By Allie Broas, IHSJ Intern

Each summer, interns for PIH's Institute for Health and Social Justice (IHSJ) get an inside look at how PIH operates, and hands-on experience working with PIH programs. This blog post is part of an on-going series following their experiences this summer, and does not necessarily reflect the views of Partners In Health.

As we settle into our internships at Partners In Health, many of us wonder how we will apply the lessons we’ve learned thus far to real world experiences. This internship exposes us to the expansive realm of possibilities for young minds interested in public and global health, and soon we will join a talented group of internship alumni who have made their mark outside the walls of PIH. In attempt to shed light on the intern experience, I spoke to four past interns about how their time at PIH influenced them in their work today.

Peter Luckow, a 2007 intern, spent his summer at PIH researching foundations and corporate giving programs as the Development Research Intern. He co-founded the student organization GlobeMed and now works for Tiyatien Health, a Liberian partner organization of Partners In Health.

A 2008 intern, Isaac Kastenbaum, worked with the Electronic Medical Records Team to develop electronic forms for use in Rwanda and to test forms and systems for use throughout PIH’s clinics. He now works at PACT, PIH’s domestic project focused on integrating CHWs into domestic healthcare delivery.

Maggie Sullivan spent her 2009 internship gathering clinical and educational resources for nurses in Haiti to advance PIH’s nursing initiatives. She is now a family nurse practitioner in Boston.

Kanu Tewari, a 2010 communications intern, covered a range of research projects while preparing materials for the Haiti earthquake Six Month Report, E-Bulletin, blog, and website. She is currently a student at Tufts University.

How has your PIH internship experience influenced the work you are doing today?

	Former intern Peter Luckow now works for Tiyatien Health in Liberia.

Peter: Well, everything that I’ve done has been heavily influenced and shaped by my internship with PIH. I stay actively involved with GlobeMed; all of the lessons I learned during my internship worked their way into my work with GlobeMed and its grounding as an organization. I now work for Tiyatien Health, which is a PIH-supported project in Liberia. All of the work that I’m doing on a weekly basis has been influenced by continuous conversations I have with my mentors at PIH and the advising that the PIH team gives our organization. Every part of PIH continues to have a day-to-day impact on my life and I think it always will.

Isaac: While at Partners In Health, I worked on the Medical Informatics team, and being a part of that community was extremely inspiring and influential for me. Seeing such great minds and resources coming together and coordinating so well to make things happen was so rewarding; it is what drew me to PACT and is still a large part of my work today.

Maggie: I'm fortunate to have helped get a global health online nursing community off the ground when I was an intern, so I continue to co-moderate that. What I learned at PIH helps me to put my work in an historical, global and economic context.

What first interested you in Partners In Health?

	Former intern Maggie Sullivan now works as a family nurse practitioner with Boston Health Care for the Homeless.

Maggie: I think my very first interest in PIH was about 10 years ago when I was in nursing school at UCSF. Every year in the Bay Area there's a global health conference and I heard Paul Farmer speak at Stanford. By that time I had already spent several summers in Mexico and Paraguay, volunteering with Amigos de las Americas on local public health projects. I listened to Paul Farmer's talk and the content of what he said not only rang very true to me, but the way in which he delivered the presentation was so compelling. I remember sitting in the small auditorium thinking, "this is what it's about for me.”

Kanu: I grew up in Cairo, Egypt, and always had an interest in global health but I was never sure how to go about pursuing these interests until my undergraduate experience. When I read Mountains Beyond Mountains in a community health class at Tufts, I began to follow the work of Partners In Health. I kept in touch with what was going on through the earthquake in Haiti and seeing PIH in the news only furthered my interest and eventually prompted me to apply for the internship. Growing up in the East, I was always intrigued by the distribution of healthcare, and coming to the West for my education, I got to see viewpoints from both sides of the world. Through following Partners In Health, I learned the feasibility of making healthcare a basic right for everyone.

Peter: I first became interested in the intersection of global health and university student engagement as a freshman at Northwestern University in 2005. I banded together with other students to think of building up an organization called GlobeMed, and, while researching health organizations, we quickly found the Partners In Health website. I was immediately impressed by the fundamental separation between PIH and the majority of international health organizations — PIH has a deep and profound grounding in social justice, not just as a fundraising lexicon, but at the heart of every decision that PIH makes and their rationale for doing their work in the first place. The more we read about PIH, the more we were electrically drawn to their work, and I knew then I needed to get involved and contribute in any way I could.

What was the most inspiring/influential moment of your internship?

	Kanu Tewari, a forner intern with PIH's Communications Team, with Right to Health Care (RTHC) patients she interviewed in Boston for a story she wrote during her internship

Kanu: One that I particularly remember was my visit to the Right to Health Care patients at a time when I was writing a story about a mother/daughter pair who had come from Haiti after the earthquake to receive treatment. It was truly one of the most important experiences I had all summer because I had been writing about them for months and being able to see them firsthand in the RHC environment was so moving; getting to know patients and hear how greatly they valued the care they were receiving was one experience that totally affirmed my decision to intern at PIH.

Isaac: Definitely our visit to PACT project. I remember meeting with Heidi and other staff and learning how the PIH models abroad were being applied in the US, specifically here in Boston. It was one of, if not the most inspiring moments during my internship because this was the population and system that I had my eyes on working with from the start; I wanted to work with issues at home and with a transformative project like PACT. The visit to PACT led me to apply to work there shortly after.

What is your advice for others looking to enter the global health/public health field?

	Isaac Kastenbaum now works with PIH's domestic project, PACT.

Isaac: I think I would say that you don’t have to be at the most transformative, well-known organization to get the experience you need to succeed in this field. Public health is not distinct — the skills you’ll gain in any industry will be extremely applicable in solving healthcare issues. Healthcare has a lot to learn from the advances of other industries — be the vehicle for that inter-industry collaboration. Also, don’t start a nonprofit; join an existing one and build capacity.

Peter: One of the things that has been most influential in my past is the constant reflection and conversations that I had as a high school student. I embedded myself at an early stage in communities of concern and had the courage to ask the tough questions about the world that we live in. I was constantly asking what I could do about the problems in our world; through learning and moral grounding, I found myself catapulted down a life dedicated to global health. It was all of this that prepared me with a skill set to succeed in this path.

Maggie: For me it's always been - follow your heart. If your heart is in business or finance, then make money doing that and become a committed donor. If your heart is in coordinating and facilitating the work, then do your best at that. My heart is in working directly with people who are impoverished, both here in the US and in Mexico/Central America. I'm a family nurse practitioner with Boston Health Care for the Homeless — I consider this work to be just as much a part of global and public health as when I work in other countries.

Allie Broas is a summer intern for PIH's Institute for Health and Social Justice (IHSJ). She is working with PIH's Communications Team. Check out more blog posts from and about IHSJ interns.

By Julie Rosenberg Talbot, GHD Project Publications and Curriculum Manager

Few resources on the delivery of health services and health technologies in low-resource settings currently exist for educators. The Global Health Delivery (GHD) Project has begun to fill this gap with a series of 21 teaching cases and accompanying teaching notes that examine principles of health care delivery in low-resource settings. These cases are freely available for download and distribution via Harvard Business Publishing.

To create the foundation of what we hope will be a growing case series, we identified innovative, successful programs and organizations working in global health. We made field visits to these projects and conducted interviews with key decision makers. We learned about the strategic and managerial principles that helped facilitate these programs' successes as well as the challenges they were struggling to overcome. We then used our findings to create detailed teaching cases illustrating these lessons and the complexities of working in the field. We developed accompanying teaching notes to guide instructors in facilitating classroom discussion of these cases in undergraduate and graduate level courses in global health.

Case topics include global public health approaches to HIV treatment, HIV prevention, tuberculosis control (including multi-drug resistant tuberculosis control), malaria control, malaria control, commodity manufacturing, tobacco control, measles and polio immunization, and malnutrition. Each case is designed to allow examination of four aspects of health care delivery: 1) local factors that affect both the health of the community and the delivery of health care, 2) the program’s or organization’s specific activities that generate value for the communities they serve, including how these activities are organized and managed, 3) how these activities are tailored to the local contextual factors and available resources, and 4) how the program or organization interacts with the existing health care system.

All cases are freely available for download and distribution.

Read more about this new resource from GHD. 

Read an article about the case studies on NPR's WBUR CommonHealth. 

Welcome to week two of PIH's Summer Reading Series.

This Thursday, we're chatting live online with PIH's Jon Lascher, who helped coordinate some of the first supply shipments for earthquake relief, and is now helping equip our teams for cholera treatment and prevention in Haiti. Also, we're listening to the voice of Dr. Paul Farmer as he reads an excerpt from Haiti After the Earthquake:

In this audio clip from Haiti After the Earthquake, Dr. Paul Farmer reads from the first chapter, "The Catastrophe" (Pages 17-21). He offers his personal account of one night treating patients in Port au Prince while aftershocks were still rocking the capital.

On Thursday, July 28 at 7pm EST, join PIH's Haiti Procurement Manager Jon Lascher for a live online chat. As part of the initial earthquake response, Jon coordinated with many of PIH's partners on the ground to deliver supplies and equipment. Hear more about Jon's personal experience in the field, and participate in the live discussion

Live chat: Thursday, July 28, 2011 – 7 p.m. EDT
Submit a question & RSVP

Catch up on our book discussion from week one here.

Scaffolding has made work on the second story easier and safer. 

Making sure the metal door frames will fit in the community health building. Looks great so far!

Newly poured concrete floor in the community health waiting room. The next step is to install porcelain floor tile.

Using a laser donated by Stanley Black & Decker to set the height of the concrete floor.

Cutting in electrical boxes with a Stanley Black & Decker grinder.

Construction on Mirebalais National Teaching Hospital reached another major milestone this week with the completion of the concrete floor slabs in the first two buildings, the women’s health building and the outpatient and community health building. The installation of floor tile will begin in the next few days, then the construction team will begin the long process of completing the installation of the plumbing and electrical systems. Once this is complete, furniture and equipment will be brought in.

The floor tile being installed is unusual for Haiti. Thanks to the help of Kim Preiss and Lucy Minturn of Fine Line Tile, our Project Architect, Ann Clark, and Eugenio Megna, the team was able to purchase Fiandre and Architectural Ceramics porcelain tile at a very discounted price. Also, a special thanks also goes out to Betty Sullivan and Josephine Miller of Architectural Ceramics for providing so much of this tile.  Porcelain tile, which has color throughout the entire piece rather than just a glaze on the surface, is much stronger and more durable that quarry tile and is usually 3-5 times more expensive.  

The block walls of the women's and children's wards are up to the top course and we will start building the roof forming next week.   

Also, we finished unloading the first ten sea containers of donated materials. These include much needed building materials and a large donation of DeWALT power tools from Stanley Black & Decker.

Furthermore, the arrival of scaffolding (donated by Marr Scaffolding Company) has allowed our workers to safely work on the cement parging on the second floor on the building that will house medical education, dental, and the blood bank.   

“Snow is causing a lot of havoc in the mountains and all the sites are cut off now both by road and air,” wrote PIH Lesotho Project Manager Archie Ayeh in an email this morning.

Although it seems counter-intuitive, snowstorms can happen in July -- in the mountainous southern African country of Lesotho, where PIH has supported rural health clinics since 2006.

Mojela Masupha, the site administrator for the mountain clinic in Nohana, sent a report detailing some of the problems caused by a recent storm at his site:

A total of 6 trees have fallen down, with one of them severing the internet connection to the main clinic. After removing the tree, the connection is back at the clinic, although the line has to be re-mounted, and the tree that has fallen on the internet line has been sawed away and removed. 

Acquisition of water is also a major challenge as the water source near the clinic is not giving out any water. Nohana has resorted to gathering up some of the snow in big containers to melt it and have water for cleaning and washing linen from the deliveries. Additionally, the Nohana truck is stuck in Maseru (Lesotho’s capital city) due to the bad road.

Relative to other days, patients are very few (so far about 5 have shown up) and the pace is not so high at work. 

All the gentlemen working at the clinic pitched in to help clear the snow at vital areas around the facility, and also to remove some of the fallen trees blocking the road leading into the clinic.

Minor damage has been detected at the staff house back window where another tree fell and affected the whole window structure leaving cracks and the window frame weak.

Despite these issues, all is under control at the facility at present.

A fallen tree severed Nohana's internet connection.		Nohana staff shovel snow and remove fallen trees.		A cracked window at the staff house in Nohana.

As roads are impassable, and the small planes that usually transport patients and supplies to the Nohana cannot land, PIH has received help from Lesotho's military. A military helicopter arrived today to air-lift a sick patient to a larger facility in the capital city. 

	Regis College President Toni Hays conducts a physical exam with Haitian nursing teacher, Canelline Brice.

When the January 2010 earthquake struck Haiti, among the many homes and buildings destroyed was the country’s public nursing school in Port-au-Prince. The collapse took the lives of nearly 100 nurses, compounding the country’s already existing nursing shortage.
 
As part of a plan to expand and strengthen Haiti’s nursing community, 12 nursing teachers from Haiti arrived at Regis College this summer to embark on a three-year master’s degree program.

The women, chosen from five public nursing schools across Haiti and the University of Notre Dame, will complete six weeks of courses at Regis. Through return visits and online training in Haiti, they will ultimately graduate from the University of Haiti as nurse practitioners with the goal of transferring their skills to colleagues and a next generation of nurses.

The program is the result of nearly three years of planning among Partners In Health, the Regis College School of Nursing, Science and Health Professions, and Haiti's Ministry of Health. Funding for the program has been provided in large part by the Ansara and Kaneb families. 

“Such a level of education for nurses is unheard of in Haiti," Regis president Toni Hays told The Boston Globe recently. She cofounded the program when she was dean of the school’s nursing program in 2007. "Most nurses in Haiti today cannot earn degrees through a university, so nursing instructors are not as respected as other faculty. But this is the beginning of a movement,” she continued.

In keeping with the vision for the program, these newly certified nurse practitioners will return to Regis College after their training to teach the next class of students.
 
"I’ve learned so many things," said 43-year-old Mirmonde Amazan. "How hospitals work. How training works. How supervision works." She said the level of supervision that nursing students have in the United States has convinced her that she must spend more time with students in a clinical setting.
 
Sheila Davis, global nursing coordinator for Partners In Health, says the degree program is designed to equip nursing teachers with a new level of critical thinking skills, the ability to problem-solve, and some of the fundamental of principles of nursing research. 

“This program represents a long-term investment in nursing in Haiti that will both educate a new generation but also improve health care for the country as a whole,” said Davis.

	The grant from the Clinton Bush Haiti Fund will launch a medical residency program at l’Hôpital Saint Nicolas in St. Marc.

The Clinton Bush Haiti Fund recently announced a $1.8 million grant to Partners In Health (PIH) and its Haitian sister organization Zanmi Lasante (ZL) to fund a program that will make long-term, sustainable improvements in the scope and quality of Haiti’s healthcare and medical education sectors. The grant will be used to launch a residency program for family practice physicians and a certification program for auxiliary nurses at a public hospital supported by PIH/ZL.

“The earthquake and cholera outbreak have only heightened the healthcare sector’s challenges,” Clinton Bush Haiti Fund CEO Gary Edson explained. “The Clinton Bush Haiti Fund’s three-year grant for Zanmi Lasante’s work is an investment in Haiti’s human capital. It will provide training for critically needed family practice physicians and auxiliary nurses at l’Hôpital Saint Nicolas, the chronically understaffed public hospital serving 220,000 St. Marc residents and, ultimately, the 1.5 million people of the surrounding Artibonite region.”

Additionally, ZL will leave a lasting legacy for the nation’s public health system by upgrading and standardizing auxiliary nurse education, creating a first-ever certification program to be replicated by other medical training centers throughout Haiti.

Amplifying the impact of the Clinton Bush Haiti Fund’s grant, PIH will match the funds more than one to one, and will work closely with the National Faculty of Medicine and Haiti’s Ministry of Public Health and Population.

“This grant represents an invaluable investment in the decentralization and long-term, sustainable reconstruction of Haiti’s health system,” said Dr. Paul Farmer, PIH co-founder and chair of the Department of Global Health and Social Medicine at Harvard Medical School. “It will enable Zanmi Lasante and Partners In Health — working in partnership with Haiti’s Ministry of Health and national medical school — both to improve the quality of care for the people of St. Marc and to train a new generation of healthcare providers to deliver comprehensive, community-based care in even the poorest and most remote places.”

IHSJ Reader     July 2011     Issue 5          

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

HAITI

As Cholera Surges in Haiti, Aid Withers Away (Richard Knox, NPR, July 15, 2011)
As the rainy season carries on, cholera continues to plague Haiti . The Haitian Ministry of Health reports that cases more than tripled between April and June, with high concentrations in rural communities. It appears that support and programs for cholera prevention and treatment have not kept pace with the expansion of the epidemic. For more information about the underlying causes of cholera in Haiti and how it can be stopped, visit: http://act.pih.org/choleraupdate and read Louise Ivers’ blog post describing the critical situation in the Central Plateau and Lower Artibonite at: http://www.pih.org/news/entry/with-choleras-return-dr.-ivers-reflects-on-9-month-effort.  

Haiti After the Earthquake (Paul Farmer, Public Affairs, July 12, 2011)
Paul Farmer's latest book provides an intimate account of events following the catastrophic January 12, 2010 earthquake in Haiti. Paul’s first-person narrative of the “acute-on-chronic” disaster reveals how Haiti’s vulnerability is rooted in a history of structural violence: foreign invasion, neoliberal economic policy, illegitimate debt, adverse social conditions, ecological degradation, and an underfunded public sector. He highlights the influx of support for Haiti from the international community while offering a pointed critique of the lack of support for the Government of Haiti and providing solutions for improving aid to Haiti within a broader vision of reconstruction and renewal. Paul’s reflections on Haiti’s past, present and future are followed by 11 moving essays from clinicians, humanitarians and those personally affected by the quake.

MENTAL HEALTH

Grand Challenges in Global Mental Health (Nature, July 7, 2011)
Results from a study conducted by the US National Institute of Mental Health calls for increased investments across all countries in preventing and treating mental, neurological, and substance abuse (MNS) disorders and sets 25 grand challenges to improving mental health. The global burden of MNS disorders is disproportionately felt in low and middle-income countries where the weak health systems often lack the capacity to provide care. Partners In Health works in low-resource settings to integrate mental health care and psychosocial support into comprehensive health services.

HEALTH SYSTEMS STRENGTHENING/FINANCING

In Sierra Leone, Heartening Progress for Pregnant Women (Adam Nossiter, New York Times, July 17, 2011)
On April 27, 2010, Sierra Leone eliminated health user fees (facility-based or co-payments) for pregnant women, new mothers, and children under five years old. The results, according to DFID senior health economist Robert Yates, have been “nothing short of spectacular”. The increased health service utilization--including a 214% increase in children receiving care at health facilities--has already resulted in significant reductions in maternal mortality and malaria-induced fatalities.  Though financing gaps remain for the health system, Sierra Leone is an example of how to provide free health care for the very poor and vulnerable, with good planning and financial backing from political leaders and international donors.

***The Impact of Reducing Financial Barriers on Utilisation of a Primary Health Care Facility in Rwanda (Ranu Dhillon, Matthew Bonds, Max Fraden, Donald Ndahiro, Josh Ruxin, Global Public Health, July 6, 2011)
Though the government of Rwanda has greatly expanded access to health care, the community-based health insurance program requires point-of-service co-payments on a sliding scale which can significantly deter patients from seeking care. This article examines the effect of subsidizing these fees and finds that by removing financial barriers, utilization rates tripled. The results highlight the fact that requiring a co-payment, however slight, prohibits patients from seeking care.

HIV/AIDS

Pivotal Study Finds That HIV Medications are Highly Effective as Prophylaxis Against HIV Infection in Men and Women in Africa (University of Washington Partners PrEP Study, July 13, 2011)
Results were released last week that should have a groundbreaking effect on approaches used to prevent HIV infections. The pre-exposure prophylaxis (PrEP) study, led by the University of Washington’s International Clinical Research Center, found that the likelihood of becoming infected with HIV was cut by more than half among uninfected individuals who took HIV/AIDS drugs daily as preventive therapy. These exciting findings confirm and expand on results announced by the Center for Disease Control: http://www.hanc.info/resources/Documents/CDC%20TDF2%20Media%20Materials.pdf. With medical advances come the questions of which populations to target with initial programs and how to ensure that those who stand to benefit the most from PrEP will have access to the medications that dramatically prevent transmission.

Medicines Patent Pool Signs License Agreement with Gilead to Increase Access to HIV/AIDS Medicines (Medicines Patent Pool and UNITAID Press Release, July 12, 2011)
The first-ever license agreement between a pharmaceutical company, Gilead, and a Medicines Patent Pool (MPP) was announced on July 12. The MPP can now offer licenses to Indian companies to make generic versions of five HIV/AIDS medications, three of which are still in the pipeline. Though the Gilead license agreement to the MPP is an important step towards achieving universal access to essential medications, there are limitations. Areas for improvement include: (1) expanding the territorial scope of the agreement to include all low- and middle-income countries; (2) expanding manufacturing partners beyond Indian generic companies; (3) expanding sourcing for active pharmaceutical ingredients beyond Gilead other Indian licensees; and (4) reducing royalties in countries without patents.  PIH applauds the progress of the MPP and encourages other patent holders to swiftly follow suit. For more analysis, see Tina Rosenburg’s “Sharing Patents to Wipe Out AIDS”: http://nyti.ms/oMwZid.

TUBERCULOSIS

An Evaluation of Drug-Resistant TB Treatment Scale-Up (Partners In Health, Medicins Sans Frontieres, Treatment Action Group, July 6, 2011)
Partners In Health, Medecins Sans Frontieres (MSF) and the Treatment Action Group (TAG), released a report assessing reasons for the slow progress of expanding detection and treatment of multidrug-resistant tuberculosis (MDR-TB). The report also provides recommendations for improving programs. In 2008 there were an estimated 440,000 cases of MDR-TB; but the World Health Organization estimates that less than 1% received adequate treatment and a mere 7% of these cases were reported.

What is Thwarting Tuberculosis Prevention in High-Burden Settings? (Edward Nardell and Gavin Churchyard, The New England Journal of Medicine, July 7, 2011)
Ongoing transmission and reinfection are fundamental factors inhibiting tuberculosis prevention in high burden settings. Intensified case finding and rapid diagnosis can control these high rates of transmission and reinfection and ensure effective treatment through the use of new Xpert MTB/RIF technology. PIH continues to work in partnership with our sister organizations to strengthen MDR-TB care in the resource poor settings by increasing the capacity for rapid diagnosis tests.

MULTIMEDIA

Paul Farmer Examines Haiti ‘After the Earthquake’ (WBUR, July 11, 2011)
Listen to Paul Farmer discuss his new book, Haiti After the Earthquake, on NPR’s Fresh Air. In this interview, he reflects on the critical challenges following the January 12, 2010 earthquake, including a weak and underfunded public sector, and the devastating cholera epidemic which "exploded like a bomb" last October.  Paul stresses Partners In Health’s commitment to working in partnership with the government to generate jobs and strengthen public sector institutions. Near the end of the interview, Paul points to lessons learned from the Rwandan experience that should inform Haiti’s rebuilding process.

It is our hope that the Summer Reading Series will serve as a means of dialogue between PIH staff and our incredible network of supporters about Haiti’s long-term reconstruction.

Released just 18 months after that devastating event that shook Haiti to its core, Paul’s book Haiti After the Earthquake recounts his own experiences of January 12, 2010, while also both praising and critiquing aspects of the world’s response to the earthquake.

Joia Mukherjee, PIH’s chief medical officer offered to help start the conversation with these thoughts and questions:

Paul’s book is written to remind us that the people of Haiti have not been simply victims of a ‘natural disaster’ but rather that the disastrous consequences of the 2010 earthquake are rooted in the international policies that serve to continually keep Haiti impoverished.

For those of us who have dedicated ourselves to accompanying Haiti, the strength of its people is obvious—which begs a few questions that I hope you’ll join us in discussing:

• First, why was Haiti so vulnerable to such a catastrophic disaster?

• Second, during the initial aftermath, in what ways was the collective response productive, where did it fall short, and does Haiti’s history offer clues as to why?

Paul and his co-authors offer their own perspectives on these questions in the book, but we’d very much like to hear yours.
 
Please use the comment section below to share your comments, ideas, and thoughts — and to begin a dialogue with other readers.

Dr. Louise Ivers is PIH's Senior Health and Policy Advisor. She has been an integral part of Partners In Health and Zanmi Lasante's leadership team in Haiti for nearly a decade. 
 

Cholera response

Early one morning in October 2010, the senior Zanmi Lasante team met in Mirebalais. Ophelia Dahl, our executive director, traveled from Boston to convene a meeting and everyone was there. Things felt like they had begun to stabilize since our lives had been turned upside down by the earthquake the previous January. So much of the first half of the year had been spent responding to the crisis while trying to keep our usual activities in Haiti going – the team was tired, but mostly there was a feeling that we had achieved our new rhythm of work. With new activities in Port-au-Prince, plans for a rehabilitation center and a residency program in St Marc, mental health care activities scaling up, and a training hospital under construction in Mirebalais, the new ZL pace was hectic but everyone’s spirits were optimistic.

I received a call from one of our colleagues to say that he would be late to the meeting – 100 people suffering from diarrhea arrived at St Marc Hospital overnight, and he was going there first to investigate. Arriving an hour into the meeting, he passed a note to ZL’s medical director and me expressing his concern. We feared what would soon be confirmed: cholera had arrived in Haiti.

From that moment – and for the next three months – we returned to crisis mode, with the often-overwhelming task of trying to provide excellent care for the patients arriving at our facilities and in the surrounding communities. Once again, the PIH/ZL teams kicked into overdrive with teams working night and day. Alerts came through by email, text message and phone from all over the Central and Artibonite departments asking for help. Our medical teams walked upwards of six hours at times to set up oral rehydration posts in distant villages, only to hear that cholera had spread another three-hour walk farther up the mountain.  

	PIH/ZL currently operates 8 cholera treatment centers, 7 treatment units, and 3 oral rehydration posts. Learn more about our response to cholera.

One saving grace in the early phases of the cholera outbreak in Haiti was that there were many partners to work with and PIH/ZL relied heavily on partnerships wherever we could – with other international non-governmental organizations (NGOs) and the Ministry of Health, whose work we support on a daily basis. Working with other organizations can be challenging and this crisis was no exception, but there was no doubt that we needed this level of support and collaboration. Health coordination meetings at that time were chaotic as many partners cramped into an overcrowded room in St Marc to yell out what they would do or were doing.

A striking difference now as the epidemic has once again spiked is that many of these partners are no longer working in the Central or Artibonite departments. Citing lack of funds for cholera activities, they have downsized, disappeared, or retreated, handing off their activities ‘to the government.’ In these departments, where the health budget is miniscule, this largely means handing off activities to Zanmi Lasante. This has made the second peak of the epidemic all the more challenging and stressful on our staff and our resources.

The Mirebalais cholera treatment center saw five times as many patients in June as in May. Alerts are the norm again – with emails and text messages reporting areas with minimal access to services suffering from high numbers of cases. Zanmi Lasante’s community teams are on high alert – spending hours on foot to reach difficult, isolated places, providing oral rehydration solution, training community health workers, distributing water purification tablets, disinfecting houses – but it is never enough. The cholera treatment centers were overwhelmed last month and although staff are dedicated, hardworking and committed, it is never enough. Once again, Zanmi Lasante is back in crisis mode, doing whatever we can to address the issues at hand, but it is never enough.

Since last year, we’ve been advocating to use all of the possible tools against cholera in a complementary and comprehensive way to reduce deaths and to minimize the impact of the disease. In places where the water and sanitation situation is dire, where plans to provide a safe public water system do not exist, it’s hard to imagine that cholera will ‘burn out’ in Haiti soon. 

We are delighted that our proposal, in collaboration with GHESKIO (a Haitian, Port-au-Prince based NGO), to pilot the use of cholera vaccine in Haiti was supported last week by the Pan American Health Organization. Now we have to set about securing doses of the vaccine and implementing the project with the Haitian government. We hope that, while focusing still on the fundamental cause of the cholera epidemic, which is lack of clean water and sanitation, we can make some progress and save some lives with the complementary use of another tool in the armamentarium.  

Visit PIH/ZL's cholera update page.
Mourning cholera victims: PIH offers therapy, public eulogies for affected communities.

Jordan lends a hand wherever he is needed.

Brian Scott, Aaron Noble, and Jordan survey a donation from Stanley Black & Decker

Site Supervisor Brian Scott helps Jordan carry equipment.

Jordan helps out Haitian workers with roof pours.

Jordan Nader is the first construction volunteer to travel to Mirebalais to lend his expertise to the new National Referral and Teaching Hospital. Site Supervisor Brian Scott says, “Jordan has been a fantastic addition to the construction team working in Mirebalais. When a job absolutely has to get done and failure is not an option, Jordan has become our go-to guy and we are very grateful to have him.” Jordan initially planned to work with us for two months this summer before returning home to continue his Engineering studies at Ohio State University. However, he has decided to take his fall semester off to continue working on the project.

Here is what Jordan has to say about his experience thus far in Mirebalais.

How did you become involved with Partners In Health?

I read Tracy Kidder’s Mountains Beyond Mountains last summer and became very excited about the work that PIH does in Haiti and other countries. Coincidentally, I happened to randomly meet [Mirebalais Hospital Project Coordinator] John Chew later that year and things came together from there.

What is your role on site? What do you do on a day-to-day basis?

Basically, I oversee construction, making sure that standards are being upheld, that we are building according to plan and that there are no construction inconsistencies. I spend a majority of my time teaching the foremen how construction is performed in the United States in order to develop a new construction standard for Haitian workers so that their buildings will be built better and hold against natural disasters.

Additionally, I have been setting grades for floor pours, checking concrete cylinders, and helping out wherever else I am needed. I have also become the onsite go-to IT guy. This includes setting up an IT system on site, ensuring that all computers work properly and that Internet access is consistent. To be honest, I do whatever needs to be done.

Have you liked working with the Haitian team on this job site?

I love it. I’ve had previous construction experiences in Haiti and found them to be very frustrating because you couldn’t always get the best tools for the job. Here we have everything we need and get stuff done when it needs to get done.

I can communicate with the Haitian team well through basic Creole. I am learning from them just as much as they are learning from me. Each day, they are teaching me new things about their culture and construction techniques. Overall, we all have the same goal to build the hospital the right way so it really has been a great experience. Each Haitian and American worker alike take the time to make sure each block is laid correctly. This isn’t something you find everywhere.  

 You mentioned you’ve been to Haiti once before. What was your first impression of the country?

My first impression was the major contrast noticed when flying into the country. You first encounter the beautiful water and mountains from above. Then you land in Port-au-Prince and witness people still living in tents. Irony is the perfect term to describe it. There is such beauty and so many resources but progress is just not happening. The people can’t be successful and sustain themselves because of the reliance on the international community.

Has your impression changed since then?

Yes, definitely. It’s a completely different experience living in a rural area instead of Port-au-Prince. People here move and work at a different pace. They are a lot more gung-ho to get this project done and have an overall better attitude. Here, the work is kept in line with what people want and what government thinks they need, not just what our organization wants to do.

Have you worked with other organizations in Haiti before?

Yes, mostly church-based organizations that provide schools and clinics to the people in Cite Soleil, which is one of the poorest neighborhoods in Port-au-Prince.  After the earthquake, these organizations recruited volunteers to construct new houses and new schools to support the expanded student population. I oversaw construction on houses, walls, schools, etc. But these were all small-scale projects, nothing of this hospital’s magnitude.  

How has volunteering with PIH in Mirebalais differed from your previous experiences?  

One of the things I like most about PIH is that they are working with the Ministry of Health. By working in tandem with the government, we can make sure that the wants and needs of the people are being met. We aren’t building this hospital for us, but to benefit the people of Haiti.

What’s your favorite aspect of working on this project?

I really like the people I work with here and the experience I am getting. I especially like working with [Site Supervisor] Brian Scott. His knowledge of construction is excellent and I’m learning a lot about working on a project of this magnitude from him. This project provides a great opportunity to learn from both American and Haitian colleagues’ experiences.

Do you have any advice for people that are considering volunteering on the hospital?

Be ready for an adventure! It takes patience. There are language barriers, but accept this and learn to communicate with your peers. Try new foods. There is no experience like this, and it is totally worth it. I think everybody should do it!

For more information, learn more about construction volunteering or email the Mirebalais Hospital Volunteer Coordinator, Heidi Burgess, at hburgess@pih.org.

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The historically marginalized communities of pygmy people in eastern and central Africa suffer some of the worst development indicators in the region. These populations consistently lack access to health services, adequate nutrition, education, and housing.

Working closely with the Government of Rwanda, Partners In Health and its Rwanda sister organization, Inshuti Mu Buzima (IMB), began a project earlier this year to construct sturdy, solid houses for an impoverished village of 39 families in the Burera District of northern Rwanda. In June, construction was completed.

In addition to the new houses, the project will also ultimately provide a full package of support to the village, including health insurance, employment opportunities, agricultural support. It will also supply the community with livestock, including sheep. PIH/IMB will also help children from the community attend school. 

	Community members in Bay Tourib remove gravel and debris from the site of the new health clinic

	Cate, center, works with community health staff throughout central Haiti

On July 14, Cate Oswald, PIH’s Haiti-based coordinator for community health, sent a general update on our work in Bay Tourib – an isolated village in Haiti’s Central Plateau. PIH/ZL staff are collaborating with Fondation KANPE, Fonkoze, and community members to build a much needed health clinic, a cholera treatment unit and a dormitory in Bay Tourib.

With cholera cases on the rise, our teams are working around the clock to build the infrastructure for critical health services in this rural town – separated from the nearest clinic by a five-hour walk through rough terrain.

On July 10, Dr. Rigaud, director of PIH/ZL’s Thomonde Clinic, and Cate met with community leaders in Bay Tourib, a necessary step to ensure continued progress on construction for the village’s first health clinic. See her first-hand account below of the rapid progress the team on the ground is making.

Bay Tourib Clinic Update

I’m happy to report that since receiving funds from Foundation KANPE last week, electricity is installed, laboratory shelving is in place, and community members have collected gravel and sand for that cement blocks that will be used to make the clinic’s addition and the staff residence. A crew of 25 is working hard to get the clinic up and running as quickly as possible.

It’s exciting to see what a difference one week can make!

The wonderful community members of Bay Tourib are putting their hands together – kole zepol – to make repairs and improvements as quickly as possible. For those of you who have made the long, bumpy trek to Bay Tourib, just the fact that we have 250 bags of cement and a whole slew of construction materials in place is a feat in and of itself.

Bay Tourib Cholera Treatment Unit 

With the rainy season upon us and cases of cholera increasing PIH/ZL and Foundation KANPE have decided to construct a cholera treatment unit in addition to the health clinic in Bay Tourib.

Instead of using tents we are building a semi-permanent structure with cement floors, plywood walls, and a tin roof – as we know cholera will be around for years to come. We are doing this at all of our 15 cholera treatment centers to make them more stable.

This approach does not require us to wait for tents to be found and available, and is our best option right now.

Dr. Rigaud and I met with the owner of the land directly adjacent to the clinic, on which the owner had planted corn, beans, and potatoes. He donated the land for the cholera center; in return he will work as head of security for the cholera center and ensure proper waste management. This will be the first time in his life that this farmer will receive a monthly salary. 

By 8am [on July 12], 50 community members had cleared the land for the cholera clinic. As we need to prioritize the cholera clinic right now, we are focusing on this ahead of finishing repairs and enhancements to the general clinic so that services can be provided ASAP.

Just yesterday our pickup truck from the Thomonde hospital had to make six trips up and down the mountain road to pick up patients sick with cholera to get them to the treatment center – a five-hour walk for a healthy person. The cholera treatment unit in Bay Tourib couldn’t be more needed.

As you can imagine, this cholera unit in Bay Tourib was not planned…it is coming as a necessity as people are dying en route to the Thomonde hospital, or arriving too dehydrated to be saved.

PIH/ZL has seen a threefold increase in cholera numbers between April and June.

Currently we need funds for consumables – like ringer’s lactate – and latrine construction. Currently, we are going through 1,000s of bags of ringer’s lactate a day across all of our sites, and with the average cholera patient requiring about 10 bags of IV solution, at about $1 per bag, this quickly adds up.

Learn how simple latrines can save lives.

We have hired and trained 13 new community health workers (CHW) for the Bay Tourib area to focus solely on hygiene – spraying homes with Clorox, distributing soap and water treatment and oral rehydration solution.

These 13 CHWs will join 75 new cholera-focused CHWs working in Thomonde and surrounding areas who are part of an effort to hire 1,000 new CHWs this summer. This significantly bolsters PIH/ZL’s cadre of 2,500 CHWs focusing on hygiene promotion and cholera prevention.

Their work is only a quick fix as rains create flash floods, pouring human waste into rivers that serve as the only drinking water source for miles. Though the situation can seem tough at times, PIH/ZL’s efforts have saved tens of thousands of people affected by cholera since last October. 

Thanks to each one of you for your ongoing commitment to our partnership in Thomonde, and especially to the 6000 community members of Bay Tourib!

In Haiti’s rural mountain communities, the stigma and fear surrounding cholera can be as life altering – and at times as life threatening – as the disease itself. The physical suffering of uncontrollable diarrhea and vomiting is often accompanied by severe social isolation, rejection by family and friends and job loss. 

“In some communities where we have arrived, incredibly remote villages in Saut d’Eau and Savanette, almost everyone in the community has been or knows someone who has been sick with cholera,” says Elysee Noesil, a PIH/ZL psychologist working in central Haiti. “There were some lucky ones who had had the chance to get to the hospital, and others who were unable to and their loved one died at home.”

Some patients are abandoned at treatment centers, while others die hiding in their homes – afraid of social rejection. Even those cured of cholera are often shunned by communities terrified of bearing the mark of the scourge.

“The stigma around cholera is killing people more than the bacteria itself,” continues Elysee. “Family members do not want to go near loved ones with cholera, afraid they will die as well. They are afraid to touch them to get them to the cholera treatment center. Still others died because they were ashamed to let their family know they had cholera, afraid they would lose status in the community.”

As part of a comprehensive treatment plan to control Haiti’s cholera epidemic, and in conjunction with a comprehensive medical and disinfection protocol, PIH has taken steps to address the psychosocial needs of cholera patients.

Healing the mind after cholera attacks the body

	Community health workers distribute soap and oral rehydration salts to people in villages throughout the Central Plateau and Artibonite

With their Haitian sister project Zanme Lasante (ZL), PIH/ZL has hired 17 additional social worker assistants to help identify patients who would benefit from psychosocial support groups intended to help reintegrate them into the local community.

Led by Father Eddy Eustache, director of ZL’s psychosocial and mental health program in Haiti, PIH/ZL developed a four-session curriculum to aid psychologists working with post-cholera patients. The initial three group sessions – including one called “Loving My Body After Cholera” – address self-worth and self-image for patients after they recover and help identify factors that could prevent or help reintegration.

The fourth session involves home visits from psychologists who speak to family members about the importance of accepting their loved one while continuing to protect themselves. After the visit, the family is given a hygiene kit with water purification tablets and soap to help sanitary conditions inside the home.

“Support groups enable cholera survivors to find a network of people with similar experiences, who have lived through the devastating physical as well as emotional stress that cholera has created. It is amazing to see the change in people’s perceptions of their self-worth from the first session, to the fourth,” adds Elysee.

Mourning traumatic death and disposal

	At memorial services, community members take time to reflect on those they've lost

Cholera deaths are dramatic and quick – people who succumb often do so within 24 hours. When cholera strikes a rural mountain village of a few hundred people, it is not uncommon for 20 to 40 people to succumb.

After death, the bodies of cholera victims are bathed in bleach, all orifices are blocked, and bodies are placed in a body bag to prevent further contamination. This strict protocol robs survivors of traditional grieving and burial practices; proper funerals and ceremonies are ignored as bodies are laid to rest in mass graves as a final precaution.

“In Haiti, we believe the dead remain with us, and this is why we perform rituals before burying a loved one, says Elysee. “For example, we hold a wake for the departed, the community provides strength and support to the family to show they are not alone in their grief.”

“But with cholera, where we must dispose of bodies in an almost-savage way, these rituals are unable to occur for infection control purposes,” explains Elysee. “When someone dies of cholera, their family is unable to truly grieve, and they don’t have the means of fully accepting that their family member is gone.”

“The services are like a symbolic funeral, we help people understand that their loved one can continue to live in their memories even if physically absent.”

As an offering of assistance during the grieving process, PIH/ZL psychologists are conducting non-denominational memorial services for each cholera victim in affected communities; including song, candle lighting and remembrances of the person who died. “Those who are stronger support those who are weak,” continues Elysee.

As with all of PIH/ZL’s comprehensive treatment and healing approaches, psychologists, social workers and community educators involved in the service take time to discuss proper hygiene and prevention measures, hoping to curb the deaths that warrant such services.

“Grief is very healthy and one of few chances communities have to express feelings and relieve stress,” says Elysee. “After the memorial finishes, we see smiles returning to people’s faces, we see people embracing and shaking hands, and we see everyone deciding that they must continue living.”

The number of cholera cases in PIH-run treatment centers has increased at least threefold in the past two months as flashfloods — a side effect of the rainy season and deforestation — spread the disease among water sources. Patients seen at PIH cholera clinics jumped from 3,932 in April to 14,425 in June. People who have died from cholera in local hospitals have increased from 21 in April to 70 in June. Trends documented by PIH are believed to be mirrored nationwide.

“If we are to truly combat cholera, we need to implement long-term solutions, like water treatment systems and latrines,” says Cate Oswald, PIH’s Haiti-based program coordinator for community health. “We need more groups to help finance latrine construction as there are some communities where I have been that have had zero latrines — literally no latrines — for a population of a few hundred people.”

With little to no access to proper sanitation systems, many Haitians have been forced to urinate and defecate directly onto the ground — often in a field or yard — where waste seeps into the soil, contaminating local water sources. Cholera-polluted primary sources for drinking water such as ground and surface water continue the spread of the disease. 

Settlement camps in Port-au-Prince and rural areas — where people are dependent on untreated water sources — are once again being ravaged by the disease.

Haiti’s rainy season is largely to blame for the dangerous uptick, further stressing and disrupting the country’s woefully inadequate water and sewage systems.

“We can find quick fixes, things like Aquatabs and clorox, and cholera treatment supplies like oral rehydration, ringer's lactate (intravenous rehydration solution) — but we need latrines,” adds Oswald. “International funders and organizations are not investing in the government's plan for constructing 500,000 latrines in remote rural areas or in helping to develop water treatment facilities.” 

More than 370,000 Haitians have been infected with cholera since the initial outbreak in October 2010. Before that time cholera hadn't been seen in Haiti since the 1960s, though poor sanitary conditions in the lower Artibonite placed the region at high-risk for decades. Following the January 2010 earthquake, conditions deteriorated even further, leading to the current endemic situation. PIH has been lobbying for the improvement Haiti’s water security for several years.

In 2008, PIH, NYU's Law School's Center for Human Rights and Global Justice, and the Robert Kennedy Center for Human Rights released a report of the denial of water security as a basic right in Haiti.

Secure and free access to clean water is a basic human right that should be delivered through the public sector. The international community’s failure to assist the government of Haiti in developing a safe water supply violates this basic right.

We’ve reached a major milestone on the first of 12 buildings being constructed for the New National Teaching Hospital in Mirebalais, Haiti! The concrete floors are laid and inside stuccowork is complete on the Women’s Ambulatory Health Building, which is now ready for paint and floor tile. The walls are almost finished for the Men’s, Women’s and Children’s Wards and we are pouring two concrete roofs this week. 

The first three 40-ft shipping containers with building materials and medical equipment have arrived on site, and we will be receiving another 82 containers in coming weeks and months. During construction, the Community Health Building has been turned into a warehouse for these supplies.  

As many buildings near completion, we need volunteers to travel to Haiti to help build this hospital. If you or anyone you know is a skilled tradesperson, we need your help! Some of the work is not common in Haiti, so we need tradespeople to help build and to train Haitian workers on their skills and techniques. Volunteers are needed in these trades:

• Carpenters
• Electricians
• Plumbers
• Medical Equipment Installations
• Bio-Medical Technicians
• Metal Workers

We ask that each volunteer travel for a minimum of eight days (Saturday through the following Sunday). PIH provides all in-country expenses, including food, board and transportation. All tools needed are provided on site and we only ask that volunteers bring small hand tools. 

Read an interview with Jordan Nader, a construction volunteer at Mirebalais Hospital. 

Many volunteers have already signed up, but we are still in need of many more! If you are interested please visit the Mirebalais Volunteer page or email Heidi Burgess, Mirebalais Volunteer Coordinator, at hburgess@pih.org. 

	Grace Egos, PIH consultant and TB infection control expert, passed away on July 12.

Partners In Health consultant and colleague Grace Egos passed away suddenly from an aneurysm on July 12 while participating in an international tuberculosis infection control meeting in The Hague. A respected expert in tuberculosis (TB) biosafety and TB infection control, Grace served as the Laboratory Director of the Tropical Disease Foundation in the Philippines, and has provided her expertise to organizations ranging from the World Health Organization (WHO) to the Centers for Disease Control and Prevention (CDC) and PIH. Grace was 42 years old. 

PIH co-founder Paul Farmer sent a message to Grace's family and friends.

To the family and friends of Grace Egos: 

We extend our profound sympathies on your tragic loss.

The battle against diseases of the poor is full of unsung heroes like Grace, who made great contributions to the safe expansion of laboratories in her own country, working closely with our friend and colleague Dr. Thelma Tupasi and the Tropical Disease Foundation. She was also effecting change on a global scale, as an independent international TB infection control consultant working with WHO, CDC, PIH, and other organizations.  Here at Harvard, working closely with Partners In Health, she recently taught in the summer course for architects and engineers on airborne infection control. And her skilled posts to the community at GHDOnline have enriched the dialogue around infection control there, offering pragmatic device to practitioners on the ground.  Her work—locally, globally, online, and in meetings like the one she was attending in The Hague—used every available means to improve the quality and safety of services, for patients and providers.

Grace's colleagues will miss her wonderful smile and her warmth as much as they'll miss her skill as a teacher and the competence and formidable effectiveness she brought to our shared work. She was part of a team stretching around the world, bound together by a shared commitment to improving health care for the poor. We will not fail to carry Grace's work forward in her name.

On behalf of Partners In Health, GHDonline, the Division of Global Health Equity, and the Department of Global Health and Social Medicine, I send condolences.  Know that Grace is, as you are, held fast in our hearts and thoughts.

Yours,

Dr. Paul Farmer

	The District Commissioner of Malawi's Neno District, Lawford Palani, cuts the ribbon to inaugurate the Neno Vocational Training Center.

“Education is the most powerful weapon which you can use to change the world,” Nelson Mandela once said. Partners In Health’s Dr. Jonas Rigodon recently quoted these famous words at the inauguration of the Neno Vocational Training Center in rural Malawi.

Malawi suffers from one of the world’s highest rates of HIV infection, and its people are among the world’s poorest. Three quarters of the population lives below the international population line of $1.25 a day, and UN estimates put HIV infection rates at 11 percent of the adult population.

PIH and its Malawian sister organization Abwenzi Pa Za Uyomo (APZU) are working to combat these dire statistics with a number of programs supported by its Program on Social and Economic Rights.  “Attending to the health of the community requires attending to the communities’ social and economic needs,” explained Dr. Rigodon, who is APZU’s Country Director. These needs include shelter, food, education, and economic opportunities. The new training center, organized in a partnership with the UK-based organization Neno Macadamia Trust, is one of APZU’s latest efforts to address these needs.

The new training facility has already enrolled 18 students—12 girls and 6 boys. Most of them are from HIV-affected households—either infected with HIV themselves, caring for patients, or orphaned by the disease. All of them had been too poor to attend school. The local Social Welfare Office worked with APZU to select the participants, reported APZU’s Edith Chihana.

	Carpentry instructor George Kasamwa demonstrates some of the center's new tools.

The training center’s first class of students will be trained in carpentry, and a future course for welding is being planned. In addition to learning skills, the center will also provide the graduating students with a set of tools, including hammers, saws, clamps, and other supplies they’ll need to begin their own carpentry businesses.

The new facility was the brainchild of David and Vanessa Maskell, volunteers with Neno Macadamia Trust. In 2009, the duo helped organize a carpentry workshop in the rural Neno district in southern Malawi, the district where APZU operates. They quickly saw the need to expand the scope of the project, and began working with Neno Macadamia Trust and APZU to construct the training center, with funding from the Miriam Dean Fund and the Alan & Nesta Ferguson Trust. Land for the facility was provided by Neno’s District Commissioner, and Tools for Self Reliance helped to equip the center with hand tools and larger power tools and machinery.

On a bright sunny day two years after the Maskells first conceived their idea, a crowd gathered in front of the freshly-painted brick building to celebrate the inauguration of the training center. As brightly-colored balloons danced in the breeze, the Neno District Commissioner Lawford Palani cut the ribbon. “Economic Development without education is useless,” he said, urging the first class of students to take advantage of the opportunities the center will offer them, and to use their newly learned skills to become models in their communities.

Other attendees of the inaugurating event included the Neno District Social Welfare Officer Peter Magomero, the Director of Administration at Neno District Council, the District Information Officer for Neno, and Village Headman Donda.

Both the Palani and Magomero expressed their expectations that the training center will not only help bring a brighter future for each individual student, but also to their families, their communities, and even the country of Malawi. Education that changes the world, just as Nelson Mandela had predicted.

PIH Malawi Country Director Jonas Rigodon welcomes the Neno community.		Some of the first students of the new training center perform a dance for the crowd.

Learn about a similar APZU program that teaches tailoring skills to women affected by the AIDS epidemic.

View recent photos of construction on the National Teaching Hospital at Mirebalais in central Haiti. Learn more about this new facility. 

On July 1, the first of more than 2,000 new cholera training manuals were delivered by PIH/ZL to community health workers (CHWs) in Haiti.

The Community Health Worker Cholera Training Manual – written to help CHWs and hygiene agents working throughout Haiti to combat, identify and treat cholera – draws from lessons learned in the nine months since the outbreak began. The first version was drafted and implemented within one day of the outbreak and allowed trainings for physicians, nurses, and cleaning staff to begin within the first two weeks.

The new manual, funded in part by the World Bank, is a formalized version that is approved by Haiti’s Ministry of Health (MSPP) to train CHWs to deal with the endemic nationwide. About 150 manuals were transported to Haiti this week in suitcases, and 2,000 more will be shipped by the end of July. The new manuals and flip books will reach Haiti at a crucial time, as the rainy season has caused cholera cases to spike to levels seen in the first weeks of the outbreak.

The materials will be used to train more than 2,000 CHWs, and a modified program will be used to train a similar amount of hygiene agents in cholera and sanitation techniques. PIH/ZL will hold trainings for dozens of new trainers, and the curriculum will be made available to CHWs from other organizations in the Central Plateau, Artibonite and Port-au-Prince to create a wide coverage area of treatment and prevention.

Learn more about PIH/ZL's efforts to fight cholera.

	PIH, MSF, and TAG released the new report on July 7. Click to download the report.

A new report released by Partners In Health (PIH), Médecins Sans Frontières (MSF), and Treatment Action Group (TAG) finds that a lack of international commitment, funding and effective reform has allowed multidrug-resistant tuberculosis (MDR-TB) to continue to spread and cost lives. Each year 150,000 people die from MDR-TB and a total of 440,000 people develop or become infected with the disease.

According to the report, “An evaluation of drug-resistant TB treatment scale-up,” a lack of urgency and commitment from governments is severely limiting efforts to identify new MDR-TB cases. The report also states that donors are failing to make TB a priority. “Almost all of the major donors we contacted were unable to tell us how much of their funding was directed at MDR-TB diagnosis and treatment,” said Javid Syed, TB/HIV Project Director at TAG.

In India, patients are concerned about poor hygiene and lack of infection control at health centers, states the report. 

Unpredictable and expensive drug supplies contributed to the poor scale-up of treatment, as well. The report, which looked at the MDR-TB treatment programs of India, Russia and South Africa, found that countries were prone to drug shortages at both a national and international level. “If MDR-TB patients can’t take their medications regularly because their local clinic has run out of supplies, then they’re at increased risk of developing resistance to second-line TB drugs,” said Donna Barry, Advocacy and Policy Director for PIH.

Download the report.

Major shortfalls are cited among initiatives administered by the World Health Organization (WHO). The report finds, for instance, that the outcome of a 20-month effort to reform the Green Light Committee — designed to help countries gain technical support for scale up of MDR-TB and access to quality MDR-TB drugs — is insufficient to address many key bottlenecks.

"Discrimination was also a repeated concern, at the workplace, in the community, and even in the health centers," states the report.

As part of its conclusion, the report offers a comprehensive list of recommendations, including the need for improved information about the quality of MDR-TB drugs and treatment outcomes, not just the numbers of patients treated. Civil society groups are also encouraged to play an important role in the monitoring of global efforts to scale up MDR-TB.

	Dr. Emma, longtime mentor, trainer and physician

During 15 years with Socios En Salud, Emma Rubín de Celis Talavera juggled the roles of researcher, educator and social justice advocate. But she always held one distinct title for those around her: mentor.   

Known simply as Dr. Emma, the longtime director of projects for SES acted as both a friend and informal advisor to her colleagues, including SES founder Jaime Bayona. Dr. Emma died Thursday in Lima, just one day before the organization would celebrate 15 successful years of work bringing health to Lima’s poorest residents.

Throughout both her career and her time with SES, Emma focused her efforts on furthering social justice at a grassroots level, working with children and new mothers on issues of nutrition and education. Colleagues who saw Emma in action considered her to embody the ideals and goals professed by SES and Partners In Health.

As a consultant for the Panamerican Health Organization and a member of the Board of Directors of the World Health Organization’s Social and Economic Research Committee of Vector-Borne Diseases, she fought to break away from biomedical paradigms, seeking a deeper analysis of the social, economic, political and cultural aspects that surround and condition the existence of disease. 

With degrees from Catholic University of Peru, Catholic University of Louvain, Belgium and University of Nijmegen, Holland, Emma trained professionals, technicians and collaborators in the health field as an instructor at several universities and in the Department of Public Health.

	A health center offering family planning services in Rwanda, supported by Partners In Health/Inshuti Mu Buzima.

“There are few places in the world where the full pressure of population growth is felt as strongly as in tiny, landlocked Rwanda,” write PIH’s Antoinette Habinshuti and Josh Ruxin of Columbia University in an article published in the June 29 issue of Nature. “Its politicians and citizens are keenly aware that their country is nearing a population crisis.”

The small nation is smaller than the state of Maryland but has almost twice as many people — over 11 million compared to 5.7 million. Women in Rwanda have an average of five to six children, giving it the sixteenth highest fertility rate in the world.

The article, "Crowd Control in Rwanda," details how Africa's most densely peopled mainland nation is working to head off this population crisis — focusing on a national family planning strategy — and why other countries should take note.

“The situation in Rwanda is forcing reality and political pragmatism together more rapidly than in neighboring countries. The choices are stark: restrict population growth or remain in poverty, without the capacity to support either a growing population or an emergent economy,” write Ruxin, who is also the founder and director of the Access Project, with Habinshuti, who is the deputy country director of PIH’s Rwandan sister organization Inshuti Mu Buzima. “The lesson from Rwanda for other nations is that without coordinated efforts… population growth will swallow up a country's potential.”

Ruxin and Habinshuti offer a simple recipe, based on lessons learned from Bangladesh, Ghana, and elsewhere: grow the economy, educate girls and women, and offer free contraceptives in every health center and through every community health worker. “That will get you 90 percent of the way,” they write.

This is more easily said than done. While policies focusing on educating girls and women, and pushing for prosperity are widely accepted both nationally and internationally, making contraception freely and widely available has historically faced opposition from local religious and political institutions. For example, Habinshuti and Ruxin note that the Catholic Church manages about half of the health centers in Rwanda and refuses to provide contraceptives on site, even to men with HIV. 

	A woman receiving an in Depo-Provera, a contraceptive injection. Access to contraceptives is one of the family planning services offered at health centers supported by PIH/IMB in Rwanda.

But public discourse and political will are changing in Rwanda. For example, some government and partner programs have set up discrete family-planning centers just outside the doors of Catholic facilities. And politicians and church leaders now often speak of kubyara aba ushoboye kurera — “giving birth to those you are able to raise fairly,” say Ruxin and Habinshuti. “Rwanda is determined to do what works.”

However, Family planning remains a low priority for many international donors. Between 1994 and 2007, family-planning aid dropped from 30% to 12% of overall aid, according to the Worldwatch Institute. Habinshuti and Ruxin strongly advocate for reversing this trend. “Family planning is cheap,” they write. “ The UN estimates that for every dollar invested there is a threefold economic return.”

Read Ruxin and Habinshuti’s full article.

To mark this milestone, a few of our friends from Peru sent a letter to the Boston office with the hopes that we’d share it with our supporters. From all of us in the US office: Congratulations, and job well done!

Estimados amigos de Socios En Salud,

July 9th marks Socios En Salud’s 15th anniversary. What began in 1996 as a small group of doctors, nurses, and community health workers treating ten multidrug-resistant tuberculosis (MDR-TB) patients in a shantytown of Lima is now a global leader in community-based treatment — not just of MDR-TB, but HIV and other infectious diseases.

In early June, SES celebrated the anniversary with an event attended by 300 SES staff, former patients, health promoters, Ministry of Health officials, and invited guests. In his opening remarks, the director of Peru’s National TB Program recalled the early days of SES: treating patients in their homes, hiking up dirt hills to the sickest patients, and winning hard-fought battles to secure quality care for the poor. The event concluded by acknowledging the contributions of (PIH co-founder) Paul Farmer and former SES director Jaime Bayona, as well as naming world-renowned Peruvian chef Gaston Acurio a “leading partner in the fight against tuberculosis in Peru.” 

Meetings with Ministry of Health and city officials throughout the week reaffirmed SES’s impact in Peru, as Lima’s mayor awarded Paul Farmer the Medal of Lima. The award recognized the success of the community-based care model, first implemented by SES, that is now the national strategy in a country still heavily burdened by TB. Today more than 10,500 patients with MDR-TB have been cared for under SES’s care model, achieving a 75 percent cure rate that is both the highest in the world, and a substantially improved adherence among MDR-TB and HIV patients.

View photo gallery in full screen. 

After 15 years of fighting for the right to health care for the poor, SES is now reflecting on the past and looking forward to new challenges. The organization will continue its work with an emphasis on research and providing scientific evidence that can influence public health policy in favor of the communities SES serves. It will also continue to expand training efforts to bring the SES model of care to other areas of Peru and throughout the region, seeking the best treatments for a variety of public health issues. 

Socios En Salud Sucursal Perú
Julio 2011

Learn more about Socios En Salud.
Visit SES's Spanish-language website.

	Clinicians in Rwanda learning a method known as Visual Inspection with Acetic Acid to screen for cervical cancer.

Rwanda recently held its first national training of trainers on quick and low-cost approaches for screening for cervical cancer using Visual Inspection with Acetic Acid, and treating pre-cancerous lesions with cryotherapy. 

Partners In Health (PIH) and its Rwandan sister organization Inshuti Mu Buzima (IMB) organized the three-week training in collaboration with the Ministry of Health and WE-ACTx, reported Dr. Jacklin Saint-Fleur, Director of Women's Health for PIH/IMB in Rwanda, who helped organize the training. Funding support came from the cervical cancer program of the nonprofit organization PATH. Certificates were awarded to eight doctors and three nurses representing health facilities in Butaro, Ruhengeri, and Rwinkwavu, and from WE-ACTx.

For the screening method, known as Visual Inspection with Acetic Acid (VIA), clinicians swab a small amount of acetic acid—common vinegar—across the cervix. Normal cervical tissue remains unaffected by the solution, but damaged tissue found in pre-cancerous or cancerous lesions turns white. To treat these pre-cancerous lesions—which could develop into cervical cancer—the training participants were taught how to use cryotherapy, which removes the lesions by freezing them with carbon dioxide or nitrous oxide.

These procedures can be used to rapidly diagnose and treat the pre-cancerous lesions during the same patient visit. This can be a major asset to accessing care in areas where taking time to travel to a clinic can mean a day where the patient is unable to tend to her family or earn an income.

This training is part of PIH's work to support the development and implementation of Rwanda's National Cervical Cancer Plan, which includes primary prevention through vaccination and secondary prevention through screening with DNA testing for human papillomavirus (HPV)—the virus responsible for most cases of cervical pathology—and VIA, cryotherapy, radiotherapy for treating cancers, as well as palliative care.

Since August 2010, PIH has worked to enable Butaro, Rwinkwavu, and Ruhengeri Hospitals to offer cervical cancer screening, with support from PATH. Over 1,170 women have been screened and 56 have been treated with cryotherapy. In addition, three patients have been sent to Uganda for radiotherapy. PIH also furnished Butaro and Rwinkwavu hospitals with new equipment, including a LEEP machine and colposcope.

In her speech at the closing of the recent training, Diane Mutamba who represented MOH, said that the training was a perfect demonstration of PIH's commitment to building capacity in the public sector. The training also coincides with growing attention on the need to address cancer in the developing world. 

In PIH co-founder Paul Farmer's March 2011 interview with Mary Carmichael of Scientific American, he insisted that tackling the growing threat from cancer in the developing world could improve health care more broadly. The article highlighted PIH's role in the global task force working to marshal support for cancer treatment in low resource settings.

“We will continue to support our partners in the MOH to ensure that they are able to provide high quality services to Rwandan women,” said Dr. Saint-Fleur. “We still have a lot to achieve in the fight against cancer in Rwanda so we will still need the support of everyone.”

	Students reading outside a PIH-supported school in Cange, Haiti.

As the number of children enrolled in primary school around the world rises, inching slowly closer to the United Nations’ goal of education for every child by 2015, one of the poorest countries in the world remains frighteningly behind the curve on literacy. 

In Haiti, where 47 percent of people over age 15 are illiterate, Partners In Health continues to provide education as a critical tool against poverty and illness. 

A group of PIH supporters who recognize this link between education and a better livelihood  – recent college graduates – have pledged their support for Partners In Health’s education programs in Haiti. By signing the PIH Grads for Literacy, these graduates choose to provide the “luxury” of literacy to Haitians who need it most.

Grads for Literacy asks recent graduates to pledge to spread awareness to friends and family about PIH and its efforts to strengthen Haiti’s educational programs. As part of the support, many also donated part of their graduation gifts, or asked family and friends to make gifts in honor of their graduation, to Haiti education programs. 

The pledge bolsters PIH’s continued commitment to basic literacy education for thousands of Haitian children, teens, and adults – creating opportunities for better jobs and better advocacy for Haitians, by Haitians.

Providing education has always been a priority for PIH. Dr. Paul Farmer saw the power of education in Haiti firsthand, years before he co-founded the organization, while working with a group of Haitians who had lost their homes and land when a dam funded by international development agencies was used to flood the valley where they lived. 

With their livelihoods under water, most scrambled up the hillside to start over with few resources and almost no compensation for what had been lost. But those who did receive compensation for what was lost to the water had one thing in common, the villagers said: they could read.  

Being literate meant having the ability to navigate documents proving ownership, and had they all been able to read, the villagers believed they could have better advocated for themselves and demanded compensation for the property that was now underwater, they said. 

Today Haitians continue to recognize the critical link between education and empowerment. Jonas Attilus, a Haitian medical student living in Mexico City, was one of those to pledge his support for PIH literacy programs. Educating the people of his home country, he said, is the first step to eliminating Haiti’s problems with poverty and disease. 

“I have a lot of reasons to pledge for literacy in Haiti,” Jonas said. “An educated (person) knows that he needs to plan and run his own development without waiting for others. An educated person will always be part of a better world and not trying to worsen it by trying to survive. An educated person will respect the earth where he is living.”

“I pledge today with PIH because only education may save this country, mine,” he said.

In early May, we told you the story of Jelen – a street vendor who fights every day against the authorities, the competition, and the street. As a single mother she fights to give her children the best life she can – working as a seamstress, running her own curtain business. With the help of PIH’s sister organization in Peru, Socios En Salud (SES), she recently fought – and won – one of the most difficult fights of her life: the fight against multidrug-resistant tuberculosis (MDR-TB). 

Read about Jelen and her family

This short documentary highlights Jelen’s struggle and her ability to persevere against overwhelming odds. 

Learn more about Socios En Salud

IHSJ Reader     July 2011     Issue 4          

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

HAITI

Has Aid Changed?: Channeling Assistance to Haiti Before and After the Earthquake (Office of the Special Envoy for Haiti, June 23, 2011)
The Office of the Special Envoy for Haiti (OSE) released a comprehensive report analyzing aid effectiveness in Haiti before and after the earthquake. Although aid to Haiti tripled in 2010, data suggests that aid recipients and modalities have not changed: resources continue to bypass Haitian public institutions, Haitian businesses and Haitian NGOs. For example, of the total amount of relief aid dispersed in the first few months after the 2010 earthquake, a mere 1% was received by the government. Recovery aid was better distributed, with a confirmed 12% going directly to the Government of Haiti. It is time international donors demonstrate their commitment to just and sustainable development in Haiti by: (1) channeling resources directly to Haitian public institutions and ministerial budgets; (2) increasing local hiring and procurement; and (3) working within the auspices of the national Action Plan and other Haitian-led plans. Guided by aid effectiveness and human rights principles, Partners In Health is dedicated to accompanying the Haitian public sector in  rebuilding and strengthening the health system.

HEALTH SYSTEM STRENGTHENING

Maternal Death Stalks Malawi’s Rural Poor (GlobalPost, John Donnelly, June 26, 2011)
In Malawi, where 82% of the population lives in rural communities, strained relationships between donors and the Government of Malawi could have a drastic impact on impoverished communities. (Most notably, the U.K. Department for International Development--formerly Malawi’s largest funder--decided to cut aid to Malawi in March of 2011.) As in most rural poor communities, health worker shortages and the lack of access to primary health care services prevent women from getting the care they need. Training and paying village health workers to connect women to family planning services, pre-and post-natal care, a safe place to deliver, and access to emergency surgery during complicated deliveries will help reduce maternal mortality among poor women. In this article, John Donnelly recounts the death of Alola, one of an estimated 3,000 Malawian women who could be saved each year if comprehensive health care existed at the community, clinic, and hospital level.

The State of the World’s Midwifery (UNFPA report, June 2011)
The United Nations Population Fund (UNFPA) released a collaborative report that focuses on strengthening the role of midwives in the 58 countries where 91% of maternal deaths occur. Every year, more than 350,000 women die while pregnant or giving birth, up to 2 million newborns die within the first 24 hours of life, and there are 2.6 million stillbirths. Nearly all of these deaths could be prevented if women had access to quality health care before, during and after pregnancies. When midwives are integrated into communities, adequately trained, focused on quality care, and located in health systems where they can refer complicated pregnancies and deliveries, midwives can help eliminate maternal and newborn deaths and prevent stillbirths. Midwives play a critical role in delivering care in many of the health facilities which PIH supports around the world.

Green Shoots in the Killing Fields (Foreign Policy, Charles Kenny, June 20, 2011)
The Democratic Republic of the Congo (DRC) is mired in poverty, largely due to a violent history of tyranny and exploitation. World Bank data suggests that 71% of the population lives on less than $1 a day, up from 60% in 1990. Yet amidst the scourge of absolute poverty and poor governance, the prevalence of maternal mortality, child undernutrition and HIV/AIDS continues to fall. These critical improvements suggest that aid, when directed at the right to health for the poor, can be a powerful tool in the fight against disease and premature death. While aid alone cannot solve the crises of poverty and inequality, health outcomes in the DRC refute the argument that foreign aid should be withheld from impoverished, struggling states.

One Million Community Health Workers (The Earth Institute, Columbia University, June 1, 2011)
As members of the communities in which they work, community health workers (CHWs) provide vital access to health care for the rural poor who live in places with weak primary health care systems. This report focuses on the necessary steps and infrastructure developments to create a reliable system of CHWs and calls for one million community health workers to be hired and trained in sub-Saharan Africa by 2015. Many governments and organizations expect CHWs to deliver essential health services on a voluntary basis. However, PIH and other partners including the Earth Institute argue that paying CHWs is a moral and economic imperative.  Scaling up CHW training, deployment, and compensation while providing strong supervision and linkages to health centers is central to achieving the Millennium Development Goals (MDGs). 

HIV/AIDS

AIDS: Let Science Inform Policy (SCIENCE, Anthony S. Fauci, July 1, 2011)
Anthony Fauci argues that thirty years after the first reported cases of AIDS, ample evidence-based tools exist to end the AIDS pandemic. "For the first time in the history of HIV/AIDS, controlling and ending the pandemic are feasible; however, a truly global commitment, including investments by those rich and middle-income countries whose contributions have thus far been limited, is essential."  UN Member states recently agreed to double the number of people on life-saving antiretroviral therapy in low and middle-income countries by 2015 and halve the number of TB-related deaths among people with HIV. Instead of the current $16 billion, an estimated $22-23 billion will be needed by 2015 to end one of the most devastating public health crises of our time.

NON-COMMUNICABLE DISEASES

Prevention and Control of Non-Communicable Diseases (UN General Assembly, Report of the Secretary-General, May 19, 2011)
The international community has focused on rolling back the tide of communicable diseases such as HIV/AIDS, tuberculosis, and malaria in poor countries, yet the epidemic of non-communicable diseases (NCDs) remains neglected.  Poor outcomes from NCDs such as cancer, mental disorders, cardiovascular disease, diabetes, and chronic respiratory disease disproportionately occur in impoverished populations with a full 80% of deaths from these conditions occurring in low- and middle-income countries. To address this gap, UN member states must commit to working with a broad range of stakeholders to make NCD prevention, diagnosis, treatment and palliative care available and affordable for the poorest populations.

MULTIMEDIA 

Slideshow of Foreign Transaction Tax Global Day of Action (Flickr, June 2011)
Activists in over 40 countries participated in a “global day of action” to encourage European leaders to back a Financial Transaction Tax (FTT) that could raise hundreds of billions to tackle poverty and climate change. From extravagant stunts to mass demonstrations, check out this Flickr slide show to get a sense of the global commitment to the FTT.

Interview with Gene Bukhman (Global Health TV, June 17, 2011).
Dr. Gene Bukhman, Director of the Program in Global Non-communicable Disease and Social Change at Harvard Medical School, discusses NCDs in the poorest countries. 

A New Paradigm for Global Health: Solidarity (TEDXRainier, Dr. Wendy Johnson, November 7, 2010)
In this compelling presentation, Dr. Wendy Johnson reveals how a model of “colonial humanitarianism” continues to define foreign aid.  Instead of creating a parallel track of disease-specific health interventions that fail to build local capacity, donors should work through the public sector to strengthen access to comprehensive health services.  Dr. Johnson argues that a paradigm shift is required to make foreign aid effective, from colonial-era charity to a model of solidarity.

Stay connected with the PIH Blog, Facebook, Twitter, and YouTube pagesMolly Franke, Megan Murray, and colleagues report that early cART reduces mortality among HIV-infected adults with tuberculosis and improves retention in care, regardless of CD4 count.

	The delegation included David Zapol, Senior Consultant from FSG (second from left); Maria Paola Lia, Lilly MDR-TB Partnership (third from left); and Rajni Chandrasekhar, SIC (fourth from left).

Representatives from the Lilly MDR-TB Partnership – the charitable arm of the Lilly Fund – travelled to Russia this May to gain an accurate picture of the country’s fight against tuberculosis (TB) and multidrug-resistant TB (MDR-TB).

The group, joined by nonprofit strategy firm Social Impact Consultants (SIC), observed various TB and MDR-TB programs and met with staff from the Russian Red Cross, Global Business Coalition, Partners In Health, and the World Health Organization.

	The team talked with staff in Tomsk, Russia

The delegation’s goal: analyze existing activities and develop a strategy for future Lilly-supported TB and MDR-TB projects.

Before extending funding to new and existing projects, the Lilly MDR-TB Partnership is evaluating existing Lilly-supported programs and developing a single policy that can be expanded to other countries and regions.

Read: PIH-Russia’s TB staff concludes 6-year alcohol study

The delegation began the series of meetings by asking to hear about problems in regional TB programs and potential solutions.

“We would like to know the results that were reached in implementing TB programs but it is also important to learn what challenges they face in their activity,” says David Zapol, FSG Senior Consultant. “This helps us understand what approaches to use to develop new strategies.” 

Once problems had been discussed, the delegation visited a successful TB/MDR-TB program – the PIH-supported program in Tomsk Oblast, a landlocked region in Russia’s southeastern West Siberian Plain, where PIH-Russia has been working with the local government since 1998.

Watch: A short documentary about PIH’s Sputnik Program

During the two-day visit, the delegation met with staff at the Tomsk TB Dispensary, where patients receive outpatient care, and at the region’s inpatient TB Hospital. The trip also included meetings at Tomsk Prison’s TB hospital. 

PIH and Tomsk’s Tuberculosis Services staff outlined the region-wide strategy aimed at containing and controlling TB – one that has resulted in incredibly high treatment rates.

With funding and support from the Lilly MDR-TB Partnership, this model has been expanded to five other Russian oblasts.

Russia is one of the four countries – the others being China, India and South Africa – where the Lilly MDR-TB Partnership provides support to public health programs and activities.

Learn more about PIH's work in Russia.

Visit PIH's Russian language website.

On July 12, 2011, PIH cofounder Paul Farmer’s new book, Haiti After the Earthquake, arrives in bookstores across the nation. 

Join PIH's Summer Reading Series, and you’ll be entered to win a signed copy of Haiti After the Earthquake.

When the January 12, 2010 earthquake laid waste to Port-au-Prince, Haiti, killing hundreds of thousands of people, it forever altered that country. Haiti After the Earthquake bears witness to the experiences of the injured and displaced, telling the stories of both those who survived and those who did not. An unparalleled disaster in an impoverished country, the earthquake pushed the international community to rethink how it initiates large-scale emergency aid and recovery projects.

Within three days of the earthquake, Dr. Farmer arrived in the Haitian capital, along with a team of volunteers, to lend his services to the injured. Haiti After the Earthquake opens with Farmer recounting his sense of helplessness immediately after the learning of bagay la — the event that so many Haitians simply called “the thing.”

On January 13, the day after an earthquake struck Haiti’s capital, I finally got through to Dr. Alix Lassègue, the medical director of Port-au-Prince’s largest hospital and a longtime friend. The hospital’s real name is l’Hôpital de l’Université d’Etat d’Haïti, but most people call it the General Hospital. I began trying to reach Lassègue a couple of hours after the quake. His cell phone number, like all the other numbers I tried, led to a recorded message or an ominous buzz. From what we knew at the time, the hospital was smack in the middle of the quake zone. The facility sat among a dozen government buildings, including the medical and nursing schools, and we could see from live reports that most of those buildings had collapsed—during business and school hours. It was clear that our work as health providers in Haiti would be changed forever.

So now what? It was hard to know how to prioritize anxieties, and as a doctor, I thought immediately of the General Hospital. It wasn’t hard to imagine the enormity of need in this struggling public facility which had, in the best of times, too many patients, too few staff, and far too few resources. After dozens of tries, it was almost a shock when I connected to Lassègue on a colleague’s cell phone.

“What do you most need?” I asked.

In this vivid narrative, Farmer describes the incredible suffering — and resilience — that he encountered in Haiti. Having worked in the country for nearly thirty years, he skillfully explores the social issues that made Haiti so vulnerable to the earthquake – the very issues that make it an "unnatural disaster."

Order Haiti After the Earthquake

Other Voices: The second-half of this new book includes essays from earthquake survivors, doctors, volunteers, and other friends of Haiti, including: Edwidge Danticat, Michèle Montas-Dominique, Didi Farmer, Nancy Dorsinville, Louise Ivers, Evan Lyon, Dubique Kobel, Naomi Rosenberg, Timothy Schwartz, Jennie Weiss Block, and Jéhane Sedky.

Haiti After the Earthquake will both inform and inspire readers to stand with the Haitian people against the profound economic and social injustices that formed the fault line for this disaster.

Join PIH's Summer Reading Series

Browse other books written by Dr. Farmer

On June 28, Léonce Byimana, a program coordinator for PIH’s sister project in Rwanda, Inshuti Mu Buzima, emailed an update about the opening of 32 new homes for the pygmy community — known as the Twa — who live in Burera District, where PIH/IMB has worked since 2008. Beginning in late 2010, PIH/IMB has worked to ensure each of the 39 families living in this community have access to a new home.
 

From: Léonce Byimana
Sent: Tuesday, June 28, 2011 6:10 AM
To: Peter Drobac
Cc: Paul Farmer
Subject: Thank you

Good morning all.

This is a letter to thank everybody who contributed to the realization of the pygmy construction project and those who attended Saturday's inauguration of 32 new pygmy houses — both physically and in spirit. Many of the beneficiaries who were present told me they have never been happier. They've never felt respected like that day, seeing their children taking pictures with the children of PIH’s founders, employees, supporters, and donors.

However, the families we relocated still need to satisfy the first level of Maslow’s hierarchy of needs — the physiological one. But they will no longer be experiencing heavy rains during the night. The prevalence of pneumonia in that population will certainly decrease.

Watch a video about the Twa housing project

The community has houses; their children can study without the risk of their books becoming soaked.

PIH has many plans for this community, like making sure everyone has access to education. Today many of their children are at school but their attendance is sporadic. Many of them attend two or three times a week and that effects their performance. We were planning to put some of them in boarding school, where they can study in good conditions and learn better. Hopefully they will serve as an example to others, who will be aware of the importance of school, and personally, I see these children as the future of their community.

	Jane and her younger brother (Photo taken by Rebecca)

The child in the picture, Jane, is now integrated in primary school, but her schooling is uncertain because she must help her parents harvest or find food most days.

Because of this, IMB is hoping to improve the Twa’s living conditions by initiating money-generating activities. The same activities will facilitate integration in the community in general because the projects will not be only for pygmies.

That's why we brought to you this message, even if two or three children can enroll in a nice school, and finish, it will be a giant step in the his{cke_protected_1}tory of this population.

If one or two farming or handicraft projects are supported it will change life in this Twa community.

Read: One Hundred Pygmy Children Receive a Chance to Attend School

The Burera team is also ready to give further information, success stories, problem analysis, pictures or any other document or idea which can help for this or that initiative from whoever is willing to make that happen.

Let's hope, one day in the near future, the same children in the new village in Nyamicucu will be able to sit with the children from the families who visited them this Saturday and discuss about various subjects, not using signs language, but using English or any other language because they'll be educated.

Once again thank you for everybody.

Thank you,
Léonce Byimana

P.S: Please, forward this message to anybody who attended the event and those who contributed directly or indirectly to the accomplishment of such a unique activity.

Learn more about PIH/IMB’s work in Rwanda

In late June, the UN Office of the Special Envoy to Haiti released a report urging the international community to continue assisting the Government of Haiti as it strives to create jobs and ramp up the nation’s economy. By supporting the Haitian Government, we ensure the country’s people and institutions have the basic resources needed to rebuild the country in a sustainable and significant way.

“To revitalize Haitian institutions, we must channel money through them,” states the report, entitled “Has Aid Changed: Channeling assistance to Haiti before and after the earthquake.”

Paul Farmer, Deputy Special Envoy for Haiti and cofounder of Partners In Health, writes in the report’s foreword, “This is the best way to ensure the strengthening of public systems, improved management of resources, increased accountability between the Government and its citizens, and greater collective impact of our efforts.”

“Perhaps most important, it will create jobs and build skills for the Haitian people,” he writes.

Read the report.

Headed by former United States president Bill Clinton and Paul Farmer, the Office’s most recent report assesses the effectiveness of post-earthquake aid delivered to Haiti.

After being devastated by a massive earthquake, the international community pledged significant financial resources for both the relief and recovery efforts to Haiti. Yet, the transition between relief aid – funds responding to the immediate after effects of the quake – and long-term recovery aid has moved slower than expected.

Over the past year, donors have disbursed more than $1.74 billion for recovery activities, but over half – $2.84 billion – of what was pledged for 2010 and 2011 remains in donors’ hands.

The report highlights the fact that approximately 99 percent of post-quake relief aid was disbursed to humanitarian agencies, NGOs, and private contractors. This circumvention makes “the already challenging task of moving from relief to recovery…almost impossible,” states the report.

Only one percent of relief aid was distributed to the Haitian Government – the democratically elected public entity most capable of producing jobs and initiating the massive rebuilding effort facing the nation.

As Secretary-General Ban Ki-moon recently noted, important progress has been achieved since January 2010. Yet Haiti continues to face daunting challenges, including a struggling economy, high unemployment and public institutions that are barely able to deliver essential services.

“We have heard from the Haitian people time and again that creating jobs and supporting the Government to ensure access to basic services are essential to restoring dignity,” states the report.

“And we have learned that in order to make progress in these two areas we need to directly invest in Haitian people and their public and private institutions,” writes Farmer in the report’s foreword.

The report urges the international community to invest a much greater proportion of its resources directly in the Haitian public and private sectors.

The Office of the Special Envoy says it will continue to explore innovative ways that donors can channel assistance to Haiti in order to “truly accompany the Haitian Government and its citizens in their efforts to build back better.”

	In Haiti, a community health worker distributes medicine and care to HIV patients living in her community.

Since the early 1990s, PIH and its sister organization in Haiti, Zanmi Lasante (PIH/ZL), have delivered high-quality care to thousands of HIV patients by sharing – or task-shifting – responsibilities among a limited number of doctors and a much larger population of specially trained nurses and community health workers.

This model eases the burden on physicians and results in healthier patients according to an article in the May 2011 edition of the journal PLoS ONE, “Task-Shifting in HIV Care.”

The article – co-authored by Dr. Louise Ivers, PIH’s Senior Health and Policy Advisor, and colleagues from PIH/ZL, Harvard Medical School and the World Health Organization – maps how staff shared responsibilities at three PIH/ZL clinics during a six-month period in 2007.

How PIH/ZL’s approach differs

While doctors exclusively perform 64 percent of HIV-related tasks in traditional clinical settings, PIH/ZL doctors exclusively perform only 2 percent. This means that nurses and community health workers (CHWs) either partially or fully participated in 98 percent of the 135 HIV-related tasks included in a patient’s treatment plan.

In fact, CHWs perform over 50 percent of HIV-related responsibilities, many of which take place in the patient’s home.

The study finds a direct link between task-shifting and high adherence rates.

For example, just over 95 percent of PIH/ZL patients living with HIV still adhere to their antiretroviral treatment after two years.

These numbers far surpass those found in comparable regions of Sub-Sahara Africa, where “the best retention rate was 90 percent at 24 months and the average retention rate was 60 percent.”

Prior to working to with HIV patients, nurses and CHWs are properly trained in tasks traditionally performed by doctors and therefore pose no danger to the patient.

Proving what PIH/ZL staff have long known

 By sharing responsibilities with CHWs, physicians and nurses have more time to focus on tasks that require advanced training, such as monitoring test results and making major treatment decisions. Employing CHWs ensures that patients have regular, if not daily, one-on-one contact with care providers.

The task-shifting model also allows for the rapid and effective introduction of services in new regions.

Between October 2002 and October 2007, PIH/ZL scaled up HIV care to the entire Central Department of Haiti (population 550,000) using the task-shifting model of care. The organization enrolled 11,114 people living with HIV and started 3,763 patients on antiretroviral therapy. At the time of the study’s completion, there were no waiting lists for treatment.

PIH/ZL’s task-shifting model serves as an example to health care organizations in other developing countries.

“The number of individuals requiring HIV treatment and care far surpasses the current capacity of most health care systems in the developing world,” according to the article. “At least 36 countries are suffering from severe shortages of health care workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care.”

Task-shifting offers a long-term solution to the shortage of HIV doctors in developing countries.

Read “Task-Shifting in HIV Care: A Case Study of Nurse-Centered Community-Based Care in Rural Haiti.”

	Paul Farmer and Ophelia Dahl speaking at the University of Notre Dame.

During two decades in various leadership roles at Harvard University, Steve Reifenberg worked closely with Partners In Health co-founders Ophelia Dahl and Paul Farmer as both colleagues and friends. Recently he had the chance to reflect on their mission to deliver healthcare to the world’s poorest people while presenting PIH with the Notre Dame Award for International Human Development and Solidarity.

The award – presented to Dahl, Farmer and Loune Viaud, director of PIH’s sister Haitian project Zamni Lasante, on behalf of thousands of workers in 11 countries – recognizes individuals and organizations that stand in solidarity with those most in need.

“There is a magical presence of watching someone do what they love doing and with joy,” said Reifenberg, who now serves as executive director of Kellogg Institute of International Studies. “Paul and Ophelia and Loune are really good – there is that same magical presence and you see that joy in their faces and in everything they do when you watch them at work, and it is just like watching a great conductor, dancer or musician perform.”

Beyond individual praise for the organization’s leadership, Reifenberg said it was the story of PIH as an institution that was most compelling. From his experiences at PIH sites around the world, he came to appreciate three key ways that PIH succeeds: “expanding our sense of the possible, creating models of institutional innovation and rethinking our concept of charity,” he said.

Reifenberg offered two stories to illustrate his own experience with PIH’s impact:

Accompaniment in Peru
I spent the time in Lima with Socios en Salud – that’s Partners In Health in Spanish – with country director, Jaime Bayona, some of his colleagues, and a community health worker, Ana, who had formerly been a TB patient. She is part health worker, part social worker. I spent the afternoon doing what Ana does every single day, climbing up and down the dusty hills of Caraballyo. She does it every single day, because if you’re a TB patient, as she had been, she needs to insure you don’t miss a treatment. 

Ana was welcomed into homes like a neighbor or an old friend. Seeing Ana, it seems, was the highlight of the day for many people at home with TB. During her visits, she not only watched the person take the medication and talked knowledgeably about TB drugs and prevention, but she also engaged in conversations about daily life ranging from counseling what to do with a misbehaving teenager (be patient) and what to do about an errant husband (don’t be so patient).

There are remarkable 99% compliance rates for taking the drugs daily, and it’s a story about community health workers connecting their lives with the people they are visiting daily.

Ana is not unlike thousands of other PIH community health worker colleagues in Haiti and Rwanda and elsewhere who might have only a few years of education, and have very likely been patients themselves. Nearly two thirds of 13,000 people working for PIH around the globe are community health workers. They now have jobs, which in and of itself is transformative, and they in turn, through their work transform the lives of others.

Ultimately this model, led by Socios en Salud and PIH in the dusty hills of Caraballyo, required international organizations to rethink what is possible – and effectively, the WHO changed its standard protocols that now recommends treating MDRTB patients in all parts of the world, including the poorest.  So Ana and thousands of other community health workers like her begin to help us imagine and expand the sense of what is possible.

Healing in Haiti
Reifenberg wrote about his experience with accompaniment in a January 8^th, 2002 journal entry following his visit to patients at Zanmi Lasante:

We are told that there is a party for Charlene who has been a patient at Zanmi Lasante for the last year. The square room that serves as meeting hall, conference room, and chapel  – is now decorated with crepe paper streamers as the “party room.”

There are about 15 patients seated around the perimeter of the room. A few of the Haitian patients smile or nod to us, but most just sit in their chairs, as our group comes in. It is apparent that the guest of honor, Charlene, is the woman wearing a pink and blue dress, and coral colored sandals.

Charlene sits in the center of the group, and although she doesn’t speak to anyone, she has an enormous smile on her face. Things seem quite somber, with the exception of Charlene who continues to smile at everyone. We say hello to a few people and nod, and then also sit quietly, waiting.

Two Haitian doctors, including Dr. Jermore, the head physician, and Paul Farmer come in, and everyone lights up.  The doctors greet each patient by name and converse in Creole.  Paul then turns to us in English.

“There is a party every time someone who has had an extended stay at the hospital is able to leave and is able to walk out of the hospital healthy… or at least a lot healthier than they were when they arrived...”

The doctors turn to Charlene. She beams.

“Charlene tells us about your story,” Paul says, “so we can all celebrate your health.” This is obviously the moment that Charlene has been waiting for.

“When I arrived at Zanmi Lasante, I was hardly able to walk,” Charlene says. “I had chills, and so much pain it was as if giant snakes were in my stomach. When I came here, I took many medicines. The doctors and nurses took very good care of me.”  She tells of specific moments of kindness, someone who brought her a fresh juice, a nurse who carefully helped her move when she could not do so herself.  “The Partners In Health doctors saved me.”

By way of conclusion she says, “I apologize that at this party, I have no gift I can wrap in a package for you. But please – my doctors, friends, and visitors” – she says, pausing, looking at each of us, “my story is my gift, and I give it to you with no wrapping, but with all my heart.”

This moment defines accompaniment. Charlene gives the great gift of her health and her story, and we each share what we can, and we are transformed in the process.  

As a part of our ongoing series of weekly updates from the Mirebalais Hospital site, here are some photos taken this week by our construction team:

A view of the whole hospital site as of mid-June. Notice the progress on the second floor.

The stucco work is almost complete inside the Women's Clinic & Community Health Center and the Outpatient Building.

The construction team has begun pouring concrete floors in many rooms of the Women's Clinic & Community Health Building.

The electrical team has begun installing temporary lighting until the permanent electrical supplies arrive on site. These are currently installed in the Community Health building and installation will begin in other buildings soon.

The rainy season continues in Haiti; thankfully, the drainage system is working very well.

Partners In Health frequently uses natural materials--like this boulder--to create a landscaped courtyard with a fountain on the campuses of hospitals and health centers. This rock will be incorporated from the landscaping designs in coming months.

	Paul Farmer monitors a patient in Haiti.

For the second time in two years, Paul Farmer, the co-founder of Partners In Health (PIH), has been named as one of Fast Company’s 100 Most Creative People in Business. The business magazine’s 2011 list ranks Farmer as number 31, highlighting his ability to “change the way public health is practiced worldwide.” Farmer’s brief biography also mentions the innovative new teaching hospital in Mirebalais, Haiti, being constructed by PIH and our Haitian sister organization, Zanmi Lasante. The hospital, which opens in January 2012, will have 320 beds and offer clinical facilities not available at any public site in the country, including an intensive care unit and an operating theatre complex with six operating rooms.

Fast Company’s top 100 list recognizes other innovators committed to expanding access to quality healthcare, including: Jim Yong Kim, Partners In Health co-founder and current president of Dartmouth University; Eric Dishman, Intel's director of health innovation; and Giovanni Colella, co-founder of Castlight Health.

See the list of 100 Most Creative People in Business.

Fast Company was launched in 1995 by two former Harvard Business Review editors. The magazine features some of the world’s most cutting-edge leaders and with the goal of inspiring its readers to “think beyond traditional boundaries, lead conversations and create the future of business.”

	This year's FACE AIDS riders celebrate after reaching Echo Summit, CA.

It was a summer night in 2009 when, having just completed a 61-day bike ride across the country to raise awareness and funds for AIDS, Austin Keeley and Dave Evans decided they needed to do more.

Sitting in a Boston hotel room with 4,747 miles behind them and $20,000 raised, the Stanford University sophomores were dissatisfied with the impact of their cross-country ride for FACE AIDS, a student group dedicated to educating young people about issues surrounding HIV/AIDS.

“We both had this sense that we hadn’t accomplished anything,” said Evans, who with Keeley revived the ride after the inaugural journey by two of their classmates in 2007. “We decided this needed to be bigger than us – we wanted this to go on after we were done.”

Two years later their dream persists, and the fourth group of FACE AIDS cross-country riders hit the road June 14 to begin the long journey to Boston. The team of six will bike from state to state, talking to anyone who will listen about the role students can play in promoting social justice and healthcare in developing nations. 

Started in 2005 by students at Stanford University, FACE AIDS focuses its efforts on AIDS patients in Rwanda and has raised more than $2 million for Inshuti Mu Buzima, Partners in Health’s sister project in Rwanda. This years riders – Lili Ferguson, Michael Henry, Vadim Kogan, Katie Lund, Laura Lynch and Tim Spittle – will champion that mission during the three month journey.

Riding between 65 and 100 miles a day, riders will stop at churches, Rotary clubs, schools, FACE AIDS chapters, and other locations along the way to talk about the problems that HIV/AIDS present to the world. While fundraising is a major component of the journey (last year’s team raised $50,000), raising awareness about the need for universal access to health care is the crux of the ride, Keeley said.

Building a movement
Being able to talk to anyone and everyone about the issues that motivate the ride is crucial to spreading the message across the country – a lesson Keeley and Evans learned on their own ride in 2009. While they were occasionally disheartened by the lack of exposure to important issues surrounding AIDS, Keeley and Evans were more often encouraged by the willingness to listen among hosts, new friends and strangers along the way.

“What we did find was an immense sense of openness from people,” Keeley said. “There were people who said ‘you’re biking 100 miles a day in the heat, at the very least I can take the time to listen to you.’”

This year’s team, who hail from four states and four universities, will face the same challenge. Now making their way through Nevada, they have blogged about the progress of their ride and the goal of spreading awareness and have already raised $18,000 for Partners In Health.

They are not the only ones riding with Partners In Health as inspiration. Peter Hines took up the same mission – a cross-country ride to raise funds and awareness for PIH – earlier this year after leaving his Peace Corps post in Panama.

Hines, who embarked from Annapolis, Maryland and finished his ride this month in Arcata, California, still hopes to raise $2,124 for PIH – or 50 cents for each of the 4,248 miles he rode.

While Hines’ solo journey was markedly different from the established route and team effort of the FACE AIDS riders, both trips exemplify a determination to challenge oneself physically in order to shine a light on issues of global inequality.

The continuation of such projects, rather than one-time efforts of donating to a cause, have the capacity to create a movement that actually makes a difference in the world of health care equality, Keeley said. 

“Its easy to get complacent and think you’ve done enough,” Keeley said. “But for this to be a movement in the fight for social justice, there has to be a constant push, a constant fight.”

On June 24, Ophelia Dahl, PIH’s Executive Director, sent this short update about the progress that has been made outfitting the PIH-supported Rwinkwavu Hospital, located in southern Rwanda, this past year and the clear impact those improvements have made for the local community.
 

	The new maternity ward at Rwinkwavu Hospital is nearly finished.

To round the corner of the red dirt road that leads to Rwinkwavu Hospital, to pass the giant dilapidated brick warehouses and see the front of the sturdy district hospital is to feel greeted by an old friend.

Each time I visit Rwanda I am witness to further magnificent transformation: new clinics constructed, gardens planted, warehouses jam-packed with supplies and medicine and support groups for vulnerable young women. To a regular but infrequent visitor like me, these changes can seem almost magical -- disguising the huge amount of work required to plan, design and build facilities and programs from scratch with our partner, the Government of Rwanda.

Perhaps the best sight of all was the nearly finished maternity clinic adjacent to the main hospital -- an entirely new, spacious and gleaming building solely for women's health. Sixty beds in total for labor and delivery, a lying-in ward, post operative ward, two ORs, one always available for emergency C-sections, and a blood bank.

In short, a full complement of services for pregnant women.

As I write, ground is being broken on a neonatology unit, the first in Rwanda. What could be better than this? How about learning that PIH has only paid for 25 percent of the construction costs of the maternity unit. The other costs have been assumed by the Government of Rwanda, UNICEF and The Global Fund.

Partnership does not feel any more rewarding than this -- except perhaps when this transformed piece of land is teeming with women seeking care. 

Huge amounts of work have been completed in the last 12 months and all credit goes to the efforts of the teams in Rwanda, their counterparts in Boston and all of you who support our work.

PIH and its sister organization Inshuti Mu Buzima (IMB) have been working in Rwanda since 2005. In partnership with the Government of Rwanda and the Clinton Health Access Initiative (CHAI), our work supports the Ministry of Health to comprehensively strengthen the public health system in rural, underserved areas of the country.

Read more about our work in Rwanda.

By Kevin Carney, IHSJ Intern

 Each summer, interns for PIH's Institute for Health and Social Justice (IHSJ) get an inside look at how PIH operates, and hands-on experience working with PIH programs. This blog post is part of an on-going series following their experiences this summer, and does not necessarily reflect the views of Partners In Health.

Esther’s tired laugh filled the hall as we slowly circled the 15^th floor corridor at Brigham and Women’s Hospital in Boston.  Five minutes prior, she awoke from a nap to find that two complete strangers— Evelyn Linares, PIH Director of Development Operations, and I—had infiltrated her room while she slept. Groggy and probably a bit confused, the 19-year-old woman from Haiti greeted us warmly as we introduced ourselves.

As she woke up, Esther’s nurses asked if we’d like to go on a walk with her. Evelyn held her hand and I followed behind pushing the I.V. pole as we slowly made our way through the hallway. Neither Evelyn nor I speak Creole, and I speak only basic French, so we communicated primarily by pointing, smiling, and laughing. Our parade—a small, Haitian woman, followed by a Latina from Boston and me, a tall, lanky white boy from the Midwest—was certainly a sight, but the knowing smiles from the nurses on the floor as we passed made it clear that PIH’s work is both known and respected.

Halfway through our journey, Esther commented that her stomach didn’t feel well, and the pain was obvious on her face. “Veux-tu retourner?” I managed to ask. Esther replied with a feeble but firm no, and bravely continued.

Though I’ve never stepped foot in Haiti, I felt that my experience with Esther and her Haitian nurses provided a small ethnographic glimpse into the spirit and pride of the Haitian people. Esther’s illness and pain were a testament to the suffering that continues in Haiti in the wake of a devastating earthquake and cholera outbreak. Moreover, her determination to keep walking and her willingness to smile and joke with strangers amidst excruciating pain demonstrate a resilience that can survive even the most destructive of disasters.

As I walked with Esther, I couldn’t help but think of those in Haiti who weren’t as fortunate as her. Partners In Health’s Right to Health Care program gave her the opportunity to receive life-saving treatments that are unavailable in Haiti. Reflecting on how fortunate Esther was to receive this care forced me to contemplate my own privilege. That I initially thought of her as “lucky” to receive such life saving care speaks to how global health inequality has hastily been accepted as the norm. If Esther had been fortunate enough to have the basic health care I’ve had all of my life, she would not be so seriously ill in the first place.

When we expect that the poor will die from easily preventable diseases, treatment such as Esther’s is lauded as a great gift of charity. In reality, the fact that Esther is one of a lucky few should make us angry. Is it not disgraceful that an entire nation of people is suffering because they lack the health care and infrastructure that we take for granted in the United States?

This is mindset that we can strive to dismantle, one patient at a time, with at least as much determination amidst hardship as Esther displayed that afternoon. We will know our work is done when people like me tell of the one Haitian who did not receive healthcare rather than the one who did. 

Kevin Carney is a summer intern for PIH's Institute for Health and Social Justice (IHSJ). He is working with PIH's Public Sector Development Team. Check out blog posts from and about IHSJ interns.

	IMB runs support groups for adolescents and children either infected or affected by HIV.

Four years ago, Jean de Dieu's family was confused and distraught. The 14-year-old from rural Rwanda had tested positive for HIV, while the rest of his immediate family had all tested negative. While questions swirled around his home, the teenager just felt alone and depressed.

Jean de Dieu’s father had been worried about his son for some time—he seemed to fall ill so often. So when a mobile clinic for voluntary counseling and testing for HIV came to a nearby school, the father quickly consented to having the boy tested. The clinic, operated by Partners In Health’s Rwandan sister organization Inshuti Mu Buzima (IMB), delivered the unfortunate news. And the IMB social work team sat down to counsel both father and son about the results. They also quickly scheduled a home visit to assess the family's situation and to provide additional counseling and resources. 

Jean de Dieu’s father had previously been tested, and knew he was HIV negative. Thankfully, the IMB team found the rest of the family—Jean de Dieu's mother and sibling—had also tested negative. But the family was still perplexed and scared—how had the boy become infected?

For Jean de Dieu, the initial confusion soon gave way to depression. A stellar student, he contemplated abandoning his studies and giving in to the disease.

To add to the family’s woes, Jean de Dieu’s mother, while HIV negative, was very ill—she hadn’t left her house in over a year. IMB clinicians found that she was suffering from advanced cervical cancer, and did not have long to live. She passed away soon afterward.

Griefstricken and unable to cope with his wife's death and what he felt was his son's impending death, the father abandoned his family.

IMB’s social work team had their work cut out for them. However, they’ve had years of experience helping many other children living with HIV, just like Jean de Dieu. They quickly arranged for continual counseling for the entire family, highlighting other possible causes of HIV infection. And while finding out how he had gotten infected may remain a mystery, helping the teen regain his health was certainly attainable. IMB ensured that he was put on an ART regimen, and assigned an accompagnateur to help make sure he has the support he needs to adhere to it. They also convinced Jean de Dieu to join a weekly counseling group for HIV-positive children.

	At a support group for children and adolescents infected or affected by HIV, participants discuss their fears, experiences, and aspirations.
	Participants also play games and form friendships with others who understand exactly what they are going through.

At the group meetings, the boy discovered that the other children seemed to be healthy, happy, and living full, ordinary lives. Moreover, the other kids understood what he was going through. There was no judgment or stigma—only support. “I cannot miss the counseling sessions,” he asserts. “I am very happy when I am with them, because we all understand each other.”

The IMB team knew that another aspect of Jean de Dieu’s treatment was to make sure that he continued his studies. They supplied school fees and supplies, as he no longer had his father to support him. Jean de Dieu didn’t let the IMB team down—he graduated from primary school as the top student in his class, and enrolled in secondary school. 

Meanwhile, IMB continued to try counseling his father. And when he saw how Jean de Dieu had begun to flourish, he returned to his family and began attending the counseling group meetings with his son.

Now 18 years old, Jean de Dieu has a completely different outlook on HIV than those dark days when he was first diagnosed. “I am HIV positive and I'm still alive, because there are drugs for what I'm suffering with,” he says.  “I now have a future to look to,” he adds, crediting his counseling group. “I want to be a doctor in order to assist other children with chronic diseases."

Learn more about PIH's work to provide psychosocial support to patients affected and infected by HIV.