s impact on service disruptions. For example, extra outreach by community health workers (CHWs) and targeted communications campaigns to educate residents about COVID-19 and alert people to safety measures at health facilities, among other measures, helped allay patients’ fears and restore trust in the health system, researchers report.  

Each country responded with somewhat different results, but—taken together—they provide concrete evidence that the current pandemic had a deep impact on maternal health services where PIH works globally. 

Sierra Leone 

In Sierra Leone, which in 2020 was found to have the worst maternal mortality of any country worldwide, the decline in maternal health visits and the 16% drop in facility-based births was worrisome, Dumbuya said, especially since the numbers had been improving before the pandemic. 

“But it could have been a lot worse,” she added. Drawing from experience overcoming previous outbreaks, notably Ebola in 2014, Dumbuya said the local team had already established strong relationships with the community and put those connections to work as COVID-19 began taking hold. “We have a history with outbreaks,” she said, “so we were able to quickly gather the support network we’d had with Ebola to let people know we can manage this, and we’re open for business.”  

Community health workers were joined by doctors, nurses, midwives, mental health practitioners, and others to visit communities, sometimes in vans equipped with loudspeakers, to offer education and the latest guidance on COVID-19, as well as recommendations for pregnant women. Plans to counteract misinformation were put in place, researchers report, “dispelling women’s fear of becoming infected at health facilities.” 

Now, Dumbuya said, the number of women seeking maternal health visits has come back “even more.” Facility-based deliveries at Koidu Government Hospital were up by 30% in 2021 compared to 2019 before the pandemic, she said. 

Haiti 

Haiti’s decline in maternal health visits, “was likely due to the full lockdown initiated in mid-March 2020 by the national government in response to the rapid spread of the disease in other countries as well as fear of COVID-19 infection in facilities,” the study said.  To minimize the disruptions, Zanmi Lasante, as PIH is known in Haiti, collaborated with the Haitian Ministry of Health to adapt safe distancing in the prenatal waiting room and encouraged women to go to the PIH-supported  Hôpital Universitaire in Mirebalais to deliver their babies. Additional support through regular telephone outreach also helped. 

Lesotho 

Lesotho was the last country in Africa to report its first COVID-19 case, researchers noted, “however, an alarming number of COVID-19 cases were detected after the influx of people traveling from South Africa for Christmas vacation.”  From March to December 2020, PIH-supported facilities in Lesotho did not experience significant declines in the number of first prenatal visits, the study said, but facility-based deliveries were 12% lower than expected. 

Researchers identified several measures that supported ongoing maternal health services, including training on all aspects of COVID-19, providing PPE, screening, testing, and patient follow-up, as well as adapting spaces for safe distancing. 

Liberia

In Liberia, researchers found that “the advent of COVID-19 was accompanied by misinformation campaigns about the disease, which spread disbelief about its potential severity and mistrust in the management of the pandemic by health authorities.” That mistrust may have negatively affected the demand for maternal health services, researchers said. In response, PIH Liberia focused on increasing the public’s awareness about the virus and the availability of services.   

The most surprising finding in Liberia, said Dr. Sarah Anyango, deputy director for clinical services and maternal health lead for PIH Liberia, was the “drastic” decline of births at health facilities—21% lower than expected during the study period. “Every pregnant mom was scared they would get it,” Anyango said. “The CHWs gave the women reassurances, but at first, the CHWs were afraid too.” Ultimately, she said, the CHWs, “played a big part in making sure women eventually felt safe.”  The so-called “household model” of care, in which health workers are assigned to visit everyone in a single home, proved particularly effective during the pandemic, Anyango added. 

“We had already trained CHWs to identify mothers with high-risk pregnancies, so when COVID came we trained them to look for pregnant moms and help them get to health facilities if needed.”

Other safety measures included establishing separate COVID and non-COVID labor suites, and testing every woman entering a delivery room were applied, she said. 

Malawi 

PIH Malawi, locally known as Abwenzi Pa Za Umoyo (APZU), provides integrated maternal care to the women in Neno District, including prenatal, delivery, and postnatal care. This, said the study, is reinforced by the CHW program that helps link pregnant women, identified in their homes, to health facilities. 

From the study: “In April 2020, the Malawi government announced plans to impose a national lockdown; however, the lockdown was canceled. ...The lack of nationally imposed restrictive measures likely facilitated maintained access to health services compared with other countries.”  

Not only did the Malawi Ministry of Health quickly develop guidelines for maternal health during COVID-19, it also “embarked on the emergency hiring of additional health workers” and Neno District’s CHW support was never suspended, indeed outreach for pregnancy-related visits increased.  As a result, the study found: “Maternity care service use in APZU-supported facilities did not suffer any significant monthly declines after March 2020. It even experienced significant increases for first antenatal visits in the months of July, September, and December 2020. Looking at the entire study period, there were no significant variations in maternity care service use during the COVID-19 pandemic in 2020.”  Additionally, the study said: “The APZU team developed a communication plan to provide reassurance about the safety of care-seeking and to dispel the fear of getting infected in health facilities.” 

Isaac Mphande, an APZU primary nursing manager, said women in Neno District have become accustomed to relying on health facilities for childbirth due to fines imposed by traditional leaders or chiefs on expectant mothers who give birth at home. “When a woman delivers at home,” he said, “they are slapped with a fine which is in the form of cash or other things like goats or chickens. These fines are collected by the chiefs and not the health facility staff...to prevent home deliveries.” He said at this point “very few women” in Neno District are giving birth at home. 

Mphande said women consistently hear from CHWS and others about the benefits of receiving care at the health facilities.   Throughout the pandemic, he said, “facilities were kept covered by skilled birth attendants such that services were not disrupted.”   

Mexico 

After the COVID-19 pandemic was officially declared a national emergency by the government on March 2020, fear and uncertainty spread throughout the areas served by Compañeros En Salud (CES), as PIH is known in Mexico. A weekly radio message by the CES birthing center’s obstetric nursing team was canceled; CHWs spaced out visits to pregnant women; and the basic community hospital in Jaltenango stopped attending deliveries to prevent pregnant women from getting COVID-19, what resulted in the adjacent CES-supported birthing center attending all pregnant women from the surrounding areas.  

The result was major disruptions in maternity service use, the study said: “Overall, the number of [facility-based deliveries] was significantly lower than expected by 16% from March to December 2020.”  

The study found significant obstacles to care. “Some rural communities prohibited people from leaving and entering, making it difficult for women to access the birthing center to give birth, the study stated. “In addition, fear and uncertainty may have led women to seek other options for delivery care. This is consistent with some reports indicating an increase in home births supported by traditional midwives during the pandemic in Chiapas.” After the first months, things began to improve, researchers found. “Fear began to dissipate as women who had experienced a safe delivery at the birthing center shared their positive experiences with other women, potentially resulting in a gradual increase of pregnant women coming to the facility for delivery.” 

A statement from the CES team summed up the study’s major takeaway: “We hope that the lessons learned at the PIH sites will help other teams develop context-specific solutions to the challenges brought on by the pandemic in their local contexts.” 

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Jessica used to run away from home. Then her mother, desperate to keep Jessica safe, found a way to keep her there: a chain around her waist.

It wasn’t a punishment. It was a last resort.

Since she was 17 years old, Jessica has lived with schizophrenia, a mental health condition that affects 24 million—or 1 in 300 people—worldwide and can lead to hallucinations, delusions, disorganized thinking and behavior, and social isolation. Life expectancy for people living with schizophrenia is reduced by 15-25 years.

The 34-year-old used to be a familiar face around her neighborhood in Comas, an impoverished district in Lima, Peru, where she sold chewing gum, candy, and cigarettes. Although she was on treatment, her symptoms took a turn.

She began to hear voices that were even louder and more disruptive. She ran away. She once tried to set the house on fire.

That’s when her mother Irene, out of desperation, gave her sleeping pills and put a chain around her waist. Sedated, Jessica was unable to continue her schizophrenia treatment and spent her days sleeping on a mattress on the floor.

Even before the chain, the house was an unstable home.

A shack made of corrugated metal and plywood, with half of the roof unfinished, the house clung to the side of a steep hill, 170 steps up from where the paved road ended. Accessing the main room where Jessica lay chained meant winding through a narrow passageway formed of mounds of trash her mother hoarded and sold for scraps in the market. Stray cats, dogs, and chickens perched on the piles and hopped along the corrugated rooftop. Strangers also came and went through the open doorway, including teenagers who stole Jessica’s identity documents.

The neighbors knew Jessica needed help. But they didn’t know where to go. It wasn’t until a police report was filed against Jessica’s mother, for abandonment, that she was connected to Socios En Salud—and support.

Mental Health Care

Socios En Salud, as Partners In Health is known locally, has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the decades since, Socios En Salud has provided medical care and social support to hundreds of thousands of people in Lima and beyond.

Socios En Salud’s mental health program has served patients with conditions ranging from depression and anxiety to schizophrenia to other severe mental disorders. It’s rooted in a collaborative, comprehensive, and community-based model, dispatching teams of psychologists, social workers, and community health workers—local residents trained to provide basic health services—to patients’ homes to provide medications, therapy, and support in navigating the health system. Most people globally do not have access to formal mental health care, even as mental health is one of the leading causes of disability worldwide.

Socios En Salud has cared for patients with schizophrenia for years through its community health program, including 23 community health workers specializing in schizophrenia care and “safe houses”—homes providing 24/7 care for women with chronic mental health conditions and without family caregivers. In 2015, Socios En Salud launched the first-ever safe house in partnership with the Ministry of Health—a house that has since provided a model for care and inspired the Ministry of Health to build 50 more safe houses nationwide.

“Forgotten Cases”

Socios En Salud staff visited Jessica in November 2021.

Along with staff from the community mental health center in Wiñay, Socios En Salud staff had come on a mission: to help Jessica and her mother understand that free mental health care and social support were available.

Jessica’s mother Irene greeted them and led them inside. The team made their way through a narrow passageway formed from solid walls of trash and found Jessica, chained to a wooden pole in the middle of a clearing that served as their main room—her hair tangled, her clothes disheveled, and her face unwashed. She was disoriented and speaking incoherently.

Her health wasn’t the only concern the team had. She and her mother had no electricity, running water, or sewage. There was no place to prepare food, and the two women relied on leftovers Irene scrounged from the nearest market. Their living space was cluttered with bags, bottles, and garbage; flies swarmed around.

After speaking with Jessica and Irene, Socios En Salud and health center staff identified three main goals: help Jessica apply for a new national identity card and disability card, refer her to the health center for ongoing medical care, and connect her and her mother with free food and stable housing.

"Stories like Jessica's are plentiful in our country,” says Milagros Tapia, a psychologist with Socios En Salud. “Unfortunately, they are forgotten cases, victims of stigmatization, and without access to health services.”

Over the next several months, Socios En Salud and health center staff worked relentlessly to help Jessica access those health services, regularly making house calls to provide medications and accompaniment as she navigated the health system. With Socios En Salud’s support, Jessica restarted her medication and scheduled check-ups at the health center in Wiñay. She also received a COVID-19 vaccine.

Week by week, her condition improved. The voices and hallucinations subsided. She was no longer trying to run away or harm herself. The team noticed changes in her appearance, too. Her face and hair were washed. Her clothes were clean. And in late December, for the first time in years, the chain came off.

Social Support

Pills and injections weren’t the only resources Jessica needed to stay healthy and manage her mental health condition. Socios En Salud staff knew that social support—such as food, housing, and transportation—would also be crucial.

To help Jessica and her mother access free meals, instead of searching for food scraps at the market, Socios En Salud provided foods that didn’t require boiling, like crackers and tuna, and met with community leaders to help reopen a neighborhood soup kitchen, where daily hot meals were provided for free.

Socios En Salud also provided support for transportation, including fares for taxi rides to the local health center for Jessica’s appointments, and housing, with the goal of helping her move to safe house. Additionally, the team helped Jessica apply for a national identity card and disability card, which would make her eligible for government benefits.

Even as Jessica’s medical care and social support fell into place, maintaining her health was often a day-to-day struggle. Following her treatment was challenging given her situation. Her mother, who also lived with a mental health condition, also struggled at times to be a caregiver for her daughter.  

But Socios En Salud, the community mental health center, and Jessica’s community—including her neighbors and local government—were there to support her and her mother, each step of the way.

"Behind Jessica, there are many people helping her,” says Belinda Pineda, a neighbor and president of the neighborhood council in Jessica’s community. “There is the NGO, the community mental health center, the community itself, and the neighborhood council that supports them. The progress and improvement in Jessica's health is evident. I feel very happy for Jessica."

That support came from unlikely places, too.

In January, Socios En Salud staff found the phone number of Jessica’s estranged sister, Rosa, and gave her a call. Rosa was willing to help in any way she could. She agreed to help Jessica follow her treatment plan, attend her appointments, and hosted her in her home for a few weeks. She also helped Jessica pick up her national identity card—issued in March, after months of advocacy by Socios En Salud.

As Jessica continued her treatment, with the support of Socios En Salud and her community, she experienced a feeling she hadn’t in years.

"I feel more confident in myself,” she says. “I now go with my mother to the market and we buy groceries together. I am taking my pills daily and doing everything I can to get better...I now know I am not alone."

Shortly after Haitian President Jovenel Moïse was assassinated in July 2021, Belennda Joseph noticed an odd discharge leaking from her vagina. At first she thought it was stress: the country had descended into turmoil, violence escalated, and citizens were on edge. But two weeks later, when she noticed some blood, Joseph made an appointment to see an OB-GYN in Port-de-Paix, where she lived. The doctor said she was anemic, prescribed medication, and sent her home without performing an exam.  

But the bleeding didn’t stop, said Joseph, speaking in Haitian Creole through a translator. Over the next several months, through a maze of new doctors, delayed test results, and rising concerns, Joseph finally got a diagnosis: cervical cancer. It was stage 2, she learned--too advanced to remove surgically. 

The news hit her hard, she said, “it broke my heart.”  Even though cervical cancer is the leading cause of cancer-related deaths among women in Haiti, Joseph, 31, formerly a nurse at the University of Notre Dame Hospital in Port-de-Paix, said she’d never known another woman who had it. That’s not unusual in a country where treatment has been scarce and diagnosis can be spotty. Women with cervical cancer—many young, in their 30s or 40s— are often left to fend for themselves, doctors say, sent home with pain medication only, left to suffer, and eventually die. 

In wealthy countries, cervical cancer is highly preventable through routine screening, like pap smears, and with HPV vaccines. In Haiti, however, where Zanmi Lasante--PIH's sister organization--has worked for decades, such screening is not part of primary care; nor are the many mainstays of gynecological cancer treatment, such as radiation or a full menu of chemotherapy drugs. And, with no fellowship-level gynecological oncology training for clinicians, there are few specialists in the country to treat such cancers.  

A $10,000 Treatment—in Another Country 

The doctor who delivered Joseph’s diagnosis did suggest one option: travel to the Dominican Republic, where more extensive treatment would be available. “Get a passport as soon as possible,” he’d said. She considered this until she spoke to clinicians in Santo Domingo, who informed her that the cost of radiation treatment would be about $10,000. For her family of five siblings and a single mother whose farm was decimated due to drought, that price tag, in a country where the gross income per capita is about $1,250, was completely out of reach. 

All the while, Joseph continued bleeding. 

What Joseph didn’t know at the time was that for just over a year, an interdisciplinary team of clinicians from Zanmi Lasante's Hôpital Universitaire de Mirebalais (HUM), Dana Farber Cancer Institute in Boston, AdventHealth in Florida, University Hospital in Kinshasa, and Massachusetts General Hospital (MGH) and Harvard Medical School had been meeting weekly over Zoom to discuss a range of gynecologic cancers afflicting patients in Haiti. The global team was launched to broaden and support local clinicians’ capacity to care for patients with gynecological cancers, including ovarian, endometrial, vulvar, and others, with particular attention to cervical cancer. In the weekly case conferences, and monthly deep dives with experts, clinicians discuss new treatment options and emerging research and bring together specialists to work through difficult cases. For instance, a recent discussion centered on a complex case of gestational trophoblastic disease with a world class expert, a Harvard pathologist and local Haitian doctors, led by Dr. Christophe Millien, an OB-GYN and medical director of HUM.  The new collaboration also initiated “telepathology” consults in which pathologist volunteers in Boston review samples from Haitian patients.  

So far, the team has discussed about 50 complex cancer cases. At HUM, more than 20 cervical cancer patients have been treated under the new global consult system led by Millien, and OB-GYNS Dr. Jean Clause Ulysse and Dr. Jean Joel Saint Hubert. 

Improving Care, Now and Into the Future 

The evolution of cancer care at HUM has a familiar PIH arc: Rather than accepting the constraints of the setting—no radiation, a severely limited blood supply which impedes major surgeries, no gynecological cancer specialists—the team instead is thinking creatively, scouring the medical literature for evidence-based alternatives to improve care. At the same time, clinicians continually strategize on how to build a system that supports even more robust care in the future.  

For example, Dr. Tom Randall, gynecologic oncologist at MGH, and associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, cites a research study out of India which led to a paradigm shift in care.  

The study, by researchers at the Tata Memorial Centre in Mumbai and published in the Journal of Clinical Oncology in 2018, involved 635 patients with cervical cancer. Patients were assigned into two groups: one received neoadjuvant chemotherapy (that is, giving chemo first) followed by surgery; the other group received the standard of care, chemotherapy plus radiation. While the radiation patients showed slightly better survival rates, the gap was not huge: Researchers reported the 5-year disease-free survival in the chemotherapy plus surgery group was 69.3% compared with 76.7% in the chemo plus radiation group. 

For Haiti, that’s good news, said Randall: the Tata study shows that it’s possible, in resource-poor settings where radiation is unavailable, to provide cervical cancer patients a viable treatment option. “The study demonstrated that neoadjuvant chemotherapy followed by radical surgery is a feasible, safe, and effective treatment for locally advanced cervical cancer when radiotherapy is not available,” he said. 

A Radical Shift 

For Millien, at HUM, the ability to provide this improved level of care is a radical shift.

“I can testify to the difference,” he said. “At first, when I got a cervical cancer patient, I could not do anything for her—no care. Now it’s different, now there is something we can do." 

HUM is one of the first centers in the world to incorporate this approach to cervical cancer treatment in a very low-resource setting. 

And so, when Joseph showed up at HUM early one morning last November to wait at the front of the line outside the facility, she met with Millien, who said he could try to treat her cancer. “How much would it cost?” she asked. He replied: “It’s free.” 

The road would not be easy: Multiple rounds of harsh chemo, surgery to remove her uterus, and reliance on others to care for her through recovery, loss of her job.  All of this made Joseph nervous, unsure about whether to proceed with her treatment. But Millien told her it was a question of life and death. “God is arranging one thing after another for me,” Joseph said. But then she re-evaluated her options and agreed to the surgery.  She met with Dr. Joarly Lormil, the chief of oncology, psychologists, and social workers, who reassured her that she’d be taken care of at HUM.  After three rounds of chemotherapy, the mass still had not shrunk enough to operate, so Joseph needed an additional three rounds. 

On March 11, Joseph underwent surgery. Despite some post-operative complications, Millien said, the procedure went well. Joseph, in the end, said she is glad to now move forward.

She said that since she was unable to travel outside Haiti for treatment, without this surgery “the cancer would have eaten me, and I would have died.” 

To ensure better, and more comprehensive care in Haiti for others like Joseph, facing gynecological cancer, the international consortium is still pushing the boundaries of what’s possible. Ultimately, the goal is to make radiotherapy available more widely in Haiti, but this is likely to take many years.  

For now, clinicians are working to develop a deeper bench of specialists who can manage these complex cancer cases. Patients in wealthy countries take for granted the availability of gynecological oncologists, but in Haiti, no such training program existed—until now.  In late April, it was announced that the Mirebalais University Hospital Gynecologic Oncology Fellowship in Haiti, the first of its kind in the country, had been approved by the International Gynecologic Cancer Society. Now that the fellowship is official, the international consortium will work to finalize its global curriculum and mentorship fellowship based at HUM. “Our plan is to ultimately train one to two residents each year,” said Rebecca Henderson, an MD/PhD candidate at the University of Florida, who has been working with the team since its inception in early 2021. 

Randall of MGH said the program will provide Haiti’s first comprehensive two-year education and training program in gynecologic oncology by pairing Haitian trainees with expert mentors who track the trainees’ progress. The plan is for mentors to eventually travel to HUM biannually to provide trainees with hands-on surgical training, and fellows will likewise complete one to three months of clinical observation at the mentor’s institution. 

After several weeks recovering from surgery, and various complications due to her advanced cancer, Joseph was discharged from HUM in early April. 

"Cancer prognoses are always uncertain and good outcomes are never guaranteed," Millien said. "In Haiti, where many of the mainstays of cancer care are missing and diagnoses are often made late, this is especially the case. Belennda can at least know she has a care team who is going above and beyond to provide everything they can in this resource-limited setting."

Yesterday, Dr. Tedros Adhanom Ghebreyesus bestowed a WHO Director-General’s Global Health Leaders Award on Partners In Health (PIH) Co-founder and Chief Strategist Dr. Paul Farmer, who passed away unexpectedly in February.

The honor was given at the opening of the 75th World Health Assembly (WHO), the annual meeting of national representatives who make up the decision-making body of WHO, and broadcast worldwide.

“Paul was a true humanitarian and a tireless champion of equity and health as a human right,” said Tedros. “His work helped to empower health and care workers in communities around the world. He worked in places that others had given up on.”

Wingdie “Didi” Bertrand, co-founder and president of Women and Girls Initiative and widow of Dr. Farmer, accepted the award on his behalf.

“We owe it to Paul to collectively keep his legacy alive,” said Bertrand. “That is why today I am encouraging all in attendance to adopt policy decisions on behalf of your fellow citizens that prioritize treating every person as a person—and invest in the provision of high quality, lifesaving health care—as health is a fundamental human right.

"This is what Paul has inspired us to do, taking, always the lead, through hard work and commitment to his patients and their families and communities around the world.”

As an infectious disease physician, Dr. Farmer earned accolades for treating patients in impoverished countries with high quality care, including those suffering from HIV and cancer. As a medical anthropologist, he was known for popularizing and deepening understandings of “structural violence,” the idea that social systems are designed to impoverish, sicken, and sideline select groups. As chief strategist of PIH, he garnered plaudits for pioneering community-based treatment strategies, building teaching hospitals, and more.

Dr. Farmer authored multiple books, including: In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez, Reimagining Global Health: An Introduction, and To Repair the World: Paul Farmer Speaks to the Next Generation. His most recent book was released in November 2020: Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. He was also a professor at Harvard University.

Dr. Sheila Davis, PIH CEO, leads PIH and advances his vision. “On behalf of the entire Partners In Health team, we want to thank WHO for honoring Paul with this award,” she said. “Paul taught us all so much—how to treat clinical maladies; how to practice pragmatic solidarity; and how to integrate dignity, beauty, and social support into care delivery. But most importantly, he taught us that our lives are in service to others.” 

The first case, diagnosed in early March, was a 57-year-old man from southern Malawi. The second, an 11-year-old boy.  

Now, cholera, spreading through six districts in the south, has killed 12 people and sickened at least 300 as of May 19, 2022.  

One of those sick patients, suffering from severe symptoms, was a 1-year-old girl. She was treated last week at Lisungwi Community Hospital in the Neno District, where Abwenzi Pa Za Umoyo, (APZU), as Partners In Health is known in Malawi, has collaborated with the local Ministry of Health to activate rapid response teams to mitigate the impact of the outbreak and help with recovery efforts. 

“This is bad,” said the child’s mother, who declined to be named. “I was so afraid to look at my child. She has had diarrhea and vomiting before, but this was different.” The child was treated, and the mother, profoundly grateful for the medical attention, was able to take her daughter home today, said Dr. Brown Khongo, secondary healthcare manager at APZU. 

Outbreak in Neno 

Neno District, one of the hard-hit areas, has had 62 cases of cholera as of May 19,  2022 with one death—a 13 year old boy who was pronounced dead on arrival at one of the health centers in the district. 

Cholera is an extremely virulent disease that can cause severe diarrhea and vomiting and can be fatal if left untreated, according to the World Health Organization. It can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between 2 hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae. 

Khongo said that, typically, cholera is seen during Malawi’s rainy season, November through April, but years have passed with no cholera at all in Neno. The current outbreak, according to health leaders, is clearly the aftermath of Tropical Storm Ana and Cyclone Gombe that, earlier this year, caused torrential rain and flooding, leaving many people “no access to safe drinking water and sanitation facilities and thus, at risk of widespread disease outbreaks including cholera,” the WHO reports. 

The storms impacted over 221,000 households and 945,000 individuals nationwide, officials said; in Neno District, more than 7,500 homes were destroyed. 

Chronic Water Problems

The storm’s pounding rain, wind, and subsequent flooding disrupted already weak structures, including water sources, Khongo said. Homes across the region collapsed and most people lost their household items for sanitation and hygiene. “Outdoor toilets collapsed and utensils were lost,” he said. Many families are still sheltering with neighbors while rebuilding their own houses, leading to possible overcrowding and further demands on the few sanitation and hygiene facilities that are available. “This,” he said, “adds to the chronic water problems, especially in Lower Neno (where all cases are coming from now) and part of Upper Neno.” 

The main sources of water in the lower region are narrow wells, or boreholes, Khongo said, and there is no piped water supply. But the water from the boreholes and the few personal wells that exist are salty, he said, “so some parts of the community use water directly from the rivers and streams because they are less salty.” 

So far, there’s been no testing of water to pinpoint the source of the outbreak, Khongo said: “But the presence of the outbreak is enough to conclude that the water is contaminated.” 

Responding to an Emergency 

The APZU team, working with Ministry of Health colleagues and others, has mounted a strong emergency response, including setting up a cholera treatment center at Lisungwi Community Hospital with 20 beds, running water, and medicines and other medical supplies. So far, over thirty patients have been admitted to the center with seven currently being managed. 

The team is also conducting: 

• Epidemiological assessments to map areas reporting cholera cases; 
• Contact tracing for all confirmed cases in the community; 
• Risk communication and community engagement; 
• Safe water and household chlorine distribution. 

APZU continues to fill medical and other gaps, for instance, by helping to procure more cholera treatment and test kits and mobilizing a cholera vaccine plan, among other efforts. This is not new for PIH: successful cholera vaccination campaigns were launched previously in Sierra Leone and Haiti. Indeed, PIH's work in Haiti during a 2010 cholera outbreak, rapidly mobilizing to treat more than 145,000 Haitians and vaccinate another 45,000, was key to the development of a global stockpile of oral cholera vaccines by the World Health Organization and other partners in 2012.  

Climate Change and Infectious Diseases 

 Of course, no single storm or cyclone can be blamed on the warming climate. But scientists and climate experts acknowledge that climate change does affect the frequency and intensity of extreme weather events, which in turn can create human disasters, particularly for the socially vulnerable. More (and more intense) cyclones lead to flooding and water contamination from runoff or sewage, which can lead to the spread of contagious diseases, such as cholera. 

Dr. Kelsey Ripp, an internist working on climate change education for medical students at the University of Global Health Equity in Rwanda, a Partners In Health-supported university sees global health and climate change as intimately intertwined. 

 “We often call climate change a threat multiplier,” said Ripp, “because it worsens various health problems by exacerbating other widespread contributors to ill health, such as poverty.” 

As a mother of five, Guerline Joseph felt her family was already complete. Then, at 41-years-old came a surprise: she was pregnant again. 

At first, no one in the family was excited, but that changed when the baby was born. “We almost have a full soccer team,” one of Joseph’s children joked (in Haitian Creole translated into English) when their sibling arrived. While Joseph was an experienced mother, she still needed support, especially considering her pregnancy was high-risk. During her first trimester she found the guidance she needed through a program called Journey to 9 Plus–or J-9 for short. 

It’s a program based on Partners In Health’s (PIH) accompaniment model, which means being there together, for as long as it takes. 

“I love our name: Partners In Health. It’s not just saying you come to us, we’re a hospital. It’s about partnering with the community and that’s what we modeled J-9 off of. The idea is that we are here to accompany our moms and babies and do whatever we can to support them,” says Marc Julmisse, interim executive director of Zanmi Lasante (as PIH is known in Haiti), who initiated the program. 

J-9 gives women and their newborns constant care and support throughout pregnancy and through the first year of the baby’s life. Based at PIH-supported Hôpital Universitaire de Mirebalais in Haiti, the integrated model of care has supported more than 2,000 women since it began in 2018 through four key services: group prenatal and pediatric appointments, psychosocial support and counseling, community-based care, and hospital-based services. 

Joseph, who was referred to J-9 by a hospital employee, had a challenging pregnancy. She suffered from pounding headaches, high blood pressure, and overall stress. She had five children—ages 23, 19 (twins), 10, and 4—at home already. Through J-9, she worked with a psychologist to learn how to manage her stress, received education about how to recognize signs of serious illness, and went to group workshops to learn about proper nutrition and hygiene for her baby.

She was also encouraged to have a facility-based delivery, becoming one of only 36% of women nationwide who give birth at a health care center instead of at home. Indeed, J-9 has successfully improved uptake of maternal and pediatric services. Since 2019, nearly every woman—about 95%— in the program has had a facility-based delivery. And word has spread quickly throughout Haiti. There are more women interested than the hospital can accommodate. Some women have even given false addresses in Mirebalais, in order to enroll, as the program currently only supports residents in that region. Due to the widespread interest, the team expanded J-9 to the PIH-supported hospital in Hinche (about 34 miles north of Mirebalais) in September. More than 100 women have already enrolled. They’ve also trained PIH colleagues in Mexico and Peru how to replicate the program while also adapting to specific cultures.

A Moment to Celebrate

Upon completion of the program, mothers, their babies, and hospital staff participate in a graduation ceremony, where they receive certificates and hygiene kits. In December, 600 babies graduated. Among them was Sonara, Joseph’s one-year-old daughter. 

“We have become very close, and it is very joyful today,” Joseph said on graduation day. “Everyone is very happy to share this moment with their children, their friends and their family.” 

Other mothers expressed their gratitude that such a program exists. One woman, who had severe preeclampsia, ended up suffering from a miscarriage. She felt incredibly alone. In J-9, she didn’t. She felt supported and empowered to ask questions. She went on to have a full-term pregnancy and delivered a healthy baby boy. Feeling overwhelmed with joy, she spoke to graduates and openly shared her journey. 

“She was just so delighted with the care that we provided and the accompaniment throughout her pregnancy, delivery, and then for the baby's first year of life,” says Meredith Jean-Baptise, the hospital’s maternal health coordinator. “Her words were really touching.”

In the future, PIH plans to expand the innovative program to expecting mothers in additional regions of Haiti. Ultimately, the goal is to reduce the country’s maternal mortality ratio—480 deaths per 100,000 live births, as of 2017—which is the highest in Latin America and the Caribbean. 

Early on in her pregnancy, 17-year-old Susan Lebbie sought medical care at Partners In Health (PIH)-supported Koidu Government Hospital. After encouragement from a neighbor, she strived to be proactive as possible in seeking care, to avoid the many challenges her loved ones, as well as many other women in Sierra Leone, faced during pregnancy–significant loss of blood and lack of access to affordable resources, to name a couple.

Lebbie’s journey, which led to the birth of a healthy baby boy, was recently featured in The Washington Post. The article, published on May 6, highlights the importance of adequately staffed facilities, such as Koidu Government Hospital, which provide high-quality care in a country where one in 20 women die as a result of pregnancy or childbirth.

Lebbie was well-aware of that risk. Her mother died giving birth to her. But, her own birth experience was successful.

“If Susan had hemorrhaged in surgery, she could have needed up to four units of blood. But the doctor said her C-section had gone “flawlessly.” No transfusion required,” writes Danielle Paquette, The Washington Post’s West Africa bureau chief. “The two obstetrician-gynecologists here, both Partners In Health employees from Uganda, were known for working more than they slept. Susan’s doctor had started his day at 5 a.m. and finished four C-sections before getting to her.”

Dr. Giuseppe (Bepi) Raviola, co-director of mental health at Partners In Health, writes this reflection as the world settles into a third year of the COVID-19 pandemic, in which at least 500 million people have tested positive and 6.2 million have died from the virus, vaccines remain inequitably distributed, and access to treatment is scarce globally.

May is Mental Health Awareness Month, a time when we at Partners In Health emphasize the need to support our friends, family members, neighbors, and colleagues who live with mental illness in its many forms. In 2022 not only are mental disorders among the leading causes of disability globally, but COVID-19 and associated stressors over the past two years have increased this burden, particularly depression, anxiety and stress-related conditions. People living with pre-existing mental disorders are also at greater risk of severe illness and death from COVID-19. Before COVID-19 only a minority of people with mental health problems received treatment. Now it has become an even greater challenge to find clinical care, if it is needed.

Each year millions of Americans face the reality of living with a mental illness, and this year the National Alliance on Mental Illness will focus on advocacy for a better mental health system in the United States. While in the U.S. there are approximately 42,000 psychiatrists, a recent study noted that upwards of 40% of Americans who had attempted suicide were not receiving services. Despite significant resources, the political commitment to mental health systems reform is inadequate.

The situation in the U.S. remains one of fragmented, expensive, piecemeal services that are not integrated into a “system of care.”

The situation of mental health in the U.S. is not one that any provider can resolve without a broader public health approach to embedding mental health support within all sectors of society. Given the challenges to mental health associated with rapid social change, economic insecurity, health inequity, climate change, migration, addictions, and global geopolitical insecurity, we should increasingly prioritize the building of a resilient social climate by integrating mental health practices through task sharing. This is a practice that Partners In Health revolutionized for TB and HIV care, for example, in which trained community health workers provide patients basic mental health assessments and refer them to specialized care, when necessary. Accepting the unique stresses of the current moment and coming times, a mental health in all policies approach—moving mental health out of the clinical world into our everyday lives—should become our national public health priority, hand-in-hand with the development of comprehensive, collaborative, community-based approaches to care.

Model for Mental Health Care

How does PIH raise awareness regarding mental health? First and foremost, we’ve concentrated on building systems to take care of people—one person at a time—living with complex mental health conditions. By complex we mean conditions that are severe, and that co-occur with other mental health conditions (for example depression, anxiety, and addiction), or with medical conditions, and which also occur in contexts of great challenge, such as poverty. As there are no formal mental health services available to people in most of the world, we’ve built our programs to foster the development of the “staff, stuff, space, systems, and social support” needed to increase access to mental health care for all of the people we serve.

We’ve done this by putting into practice a model that emphasizes care delivered by community health workers during home visits, yet it does so with these providers as one component of functional, sustained system of mental health care delivery that strengthens the health system as a whole, from district hospitals to primary care clinics to community-based care, and sometimes even national psychiatric hospitals. Community health workers operate in extremely challenging conditions, and to expect a mental health system to depend on them completely would be a serious disservice to them. This means that there is a need to strengthen all levels of care systems, including primary care systems with nurses and physicians, and hospital systems as well, to support the management of more severe illness.

In Haiti and Rwanda each, over more than 12 years, we’ve developed systems of care that could be useful in the U.S. context as well. These models have sought to develop coordinated care for both severe mental disorders (psychotic illness) and common mental disorders (depression, anxiety, and stress-related conditions), care delivered both at health centers (that is, delivered by nurses and physicians) and in communities by community health workers, as well as care that ensures availability of pharmacologic and psychological treatments, psychosocial support, and social support.

Across PIH sites we’ve used crises and disasters as opportunities to strengthen systems, for example in our cross-site response and in our Peru response to COVID-19. This work has most fundamentally been based in solidarity with people living with illness—one person at a time— and with our peers delivering needed care in very difficult conditions. This work is done across 12 countries, in collaboration with governments, through a functional cross-site learning collaborative that expands access to care, improves the quality of services, and pilots implementation strategies to strengthen mental health services provided to their communities. PIH now works as a lead partner to at least five government ministries of health in supporting implementation of their national mental health plans. The work is multinational and multidisciplinary.

In the U.S. we also responded to COVID-19, leading the mental health component of the Massachusetts Community Tracing Collaborative, and took the opportunity to build a staff wellness program for the organization. We are now also applying our learning and practice in collaboration with the Family Van, a mobile wellness unit increasing access to health care in Boston. Through this work we seek to show what is possible.

Dr. Paul Farmer's Impact

In facilitating our work, building platforms, articulating theories, and providing moral support and friendship, Dr. Paul Farmer opened up new worlds in health care delivery, including in mental health. In a piece in the journal Science on Paul’s radical intellectual vision, Matt Bonds, an associate professor of Global Health and Social Medicine at Harvard Medical School and co-founder of PIVOT—a PIH partner in Madagascar, writes about Paul as a fearless, complex systems thinker, “not reductionistic, but constructive, integrative, and radically inclusive. He planted seeds and trees…What he created is nothing less than the modern global health movement. ‘Don’t fetishize your model,’ he would often say. ‘Be the house of yes.’” This effectively captures the inspiration that he provided for us in being bold in our aspirations for building comprehensive mental health systems. To build models, but hopefully not lose our hearts in the process. While he and other colleagues provided us with blueprints for effective global health delivery, which for example we adapted into a set of practices to guide systems building in mental health care, he most importantly provided us with moral clarity and an unrelenting commitment to go the extra mile, every day. This is exemplified in the mental health work at each PIH site.

PIH’s work in mental health is grounded in Paul’s concept of accompaniment and social support for the most vulnerable.

In his new book, Healing: Our Path from Mental Illness to Mental Health, the former director of the National Institutes of Mental Health, Dr. Tom Insel, credits Paul’s idea of accompaniment and describes how he applied it to mental health. He writes: “’To accompany someone is…to break bread together, to be present on a journey with a beginning and an end. There’s an element of openness, of mystery, of trust, in accompaniment.’ Farmer argues that accompaniment or social connection cannot only lead to recovery, it is essential for recovery. That is why I have come to think of mental illness as a medical problem that requires a social solution.” This speaks to the spirit of our work and its applicability of mental health care delivery across low- and high-income countries.

Grief in the Time of COVID-19

What have I learned from the past few years? At the outset of the COVID-19 crisis, I wrote about steps that we could take to manage the emotional challenges of social distancing. I ended by noting that, should anything positive come from this tragic situation, it’s that we will all understand our interconnectivity, the importance of being present for those we love, and the necessity of caring for the most vulnerable in our communities — wherever that may be. Today I can add that the past few years have brought a grief, individual and societal, to which we each must try to attend, so as to enhance our capacities for love, support, and compassion. These are very personal journeys. It is this kind of internal work that will strengthen our individual and collective mental health as we move forward, being able to be present for others, and to also bear witness, see and transcend the world as it is, in its suffering, and in all its beauty.

Dr. Giuseppe (Bepi) Raviola, MD, MPH, is the co-director of mental health at Partners In Health with Dr. Stephanie Smith, MD. He is also an assistant professor of psychiatry, global health and social medicine at Massachusetts General Hospital and Harvard Medical School. In 2021-22 he was named an Outstanding Psychiatrist in the Commonwealth of Massachusetts by the Massachusetts Psychiatric Society, a Distinguished Fellow of the American Psychiatric Association, and was a recipient of the Bruno Lima Award of the American Psychiatric Association for outstanding contributions in the care and understanding of victims of disasters.

As mask mandates lifted in April, many celebrated—some of them, mid-flight. Others watched in horror.

For some, the moment marked a long-awaited return to “normal.” But for others, including millions of people living with chronic illnesses and millions more who have yet to receive a single dose of a vaccine, the moment was a stark reminder of the disparities that have persisted three years into the pandemic.

Since vaccines first became available, the U.S. and other wealthy nations bought up the world’s supply. The Biden administration refused to take necessary steps to scale vaccine supply to meet global demand, such as building new factories and compelling the sharing of vaccine technology, despite calls from Partners In Health and others in the People’s Vaccine movement to do so.

Now, that inaction has cost millions of lives. And it’s created a breeding ground for variants.

There remain many unknowns about these variants—for instance, how “mild” they are, or how long currently available vaccines will protect against severe illness. But for public health experts, including those at PIH, the message is clear: COVID-19 isn’t going away. It’s just getting smarter.

“I don’t think that the pandemic is over,” says Dr. KJ Seung, senior health and policy advisor at PIH and co-leader of endTB. “I think that we’re going to have successive waves of death and sickness because of multiple variants. Some may not be as bad as what we’ve had in the past, but some could be worse.”

A Missed Opportunity

As variants like Omicron BA.2 threaten to weaken the impact of the vaccines, U.S. drug-makers are scrambling to update their shots to protect against severe illness. An annual shot, like the flu vaccine, may be needed, says Seung. And that’s where the conversation is focused in wealthy nations.

A third of the world’s population hasn’t received a single dose of any COVID-19 vaccine. Millions more lack access to three doses of a mRNA vaccine—currently considered the gold standard COVID-19 vaccination series in the U.S.

“In terms of vaccine equity, it’s a major problem,” says Seung, whose career has focused on fighting infectious diseases like tuberculosis. “We can’t even get first doses into most of the world. So now if people need annual vaccines or annual boosters on top of that, we’re going to have a really difficult time meeting demand.”

Public health experts are watching another troubling trend: Variants like Omicron BA.2 are spreading even in populations with 70% vaccination and booster coverage, showing that the virus, unchecked in its spread, is evolving in ways that can evade the vaccines' protections.

“We have billions of people who are infected with this virus. And when we just have that huge ocean of virus going around, the likelihood of mutations goes up exponentially,” says Seung. “You just don’t know what sort of variants are going to come out of that.”

Much of that suffering could have been prevented, experts say, had the U.S. allowed its vaccines to be mass produced and distributed to the world’s population, as PIH has called for since 2020.

“Vaccines were so effective against the earlier strains that we might have prevented the Omicron variant had we vaccinated the world fast enough with our most effective vaccines,” says Garrett Wilkinson, government relations and policy officer with PIH’s Advocacy team. “We really missed that opportunity.”

As Big Pharma Profits, Thousands Die

Instead, the U.S. government failed to act. That inaction has only continued.

Even as Omicron cases tick upwards, the U.S. has dialed down its COVID-19 response. The U.S. Congress recently cut $5 billion in proposed funding for the global COVID-19 response, though it kept funding for domestic efforts.

These setbacks have led public health experts and advocates to grapple with the reality of a world where vaccine protection has been secured for the world’s wealthy—at the expense of the world’s poor—even as that protection itself has begun to wane.

“We lost,” says Wilkinson. “Just as we warned could happen, our vaccines that we poured tens of billions of dollars into developing and producing now don’t work as well as we thought they would, because we waited too long to vaccinate the world and let new variants emerge.”

Without any U.S. government intervention in the interest of public health, pharmaceutical companies continue to refuse to share vaccine technology or scale vaccine production to meet global needs, even as thousands die every day from COVID-19. Pfizer stands to make $101.3 billion this year, in large part due to its COVID vaccine—an unheard-of level of revenue in the pharmaceutical industry.

“With the mRNA vaccines, big pharma is really trying to keep a monopoly situation as long as possible,” says Seung. “That’s clearly not going to work at this point. We thought people were fully vaccinated at two doses. Now they’re talking about four. This doesn’t even get into variant-specific boosters.”

It’s unclear what the next chapter of global COVID-19 advocacy will involve. But one thing is certain: vaccinating wealthy nations and leaving the rest of the world behind has come with consequences.

“Although COVID-19 vaccination still prevents hospitalizations and saves lives, our vaccines no longer work as well against Omicron as they did against previous variants,” says Wilkinson. “That’s precisely because of a failure of global solidarity.”

PIH CEO Dr. Sheila Davis reflects on the impact PIH Co-founder Dr. Paul Farmer had on her career as a nurse and leader and discusses the ways in which he inspired, and was inspired by, nurses all around the world.

As I prepare to celebrate Nurses Week this year, it is with both immeasurable admiration and immense sadness, as I can’t help but reflect on the legacy of Dr. Paul Farmer and his impact on the field of nursing.  

As a nurse in the 1980’s in Boston working in the HIV field, I often crossed paths with a young Paul Farmer, and after joining Partners In Health in 2010, I was fortunate to work closely with Paul for over a decade. It was in that time that I came to realize how much he cultivated, guided, and inspired an entire generation of nurse leaders around the world who continue to build on his work to this day.  

Since PIH’s inception in 1987, we have grown into a team of over 19,000 employees across 11 countries who provide care to over 8 million people. And the largest clinician cadre amongst our staff are nurses and midwives. Throughout his lifetime, Paul was a staunch believer in the value of nursing and the extraordinary role that nurses and midwives play in the strategic delivery of health care. His perspective on nursing was largely shaped by humility and exposure to the incredible work nurses were doing at PIH’s care delivery sites.

He witnessed the consistent presence of strong nurse leaders around him demonstrating their expertise while fulfilling our organization’s mission. 

As Paul designed and as core to PIH’s commitment, medical education and health care delivery are deeply intertwined. As so many of us have witnessed firsthand, Paul was an extraordinary educator and knew that the way to build sustainable change was to invest in quality education in the classroom and at the bedside. Paul fulfilled his aspiration to create the University of Global Health Equity (UGHE) in Rwanda, which advances global health delivery by training a new generation of global health leaders equipped in not just building, but sustaining, effective and equitable health systems. Specifically, the university is home to the Center for Nursing & Midwifery, which began with an executive education leadership program and will expand to include master’s programs in nursing specialties. 

PIH and UGHE leaders are committed to ensuring that the university evolves into a transformational platform for nurses globally. I could not be prouder of what that means for us as an organization as we continue to build our nursing programs, such as those at Hôpital Universitaire de Mirebalais in Haiti, which trains nurse anesthetists, neonatal intensive care unit, oncology, emergency, as well as other nurse specialists and was where PIH’s first Nursing Center of Excellence opened.   

Paul was a vocal and relentless advocate for nurses to be in leadership positions worldwide, and he was instrumental in supporting my upward trajectory within the organization, resulting in me becoming the first nurse CEO of PIH in July 2019. His mentorship and partnership provided me entry into the physician-dominated domain of global NGOs. Throughout our 12-year friendship, I witnessed how the values he lived by inspired an entire movement toward global health equity. His values were rooted in the foundation of PIH and in each of us as nurse leaders – values of commitment, pragmatic solidarity, accompaniment, humility, and integrity. These are values that set the foundation of my training as a nurse, as a CEO, and as a global citizen, and are values that I see in each of our nurse leaders across PIH. 

A few days before he passed, Paul sent me a text message from Rwanda with a picture of one of PIH’s nurses teaching a group of medical residents how to do an echocardiogram, stating: “Nurses have always been my best teachers.” Paul saw the potential in each human being, and he saw the potential in me as a nurse leader. He had extraordinary courage to challenge the status quo, to call out the vast injustices in health care while using his voice to influence and raise the visibility of nurses and midwives globally. Paul was inspiring, but he was also inspired. He was inspired by this work every day, and he was inspired by the nursing teams, the nurses at each of our sites that he got to work with side-by-side. I know he would want each of us to continue to work together towards the vision he had for PIH and for the future of the nursing field. 

I am deeply grateful for the time I shared with Paul and for the memories I keep close to my heart. 

It was such a gift to have experienced life with him and to have felt seen by him. As we celebrate the field of nursing, I hope that we all take a moment to thank those who have helped support, encourage, and amplify nurse leaders for the betterment of global health care for all. I hope we also take the time to celebrate the compassion and leadership that nurses demonstrate every day. During this global pandemic, nurses have stepped up in unimaginable ways. I feel honored to be a nurse and to work alongside my colleagues all around the world.  

Alice Ukwitegetse, 20, was excited to become a mother of twins; she had already thought of names for her babies, who were due in late 2020. The only concern in the expectant mother’s mind was how she would be able to tell them apart.  

Then, she started to experience serious complications.  

When Ukwitegetse kept suffering from progressive pain and bleeding, she was concerned and decided to visit Gahara Health Center, a clinic in eastern Rwanda supported by Partners In Health. There, she learned that her cervix had started to open three months before the due date—a condition that could cause miscarriage and other problems. 

“I started to feel my chances of being a mother fading away,” said Ukwitegetse. 

Fortunately, the team at the health center, already familiar with the procedure that would be needed, transferred her to Kirehe District Hospital for emergency care. Partners In Health, known in Rwanda as Inshuti Mu Buzima, has supported Kirehe District Hospital since 2006 with staff, resources, and funding. 

In Ukwitegetse’s case, urgent care would be essential to save her life and her babies.  

A Premature Birth 

Despite significant progress by the Rwandan government in reducing maternal and newborn mortality, 203 maternal deaths per 100,000 live births occur each year due to birth- or pregnancy-related complications. 

As it seeks to eliminate all preventable maternal deaths, Inshuti Mu Buzima works with the Ministry of Health to improve the quality of maternal and newborn care, provide timely access to care, update maternal health infrastructure, and offer family planning and counseling services. 

This partnership has helped to avert many preventable maternal and newborn deaths. When Ukwitegetse arrived at Kirehe Hospital, the team was ready to put their skills and medical technology to use. But there was another challenge. 

“When we received Ukwitegetse on September 6, 2020, she had strong contractions and signs that giving birth was very close,” said Dr. Sadoscar Hakizimana, an OB-GYN surgeon and Inshuti Mu Buzima’s Kirehe program director. “This was dangerous for the mother and baby because it was not yet her due date.” 

Babies born before 37 weeks of pregnancy are considered premature and can have health problems at birth and later in life. With Ukwitegetse’s pregnancy having been less than 29 weeks, her babies were at an even greater risk of suffering from health complications or dying within hours of birth.  

Inshuti Mu Buzima staff knew that delaying contractions could help prevent premature birth and save the mother and babies’ lives.  

“We gave her medication to stop contractions,” said Hakizimana. "But it was too late.” 

Ukwitegetse gave birth—to one girl—without a C-section. The newborn was transferred to the neonatal intensive care unit. Healthy newborns typically weigh at least 5.1 pounds. Ukwitegetse’s daughter weighed 1.7.  

In the delivery room, the team found themselves faced with another dilemma.  

“The cervix closed and the contractions stopped before the second baby was born,” said Hakizimana. “This was the first time such a case had happened in the hospital.” 

Three lives were at stake: the mother, the newborn, and the baby still in the womb.  

The newborn needed milk, ideally breastmilk, to survive—but pumping it from the mother could trigger the birth of the baby still in the womb. More time in the womb would help the unborn baby develop further—but it would risk the life of the newborn, who wouldn’t have breast milk. 

‘A rare and delicate procedure’ 

For four days, the team monitored the health of the newborn day-and-night in the neonatal intensive care unit to give her a fighting chance, while also caring for the mother to prevent any infection. 

But two questions loomed: how long could they keep the unborn baby in the womb and where would the milk for the newborn come from? 

“There were two possible options,” said Dr. Angelique Charlie Karambizi, a pediatrician with Inshuti Mu Buzima who was caring for the newborn. “A mother to donate milk or a milk bank. Unfortunately, there was neither a donor at the hospital nor milk bank in the whole country.”  

Inshuti Mu Buzima buys and provides preterm infant formula to those in need at Kirehe District Hospital, but it is only used as a last resort. Breastmilk—which is rich in the nutrients that help brain growth and substances that boost the baby's immune system—is crucial for newborns. 

“The first baby needed breastmilk to survive,” said Karambizi.  

Finally, after day four, the team made a decision: they decided to pump breast milk from the mother to save the life of the newborn. 

As a result, the second baby was born prematurely. But the extra days she had spent in the womb had increased her odds. She weighed 2.6 pounds, and her organs had developed significantly.  

“It was a rare and delicate procedure,” said Hakizimana. “The twins [will] celebrate their birthdays on different days.” 

After almost a week, Ukwitegetse met her babies. She was overcome with emotions when she visited the NICU where they had been under constant monitoring.  

“On the delivery bed I had a picture in my brain of a very tiny baby that had spent her first days on earth fighting to live,” said Ukwitegetse. “When the doctors finally took me to see my twins, I couldn’t hold back my tears.” 

‘I spent the whole day holding them’ 

In the days and months that followed, Inshuti Mu Buzima staff at the hospital worked to ensure that Ukwitegetse and her daughters not only survived but thrived.  

“We have a well-equipped neonatal care unit,” said Karambizi. “As the babies were being monitored to ensure the development of their organs, we focused on training the mother on how she will care for them after getting out of the neonatal intensive care unit.” 

Karambizi and his team connected Ukwitegetse with expert mothers and hospital staff for training in breastfeeding techniques, hygiene, assessing health risks, and other parenting skills.  

After three months at the hospital, in December 2020, she was able to return home with her twins. She gave them similar Kinyarwanda names but with profound meanings: Shimwa (“thankful to God”) and Himbazwa (“praise to God”). Now, more than a year later, Ukwitegetse and her daughters regularly visit the one of the PIH-supported Pediatric Development Clinic at Rwantonde Health Center, where premature babies are monitored to ensure their full development. 

“The doctors (meaning all hospital staff) taught me so much before I was able to touch my babies,” said Ukwitegetse. “When I was finally able to hold them, I was an expert. I spent the whole day holding them; it was the best time of my life.”  

Growing up in rural Rwanda, Florence Musabyemariya used to get sick as a child and “really feared infection.” It was always nurses, she says, who calmed her and helped her feel safe to continue her treatments and check-ups, which included painful shots.

“They assured me that it wouldn’t hurt and that assurance always worked for me as a kid,” she says. “Those nurses who were taking care of me inspired me to join the profession.”

Now, Musabyemariya has been a nurse for more than 10 years and was among the second cohort of the Global Nurse Executive Fellowship (GNEF)—Partners In Health’s fellowship for nurses and midwives on staff who show outstanding leadership and the desire to tackle global health challenges and transform health systems.

Nurses account for nearly 50% of health workers worldwide. Yet they often receive little pay, training, and recognition. Since 2017, PIH’s GNEF program has aimed to upend part of that paradigm, providing nurses the opportunity to gain new theoretical knowledge and develop their practical skills to succeed in executive positions. The fellowship accepts a new cohort of nurses each year from the 11 countries where PIH works.

In honor of Nurses Week, PIH caught up with alumni of the first and second cohorts to learn how the fellowship has impacted their careers.

Gladys Mtalimanja Banda was familiar with health care long before she became a nurse midwife. She had malaria as a child and the hospital quickly became her second home. Among her frequent visits, one trip in particular stands out.

As a nurse cared for her, Banda looked over and noticed a baby having a seizure. The baby’s mother was in tears. Banda’s nurse noticed and rushed over to help. After a quick injection, the convulsions immediately stopped. 

“After I saw the baby was back to a normal state, I felt so happy and I said when I grow up, I also want to be a nurse,” says Banda. 

For the past 14 years Banda has worked as a nurse midwife in Malawi. She is currently a nursing officer at Partners In Health (PIH)-supported Neno District Hospital and recently earned another title: fellow in PIH’s Global Nurse Executive Fellowship (GNEF). 

Unlike Banda, Charles Jarsor didn’t have a positive first impression of nursing. Before entering the profession, he witnessed nurses speaking aggressively to their patients. While it discouraged him, it sparked action. Jarsor went on to study nursing to evoke change in the system. Now, as a fellow in this year’s cohort, he hopes to continue to improve his communication skills through GNEF.

“I applied to GNEF to positively contribute to the health care delivery system of [Liberia] and the world at large by leading my people positively and influencing the lives of people around me,” says Jarsor, who is director of nursing services at PIH-supported J.J. Dossen Hospital in Maryland County, Liberia.

Jarsor and Banda are among ten nurse leaders, from seven countries, in the third cohort of the yearlong program. GNEF launched in 2017 to help global nurse leaders succeed in executive positions. Many times those who are placed in such roles lack the support and resources needed to be successful. 

All fellows complete a yearlong executive style curriculum, which includes mentorship, coaching, and professional development opportunities. The curriculum involves three, weeklong intensive bootcamps. Each session kicks off a key area of focus: self, others, and systems. In the leading self phase, participants learn skills to lead with purpose and increase self-awareness. In the leading others phase, fellows hone their communication skills, and learn to leverage diversity and difference. In the final phase, centered around leading systems, nurses explore systems thinking and ways to make innovative improvements. Additionally, each fellow works on an individual capstone project which they present at the end of the program. Previous projects have ranged from professional development programs for nurses to cervical cancer screening improvement programs.

It’s an intense but rewarding year of growth and development for all involved–from fellows to faculty.

“I am constantly impressed by the fellows’ willingness to push themselves outside their comfort zones and stand up as patient-care experts and leaders in places where the profession isn’t always highly-regarded. They’re trailblazers,” says Kyra Sarazen, PIH’s nursing program associate, who supports GNEF activities and fellows.

Since GNEF's inception, 13 clinicians have graduated from the program and gone on to various leadership roles, including Viola Karanja, deputy executive director of PIH Liberia and Angeline Charles, PIH’s clinical systems and education specialist. Alumni have also been published in academic journals, carried out quality improvement projects, and received international acknowledgment. Ten more fellows will now follow in their lead: Gladys Mtalimanja Banda (Malawi), Daniela Puma Abarca (Peru), Mary Lesesa Toti (Lesotho), Evaline Wangui Ngige (Sierra Leone), Ruth Férinah Butair (Haiti), Claudinette Favard (Haiti), Charles Jarsor (Liberia), David Tuyisenge (Rwanda), Lemekeza Namwali (Malawi), and Billy Mawindo (Sierra Leone). 

In the future, GNEF plans to roll out a curriculum in Spanish. It’s currently only available in English.

Yareth Macías, 30, is originally from Jaltenango, a rural city in the Sierra Madre region of Chiapas, Mexico, but has lived in Lima, Peru for the past year with her husband. In early 2021, she found out she was pregnant for the first time—a moment she and her husband had dreamed of for years.

The pregnancy went smoothly for the first seven months. Macías then returned to Jaltenango, because she wanted her daughter to be born with her family there. That’s when the challenges began.

One day, Macías felt her baby not moving as it normally did. Following the advice of her relatives, she drank orange juice, ate chocolate, and massaged her stomach to see if anything would stimulate her baby. But nothing worked. Four long hours passed, and she could no longer bear the worry.

She rushed to Casa Materna, the birthing center in Jaltenango supported by Compañeros En Salud, as Partners In Health is known in Mexico. Compañeros En Salud has worked in Mexico since 2011, providing medical care and social support to thousands of patients in the rural, mountainous, coffee-growing communities of the Sierra Madre region of Chiapas.

Since 2017, Casa Materna has provided dignified care to pregnant women, with the support of professional midwives and first-year clinicians hired and supported by Compañeros En Salud. The center, based at the community hospital in Jaltenango, has helped more than 1,000 women give birth, providing safe, respectful care for maternal health patients in a region where obstetric violence in hospitals is common.

Casa Materna

When Macías arrived, she was cared for by Estefania Monterrosas, a nurse who has worked with Compañeros En Salud since 2020. With patience and dedication, Monterrosas performed ultrasounds, checked the baby's heartbeat, and explained that there was nothing wrong with her: the baby was just sleeping.

As Macías spoke with the nurse, she began to feel more at ease. Monterrosas also told her about Casa Materna’s humanized birthing model where women can choose their birthing positions, listen to music during labor, and have a family member in the room. Macías decided she wanted to give birth there.

The delivery date was fast approaching. Macías’ husband, Fernando, was still in Peru. He did not want to miss such an important moment, so he made plans to travel to Mexico.

Then, contractions started—three weeks early.

On September 19, 2021, Macías began to have pain in her belly.

"I didn't know if it was the false contractions (Braxton Hicks) or if my baby was already going to be born," she says.

The contractions wouldn't go away. After three hours, her water broke. Her mother immediately took her to the Casa Materna.

"Many things were happening,” she recalls. “My husband was already in Tuxtla, three hours away from Jaltenango, but we didn't know if he would make it to see the birth of our daughter."

Dignified Care For Mothers, Newborns

As Macías was in labor, the obstetric nursing team at Casa Materna helped her do exercises with birthing balls and provided massages, aromatherapy, and a hot water bath with herbs to reduce the pain. Macías tried not to focus on the pain, as she was supported by her mother and a team of nurses.

She was dilating slowly. By 11 a.m., she was almost ready to give birth. Her husband arrived just in time, at 11:45. A half hour later, her daughter was born.

"I was impressed with the treatment at Casa Materna," says Macías. "Many times, you don't want to go to hospitals for fear of mistreatment. Obstetric violence is a reality that many women experience in Mexico, where they are scolded, mistreated, humiliated, and put through unauthorized procedures.”

That mistreatment includes health workers in Mexico's hospitals ignoring and dismissing the concerns of mothers, even as the women are in labor, leading to trauma and mistrust in the health system.

In Chiapas, women in labor have also been subjected to illegal, unauthorized procedures, including forced sterilization through tubal ligation or IUD. These procedures are carried out by doctors operating on the racist, classist belief that poor people shouldn't have too many children. These doctors are rarely ever prosecuted; the victims are almost always women living in poverty.

At Casa Materna, Compañeros En Salud seeks to upend these norms and provide humanized care at every step of the process, helping mothers give birth in the way most suited to their needs.

As she held her daughter for the first time, surrounded by her family and Compañeros En Salud staff, Macías expressed her gratitude.

"I didn't know how to thank them for what they had done for me,” she says.

After centuries of extraction by foreign powers, Sierra Leone remains resource-rich but cash-poor, with little to spend on its population’s health. This injustice takes an extreme, visceral form in Kono District, where West Africa’s largest diamond mine sits a short walk away from Koidu Government Hospital (KGH), the district’s only hospital.

When Partners In Health (PIH) began working there in 2014, during the height of the historic Ebola epidemic, KGH was all but shuttered. For fear of contracting the virus, barely any patients were visiting, and routine health services—necessary and lifesaving no matter what—all but ceased.

But even before that, most families opted not to seek care at KGH, mindful that fees were high and quality of services was low. Few of the hospital’s clinicians were well-trained and specialized; most of its pharmacy shelves were empty; and medical technology, let alone reliable access to electricity and plumbing, was out of reach. When a woman needed an emergency C-section, she and her family would have to pay for fuel to run the hospital’s generator, and hope the surgery went smoothly without properly sterilized instruments, a functioning blood bank, or an obstetrician.

Today, Koidu Government Hospital is unrecognizable--for good reasons.

With investments from PIH, made in partnership with Sierra Leone’s Ministry of Health, the hospital boasts more staff than ever, with specialist clinicians and medical education programs. Its supply chain provides continuous access to medications and essential equipment. And 24-hour electricity and running water are guaranteed across a growing number of departments. Once neglected—or worse, feared—the hospital, as well as nearby PIH-supported Wellbody Clinic, is seeing more and more patients year after year, a tribute to their  growing reputations as offering quality, accessible services.

And yet—availability does not equal access. For thousands of families living in rural sections of Kono, hours away from KGH and Wellbody, visiting their local community health center is the only feasible option for health care. Taking time away from work and paying for a motorbike trip—sometimes hours long, over nearly impassable roads—is too expensive.

But with few trained clinicians, the lack of continuous electricity, or poorly stocked pharmacies and laboratories, visiting these community health centers is like reverting to the past. And so, much like as it was with KGH, people don’t. And that means living without health care at all.

Knowing the sacrifices that geography and poverty force families to make when it comes to their health, in 2019, PIH formally expanded its support to six community health centers scattered throughout Kono. Sewafe Community Health Center, located a 45-minute drive from KGH, was the first of these facilities to receive comprehensive investments in staff, stuff, space, systems, and social support, resulting in a notable uptick in patients arriving for care.

At the end of 2021, PIH and its Ministry of Health partners celebrated the re-opening of the second of these small, rural clinics: Kombayendeh Community Health Center. Below, see how Kombayendeh—one of the most direly under-resourced clinics in Kono—has transformed with tried-and-true investment from PIH.

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The road between KGH and Kombayendeh is notoriously long, bumpy, and, during Sierra Leone’s rainy season, muddy. At best, a trip to the hospital for a family in Kombayendeh would take around three hours; at worst, their motorbike could get stuck in the mud, leaving them stranded for a whole day.

Kombayendeh Community Health Center, meant to serve more than 7,000 people, struggled with access to basic infrastructure needed for health care, including reliable, 24-hour electricity and running water. Clinicians had difficulty sterilizing equipment, storing temperature-sensitive medications, and providing care at night. When women went into labor after the sun went down, clinicians often had to deliver the baby using the flashlight on whoever’s smartphone was most charged.

The clinic also lacked a strong supply chain system for drugs and medical supplies; training opportunities for clinicians and lab technicians, to ensure both baseline skills and growth; and dignified spaces in which to deliver and receive care. As a result, most days, Kombayendeh’s waiting room was empty, with families forgoing care they knew wouldn’t be adequate.

PIH first began working on Kombayendeh’s infrastructure, including expanding the building to introduce a new laboratory and pharmacy; renovating interiors; improving air circulation, to better prevent and control infections; and introducing 24-hour electricity and plumbing, which enabled the installation of air conditioning for the safe storage of drugs.

Inside the new Kombayendeh Community Health Center building, PIH staff, alongside local health officials and the facility’s clinicians, were able to begin strengthening other areas of care. PIH began supporting Kombayendeh’s supply chain, ensuring a continuous flow of medications, lab equipment, and other supplies; and established new systems to effectively screen patients, triage them, and safely record and store their medical records. The screening process includes never-before-asked questions to better capture patients who may be suffering from unjustly common illnesses like malnutrition and tuberculosis.

PIH also hired additional staff to work at the facility and provide ongoing clinical training and mentorship. Sulaiman Sawaneh (above) is PIH’s pharmacy assistant at the clinic who helps pharmacy staff develop their skills dispensing medications, managing inventory, and more. He works alongside a pharmacy technician, community health officer, lab mentor, and midwife mentor, all of whom are charged with helping Kombayendeh staff grow as health care providers. PIH also introduced a facility-based officer to the clinic, whose job is to work with community health workers referring patients to Kombayendeh; and a monitoring and evaluation coordinator, whose job is to collect and analyze data around the clinic’s performance.

PIH also helped fill in operational gaps at the clinic. Staff replaced worn out desks and chairs for clinicians and beds for patients, and added new furniture to accommodate the facility’s anticipated growth. Internet was introduced. And health care workers were added to a paid-for phone line and purchased new motorbikes, so that communication and transportation would never be barriers to them getting to work and serving patients.

And to ensure the improved care available at Kombayendeh proved truly accessible to all, PIH and its government counterparts introduced a flat fee of 10,000 leones—about one dollar—covering the full spectrum of care, from consultation to lab tests to all prescribed medications. For any patient unable to pay, the fee is waived.

This new policy, combined with the health center's elevated level of care, has brought a steadily increasing number of patients to visit. In July 2020, before PIH began serving Kombayendeh, a recorded 310 patients sought care at the clinic. The following July, after renovations and improvements had begun to take shape, that number more than doubled, to 649 patients.

As comprehensive support to Kombayendeh’s staff, stuff, space, systems, and social support programs continues, PIH envisions additional investments, such as the construction of a permanent isolation ward and renovations to staff living quarters. But at a ceremony formally opening the new and improved health center, PIH and facility staff, local health officials, and Kombayendeh residents were focused on the present, admiring just how far the clinic has come.

With Kombayendeh as another example of how we can transform rural, impoverished health facilities, PIH is set to begin supporting another under-resourced clinic in Kono: Kayima Community Health Center. Below, take a tour of this facility, and learn about our plans to invest in it just like Kombayendeh:

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It was early 2021 when 15-year-old Juan Carlos Pérez first arrived at the clinic in Soledad, a rural community in Chiapas, Mexico, with his mother, Anita Linda Escalante. But it was not the first trip the two had made in search of medical care—and answers.

Pérez’s symptoms had started out like a cold: a runny nose and phlegm. But weeks later, he began to notice a bad smell inside his nose. Escalante took him to private doctors across Chiapas, where he received allergy medication. But the discomfort did not go away.

Pérez and his mother live in Tapachula, Chiapas, very close to Mexico's border with Guatemala. Tapachula is the second largest city in Chiapas, after the capital, Tuxtla Gutiérrez, where advanced medical services are available, but difficult for most patients to access. Those challenges were not lost on Escalante, a single mother of four children, who had to take time off work, losing valuable income, and arrange for childcare as she accompanied her son to his medical appointments.

A couple of weeks later, Juan Carlos began to feel what he described as a "little ball" inside his nose, which obstructed air from flowing to his lungs. At private clinics, the doctors told Escalante that this bump was a tumor, but they did not know if it was malignant. To determine that, Pérez would need a biopsy. But his family did not have the resources to pay for this surgery.

About two months passed and the tumor inside Pérez’s nose kept growing, to the point of causing bleeding, intense headaches, and eventually blocking his nostril completely.

Desperate, Escalante looked for public hospitals, where the procedure would be available for free, but waiting lists were long. At private hospitals, the procedure would be expensive. Many hospitals also required a reference paper from a doctor in order to accept patients; but Escalante and her son didn’t have one. Each time, they were rejected.

"How is it possible that no clinic in these cities could attend us?" Escalante recalls thinking at the time.

There was nothing more they could do, she thought, but watch the tumor continue to grow.

It wasn't until a family member told her about Compañeros En Salud, as Partners In Health is known in Mexico, that Escalante began to feel hopeful. Without a second thought, she took Pérez and traveled five hours from Tapachula to Soledad, one of the rural communities where Compañeros En Salud supports a primary care clinic.

Compañeros En Salud has worked in Mexico for more than a decade, supporting nine rural clinics, a birthing center, and a community hospital, as well as training the next generation of clinicians through the pasante program.

Dr. Emiliano Hersch, then a pasante (Spanish for first-year doctor) completing his year of service at the clinic, treated Pérez—for free. Hersch quickly determined that Pérez’s tumor was a nasopharyngeal angiofibroma: a rare type of tumor that most often affects young men, but is benign. If the tumor continued to grow, however, it could cause damage to Pérez’s ears, teeth, and nasal septum.

To ensure that care continued, Hersch connected Escalante and Pérez with Compañeros En Salud’s Right to Health Care program, which helps patients get referrals to advanced care at hospitals and connects them with social workers and community health workers to manage their cases. The program also provides funding for transportation, food, housing, and medical expenses, also known as “social support,” making care accessible to all patients, regardless of income level.

For Pérez, recovery, for the first time in months, felt within reach. Through Compañeros En Salud’s support, he met with a specialist at the pediatrics hospital in Tuxtla Gutiérrez. There, he learned he would need surgery to remove the tumor so that he could breathe normally. But, before that was possible, he would need an embolization.

Embolization is a common procedure for tumor removal in which some blood vessels are intentionally blocked. But the procedure requires surgical materials such as needles and microcatheters that are often expensive and difficult to obtain. If the materials aren't available from the Ministry of Health, hospitals in Chiapas often make the patients cover the costs. Pérez's family was unable to afford these expenses, so Compañeros En Salud paid the bill.

Months later, in June 2021, the long-awaited day arrived. With his mother and case workers from Compañeros En Salud by his side, Pérez underwent surgery. The tumor—that had spread to his face and begun to affect his teeth—was removed, setting him on the path to healing.

That journey continues to this day. Pérez continues to attend follow-up appointments at the pediatrics hospital with the support of Compañeros En Salud.

"We are very grateful because Compañeros En Salud has always been there, supporting us so we can move forward," says Escalante. “I know that it's not just Juanito and I, but many families whose lives are changed."

Jimmy Forest first trained as an electrician in the wake of the historic 2010 earthquake in his home country of Haiti, as part of the team constructing PIH’s University Hospital in Mirebalais. The years following were ones of transformation: Spurred by the process of building and operationalizing University Hospital, the nonprofit Build Health International (BHI) was founded, and today is a key PIH partner whose mission is to design and construct high-quality, low-cost health facilities in resource-constrained settings. University Hospital opened its doors to a steady flow of patients, and today cares for hundreds of thousands of people every year and is internationally accredited as a teaching hospital. And Forest continued to pursue work as an electrician, today serving as BHI’s general electrical supervisor in Haiti. 

In this role, Forest spends his days “planning and overseeing all of BHI’s electrical work in Haiti, including hiring, supervising, and training electricians.” A few weeks from now, he’ll be applying these skills in a new setting, on another collaboration between BHI and PIH, this time in Sierra Leone: The Maternal Center of Excellence (MCOE). 

Forest, along with several fellow BHI staff—all Haitian, all trained in infrastructure work during the construction of University Hospital—will be spending significant time in Kono District, training and mentoring local Kono residents who will serve on the MCOE’s construction team over the next year. 

It’s a new leadership opportunity for Forest and his colleagues traveling to Sierra Leone, as well as their team members in Haiti who will be managing projects in their stead. And it will be an opportunity for young people in Kono to launch careers in infrastructure and construction via the MCOE—much like Forest did via University Hospital. 

This symbiosis is Forest’s favorite aspect of his work. 

“The best part of my job is sharing knowledge with others to help them grow,” he says. “By sharing knowledge, I am also learning more. I am most excited to see how the Sierra Leoneans build, learn about the culture, and be ready to help. I will be helping my African brothers and sisters to grow professionally, while learning from them too.” 

Forest also notes that his greatest motivation lies in how infrastructure can promote social justice—a lesson learned time and again throughout his career, from constructing University Hospital and a maternity center at the PIH-supported clinic in Boucan Carré, Haiti, to ensuring sustainable, reliable power at Wesleyan Hospital in La Gonâve, Haiti, through the installation of a solar grid. 

“What inspires me about my work,” Forest says, “is contributing to help the poor get access to health.” 

As COVID-19 cases surged across Peru in early 2021, many people had no choice but to stand in line for hours on the streets of Lima, even as they or their loved ones struggled to breathe. They weren’t lining up for masks, or tests, or sanitizer. They needed oxygen.

The lifesaving resource was already nearly impossible to find in Lima, a city of more than 9 million—running low in hospitals, selling out in stores, and price gouged by online vendors. Medical oxygen is a last line of defense against COVID-19, a virus that attacks the respiratory system. And for tens of thousands of Peruvians, it never came.

Although COVID-19 cases have since fallen, oxygen remains an essential—but limited—resource in Peru, where new variants and respiratory diseases such as tuberculosis remain ever-present threats.

To tackle the oxygen gap in Peru, Socios En Salud, as Partners In Health is known locally, plans to repair at least 15 oxygen plants across the country as part of BRING O2—PIH’s new initiative to accelerate access to safe, reliable oxygen in five countries, supported by Unitaid. As part of a broader COVID-19 response with other partners, Socios En Salud has also opened five oxygen centers to help patients access the lifesaving resource without occupying an ICU bed.

The Oxygen Gap

Oxygen is critical for patients with hypoxia—low oxygen levels in the blood—which can be caused by a multitude of conditions from tuberculosis to heart failure to newborn prematurity. COVID-19 is especially demanding on oxygen supply, with the most severely ill patients requiring over 1,000 liters of oxygen per hour.

Oxygen in Peru is typically sourced from oxygen plants (an industrial system that fits in standard-sized shipping containers), oxygen tanks (pressurized cylinders that need to be refilled), or oxygen concentrators (portable devices that the patient can have at their bedside or take home).

But in Peru, as in many low- and middle-income countries before and during COVID-19, there wasn’t enough oxygen to meet demand. By early 2021, the country’s oxygen deficit had reached 110 tons per day. An estimated 225,000 patients died at home or in the streets, waiting for oxygen that never arrived, according to Socios En Salud staff.

That breakdown happened for several reasons.

Oxygen plants in Lima’s hospitals were in disrepair, without mechanics to fix them, or lacked reliable electricity to run. Oxygen tanks and concentrators were sold out, price gouged, or delayed due to supply chain issues. That left patients and families to scramble to find oxygen anywhere they could, including the black market. But even if patients had a tank—which range in price from 500 soles ($1.31 USD) to more than 5,000 soles ($1,306 USD)—there was no guarantee of a refill.

Even as thousands struggled to breathe, hospitals were running out of beds. Peru has less than two hospital beds per 1,000 people, a reality that, at the peak of the pandemic, led to overcrowding in some hospitals and patients turned away.

Since 2020, Socios En Salud has led a comprehensive COVID-19 response in partnership with Peru’s Ministry of Health—a continuation of its longstanding work in the country, which began in 1994 in response to a deadly outbreak of multidrug-resistant tuberculosis in Carabayllo.

BRING O2 is the latest chapter in that long-running partnership.

Helping Patients Breathe

PIH launched BRING O2 earlier this year with funding from Unitaid and in partnership with Build Health International and PIVOT Health Madagascar. The initiative focuses on strengthening oxygen systems in Peru, Malawi, Lesotho, Rwanda, and Madagascar—countries where the need is great.

With the BRING O2 Initiative, Socios En Salud has redoubled its efforts to procure and provide oxygen in a variety of ways—from repairing oxygen plants to training health workers.

LEARN MORE

Socios En Salud plans to repair at least 15 oxygen plants this year across Peru, from Loreto in the north to Arequipa along the southern coast. Most recently, Socios En Salud completed repairs of an oxygen plant at San Juan de Dios Hospital in Ancash.

These oxygen plants provide between 10,000 and 50,000 liters of oxygen per hour, enabling oxygen tanks to be refilled and oxygen outlets near the patients' bedside to provide a steady flow of the lifesaving resource.

Along with each installation or repair of an oxygen plant, Socios En Salud has trained biomedical engineers and technicians on how to use and maintain the equipment.

Oxygen plants aren't the only resource Socios En Salud has enlisted in the fight against COVID-19. Socios En Salud has also opened five oxygen centers, most recently a 14-bed center in Florencia de Mora, a city in Trujillo province, and a 26-bed center in Los Olivos de Pro, a district in Lima.

These centers are meant to prevent hospitals, particularly ICUs, from overcrowding with patients who require oxygen and monitoring, but not intensive care. The centers provide patients with beds, oxygen concentrators, and 24/7 care. Typically, patients stay three to five days.

“This will save the lives of thousands of people who continue to suffer the consequences of the coronavirus and other respiratory diseases," says Dr. Marco Tovar, Socios En Salud’s medical director.

Socios En Salud outfitted the center in Florencia de Mora with 24 oxygen concentrators and hired 60 health workers to provide around-the-clock care. The center will serve the La Libertad region—home to more than 2 million people.

Just miles away, an oxygen plant operates at Belén Hospital, installed by Socios En Salud in January. The plant can produce 20,000 liters of oxygen per hour, strengthening the hospital’s response not only to COVID-19 but to other respiratory diseases, such as pneumonia and tuberculosis.

“All those who require oxygen…will be able to access hospitalization and oxygen therapy services,” says Kerstyn Morote García, regional health manager in La Libertad. “We are very grateful for the support provided by Socios En Salud.”

As a branch manager in one of the public libraries in Pima County, AZ, much of Em DeMeester-Lane's time is spent connecting community members to vital resources. On any given day, DeMeester-Lane will offer guidance on job training, share information on utility, rental, and food assistance, or direct visitors to immigration and refugee services. Sometimes, DeMeester-Lane and his colleagues will help visitors find a shower and a place to sleep. As community hubs, libraries have always offered safe, inclusive spaces for everyone. During COVID-19, this refuge became more important than ever.  

“We see ourselves as active participants in communities,” says DeMeester-Lane, a branch manager at the Joel D. Valdez Main Library. “You are more likely to know where your local library is than a health center. People come to us because they know us, and in turn we can offer a gateway to better health access.” 

When COVID-19 hit, libraries across the county stepped up to meet the needs of their communities. Working side-by-side with the Pima County Health Department––which receives support and technical advising on COVID-19 response and recovery from Partners In Health United States––the county’s library workers quickly adapted traditional programs, while also expanding services to respond to the impacts of the pandemic. Embedded within the health department as a trusted advisor, PIH-US has been supporting the Pima County Health Department’s overall pandemic response, while also partnering on a broader health equity agenda. 

With buildings closed to the public, library meeting rooms were converted into food hubs, as library staff distributed boxed food to individuals and families lined up in their cars. Between April 2020 and August 2021, library branches distributed over 200,000 produce boxes, snacks, and meals. When vaccines became available, library employees set up a hotline to help residents navigate complex scheduling, registration processes, and other technological issues. Library staff handled over 42,000 phone calls for individuals seeking assistance with vaccine registration and scheduling. And last October, with rapid tests either unavailable or unaffordable amid a national surge in COVID-19 cases, the health department began distributing free rapid test kits at local libraries. By the end of December 2021, over 35,000 COVID-19 test kits had been handed out––the vast majority of which went to people who experience homelessness, chronic illness, or food insecurity. 

“The public library system was a critical partner in our ability to increase access to home COVID-19 testing,” says Dr. Theresa Cullen, director of the Pima County Health Department. “Libraries are a safe space for so many communities throughout the county. Working with the libraries to distribute rapid tests further demonstrated the essential role they play in providing access to much needed services.” 

The symbiotic relationship between Pima’s public libraries and the health department is not new. In 2012, when library workers regularly found themselves assisting visitors with unmet medical and behavioral needs, the county libraries partnered with the Pima County Health Department to place public health nurses in libraries through the Library Nurse Program. The first of its kind in the country, the program sends a team of public health nurses to libraries to provide basic medical and behavioral health services. At the main library alone, this program has enabled close to 16,000 nurse interventions since its inception 

Looking to the future, as the health department continues to improve access to care and make Pima County the healthiest county in the United States by 2030, the county library will be critical to its success. And like they have prior to and throughout the pandemic, libraries will continue to extend necessary support to communities. 

As DeMeester-Lane says, “Everyone loves the library––it’s a universal sentiment. But during COVID-19, there was a small population of people who needed the library.” 

Just days after the first COVID-19 case was detected in Rwanda, the government suspended all international commercial flights and instituted a national lockdown.

At Inshuti Mu Buzima, as Partners In Health is known locally, staff were worried.

“We thought, ‘Our patients are going to die because they can’t reach our center,’” recalls Dr. Cyprien Shyirambere, Burera District program director with Inshuti Mu Buzima. “We had to come up with innovations.”

Those innovations would involve cars, trucks, and drones.

In 2020, even as the pandemic surged, lifesaving cancer drugs were delivered to patients in Rwanda and beyond, thanks to the efforts of Inshuti Mu Buzima, the Rwandan Ministry of Health, and key partners.

That continuity of care is the focus of research co-authored by PIH staff, published in the April 2021 edition of the Journal of Global Health, titled “Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience.”

The paper comes as the latest evidence of the importance of building deep partnerships with local governments and others to ensure that patients continue to receive chronic care in times of crisis.

A Growing Need

Inshuti Mu Buzima has worked in Rwanda since 2005, strengthening the health system in collaboration with the Ministry of Health. Butaro District Hospital was one of the early fruits of that partnership, with doors opened in January 2011.

The Butaro Cancer Center of Excellence soon followed, launched in 2012 and located next to the hospital. Its services include diagnostics, chemotherapy, surgery, and palliative care. Breast cancer and cervical cancer are among the types of cancers most often treated at the center, as well as pediatric cancers such as nephroblastoma.

Nearby, a 68-bed cancer support center offers free housing where patients can stay short- or long-term while they receive treatment, removing the financial burdens of lodging and transportation for patients who may have to travel as far as six hours to reach Butaro.

The center has quickly become a regional hub for cancer care—and it’s responding to a growing need.

Cancer is the second leading cause of death worldwide, eclipsed only by heart disease. But not all patients have equal access to care. Of the 9.6 million people who died of cancer in 2018, more than 70% of those deaths occurred in low- and middle-income countries, according to the research.

While Rwanda has made huge progress over the past 20 years on health indicators such as maternal mortality and infectious disease control, non-communicable diseases such as cancer have seen only modest gains. Cancer cases in Rwanda increased by 60% between 2012 and 2018.

At the cancer center, the beds have been filling up. In its first year, the center saw 561 patients. By 2015, that number had jumped to 4,500. To date, the center has enrolled nearly 13,000 patients.

When the first COVID-19 case was discovered in Rwanda in March 2020, Shyirambere and his colleagues feared that work would grind to a halt.

‘Our Patients Are Going to Die’

With a curfew of 7 p.m. and movement restricted between districts, the cancer center temporarily paused its services. But its doors stayed open.

Inshuti Mu Buzima staff called an emergency meeting. The longer they waited, they feared, the more cancer patients would be at risk of worsening symptoms or even death.

In the days that followed, a strategy quickly took shape. The team asked the Ministry of Health for permission to circumvent the lockdown and readied its fleet of cars and trucks.

“We had to improvise,” recalls Shyirambere, who was Inshuti Mu Buzima’s director of oncology at the time. “It was really amazing to see.”

For patients who needed their treatment but didn’t need to see a doctor, the team delivered the drugs by car to local health centers, where patients could pick them up just minutes away from their homes.

There was another tool at the ready: drones.

To reach those in remote areas, the team partnered with Zipline, a drone company, to identify patient locations, design flight routes, and drop off the drugs at the nearest health center.

These innovative strategies allowed patients to continue their treatments while staying close to home, reducing their risk of exposure to the virus.

For patients who needed in-person care, Inshuti Mu Buzima dispatched cars to pick them up and bring them to the cancer center in Butaro, where they could stay overnight, if need be, in a home with free meals and health staff on call.

The center treated 935 patients, conducting over 1,982 visits, from March to June 2020. More than half of these patients received IV chemotherapy.

That care extended beyond Rwanda’s borders, including 93 patients from the Democratic Republic of the Congo and Burundi.

Congolese patients were picked up at the border and, after they cleared immigration, driven directly to the center, where they were given a space to quarantine with free meals. Burundian patients, who couldn’t cross the border, received their drugs in the mail, with assistance from the Burundi Cancer Patient’s Association.

Finally, Inshuti Mu Buzima provided social support to 568 patients among the most vulnerable. This support included essential resources like hand sanitizer, face masks, and direct cash transfers—helping patients living in extreme poverty access lifesaving care and prevent COVID-19 infection.

For Shyirambere, who has been treating cancer patients for eight years, the team’s cancer care strategy amid COVID-19 was a lesson in three things: innovation, flexibility, and partnership.

“There is always something you can do, if you think outside the box,” he says. “Seeing patients who were desperate, who were waiting at home to die…come and get the treatments…that was really amazing.”

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The connections between climate change and health are complex and far-reaching, and their resulting repercussions are getting worse fast. To better understand the many implications of our warming planet, we spoke with Dr. Kelsey Ripp, internist and pediatrician, and University of Washington Global and Rural Health Fellow at the University of Global Health Equity (UGHE) in Rwanda, a Partners In Health-supported university.

Ripp, who is currently based at UGHE’s Center for One Health and the Butaro District Hospital, is working to integrate planetary health and other climate-related topics into the UGHE curriculum. She has studied the links between health and the environment throughout her career, with an interest in social and climate justice, influenced early on by Hurricane Katrina and, more recently, her work in Alaska, where she witnessed how the loss of subsistence hunting and fishing impacted people’s mental health as well as food security in the community.

Here, Ripp speaks broadly about issues ranging from rethinking medical education to better address climate change and how poverty makes people more vulnerable to global heating. She also explains the One Health program at UGHE, a multidisciplinary, collaborative approach to improving health outcomes by focusing on the intersection of animal, human, and environmental health.

How would you explain the relationship between human health, climate, and environmental change?  

At its simplest, the air we breathe, the water we drink, the food we eat, all comes from our environment. Our sophisticated technologies and complex built environments can work to obscure this essential fact but ultimately, air, food, water, and even diseases that come from the environment all very much affect our health. From that basic standpoint, our health is integrally related to the health of the environment. 

Global environmental change refers to damage to essential planetary systems which have widespread effects, including climate change, biodiversity loss, freshwater depletion, and environmental contamination, such as water or air pollution. These are changes that are human imposed or human initiated that have effects throughout global ecosystems.

Let’s go on to specific examples and start with natural disasters, because that’s what most people think about in relation to climate change.  

Climate change directly affects the frequency, intensity, and distribution of extreme weather events or weather hazards, including hurricanes, droughts, or floods. Once you impose them on a population, they can cause natural disasters. But natural disasters are not really natural, what actually creates human disaster is human and social vulnerability. Populations have different degrees of vulnerability to disasters because of social, economic, or health differences, and these factors are also affected by climate change. 

I'm not an expert on the cyclone that happened in Malawi or on Malawi specifically, but think of that as an example. Cyclones are more likely to occur because of climate change. But climate change also has effects on that population at baseline before they even had that cyclone. If changes in weather patterns like drought or flooding impair crop yields—particularly in areas with high levels of poverty without other systems in place to ensure populations have alternative access to food—rates of malnutrition will increase, particularly in children. And if a community is already malnourished, this can make them more vulnerable to the effects of a severe cyclone—on food and other health and economic outcomes. 

Another example would be drinking water contamination after the cyclone from runoff, sewage, or saltwater. If people already have precarious access to clean water, and this is worsening due to freshwater depletion, then after the cyclone when water contamination occurs, the population is less able to find alternative sources of clean water, intensifying the health effects of the disaster. 

Malaria incidence is anticipated to shift due to climate change, with some areas experiencing an increase due to warming temperatures or precipitation. This impacts the baseline health of a community. At the same time, cyclones have the potential to increase malaria risk in certain areas by increasing areas of standing water where mosquitos breed. Thus, climate change can increase the risk of certain infectious diseases, like malaria, in both the short- and long-term.

All of these things can put people's health at risk at baseline. And then that extreme weather event just makes it even worse and leads to disaster. We often call climate change a threat multiplier, because it worsens various health problems by exacerbating other widespread contributors to ill health, such as poverty. And not only does it exacerbate existing health problems, but climate change also increases the risk of developing new health problems, and creates difficulties for prevention and treatment of these problems.

Can you speak about any other examples of consequences of climate change that affect health?

Alaska, and really the Arctic in general, is experiencing global warming and rising temperatures, much faster than the global averages. That has numerous effects on the ecosystem.

Many Alaska Native communities rely closely on fishing and hunting for a lot of their food intake and, culturally, are closely linked to the environment. These rural communities, in particular, are seeing a ton of changes. At its most extreme, there are villages that will have to, or have already had to, completely relocate.

This is often related to erosion or lack of sea ice, things that make it physically unsafe to live there. The way that food is stored can be affected by changes in temperature, and so that can increase the risk of food-borne illness, like food poisoning, or diseases, including zoonotic diseases that are passed from animals to humans. The mental health effects of these climate-related changes are enormous. People and communities who have lived there for thousands of years needing to plan to move their entire lives and homes have very significant, though sometime hidden, mental health consequences. 

How does poverty factor into all of this?  

Poverty creates vulnerability to the effects of climate change. An example would be urban areas and heat waves. People with lower incomes and less resources tend to live in the more densely populated urban areas that don't have tree cover or green spaces. And these specific locations are significantly hotter, even up to 10 degrees Fahrenheit or higher, than the suburbs. This is called the urban heat island effect. And if there is a heat wave, not only will these people be exposed to higher temperatures, but they would have less access to cooling shelters, air conditioning, or other resources to prevent the health effects of extreme heat.

In populations that are already experiencing food insecurity, which is closely associated with poverty, climate change can worsen food insecurity by changes in crop yields or impaired health of animals used for food. This contributes to a cycle of poverty as well.

Poverty tends to focus energy on survival—often short-term survival—and less energy, effort, and resources are available to improve or protect the environment. An example would be illegal subsistence hunting for food. This is often done out of need and desperation for food, but sometimes the depiction of this gets twisted and the poor end up getting blamed for these actions. But really poverty constrains their choices and also limits their ability and energy to invest in protecting their environment, which creates a vicious cycle. 

How is disease emergence connected to environmental change?

Loss of biodiversity affects the emergence of zoonotic diseases, which are passed from animals to humans, like SARS, COVID-19, Ebola, etc. In simple terms, if you have a healthy forest with a whole bunch of different species living there and then you have a pathogen, that pathogen may have a lot of different animals to infect. It hangs out in its normal system and doesn't spread. But if you have deforestation and people are starting to settle in that forest and you're killing off some of those species, that pathogen has to find new hosts, and humans might be the host. It's not always directly related to changes in the climate, but all these environmental changes are very interrelated. 

Tell us about “One Health” and how it’s connected to climate change?

It's not a new concept. Scientists hundreds of years ago, and long before them many indigenous cultures, then and still, use this holistic, integrated way of thinking about health that sees human, animal, and ecosystem health as integrally connected. 

So many of the big health issues—antimicrobial resistance, neglected tropical diseases, unsustainable food systems, not to mention the health consequences of climate change and biodiversity loss—are all massive and complex problems that require a different approach.

One Health is key to studying and designing solutions to climate change-related human health effects, since it recognizes that climate change affects animals too, and animals are integral to human health. One Health is an approach to emphasize that we're all connected and only by recognizing this and acting with this understanding can we begin to design meaningful solutions.

How do you think medical education should change to address climate and health?  

Clinicians don't need to be climate scientists. They don't need to be infectious disease experts. But they need to be aware that there are environmental changes going on that can affect human health. We need to come up with some skills that clinicians should be able to perform, like being able to take a good animal and environmental exposure history, for example, and then making sure we teach this to our students. Asking questions like, "Do you have any animals in your home? Are they sick or well? Or have you had any environmental exposures?" Physicians should be taught to consider whether they have a patient with exposure to indoor or outdoor air pollution. 

It's also an attitudinal shift. Perhaps that's the most important piece of it. Really understanding and acknowledging how human health depends on the environment and animal health.

What are some solutions to such massive, complex problems? 

From a social justice standpoint, it's really important that solutions need to be collaborative, and equity-focused. And in turn, solutions need to be locally focused with community-placed effects.  

At UGHE we are focusing on One Health research and education. Particularly within education, which is where my focus is, we are building long-term capacity by educating our students, both within the Masters in Global Health Delivery Program (MGHD), which now has a concentration in One Health, and also the medical students in the MBBS/MGHD program about the effects of environmental change on health. These students will be agents of change and will help to create more equity in who is doing the research and coming up with the solutions.   

Other solutions include making health care systems more climate resilient. For example, for a health system that's in an area where there are hurricanes, this entails building infrastructure that can withstand bigger hurricanes, while minimizing the environmental impact, as well as creating early warning systems for disasters. Also, building a climate resilient health care system means trying to figure out ways to reduce its carbon footprint and reduce waste.

In addition, we need to take into consideration the environmental impacts of interventions and always look out for environmental co-benefits. If you invest in building more bike lanes so that more people can safely bike, less people are driving. This can also directly improve people's health, because they're being less sedentary, while having both human and planetary health impacts by reducing air pollution and reducing carbon emissions. This is an example of an intervention that has co-benefits both for the climate and for human health.

United Nations policy advisor, grassroots activist, and scholar were just a few of the roles Nancy Dorsinville held throughout her life. But to those who knew her personally, she was family.

“We were all in it, doing the work,” says Didi Bertrand, PIH’s senior adviser on community health and strategist for adolescent youth’s health, gender, and development. “She was a soul sister.”

Whenever she traveled to Haiti from the United States each month, Dorsinville would have two suitcases full of candy, clothes, sanitary items, cash and other things to give away.

For Bertrand’s father, those gifts were socks. For Natacha Jean—then a young patient with tuberculosis—chocolate, lollipops, and toys.

“I miss her so, so much,” says Jean. “She was like a mom to me.”

Dorsinville passed away in her sleep on April 11, 2021, just days after her 65th birthday. A year later, her legacy lives on at Partners In Health and beyond—a testament to the countless lives she touched in Haiti and around the world.

‘She took me under her wings’

A Haitian American, Dorsinville grew up in the U.S.  with her parents, a Haitian diplomat and teacher. She eventually came to split her time among New York City, where she studied at Columbia University, Boston, and Haiti. She was a founding member of Zanmi Beni, a PIH-supported home for over 60 children and young adults, and The Women and Girls Initiative, a grassroots initiative focused on psychosocial support, education, and leadership development and empowerment for young women and girls in Haiti and Rwanda. She was also a program associate with Zanmi Lasante, PIH’s sister organization in Haiti, where she supported the women’s health and HIV/AIDS programs.

Additionally, she served as a senior policy advisor to the UN in Haiti, both before and after the 2010 earthquake. As an anthropologist, she worked closely with PIH Co-founder Dr. Paul Farmer in Haiti, contributing to his book Haiti After the Earthquake, and continued to work alongside him at Harvard University.

Bertrand met her after coming to Boston with Farmer, who she had met in the Central Plateau, where Zanmi Lasante started, and then married. It was Bertrand’s first time in the U.S.

“She took me under her wings,” says Bertrand. “As social science students in universities in France, we shared common interests on matters surrounding gender, women and girl’s rights and female empowerment. She was a mentor and a dear friend. She really guided me on that personal level.”

Their shared passion for global health equity would take them both back to Haiti, where they advocated for the expansion of HIV treatment for people living in poverty, alongside Farmer and other PIH leaders, leading to the HIV Equity Initiative in 1998—one of the first programs to provide free, comprehensive HIV/AIDS treatment in Haiti, establishing a global standard for what was possible in impoverished nations.

An advocate, a friend

The work, for Dorsinville, was never just about policy—it was always about people.

Emilio Travieso, a Jesuit priest, remembers how Dorsinville “became a neighbor” to anyone who was sick or oppressed.

“She quickly became a sister to me,” he says.

The two met while Travieso was a student at Harvard, getting to know the Haitian community in Cambridge, Massachusetts. He lived in Eliot House, where Farmer was a resident tutor and had patients from Haiti staying in his apartment there. Dorsinville, he remembers, would often come to visit those patients and encouraged him to do the same. The two quickly connected over their shared Catholic faith and calling to serve the poor.

From Cambridge to Port-au-Prince, he remembers Dorsinville was always ready to help if he needed anything.

“But mostly, she was just a part of my life,” he says. “Someone I could count on to always be there.”

As she traveled between the U.S. and Haiti, her schedule packed full of meetings and conferences, Dorsinville was somehow always there for others—in their proudest moments and their darkest hours. No celebration was too trivial, and no wound too raw.

“I was really sad, really depressed,” says Jean, who met Dorsinville in 2001, when she was 19 and newly diagnosed with tuberculosis at PIH’s clinic in Cange. “I felt like it was the end of my life.”

The diagnosis was terrifying; but Dorsinville knew how to put her at ease—spending hours talking with her, bringing her on trips around Haiti, and giving her candy, along with a reminder to take her pills.

“We connected very fast,” Jean recalls.

‘Nancy knew everyone’

Connection came naturally to Dorsinville. After the 2010 earthquake in Haiti, which displaced more than 2 million people, Dorsinville used her relationships in the UN, Haitian government, and the global health field to support the public health response and rebuilding efforts.

“Nancy knew everyone—from presidents, prime ministers, ministers,” says Bertrand. “She could navigate the system from top to bottom. She used her family connections to make things happen, and people trusted her.”

Days after the 7.0-magnitude earthquake, Dorsinville went with Loune Viaud, then-co-executive director of Zanmi Lasante, to the general hospital in Port-au-Prince, where they found a group of children living in a rundown ward. Many of the children were disabled, orphaned, or had been abused. Dorsinville and Viaud knew they had to do something, so they partnered with local organizations to build Zanmi Beni (“Blessed Friends” in Haitian Creole), a home that provides food, shelter, education, and medical care for more than 60 orphaned and displaced children.

“There was no one like Nancy,” says Viaud, who is now vice chancellor of the University of Global Health Equity in Haiti and PIH’s chief gender and social equity officer. “She had this way about her and could speak to anyone, community health workers to presidents, without missing a beat.”

Dorsinville also co-founded, along with Bertrand, The Women and Girls Initiative—a grassroots initiative to support young women and girls in Haiti, Rwanda, and beyond—after spending hours visiting young women and girls on the brink of survival in settlement camps after the earthquake.

“She always advocated for the marginalized,” Bertrand says.

That advocacy earned her respect—and recognition. At an awards ceremony in 2010, Farmer recognized her accompaniment, courage, and “stubbornness on behalf of the poor.”

“Nancy has worked tirelessly to redress the disparity between our society’s vast resources and the great needs of our near neighbor,” Farmer said at the time. “As comfortable—and as skilled—discussing democracy in Haiti with Noam Chomsky at MIT as she is recording the story of a farmer in rural Haiti, Nancy is a true and gifted servant of the poor.”

That service continued throughout her life, as Dorsinville supported several women-led, grassroots organizations in Haiti, training staff and helping them fundraise, aware that they lacked the level of support and attention that international nonprofits received. She also engaged with leaders beyond the global health space, including Catholic priests and nuns—a reflection of her own faith.

“When I ended up becoming a Jesuit priest, we would joke that Nancy still knew more Jesuits than I did,” says Travieso. “Her spirituality, genuine and deep, was a light for many of us.”

He notes that she was born on Easter Sunday and passed away on Divine Mercy Sunday, both considered holy days by practicing Catholics.

“That her life was punctuated in this way, to me, is somehow just right,” he says. “I miss her sorely, but I still feel her presence, even today.”

In 2014, a health reform model was piloted in four districts in Lesotho. Now, it’s present nationwide. The decision to expand to all ten districts was due to many achievements, including a substantial increase in outpatient visits, HIV treatment enrollment, and facility-based deliveries.  All of these successes, among many others, are bringing the mountainous nation closer to universal health coverage. This is possible because of a strong partnership between Partners In Health Lesotho and the country’s Ministry of Health.

Dr. Melino Ndayizigiye, executive director of PIH Lesotho, and Dr. Afom Andom, clinical director, have helped plan and implement the model. In the interview below, which has been edited for clarity, Drs. Ndayizigiye and Andom discuss the past, present, and future of the National Health Reform.

What is the history of the National Health Reform?

Dr. Andom: This is one of the largest projects we have at PIH Lesotho and in terms of impact, it’s the most prominent to the health system. Similarly, I feel this is one of PIH’s biggest contributions to the government of Lesotho.

Since 2006, PIH Lesotho has accompanied the Ministry of Health in providing primary health care services in the rural, hard to reach areas of Lesotho. In 2013, the former prime minister, Dr. Thomas Thabane, visited one of the PIH Rural Health Initiative sites, Bobete Health Center, and was impressed with the transformational impact. All indicators, including maternal mortality and HIV, were good. Also, the investment in equipment, such as ultrasound and x-rays machines, was unbelievable to see in those remote health facilities.

The government of Lesotho then asked: “Why doesn’t PIH help the Ministry of Health to replicate what it has done in those sites in other parts of the country?”

Next, the Ministry of Health and PIH Lesotho convened to strategize the best method to adapt the PIH model of care into the National Health Reform. To start, PIH Lesotho supported the Ministry of Health in conducting a baseline study which identified the gaps and barriers in Lesotho’s health system. The study included information from partners at the national level, all the way to the community level.

The study found clogged channels of communication within the national public sector, limited capacity at the district level, and insufficient strategies to effectively monitor the impact of village health workers.

In 2014, PIH Lesotho co-created a strategic plan with the Ministry of Health and began to implement the Health Reform in four pilot districts: Berea, Botha Buthe, Leribe, and Mohale’s Hoek. PIH Lesotho became the government’s primary technical advisor on its National Health Reform.

As part of the Health Reform, all health facilities under the pilot districts were managed by their respective district and under the leadership of a district manager. Once the office was identified, it was fully equipped with supplies and human resources. Fourteen positions were created in each district—ranging from a district health manager to public health nurse and technical support—to form the District Health Management Team (DHMT).

What is the current status of the Health Reform since its inception?

Dr. Andom: Back in 2017, an evaluation was conducted to understand the Health Reform’s impact on service delivery and the health system.

Dr. Ndayizigiye: Currently, the Health Reform model has been scaled up to the whole country. Each of the 10 districts of Lesotho has a DHMT responsible for implementation of Health Reform interventions at all levels of care. PIH Lesotho has further extended its support to the Ministry of Health by developing the now implemented Village Health Workers (VHW) Program Policy. With the Health Reform, the structure of the VHW program has been expanded and professionalized. VHWs and VHW Supervisors are creating impact at the community level; while VHW Coordinators placed in the health center, support VHW’s activities.

Through the DHMT’s supervision and leadership, health facilities have improved their capacity to provide integrated primary health care services. With this record of success, the government of Lesotho is now incorporating VHWs as formal personnel and increasing professional development opportunities to enhance their skill sets and service delivery.

In February 2022, PIH continued to support the Ministry of Health by training all senior management about transformational leadership. PIH Lesotho remains steadfast in its commitment to provide technical support and develop additional tools, policies and strategies, including mental health policies, emergency and critical care strategies, and cancer prevention strategies.

What impact has the COVID-19 pandemic had on the health reform facilities in the pilot districts?

Dr. Ndayizigiye: The COVID-19 pandemic has negatively affected health service delivery in the pilot districts and across the country. A lot of health care workers have been infected and some unfortunately lost their lives. Use of essential health services has decreased as a result of the pandemic. However, the DHMTs managed to organize COVID-19 infection control at all levels of care and rolled out COVID-19 vaccination in the districts. As result of the well-organized district health leadership, Lesotho has one of the highest COVID-19 vaccination rates among African countries.

After the evaluation, what were some of the most notable achievements for the National Health Reform?

Dr. Ndayizigiye: After the Health Reform evaluation, the Health Reform interventions have been scaled up across the country. New policies and strategies based on lessons learned from the pilot phase of the Health Reform have been developed, including the National Primary Health Care Strategy, National Strategic Health Plan, National VHW Program Policy, and Mental Health Policy. Most of those policies and strategies are being implemented. In addition to improving access to health services, new initiatives on health care quality improvement and continuous capacity building for health care workers have been implemented.

What are some of the challenges of the National Health Reform?

Dr. Ndayizigiye: I have just one sentence to summarize all of the challenges: we do not have enough funding to meet the increasing demand for health services at all levels of care.

What are you hoping the National Health Reform will achieve across the country in the next five years?

In the next five years, the Ministry of Health and PIH Lesotho hope that at least 90% of the country's citizens will have universal health coverage, and ultimately that everyone, everywhere in Lesotho will have access to high-quality, affordable health services. The National Health Reform program is integral to the steady progress in reaching universal health coverage goals. To adapt and address challenging health determinants and health conditions, PIH Lesotho will continue to accompany the Ministry of Health in its implementation of new and innovative interventions to strengthen Lesotho’s health system.

As we remember the life and legacy of Dr. Paul Farmer, we are guided and grounded by his words—tender and powerful, simple and profound.

These five quotes offer just a glimpse into the wealth of knowledge and insights Farmer shared with all of us, captured in books, speeches, and conversations throughout his life.

His words live on in our hearts and minds, especially as we put his teachings into practice every day at Partners In Health and work toward a world where health care is free and accessible to all patients, everywhere.

Here are five quotes from Farmer that continue to inspire us:

1. “Medicine should be viewed as social justice work in a world that is so sick and so riven by inequities.”

Farmer shared this insight in an interview with The Boston Globe. Throughout his life, he aimed to bring the worlds of medicine and social justice together. Guided by what he called “expert mercy,” an “alchemy that mixes compassionate fellow feeling with interventions that save the sick,” Farmer’s vision for the delivery of high-quality care was both medical and moral—and continues to drive forward PIH’s mission.

2. “If access to health care is considered a human right, who is considered human enough to have that right?”

These words appear in Farmer’s book Pathologies of Power: Health, Human Rights, and the New War on the Poor, which examines the social and economic forces that are responsible for illness and death among the world’s poor. Farmer’s dedication to the principles of universal health care and social medicine guides PIH’s work, as we tackle the root causes of health inequities and focus our energy against unjust policies and systems in service of the patients who suffer from them.

3. “To pull a million people out of poverty in the last several years, to build stable institutions where none existed—to me, that is about hope and it’s about rejecting despair and cynicism. Those are the two biggest dead ends we’ve got: despair and cynicism.”

Farmer shared these words in Bending the Arc, an award-winning documentary that tells the story of PIH and the movement for global health equity he and PIH leaders helped ignite. A defiant optimism marked Farmer’s life and work, as he inspired millions with his refusal to give in to cynicism and his dedication to the vision of a world where every patient has access to quality care. That vision was called “unrealistic” by some global health leaders, but it led to worldwide access to antiretroviral drugs for HIV patients, multidrug-resistant tuberculosis care in Peru, a world-class teaching hospital in Haiti following the 2010 earthquake, and many more revolutionary projects that have saved millions of lives.

4. “Since I do not believe there should be different recommendations for people living in the Bronx and people living in Manhattan, I am uncomfortable making different recommendations for my patients in Boston and in Haiti.”

These words, shared in an interview with Satya magazine in April 2000 on the HIV epidemic, illustrate Farmer’s lifelong commitment to global health equity and the belief in a “preferential option for the poor”—the notion that patients living in poverty should receive the best quality of treatment and care available and such care should rectify the historic and ongoing structural violence that left communities impoverished and health systems weakened.

5. “With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.”

Farmer shared this reflection in his book To Repair the World. The book, which is a collection of Farmer’s speeches, casts a lack of health care access and other issues as “failures of imagination”—a phrase Farmer often used to describe world leaders’ apparent inability to fix unjust policies and systems. In the speech, Farmer calls for partnership as the path forward in the face of poverty, climate change, and other seemingly intractable global issues. He was proud that “Partners” was central to the name of the organization he co-founded with his lifelong best friends, Ophelia Dahl, Dr. Jim Yong Kim, Todd McCormack, and Thomas J. White. Throughout his life, Farmer exemplified this spirit of partnership, accompanying patients and doctors, students and drivers, and presidents and philanthropists alike.

Dr. Paul Sonenthal will never forget the sounds that erupted in the ward day after day: patients suddenly gasping for breath, almost in unison. 

This painful soundtrack stemmed from oxygen deprivation. At the small, regional hospital where Sonenthal worked, oxygen was delivered to patients from a single cylinder that required daily refilling by clinicians and staff.  

“When the patients started screaming, a few of us would sprint out, grab a backup 100-pound cylinder, and bring it to the ward,” Sonenthal recalled. “When we’d open the valve and the oxygen started flowing again, the gasps would stop.” 

Even before the COVID-19 pandemic, the lack of medical oxygen in impoverished regions worldwide was a crisis: 9 in 10 hospitals in low-and middle-income countries lacked access to oxygen therapy. It’s hard to quantify the number of deaths linked directly to the oxygen gap, but it is estimated that as many as 320,000 pneumonia deaths a year could be prevented by increasing access to oxygen therapy. And that doesn't include COVID-19. 

COVID-19, a respiratory virus that, in severe cases, can leave patients desperate for supplemental oxygen, only deepened the crisis. A year into the pandemic, it is estimated that only 40% of health care facilities in low-to-middle income countries have a reliable oxygen supply. Without medical oxygen, nearly 1 in 5 people with COVID-19 will die. In hard hit countries, thousands of people literally suffocate to death due to inadequate supply of affordable oxygen. 

A new initiative, BRING O2, will help accelerate access to safe, reliable, and quality oxygen in Malawi, Rwanda, Peru, Lesotho, and Madagascar. To explain this just-launched collaboration, and offer details on the global oxygen crisis and plans to address it, we spoke to Sonenthal, an associate physician in the Division of Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital in Boston and associate director of inpatient medicine for Partners In Health; Dr. Melino Ndayizigiye, executive director of Bo-mphato Litsebeletsong Tsa Bophelo, as PIH is known in Lesotho; and Dr. Marco Tovar, medical director at Socios En Salud, as PIH in known in Peru. 

How dire is the oxygen shortage right now, as we enter the third year of the COVID-19 pandemic? 

Sonenthal: It is estimated that 38 million patients were admitted to hospitals in low-to-middle income countries in 2020 for hypoxemia, which is when blood oxygen levels become dangerously low. It’s hard to quantify the total number of deaths linked directly to the oxygen gap, but the Clinton Health Access Initiative estimated that 800,000 children died due to lack of oxygen. And that was before COVID-19.  

For people in wealthy countries, it’s difficult to imagine a hospital without oxygen. There are so many respiratory conditions, and now COVID-19, that require oxygen, it seems basic.  

Sonenthal: I agree. Oxygen isn’t a disease specific treatment; for a hospital, oxygen is like gauze or syringes—something a health care system needs just to function. There are so many diseases, chronic and acute, that require oxygen. When you go to the hospital with an acute illness, there is a good chance you’ll need oxygen. Without it, you are missing a fundamental part of the hospital.  

What’s the new initiative, BRING O2, and how will it address the problem? 

Sonenthal: With funding from Unitaid and in partnership with Build Health International (BHI) and PIVOT Health Madagascar, PIH has launched Building Reliable Integrated and Next Generation Oxygen Services, or BRING O2, to accelerate access to safe, reliable, and quality oxygen in Malawi, Rwanda, Peru, Lesotho, and Madagascar. Why those countries? Broadly speaking, they are all high priority based on need. 

Ndayizigiye: For context, in Lesotho, we have realized the need for oxygen for a very long time. Before COVID-19, we had been importing oxygen from South Africa. With the surge of COVID-19, we realized that the demand for oxygen was huge, and South Africa began saying, ‘Now we want to serve our own patients,’ so Lesotho was left without support. PIH helped to build the country’s first oxygen plant in December 2020. We were able to supply oxygen to many facilities, but we couldn’t meet the demand. When the Ministry of Health decided to establish additional PSA (Pressure Swing Adsorption) plants, another issue came up: those plants didn’t have mechanics who knew how to run them. Pressure swing adsorption uses high pressures and a sponge-like material to pull nitrogen out of the air, leaving mostly oxygen. It requires specialized staff to run and maintain, and many of the existing plants were non-functional due to lack of technicians and training. Unitaid is helping with that training and recruiting more biomedical engineers to maintain and develop the plants.  

Now as we are thinking beyond COVID-19, there is so much need for oxygen. People working in mines develop chronic lung disease from toxic exposures. Lesotho has the highest tuberculosis incidence in the world, and patients not only need drugs, they need oxygen. I remember a 32-year-old ex-miner who was diagnosed with drug-resistant tuberculosis and referred to us. His breathing was labored and his oxygen levels were very low on admission. A chest X-ray showed damage to 75% of his lungs. We gave him medical oxygen therapy and treatment for drug-resistant tuberculosis. After a week on oxygen in the ICU, giving the medication time to start working, his breathing became less labored and his oxygen saturations improved.

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He is now healed and was discharged home to his family. Without medical oxygen, this young man would have died. Oxygen is life.  

Tovar: Peru is the country hardest hit by COVID-19. We have the highest death rates per capita, highest case rates, and this has been driving and expanding the need to access oxygen. The oxygen gaps reported by the government were difficult, but we found even more gaps. We are gathering data only for three hospitals north of Lima, and we found from April through December 2020, more than 2 million hospitalized patients required oxygen, and another 2 million needed oxygen at home. But more than 225,000 people died, either at home or on public roads, in need of oxygen.  

Sonenthal: What Dr. Tovar and the team at Socios are doing here is so important. We don’t know how many people are dying at home without oxygen. And without pulse oximeters, it’s hard to know. The thing about oxygen is you need the right amount at the right time in the right place, and this requires strong health systems. Many people emphasize how hard it is to quantify oxygen demand, but when it comes to oxygen, we can be certain about one thing: we don’t have anywhere near enough, and people are dying without it. 

What are some of the other challenges countries face in getting oxygen to patients? 

Sonenthal: Even in places where there is enough oxygen, there is no oxygen security. Without a backup generator, a PSA plant delivering piped oxygen across a hospital becomes worthless during a power outage. A surge of hypoxemic patients with COVID-19 suddenly increases demand for oxygen three-fold, outstripping supply. During a surge, a large referral hospital may be able to meet its own demand, but may no longer be able to send excess oxygen to smaller hospitals in the region, which are unable to give medical oxygen to their patients as a result.  

Even with stable electricity and no demand surge, PSA and concentrator-produced oxygen require constant, careful maintenance. A clogged filter or tube can jeopardize oxygen supply.  The technology was not built to run on its own—you need mechanics for maintenance. 

Some hospitals rely on oxygen tank delivery, which has the benefit of needing no electricity or complex engineering to operate. However, any disruption in the supply chain can be devastating: from production issues, resource rationing, unsafe borders, flooded roads, theft...the list goes on and on.  

Reliable oxygen delivery systems must be built with redundancy in order to ensure consistent access to oxygen. Hospitals that use PSA plants need a secondary supply of backup cylinders for power outages; hospitals that rely on tank delivery need bedside concentrators and back-up generators to fill gaps when deliveries arrive late. Whole oxygen delivery ecosystems must be created to ensure supply.  

Ndayizigiye: We are working in the mountains, in remote regions. Someone might be having an asthma attack and even if you have a car or an ambulance, if you have no oxygen, it’s unlikely the patient will make it to the ICU in the referral hospitals. Lesotho has one of the lowest life expectancies in the world: 53, compared to the global average of 74. The leading causes of death are chronic and acute conditions, pneumonia, HIV, TB. You can imagine, in the context of COVID-19, what happens to life expectancy without adequate tools and supplies like oxygen? 

Tovar: One thing I’d like to add is when you offer important medicine, when you give the oxygen to people in the hospitals, you create new trust in the health system. 

Sonenthal: Exactly. If people know when you go to the hospital with COVID-19, you will get high-quality, supportive care including oxygen, this will build trust.  

Beyond the current crisis, what is the long-term goal of this campaign? 

Ndayizigiye: BRING O2 will strengthen oxygen ecosystems so that patients will no longer have to struggle to breathe. This will save lives during COVID-19 and beyond. As for the nuts and bolts, from December 2021 through November 2022, we are conducting on-site assessments in the five target countries and then doing everything from building new oxygen production plants and repairing broken or malfunctioning plants to overall improvements in facility infrastructure, as well as providing comprehensive training for biomedical engineers and clinicians. The long-term vision is to improve local biomedical and clinical capacity and strengthen the entire oxygen ecosystem at the national level.  

Tovar: We need to reduce the oxygen gap, but it’s not enough. We need to try to strengthen the health system.  

Sonenthal: That’s right. Rather than just responding to or planning for the next pandemic, PIH has always used health crises to build and strengthen health systems. Responding to the AIDS pandemic, we built hospitals, not for AIDS alone but to provide comprehensive health care from maternity care to surgery. When the 2010 earthquake hit Haiti, PIH had the oxygen, surgical supplies, and drugs to support 10 operating rooms that performed over a thousand surgeries. When building health systems in the wake of the Ebola epidemic in Liberia and Sierra Leone, oxygen plants were central to our efforts. These same facilities are now working around the clock to provide oxygen for patients with COVID-19.  

Learn How PIH Builds Strong Health Systems

For Catherine Benito, a community health worker (CHW) in Neno District, Malawi, Cyclone Ana may have ripped out an entire wall of her home in January, but it didn’t stop her regular visits to 26 households nearby. 

Benito, a divorced mother of four children, has been a community health worker for six years, making the rounds by foot through Neno, an impoverished, rural area with about 140,000 residents, still incomplete tarmac roads and scarce electricity. She visits each household once or twice a month, she said, speaking in Chichewa translated into English. If someone in the home is sick—with HIV or diabetes, or if she hears of pregnancy complications or a child appears malnourished—she visits more often.  

This so-called “household model,” in which CHWs tend to everyone living in the house whether they are ill with a specific disease or not, represents an evolving approach to care and was designed in partnership with communities. From Benito’s perspective, it’s effective. “Now people don’t wait until they are very sick to go to the hospital,” she said. “We can identify the disease faster…and refer people to where they can access treatment.   

Everyone Under One Roof

A study published in BMJ Global Health in September 2021 found various benefits from this “household model” compared to an earlier approach in which CHWs were assigned to visit individual patients already diagnosed with a specific illness. Under the new model, many more residents enrolled in health care, the study found, and fewer dropped out of the system. 

But even before the research study concluded, it became clear that accompanying all members of the households made sense, said Dr. Chiyembekezo Kachimanga, chief medical officer of Partners In Health Malawi, or Abwenzi Pa Za Umoyo (APZU), as PIH is known locally. 

Now, each of Neno District’s 1,228 CHWs visit and monitor households, offering check-ins and medical and social support as needed to everyone under one roof.   

“I think the biggest takeaway is that every house—whether they have an illness or not—has a community health worker,” said Kachimanga. “Most programs are geared to specific conditions, so if you’re not sick, you’re not visited. Here, the work of the CHW is not narrow, it’s broad, they are monitoring eight disease conditions, and they do other things. If they see that people require other medical intervention, the CHW can help.” 

The flexibility to address what’s needed is built into the household model, clinicians said. For instance, during the recent cyclone, about one-fourth of CHWs reported some losses, and about 179 of them received food packages, household items, or other support. “Otherwise for the rest, work is continuing as normal,” said Kachimanga. A number of CHWs also worked at the camps for displaced people set up in the district, offering referrals for psychosocial support, medical supplies, food, and other basics.  

CHWs as Core of Primary Care 

As part of the study, CHWs are assigned to visit 20 to 40 households each month, focusing on a set of priority conditions, including HIV, TB, pediatric malnutrition, maternal and child health, and non-communicable diseases. Additionally, pregnant women were enrolled in primary care programs and any symptomatic individuals were accompanied—literally walked— to the nearest health facility to help them navigate screening, care, and treatment. Certain patients, like those with HIV and other chronic conditions were seen more frequently. 

The study had significant findings for patients with chronic disease, such as HIV or a non-communicable disease (NCD) such as diabetes or asthma. The household model approach reduced the monthly “default” rate – when patients are lost to care – by approximately 20%. This amounts to about 1,200 additional patients being retained in care and treatment every year and has great potential for impact because this program continues to rapidly grow in Neno and currently cares for more than 15,000 patients with HIV and/or an NCD.   

Dr. Emily Wroe, the study’s lead author, and now a PIH senior advisor on COVID-19 response, said the research led to several important findings. First, she said, under the household model, CHWs helped more women get antenatal care early in pregnancy. This connected women throughout pregnancy to routine care, such as checkups and accessing vitamins, and, when complications arose, enabled swift action since the women were already linked to a health care system. 

Greater Prevention, Faster Access to Treatment 

Second, Wroe said, people with chronic conditions such as diabetes or asthma, remained supervised and supported by CHWs. “This means they have routine access to treatment, monitoring, and counseling,” she said. “Keeping people with chronic conditions under care prevents diseases from getting worse and keeps patients out of the hospital.”  

This type of research, a stepped-wedge randomized controlled trial, is a big deal for understanding the impact of the CHWs and the household model. But the team was confident it would work and had an earlier success story in mind when formulating the new study: a program providing ongoing CHW support to patients with HIV in Neno led to high treatment and retention rates. Indeed, as of late 2021 in the Neno district, 94% of people living with HIV (ages 15-49) were enrolled in life-saving antiretroviral treatment; in 90% of these patients the virus was undetectable.   

The recent study was fashioned to achieve that level of impact for all other conditions: household support means identifying problems early, whether it’s adherence to medication regimens, dealing with side effects, or missing medical appointments.  

“It really proved what we suspected,” added Wroe. She said her “favorite” finding is that the biggest benefits from the CHWs were for diseases where the primary care system was strong: “This taught us that CHWs are synergistic with strong primary care — they don’t replace primary care but boy can they amplify it.”  CHWs are not “cheap alternatives” for strong primary care systems, Wroe said, they are embedded in the system. “That really came out in our results…if you build a CHW system without strong primary care you can support people, but if there’s no microscope to check for TB, the impact will be limited.” 

Feeling Better 

For Benito, the CHW, there can be a few bumps in the system. Sometimes, she says, if no one  is sick in the household, families can be reluctant to open their homes to her. “But we are able to continue to visit,” she said, “and it helps the community.” 

Recently, a woman in one of Benito’s households was complaining of weakness and fatigue. Benito urged a medical appointment, but doctors found nothing and sent the woman home. Still, she told Benito, she continued to feel unwell and began suffering from numbness on one side of her body that ran down her leg. Once again, Benito arranged for a hospital visit. This time the woman was diagnosed with high blood pressure and put on medication. “Now,” Benito said, “she is starting to feel better.” 

More on Malawi

Stopping the spread of COVID-19 requires rapid, widespread vaccination coverage. Yet there are big differences in vaccine uptake rates among communities. To use their scarce time and resources effectively and equitably, local health authorities must identify pockets of under-vaccination. And, if they are to tackle inequities in vaccine rollout, they must also understand the particular challenges these communities face.

To address this challenge, the Pima County Health Department collaborated with Partners In Health United States and Surgo Ventures to improve COVID-19 vaccination rates by focusing their resources on areas most at risk from the negative impacts of the pandemic. To accomplish this, Surgo Ventures created a dashboard that provides real-time, geographically precise insights into the barriers to higher vaccination coverage and why some areas are more vulnerable. 

The COVID-19 Vaccine Solutions Dashboard enables decision-makers to:

• Identify vulnerable areas with rising COVID-19 case rates and low vaccination coverage
• Understand the factors making these communities more vulnerable to the negative health, social, and economic impacts of COVID-19
• Understand the possible drivers of lower vaccination rates, from poor infrastructure and access to irregular care-seeking behaviors

This hyperlocal analysis makes it possible to design locally appropriate and precise vaccine uptake strategies for each census tract. Health department teams and local community-based organizations can use this tool to design coordinated, tailored interventions – such as campaigns or communications strategies – to drive demand for COVID-19 vaccines or improve vaccine access. And it can identify areas that are underperforming or exceeding expectations, so that the lessons can be applied to wider efforts to reduce COVID-19 vaccine inequity. For the first time, decision-makers have a single tool supporting a precision response to reduce vaccine inequities.

While the dashboard currently focuses on Pima County, this approach can be adapted to any other community in the United States.

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For many first-year clinicians in Mexico who complete their mandatory year of social service with Compañeros En Salud, there are two distinct phases of their career: before the internship and after the internship.

Each year, Compañeros En Salud welcomes 10 first-year doctors, nurses, and midwives to complete their year of service in the rural communities of Chiapas, Mexico. Compañeros En Salud, as Partners In Health is known locally, has worked in the mountainous Sierra Madre region of Chiapas since 2011 and training the next generation of clinicians has been a cornerstone of its work there.

For the students who serve with Compañeros En Salud, the pasante program is a time of change and discovery—shaping their perspective and approach to providing medical care and a preferential option for the poor.

Andrea Jiménez completed her year of service in 2015 in the rural, coffee-growing community of Matasano at a clinic supported by Compañeros En Salud and the Mexican Ministry of Health. She was one of more than 100 pasantes—a Spanish word for first-year clinicians—who have served with Compañeros En Salud over the years. And she’s one of dozens who have since felt called to return to the highlands of Chiapas and care for even more patients.

Social Medicine

Ever since her childhood, Jiménez had dreamed of becoming a doctor and exploring the different specialties of medicine.

"My parents are physicians, and they were always very involved in social medicine," she recalls. "When I was a child, my parents would take me with them to Rotarian medical days [mobile clinics]."

Social medicine is a field that seeks to understand the social and economic conditions that impact health and prevent patients from accessing care. For Jiménez, that concept was always more than a theory learned in a classroom.

From an early age, Jiménez witnessed the impact that a van full of medicine and a few doctors giving consultations could have on people's lives in rural Chiapas. Huge lines would form in the communities where these mobile clinics came, providing free check-ups, testing, and medications.

It was through these experiences that her passion for providing dignified health care for the poor was born and that, years later, she learned about Compañeros En Salud. She began talking to pasantes in the communities where they worked and made the decision to do her year of service with Compañeros En Salud.

"My way of practicing medicine changed forever," says Jiménez. "I will never understand 100% what it's like to live in the shoes of people living in rural communities. But now I understand the heavy burden of a person's life context on their health."

For instance, she learned that patients often had complex reasons for missing appointments or skipping their medicine—and blaming them wouldn’t improve health outcomes or fix the social and structural barriers that prevented them from accessing care. These barriers often included distance, a lack of specialists, and stigma around certain conditions and diseases. And the impact on health was often devastating—patients waiting years for surgeries, even as their health conditions worsened.

In the communities where Compañeros En Salud works, there were no gynecologists, meaning that women would have to travel for up to eight hours to see these specialists in Tuxtla or Tapachula.

That critical need inspired Jiménez to pursue a residency in gynecology, after completing her year of service.

"Even during the specialty [residency], I always had in mind wanting to return to be able to support with these newly acquired skills," she says.

A Call to Return

A few years after finishing her residency, Andrea returned to Compañeros En Salud—this time, as a specialist.

In collaboration with Dr. Jimena Maza, director of clinical quality and teaching, and Dr. Karla Saldivar, a gynecologist formerly with Compañeros En Salud, Jiménez began to plan “surgical campaigns”—an initiative where obstetric, urological, and gynecological surgeries would be provided to patients at the hospital in Jaltenango, allowing them to access care close to home and avoid traveling to advanced hospitals in faraway cities, incurring food, lodging, and transportation costs.

The campaigns were difficult to plan. Jiménez and the team faced many challenges, such as limited hospital capacity, surgical materials, and specialists—from patient admission to post-operative care—who would be willing to travel to Chiapas to perform these surgeries.

But the initiative was much needed. In the first week alone, Jiménez provided consultations, surgeries, and post-operative care for more than 90 patients in need of various gynecological surgeries.

To date, Compañeros En Salud, in collaboration with the hospital in Jaltenango, has carried out four surgical campaigns and 140 surgeries, ranging from c-sections to salpingoclasies (tubes tied) to endometrial biopsies.

For Jiménez, each surgery deepens her commitment to social medicine and reminds her of why she chose a career in health care.

"All the work is worth it to see the positive results in the patients, knowing that you took part in improving their quality of life," she says.

In the days following Dr. Paul Farmer’s passing, hundreds of people posted pictures on social media of selfies with Paul. The Partners In Health co-founder and chief strategist had been their mentor, professor, colleague, friend, or doctor. Regardless of role, he had touched them personally and inspired them with his innovative and radical approach to seeking health equity around the world. 

Given that outpouring of love, reflected through imagery, we wanted to share some of our fondest memories of Paul over the years, from when he first started traveling to Haiti in the early 1980s to his final days in Butaro, Rwanda. As many have said before, Paul was happiest at PIH sites when he was sitting at a patient’s bedside, rounding with medical residents, and sharing his worldview with others—be they supporters, undergraduates, or global leaders. 

Below, accompany Paul through the years, as he did so many of us. 

Father Fritz Lafontant (left) and his wife, Yolande (right), were among Paul’s first partners in Cange, Haiti, where the Episcopal priest and his family lived and advocated for quality health and education for the poor and marginalized. Lafontant became a founding member of Partners In Health and founding director of Zanmi Lasante, PIH’s sister organization in Haiti. 

When 11-year-old Cecilia Kadzanja’s father died in 2011, her mother struggled to support six children. Although Cecilia desperately wanted to continue primary school in the rural Neno District of southwest Malawi, her family could not afford the essentials like notebooks, uniforms, and fees—the equivalent of less than $2 per child, and far more than her mother could spare to spend.  

Then following an assessment of her family’s income, Kadzanja was selected to become part of a program sponsored by Abwenzi Pa Za Umoyo (APZU), as Partners In Health is known in Malawi. The Program on Social and Economic Rights (POSER), established in 2007, pays education-related costs for Neno District children.  Since it began, POSER has helped cover school fees and the cost of other scholastic materials for more than 1,000 students in secondary schools and over 2,000 primary school children. Additionally, the program provides food, housing, and transportation assistance to qualifying families to ensure they can access care and remain healthy. 

The importance of educating children, especially girls, cannot be overemphasized, program administrators say. Educated girls can make informed decisions about their lives, including having safe sex, waiting longer to marry, and taking control of the number of children they have. Kadzanja said the program has been life-changing. “I took this as an opportunity and promised myself to work hard in class,” she said.  In 2009, Kadzanja was selected to go to Chiwale Secondary School in Neno. After a few setbacks, like repeating a year of school, she was accepted at University of Mzuzu.  

Once again, however, Kadzanja was forced to grapple with the high cost of education. So she approached APZU staff for continued financial support. In 2015, APZU made the decision to extend its assistance program to include university students; Kadzanja was the second student to benefit from the new policy. She completed her degree program in Hospitality Management in 2021. 

“I am more than happy to be a graduate,” she said. “It does not only open doors to my bright future, but more importantly, it has given hope to other girls in my community to believe that a girl child from Neno can also get educated to tertiary level.”  

Kadzanja noted that many girls from her community drop out of school early, get married young and have children, thereby diminishing their chances of a professional, independent life. They are, she said, “without hope for a better tomorrow.”  

Malawi has been in the news for powerful cyclones and other extreme weather that has battered homes, clinics, communities and farmland. But the country is also recognized for other reasons, including innovative approaches to delivering comprehensive health care in remote communities.

Abwenzi Pa Za Umoyo, (APZU), as Partners In Health is known in Malawi, has worked in the landlocked nation in southeastern Africa since 2007.  Focusing efforts in Neno District, a rural, remote area of approximately 165,000 residents, where tarmac roads remain a work in progress, and just over 3% of households have electricity, the APZU team has developed effective models of integrated health care to deliver top quality treatment and critical social services to patients. Together, the efforts have led to measurable improvements for people afflicted with HIV/AIDS, mental illness, chronic conditions, and more.

Barriers Abound

Life in Malawi can be harsh: it’s one of the most impoverished countries in the world, with a daunting HIV epidemic, a significant non-communicable disease burden, and high rates of infant and maternal mortality, as well as sexual and gender-based violence. Making matters worse, access to decentralized, high-quality care is scarce or unaffordable for most people. Even those who can pay for treatment are often unable to reach clinics, especially over mountainous terrain and rugged roads in remote areas.

In response to these challenges, APZU is building and supporting a model of free, accessible, one-stop-shop health care in Neno District through two hospitals, 12 health centers, and a network of 1,228  community health workers (CHWs) offering treatment for everything from HIV and malnutrition, to mental health support and diseases such as hypertension, diabetes, and sickle cell anemia.

Below are four of APZU’s key programs:

Social Support

A pillar of APZU is its Program on Social and Economic Rights, (POSER), which empowers community members to live with dignity, security, and independence. POSER delivers cash assistance to help patients address costs related to health care, ensuring that Neno’s most vulnerable have access to medical care and the basic necessities to stay healthy, such as housing, employment, education and transportation.

CHWs and clinicians, along with local community leaders, identify people who could benefit from POSER support through home visits, checkups at local health facilities, connections with local government, and community-based organizations. POSER staff register eligible people in the program and conduct a vulnerability assessment to gauge which needs are most urgent. 

Once support begins, POSER staff ensure the continuity and effectiveness of care by regularly visiting patients and families at their home. Using a mobile health app, Medic Mobile, CHWs have already registered more than 76,000 individuals to track their ongoing care in more than 16,000 households since 2019—with more added on a regular basis.

One Stop Health Care

APZU’s Integrated Chronic Care Clinic (IC3), launched in 2015 as a collaboration with Malawi’s Ministry of Health, brings patients for asthma, hypertension, diabetes, mental illness, and other non-communicable diseases under one roof for treatment that is intertwined with HIV care across 14 health facilities in Neno District. This integration takes into consideration chronically ill patients’ needs for one-stop care and diminishes stigma associated with specific conditions. In a three-year study of the integrated care model, clinical measurements—such as blood pressure, asthma severity, blood sugar, or number of seizures per month, for patients with epilepsy—showed statistically significant improvement. One year after enrolling in IC3 care, more than half of hypertension patients had controlled blood pressure, and patients with epilepsy were reporting fewer seizures overall—with more than 40% regularly reporting no seizures since their previous visit.

Starting in 2019, trained mental health counselors began screening mothers for depression at routine antenatal visits as part of this comprehensive approach. So far, 91 people have participated in the group Problem Management Plus (PM+) intervention and preliminary data show that over 90% of patients’ depression improved from moderate and severe to minimal or no depression at all after the intervention. Data also indicate that over 90% of patients who benefited from the intervention remained stable with no depression six months after completing the group therapy program.

Sexual and Gender-Based Violence

In 2019, to address widespread sexual and gender-based violence (SGBV), APZU launched a program called No Woman or Girl Left Behind. In addition to supporting SGBV survivors, the program also aims to advance sexual and reproductive health and rights for adolescent girls and advocates for those rights nationwide.

APZU established a gender-based violence task forces in all health centers across Neno District, each bringing together health workers, social service providers, and police in one place. Previously, these services were sometimes located hours apart, making such support inconvenient and largely inaccessible. Now, patients are offered a menu of services at nearby sites, including testing for sexually transmitted infections, HIV post-exposure prophylaxis, pregnancy testing, social support, and psychological counseling.

From January 2020 to December 2021, Neno’s SGBV team worked on 228 such cases, including 26 victims under 10, and 48 cases involving victims under 14.

HIV/AIDS

When clinical and support staff began caring for people living with HIV/AIDS in 2007, the conventional wisdom among global health officials was that treatment was not an option in impoverished communities. “Focus on prevention” was a common refrain for decades. But this mindset would have left millions of people worldwide without care; it is a worldview PIH refused to accept.

Malawi has one of the world's highest rates of HIV. Specifically in Neno District, 1 in 10 residents live with the virus, and many used to struggle to access medications and the care necessary for long-term survival. For the past 15 years, APZU has worked with community health workers and Malawi’s Ministry of Health to provide comprehensive care in 14 health facilities, including more HIV tests and access to treatment.

As of late 2021 in Neno district, 94% of people living with HIV (ages 15-49) were enrolled in life-saving antiretroviral treatment; in 90% of these patients the virus was undetectable.  

Stay Informed

Each morning, Flormila Antaurco emptied dozens of pills from carefully labeled bottles in her home in Carabayllo, Peru.

The first 11 were prescribed for her. The others, for her children.

“It was painful to watch,” she recalls. “It hurt their throats…I had to break the pills and give them in liquids [like] juice or water.”

But it’s what the doctor had told the 29-year-old mother to do, ever since she was diagnosed with tuberculosis.

It wasn’t a diagnosis Antaurco was expecting.

She had just begun to recover from COVID-19 when her cough returned and lasted for more than two weeks, followed by fatigue, weight loss, and a fever. A free screening at a mobile clinic run by Socios En Salud, as Partners In Health is known in Peru, revealed the news: she had tuberculosis, as well as COVID-19.

“At the beginning, I was very afraid,” she says. “I was afraid of infecting my family…And I was afraid to confirm it because of what people would think of me.”

A Silent Killer

Tuberculosis is one of the world’s deadliest infectious diseases, despite being curable and preventable. Each year, 10 million people contract the airborne disease and 1.4 million die—a burden that disproportionately affects low- and middle-income countries like Peru, which has one of the highest incidence rates of tuberculosis in the Americas.

Socios En Salud has worked in Peru since 1994, when it responded to an uncontrolled outbreak of multidrug-resistant tuberculosis (MDR-TB), an especially deadly form of the disease, in Carabayllo, an impoverished community about 20 miles north of Lima. The response, which ultimately saved thousands of lives, prompted the World Health Organization to change its global MDR-TB policy, as shown in Bending the Arc.  

In the years since, Socios En Salud has expanded its tuberculosis work, delivering that care in clinics, blue trucks, and backpacks in Lima, Carabayllo, and beyond. That care has continued even amid COVID-19. More than 670 people received screenings for tuberculosis and COVID-19 at Socios En Salud’s mobile clinics between August and September 2020—an effort that proved especially crucial for patients like Antaurco, who had both diseases at once.

A Second Chance

The diagnosis wasn’t the only thing that frightened Antaurco. The treatment would be long—at least six months—and painful.

“I felt very bad,” she says. “I could only cry.”

Treatment for tuberculosis is notoriously grueling, with side effects including fever and nausea, even as global efforts like the endTB project are on a mission to change that. EndTB is a multi-year R&D effort launched by Partners In Health and other NGOs to discover safer, shorter treatments for MDR-TB in 17 countries, including Peru.

Antaurco was prescribed four medications for tuberculosis for six months—a daunting treatment plan to follow, especially as she struggled to manage the symptoms of the disease. But she wasn’t alone.

To help Antaurco follow her treatment plan and navigate Peru’s complex health system, Socios En Salud connected her with Cristina Capristano, a community health worker.

“[Flormila is] a very brave woman,” says Capristano. “She never gave up.”

For the next six months, Capristano checked in with Antaurco at home, went with her to the clinic for check-ups, and helped her refill her prescriptions—providing the accompaniment at the heart of PIH’s community health worker program worldwide, as teams from Peru to Lesotho recruit local residents and train them to provide basic health services in their communities.

Capristano, 45, has been a community health worker with Socios En Salud for more than a decade. Through the years, she has supported several patients living with tuberculosis. Each case is unique; but for Capristano, each evokes similar feelings.

“At Socios En Salud, I have met many patients who overcame TB,” she says. “It is very rewarding to be part of the recovery process. That is priceless.”

Antaurco’s long-awaited recovery came in September 2021, when she was declared free of tuberculosis. For the first time in months, she felt like she could breathe again.

“I thank God for giving me a new chance at life,” she says. “Let’s put aside the stigmas that surround this disease and the fear of what people will say. Our health comes first.”

Tuberculosis (TB) shouldn’t be ignored. This is especially true for pregnant women, as the disease can harm both mother and child. If an expectant mother is not diagnosed and treated in a timely manner, the baby can potentially contract TB—a common, but often deadly, infectious disease.

Despite efforts to identify, treat, and control TB, there are instances of misdiagnosis, as was the case for 30-year-old Rachel (pseudonym) in Liberia. Rachel was four months pregnant with her first baby in 2009 when she visited the hospital complaining of swollen feet, chills, and a fever. She experienced hallucinations too, which doctors told her was as a result of severe malaria. She was immediately admitted to the hospital and was also treated for typhoid after several tests.

For four years she received treatment at different hospitals for typhoid, a disease caused by consuming contaminated food or water. However, she continued to feel ill. Finally, she was referred to the Partners In Health (PIH)-supported TB Annex in Monrovia and was admitted after testing positive for TB. This time, she had an eight-month-old baby and had to leave the child with her sister. The standard protocol for drug-resistant TB treatment in Liberia involves taking at least 6 to 20 pills per day for 9 to 24 months. Rachel went on to receive medical treatment, as well as psychosocial and nutritional support, in the ward for two years.

According to the World Health Organization's (WHO) 2021 Global TB report, Liberia reported about 7,000 TB patients of which 55 had drug-resistant TB. The WHO further estimated that 75% of the patients that start TB treatment will be cured or at least successfully complete the regimen. The proportion of those being cured or completing TB treatment was reported to be lower—about 70%—for patients with drug-resistant TB.

In 2018, Rachel once more began to experience symptoms of TB. “I was feeling cold on my left side. It was even hurting to bend,” says Rachel. “I went to the hospital but they refused to do an x-ray because I was pregnant.” In the same year, an estimated 3.2 million women fell ill with TB globally.

In February 2021, Rachel was diagnosed and admitted to the TB Annex for a second time; again, she was five months pregnant. She was worried about death, but the nurses comforted her by sharing the story of another woman they treated who survived. Fortunately, Rachel also responded well to treatment and was discharged to continue her treatment at home, just a week before she delivered her baby.

“I felt so happy to be home to give birth. PIH played a major role,” says Rachel, who noted the many ways PIH staff supported her. Drivers brought her to the hospital for every appointment. Staff always made sure she had food and personal hygiene products. Every Monday, they gave her beans, rice, peanut butter, tissue, and roll-on deodorant, among other items.

“I named my daughter after Drs. Rebecca and Megan (both PIH staff) because when I was in the hospital they did well for me; you don’t have a family at the hospital, but they were like family to me,” says Rachel.

In Liberia, TB prevalence has increased from 245 to 314 per 100,000 people from 2001 to 2020. PIH Liberia is working with the country’s Ministry of Health to improve care for those with TB, especially pregnant women, by increasing drug supplies in health clinics and mentoring and training clinicians. There were 260 patients with drug-resistant TB receiving treatment in the TB annex in late 2021. For patients, such as Rachel, these efforts have proved to be life changing—for her, personally, and for her growing family.

Dear President Joseph Biden: Stop using public health as a pretext to block asylum seekers at the United States borders. 

That’s the message from a new Perspective piece in The New England Journal of Medicine, written by Partners In Health leaders and collaborators. 

At issue is a March 2020 order by the Trump Administration overriding national and international legal protections for asylum seekers at the U.S. border and using the COVID-19 pandemic as the rationale to do so. 

The “Title 42” order, which has been extended by the Biden administration, “suspended the right of these migrants to have their claims heard and singled them out for immediate expulsion,” write the authors, Dr. Anne G. Beckett, assistant professor of medicine and pediatrics at Boston University School of Medicine; Loune Viaud, Partners In Health’s chief gender and social equity officer; Dr. Michele Heisler, medical director of Physicians for Human Rights and professor of internal medicine and public health at the University of Michigan; and Dr. Joia Mukherjee, PIH’s chief medical officer.  

The order, issued by the Centers for Disease Control and Prevention, draws on a previously obscure public health law enacted in 1944 to single out asylum seekers “by reason of the existence of any communicable disease in a foreign country,” essentially arguing that the migrants pose a serious threat of bringing more COVID-19 cases into the U.S. and increasing its spread. At the same time, other travelers, such as students and drivers, were allowed to enter the U.S. without COVID-19 testing, demonstrating a blatant double-standard, which the authors call out: “There is no evidence that noncitizens who lack documentation are more likely to transmit Covid than are residents, citizens, or tourists entering the country.” 

The bottom line, they write, is this: 

“There was — and remains — no public health evidence that singling out asylum seekers or other migrants for exclusion is effective in stemming the spread of Covid-19.”  

Or, as first author Beckett puts it, “The Title 42 order is a racist policy that targets Black and Brown migrants and causes unthinkable harm. President Biden campaigned on a pledge to restore the U.S.'s commitment to asylum-seekers, and instead his administration has increased the use of Title 42. The hypocrisy is staggering: under the false guise of protecting public health, the order has had a devastating impact on the physical and mental health of vulnerable and marginalized migrants who are denied access to a safe asylum process and expelled to dangerous conditions.” 

Moreover, the authors add, by expelling asylum seekers, the Title 42 order violates this country’s obligations to not send migrants back to dangerous regions. Since the order went into effect, the authors say, more than 1.6 million people entering the U.S. from Mexico or Canada have been expelled to countries where they could face persecution or torture, with no chance for asylum. Still, "asylum seekers represent a small fraction of the travelers who cross the border; in the same period in which 1 million asylum seekers were expelled, nearly 100 million other travelers were admitted at U.S. land borders," the authors write.

The health implications are severe: people who “already had experienced much trauma from persecution in their home countries have been even further traumatized, with profound mental and physical health consequences,” the authors write. 

People from Haiti seeking asylum in the U.S. have been particularly mistreated, says Mukherjee. “The Title 42 order has been disproportionately enforced along racial lines, particularly against Haitian asylum seekers,” she says. “This policy has no public health evidence behind it. U.S. citizens, not Haitian nationals, had a far higher rate of COVID-19.” She notes that Haiti is in the midst of a political crisis, and to deport asylum seekers into such insecurity and violence against the backdrop of a pandemic is “immoral and even lethal.” 

The piece also takes on several myths surrounding the order. For instance, one justification rests on the assumption that migrants must be held in “congregate settings,” typically crowded quarters that can drive infections. But there are alternatives, the authors write, for instance, “programs that allow migrants to shelter, under parole arrangements, within the community have been demonstrated to be effective alternatives to facility-based detention;” indeed, such programs are associated with “improved health outcomes...excellent compliance with immigration court requirements, at a fraction of the cost of detention.” 

Medical and public health practitioners must advocate for the end of the misuse of the Title 42 order, the authors conclude. They must do this “through the use of evidence-based Covid-mitigation measures at the border, including avoidance of inhumane and unnecessary immigration detention, rapid expansion of vaccine access, and implementation of data systems with public reporting to ensure the protection of the health and rights of asylum seekers. As the CDC considers extending the order yet again, health professionals should join in calls to the agency and to Biden to end the misuse of Title 42.” 

Advocate for Change

A year ago, Marat* was confronted with a slew of alarming symptoms: constant fatigue, occasional spikes of fever, coughing up blood, and dramatic weight loss. In just one month, he lost 26 pounds. Despite these signs, Marat continued to work as a stone mason at a construction site in Nur-Sultan, Kazakhstan, hoping he would feel better. On weekends, he often had a drink with friends. But the symptoms only exacerbated. Following a visit with a doctor and an X-ray, he received a shocking diagnosis—he had multidrug-resistant tuberculosis (MDR-TB), among the most deadly strains of the disease, and would need to be hospitalized for six months.

“This diagnosis was psychologically traumatic,” said Marat, a 34-year-old father of four, who chose to use a pseudonym in sharing about his journey toward recovery from TB. “I had a really hard time accepting it.” As the primary breadwinner for his family, leaving his wife and children without his support seemed unfathomable. One of his children has special needs and his wife was expecting their fourth child. “I began to think about them, what will they do without me?”

But after a serious conversation with the doctor, Marat made the decision to commit to the necessary treatment, beginning with a months-long hospitalization. The day after receiving his diagnosis, he was admitted to the City Center of Phthisiopulmonology in Nur-Sultan. 

“Everything has changed from that moment,” he said.

A Global Clinical Trial

Marat is one of 754 patients across seven countries who joined a clinical trial as part of the Expand New Drug Markets for TB (endTB) project, an international partnership launched in 2015 among Partners In Health, Médecins Sans Frontières (MSF), Interactive Research and Development (IRD), and financial partner Unitaid to find safer and shorter treatment regimens for MDR-TB, using the first new TB drugs developed in more than 40 years–bedaquiline and delamanid. 

Most clinical trial participants receive nine months of daily oral medication, in contrast to the typical regimen of 18 to 20 months of treatment–including pills and many months of daily injections. 

By October 2021, 184 patients had enrolled in the endTB clinical trial in Kazakhstan, which has some of the world’s highest rates of MDR-TB. To respond to this deadly epidemic, PIH has partnered with the local and national government since 2010. 

All Around Care for TB

For the first two months, Marat diligently followed his daily medication regimen at the hospital. His treatment included: bedaquiline, linezolid, clofazimine, cycloserine, moxifloxacin, and pyrazinamide. He experienced side effects, which manifested in weakness, dizziness, and heartburn, but doctors helped mitigate them.

PIH Kazakhstan and several charity organizations came together to create a network of support for Marat’s family when he was undergoing treatment at the hospital. Thanks to Sanat Alemi Kazakhstan, Marat’s 6-year-old son got a spot at kindergarten. Other organizations like Nur Alem Kazakhstan and Red Crescent of Kazakhstan, as well as volunteers from The Club of Kind Souls, regularly provided humanitarian aid through food deliveries, cleaning and school supplies, and clothing and baby items. PIH supported the family through food vouchers to a local supermarket. “The family has been really cared for,” said Gulmira Tanatarova, a member of PIH Kazakhstan endTB staff and Marat’s ambulatory coordinator.

Tanatarova has been a pillar of steady support to Marat and his family since the day he embarked on the treatment as part of the clinical trial until now, back home from the hospital, where he continues his regimen.

She calls her patient or his wife every other day, ensuring they’re getting nutritious meals, that Marat is taking his medications, and that he has warm clothing, particularly since his return to his job at the outdoor construction site. Occasionally, she visits Marat’s family to ensure that the living conditions are conducive to his full recovery. 

“The support and the role of a social worker is huge in the treatment process,” said Tanatarova. “Every patient needs an individual approach— you need to deeply understand their particular challenges.”

Most of the patients belong to socio-economically vulnerable groups and need emotional and psychological help. “During every encounter, I try to buoy them up and help them remain optimistic,” Tanatarova said. 

“I Consider Myself Lucky”

Currently, Marat shows up for his video treatment support every day. Shortly after breakfast, he connects with the nurse through a video call to ensure consistency in taking his medication. “He’s very diligent about not missing a day of his daily therapy,” said Tanatarova. 

Through Sanat Alemi Kazakhstan, Marat participates in a support group twice a month, where TB patients can ask clinicians and other experts questions and support each other. “On the days that I work, I ask to leave early to attend these meetings,” Marat said. 

At work, Marat doesn’t speak publicly about his diagnosis, even though his infection is no longer active. This airborne, infectious disease remains severely stigmatized in Kazakhstan and other post-Soviet countries given increased risk of infection among the marginalized groups of society. 

Looking back on his experience, Marat hopes that patients don’t delay turning to professionals once they experience symptoms. “I first had to believe myself that I could fully recover. The cure is within reach, if you commit to taking medication consistently and refuse alcohol,” Marat said. “It’s a hard and lengthy path, but it’s possible.

“I feel so much better than last year,” said Marat. “I consider myself lucky to have been part of this trial.”

*Name has been changed to protect patient privacy

Límbano Castro is 75 years old and has run a laundry business for several years, using the two washing machines at his home, in addition to selling snacks and decorations.

"Before [COVID], one was free to go out on the street, walk and see whoever one wanted,” he says. “But with the arrival of COVID two years ago, it was no longer like that."

Castro, like many others in Chiapas, Mexico, saw his community devastated as the pandemic swept through the rural, coffee-growing Sierra Madre region, where tests were not widely available until January 2021. When long-awaited vaccines became available in March 2021, he felt hopeful.

He received a one-shot vaccine that month. But he never received a booster.

While Mexico has a stockpile of vaccines, the country didn’t have enough booster doses, according to its president, until January 2022—several months after wealthy nations such as the U.S. had begun to rollout their booster programs.

That meant Castro, like millions of patients in low- and middle-income countries, lacked access to the same level of protection as those in wealthy nations. Such disparity came with consequences.

The cough began in October. At first, Castro thought it would last just a few days. But as time went on, the cough only got worse, along with a general malaise. It was then that his children took him to the Center for Respiratory Diseases at the community hospital in Jaltenango.

Compañeros En Salud, as Partners In Health is known locally, has worked in Mexico since 2011. Since 2020, Compañeros En Salud has staffed and supported the Center for Respiratory Diseases, a 6-bed center that provides antigen tests, consultations with doctors, and bedside oxygen for patients struggling to breathe. It’s part of Compañeros En Salud’s comprehensive COVID-19 response in Chiapas, where 1 in 3 families live in poverty and the nearest clinic can be hours away.

Last year, the team administered 2,820 antigen tests and treated 85 patients at the respiratory disease center.

At the center, Castro was tested for COVID-19 and his diagnosis, confirmed: positive.

Doctors gave him medication for his fever and sent him home to rest. But Castro's condition wasn’t improving. By day nine, his breathing had become more and more difficult, his cough had worsened, and his lungs had weakened. Fearful, his son rushed him back to the center for respiratory diseases, where Castro learned that he needed to be hospitalized—immediately.

"I didn't want to stay hospitalized, because I didn't want to be away from my family,” he recalls. “It's terrible to be in a hospital."

COVID-19 remains in the body for approximately 10 days, after which most people with mild-to-moderate illness no longer have a viral load that allows them to infect others; however, complications and lung damage can cause problems even months after infection—especially for those with preexisting conditions.

Castro had suffered from hypertension and diabetes for several years, but had gone untreated. Now, facing COVID-19 and pulmonary fibrosis—a condition where the lungs became damaged and scarred—he was struggling to breathe.

He would need bedside oxygen.

For patients with severe COVID-19 or other respiratory illnesses, medical oxygen can mean the difference between life and death. It’s one of the last lines of defense against COVID-19, a virus that attacks the respiratory system and, in its most severe form, requires intubation.

Hospitals typically provide medical oxygen in three ways: oxygen plants, oxygen tanks, and oxygen concentrators (bedside or portable machines). Castro received oxygen through a concentrator and was constantly monitored by doctors and nurses.

"Much of a patient's recovery is centered on three important pillars: a good response from the medical team, support from family members, and the cooperation and patience of the sick person," says Dr. Carlos Popoca, a doctor with Compañeros En Salud who treated Castro while he was hospitalized.

Despite the constant attention and care of Compañeros En Salud staff, Castro’s life was in danger.

"I thought I wasn't going to make it out of there alive," he recalls. "I was afraid I would never see my children again...or my granddaughters."

But Castro and his family didn’t give up. And neither did Compañeros En Salud. After nearly one month in the hospital, he recovered and was able to return home.

The care didn’t end there. Doctors followed up with Castro after his release—three times per week for the first two weeks—teaching him how to breathe again and helping him strengthen his lungs through breathing exercises.

While Castro has since recovered, his month-long stay in the hospital, on oxygen, could’ve been avoided, doctors say, had boosters been available earlier in Mexico.

“Vulnerable populations, or those with difficulties accessing medicines and vaccines, are the ones who are the most damaged and hit the hardest with the disease,” says Popoca.

That applies not only to COVID-19 patients, but to those with other respiratory diseases, such as tuberculosis.

“Castro is one of the success stories. They really thought he was going to pass away,” says Popoca. “Many patients decide to leave [because] they want to die at home. He believed in us.

At around 8:00 a.m., PIH staff are in a car bound for Bungwe, a village in Northern Rwanda where farming is the heart and soul of the community. The village is about 20 miles from the hospital and university campus in Butaro, where Inshuti Mu Buzima, as Partners In Health is known locally, works. But, unlike other such journeys, this visit isn’t about delivering medical care—it’s about meeting patients turned entrepreneurs.

Jean Nepomuscene Nkiliyehe, who always starts the day with a joke to keep his colleagues entertained, starts the car to begin the journey—or home visit, as it is called at Inshuti Mu Buzima.

For Nkiliyehe, a driver with Inshuti Mu Buzima for almost a decade, and Eddy Mukwiza, livelihood program coordinator with Inshuti Mu Buzima, this is a route they are accustomed to. They are part of a team that travels beyond the walls of Butaro Hospital to follow up with patients across rural Burera district who live in poverty and face financial barriers to health care.

That outreach is part of a Partners In Health program called POSER. The Program on Social and Economic Rights (POSER) stems from the belief that care must extend beyond medical and addresses the whole patient. PIH offers the program in Rwanda and Malawi and provides social support—such as food, housing, and transportation—in all countries where it works.

Inshuti Mu Buzima has worked in Rwanda since 2005 and focuses its work in three rural districts—Burera, Kayonza, and Kirehe—home to more than 1 million people. In partnership with the government, Inshuti Mu Buzima strengthens the public health system to provide not only quality medical care, but also financial resources to ensure that patients have the means to stay healthy.

After a 50-minute drive, Nkiliyehe and Mukwiza reach Bungwe and are welcomed by Sylvien Gakwenza, secretary of a local farmers’ cooperative called INZIRA Y’UBUKIRE (“Path to Wealth” in Kinyarwanda), near a 6.7-hectare (16.5 acres) field that still has remains of trunks of cassava from the last harvesting season.

For at least nine months of the year, this field is where Gakwenza and some 140 members of INZIRA Y’UBUKIRE spend their days planting or harvesting crops such as Irish potatoes, beans, corn, and wheat.

“I am a farmer, my parents were farmers, and their parents were farmers too,” says Gakwenza. “Farming is important to our everyday life.”

A Community Effort

Farming is the foundation of people's wellbeing and livelihoods in Burera, a rural district with volcanic fertile soils located near the Virunga Mountains in northern Rwanda.

But over the years, climate change, coupled with obsolete traditional farming methods, has threatened to push many farmers to the brink of starvation and destitution, leaving them exposed to a cycle of poverty and illness.

Before joining the cooperative, Gakwenza and his family of eight, like many members of the cooperative, used to cultivate small, segmented plots of land, which not only severely limited the amount of crops they produced but also was very hard to manage, especially when some members of the family were too sick to do any physical activity.

In 2012, following a dry season that led to fewer crops in Bungwe and left many farmers struggling financially, Gakwenza had no option but to sell land. Without any other source of income, he was destined to lose all of his land, despite it being essential to his livelihood.

“After failing to get enough harvest for a long time and selling a big portion of my wealth,” he says, “my family started to rely on in-kind food assistance from neighbors and local government.”

Then, in 2013, Gakwenza was one of dozens of people who started to receive economic support from Inshuti Mu Buzima through the POSER program. The program brought together local farmers—most of them patients with chronic illnesses—into saving groups, which allow members, who usually don’t have the means to deal with a bank, to save money and borrow money on flexible terms. Eventually, that group became the INZIRA Y’UBUKIRE farmers cooperative. Through this cooperative, the farmers received resources and financial support from Inshuti Mu Buzima, including livestock, fertilizers, seeds, land for cultivation, and training in modern and commercial farming methods.

“We believe that the most important way to support farmers is to be closer to them to understand the challenges they are facing,” says Mukwiza, who coordinates the program. “We also provide training on saving and modern farming to equip them with the skills needed to generate their own sources of income and then give them starting capital like land, agricultural inputs such as seeds and fertilizer, and livestock.”

For farmers like Gakwenza, that support has been life-changing.

“I managed to move from an old house to this beautiful house, thanks to the skills and money I gained from the cooperative,” he says, standing in front of his house. “I also bought a cow and a big plot of land.”

Now, Gakwenza is the village’s agricultural advisor and well-respected for the advice and mentorship he provides. He uses the skills he learned from the cooperative to train farmers in Bungwe, helping them embrace modern farming methods to earn income, reduce poverty, and have the means to access health care, including associated costs such as transportation, lodging, and medications.

‘We Have Seen Tremendous Change’

In the same village, less than a mile from Gakwenza’s house, Evaliste Nsengiyaremnye, Joseline Urayeneza, and their five children have also reaped the benefits of the POSER program.

The family was referred to the program by their neighbors, who saw how they spent months cultivating other people’s land for low wages and still struggled to put food on the table. 

“Watching helplessly my children crying because of hunger broke my heart,” says Urayeneza.

The hunger took a toll on the family in more ways than just health. As Nsengiyaremnye and Urayeneza worked on other people’s farms, they barely had time to spend together. After a long day of work, they would return home to crying, hungry children and despair about where the next meal would come from.

The POSER program came as a lifeline.

After they started receiving support from Inshuti Mu Buzima, they were able to save money and use pooled funds from INZIRA Y’UBUKIRE to buy land of their own, which they cultivated using modern farming techniques and fertilizers and seeds from the cooperative. Within months, they had harvested enough food to feed their family and sold the remaining yields at the local market and to wholesalers from as far as Kigali and neighboring Uganda.

Now, the family is healthy and their farm is thriving—so much so that they are able to provide job opportunities to their neighbors.

When asked about how his life turned around, Nsengiyaremnye points at a big plot of land he recently bought.

“Today, you can’t afford to pay me to work for you,” he says. “We have just bought this land for 2.5 million Rwf [Rwandan franc] and we own multiple plots of land in different places.”

Programs like POSER are crucial to breaking the cycle of poverty that prevents many farmers in Burera from accessing health care and living a healthy lifestyle. To continue and strengthen this life-changing source of support, Inshuti Mu Buzima works with Rwandan government officials and all health centers across Burera district to provide health insurance to farmers, make sure they have enough land for cultivation, and help them to find markets for their yields. Inshuti Mu Buzima also conducts home visits to identify people in need of social and economic support and enroll them in POSER.

Over the years, Mukwiza has seen the program change lives—and communities.

“We have seen tremendous change in the lives of families who went from not being able to pay for health insurance to owning multiple income-generating projects,” he says. “We plan to scale up our support to even more people in need.”

Women’s health care has always been a focal point for Partners In Health (PIH). From gender-sensitive programs in Sierra Leone to several dozen maternal waiting homes around the globe, PIH has consistently prioritized women’s rights through accompaniment.

“When we look at someone as a number rather than a person, you are blaming the victim of terrible care...But when you actually talk to the women, and walk with them, and see what sort of care they need, you put the person at the center of care,“ said Dr. Joia Mukherjee, PIH’s chief medical officer.

On March 8, Mukherjee joined a PIH-organized livestream alongside Dr. Cindy Duke, founder and director of the Nevada Fertility Institute; and Edward Wageni, global head of the UN Women’s HeForShe initiative. The conversation was moderated by Winston Duke, an actor, producer, philanthropist, and advocate for women’s empowerment who helped shape the conversation with thoughtful questions and reflections. During the virtual event, which celebrated International Women’s Day, panelists discussed how gender bias impacts health care, ways to humanize conversations around women’s care, and strategies to advance gender equality for women.

Panelists agreed that women’s empowerment needs to happen beyond the medical setting and that all people—regardless of gender—must be involved. 

“We need to be all hands on board; ensuring that there are both men and women, boys and girls  to promote gender equality in partnership with women,” said Wageni. 

And the commitment to equity needs to begin early in life.

“When talking about a ‘women’s role’, we have to acknowledge that in order for women to function, we first have to make sure there is equity at the start. Part of that equity is access to care, access to skilled birth attendants, and access to accurate statistics,” said Cindy Duke. 

At PIH, one example of equitable access to care is Lesotho’s Maternal Mortality Reduction Program, which Mukherjee highlighted during the hour-long conversation. The program involves training village health workers to accompany women in remote regions of the country, ensuring they attend all prenatal visits and have a facility-based delivery. Those visits are among the 2.1 million women’s health visits PIH provided across countries in 2020. 

To watch the full discussion, visit PIH’s Youtube channel or view the recording above. To learn more about our panel partner, HeForShe, visit HeForShe.org. 

Partners In Health honored the life and legacy of Dr. Paul Farmer in a memorial service in Boston on Saturday, March 12, alongside friends and family of the late PIH co-founder and leaders in the global health community.

The two-hour memorial service took place at Trinity Church in Copley Square, where more than 600 people gathered and thousands more joined virtually, from Rwanda to Peru.

Eulogies were delivered by PIH Co-founder Dr. Jim Kim; Catherine Farmer, Paul’s oldest daughter; Dr. Anthony Fauci, a friend and chief medical advisor to President Joseph Biden; and PIH Co-founder Ophelia Dahl, who remembered Farmer’s fierce love and compassion, visionary leadership, and relentless humor.

Dr. Paul Farmer unexpectedly passed away on February 21 while in Butaro, Rwanda, teaching and mentoring the next generation of clinicians at the University of Global Health Equity and caring for patients at Butaro District Hospital.

Follow the links to see a tribute video to Dr. Paul Farmer and a photo slideshow commemorating his life and legacy, as well as reflections written by his friends, colleagues, and admirers.

A Celebration of Life

View the full program from Dr. Paul Farmer's memorial service.

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