Today marks the second anniversary of Nyaya Health’s Bayalpata Hospital.

Nyaya Health works with the Nepali Ministry of Health and Population to develop health care services in the impoverished western regions of the country. Working to advance the solidarity model of Partners In Health, Nyaya aims to scale-up not only medical services, but also services targeting other population-level interventions. 

Nyaya is one of PIH’s six supported projects, each dedicated to implementing the organization's philosophy on a global scale by working with local communities and governments to create change.

Today, Nyaya Health cofounder Ryan Schwartz shared some of the organization’s successes in an email.

Dear friends and family,

Last month a 29-year-old woman walked for over a day, and then rode on a tractor for another half day, to reach Nyaya’s Bayalpata Hospital. She had begun having labor pains more than a day earlier and had already been bleeding quite a bit – there were unfortunately no functioning health centers anywhere closer for this woman. Our team of doctors and midwives met her upon her arrival at Bayalpata, and she delivered a healthy little girl in a clean and safe healthcare facility several hours later. Unfortunately, she then suffered from a post-partum infection, but due to the excellent care of Bayalpata’s staff, she and her newborn daughter walked home healthy several days later.

When Dr. Jason Andrews, Nyaya’s Co-founder, first visited Achham over five years ago, there was no hospital. In fact, there was not even a functioning health center. In 2008 Nyaya opened the first health center in the region, and on June 21st, 2009, in partnership with the Ministry of Health and Population, Nyaya opened the Bayalpata Hospital.

Today we are proud to celebrate Bayalpata’s second anniversary, and on this special day offer our deep gratitude to the staff who make Bayalpata’s services a reality, to our partners in Nepal and throughout the world, and to you our supporters, without whom this work would simply not be possible. Since 2006 when we first visited, Achham has grown and developed immensely. With the support of the government, Nyaya, and other critical local non-profit organizations, Achham’s infrastructure, services, and even healthcare have improved markedly. Two years ago, and certainly five or ten years ago, women like the patient described would not have had access to even basic healthcare. Today services like roads have improved, and through your support, there is a rapidly growing healthcare system with a hospital, improved community health centers, a community health worker network, and even ambulance services.

Yet sadly, Achham also remains one of the poorest regions in South Asia and has appallingly high rates of poverty and illness; while there are daily stories of success, there remain unconscionable tragedies. And so today – on this second anniversary – Nyaya has recommitted to Achham and to the struggle for equitable healthcare. We envision an Achham in which women are not forced to walk for two days to deliver their babies, and we dream of a world where future generations will not believe such stories ever had to be told. We thank you again for your continued support – we are deeply proud of Bayalpata Hospital and of each and every success that has come from its work – and look forward to working with you more to continue the success of the last two years.

Warm regards,

Ryan Schwarz
Vice President of US Operations 

Learn more about Nyaya Health.

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An example of the seamless flooring that will be installed in November.

A few months ago, Chett Walsh of Shawmut Design and Construction approached Troy Bickford, President of Raynham, MA-based Contract Flooring, for his professional opinion on some technical details regarding the seamless flooring to be used in the sterile areas of the hospital. Troy offered much more than his thoughts -- he offered to help PIH get the flooring at a substantial discount and he volunteered to send a crew, including himself and his family, to do the installation in Haiti.  

 “I liked the idea of helping a worthwhile cause and the challenge of this project, so I jumped at the chance,” said Troy. 

In November, the Contract Flooring team will travel to Mirebalais for approximately 3 weeks to install the seamless flooring. Troy already has his whole installation team lined up, including his brother Joe, his nephew Erik, and his son Daniel, along with CJ Costa and Mynor Perez.

“I hope to bring as many guys down as I can,” says Troy, “I always have people asking when we are leaving. I hope they have this same sense of spirit when the time comes!” 

Seamless flooring is used to protect against the spread of infectious diseases in hospitals. Without seamless flooring, blood spatter and other bacteria from fluids can seep into the space between floor and walls or be absorbed by grout between tiles. Once absorbed, the bacteria are not easily cleaned and can multiply and spread. 

This will be especially critical in the Mirebalais operating rooms where the Zanmi Lasante medical teams hope to perform surgeries like large orthopedic procedures that require a very high degree of infection control.  Seamless flooring is flashed and sealed six inches up the wall so spills can be easily cleaned and there is no joint or seam. 

Not only has Troy helped design the installation of the flooring, but he has also networked within the flooring industry to procure the materials either as donations or at a substantially discounted rate.  

Troy is most excited about working on site in November, as one of the final steps of construction completion and shortly before the hospital opens to the public. “I’m eager to see the project complete and up and running. We’re ready to get out there and get it done.  I hope people respond well to our work and hope it makes the hospital run smoother on a day to day basis.” 

However, Troy has another goal for this trip as well: “I hope [this trip] is educational for my son. I would like him to have more perspective on just how much we have and how fortunate we are to live like we do.”

IHSJ Reader     June 2011     Issue 3          

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

HIV/AIDS

Bold New HIV/AIDS Targets for 2015 Set by World Leaders  (Press Release – UNAIDS, June 10, 2011)
The UN General Assembly adopted the “Political Declaration on HIV/AIDS: Intensifying our Efforts to eliminate HIV/AIDS” at the conclusion of the High Level Meeting on AIDS in NYC. The Declaration sets forth bold new targets for putting 15 million people on life-saving antiretroviral therapy in low and middle-income countries by 2015 (about twice the number currently on therapy) and halving the number of TB-related deaths among people with HIV. The declaration also calls for eliminating HIV infections among children, reducing sexual transmission of HIV, halving infections among people who inject drugs, and increasing AIDS-related spending to reach between US $22-24 billion in low- and middle-income countries by 2015.  PDF of Declaration:  http://www.ip-watch.org/weblog/wp-content/uploads/2011/06/2011-Political-Declaration-on-HIV-and-AIDS.pdf.

We CAN End the AIDS Epidemic (AVAC: Global Advocacy for HIV Prevention, June 2011)
For the first time in the 30 years of the AIDS epidemic, there is now conclusive evidence showing that earlier initiation of combination antiretroviral therapy at 350-550 CD4 cells/mm3 is a powerful tool for reducing transmission and has clinical benefit for HIV-positive people. In light of these results, this statement calls for increased funding to be directed to the treatment and prevention of HIV through community-based mobilization for health and human rights.

World Leaders Launch Plan to Eliminate New HIV Infections Among Children by 2015 (Press Release – UNAIDS, June 9, 2011)
Last week, world leaders also launched a Global Plan for eliminating all new HIV infections among children by 2015, and for extending access to life-saving HIV prevention and treatment to all–but especially pregnant–women. The plan focuses on a series of specific policy and programmatic measures that countries will take to ensure that all pregnant women living with HIV have access to HIV prevention and treatment services. PDF of Global Plan: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children_en.pdf

The 30^th Anniversary of the First Reported Case of AIDS (National Institute of Allergy and Infectious Disease, Anthony Fauci and Jack Whitescarver, June 2, 2011)
Thirty years after the first reported cases of AIDS, the epidemic continues to be one of the most serious public health crises of our time and will continue until more effective and affordable prevention and treatment regimens are developed and made universally available.  Read more about past and future efforts from the National Institutes of Health on research efforts to halt the epidemic from two preeminent scientists.

States Cut Back Efforts to Provide Drugs for HIV, AIDS (Washington Post, Shefali S. Kulkarni, May 22, 2011)
A May 2011 article in the Washington Post illustrates how important it is to increase domestic spending on HIV/AIDS as well. Several states are scaling back efforts to provide life-saving medication to HIV patients due to budget restrictions. A record number of people–more than 8,300–are now on waiting lists for drugs used to treat HIV and AIDS or side effects and opportunistic infections. The AIDS Assistance Drug Program (ADAPs) is not an entitlement program, so as state budgets are cut, more and more low-income applicants who cannot afford the drugs are turned away or placed on waiting lists until further notice. 

Effectiveness of Early Antiretroviral Therapy Initiation to Improve Survival among HIV-Infected Adults with Tuberculosis: A Retrospective Cohort Study (PloS Med, Molly F. Franke et al., May 3, 2011)
This study used randomized clinical trials to examine the optimal time to initiate combination antiretroviral therapy (cART) in HIV-infected adults with tuberculosis. The results were clear: early cART reduced mortality among individuals with low CD4 counts and improved retention in care, regardless of CD4 count. It is still unclear whether these results can be generalized to the vast majority of people co-infected with TB and HIV, given their limited access to standard diagnostic tools.  

***Occupational Segregation, Gender Essentialism and Male Primacy as Major Barriers to Equity in HIV Care giving: Findings from Lesotho (International Journal for Equity in Health, Constance Newman, Linda Fogarty, Lucia Makoae, Erik Reavely, June 8, 2011)
Gender segregation within the health workforce has been recognized as a major source of inequality worldwide. Gender segregation is particularly dramatic in HIV/AIDS occupations, which typically allocate caring/nurturing jobs to women and technical/managerial jobs to men. This study investigates strategies for increasing equity in caregiving, including ways in which men may be recruited into the community workforce. 

GLOBAL HEALTH FUNDING

Donors Pledge $4.3 billion for Vaccines for the Poor (Reuters, Kate Kelland and Adrian Croft, June 13)
International donors led by Britain and Bill Gates pledged $4.3 billion on Monday to buy vaccines to protect children in poor countries against potential killers such as diarrheal diseases and pneumonia. "Today is an important moment in our collective commitment to protecting children in developing countries from disease," said Liberian President Ellen Johnson Sirleaf, who attended the pledging conference in London.

GAVI’s future: Steps to Build Strategic Leadership, Financial Sustainability, and Better Partnerships (CSIS and CGD, Lisa Carty et al., June 7, 2011)
This policy brief, developed collaboratively by the Center for Strategic and International Studies Global Health Policy Center and the Center for Global Development, provides analysis and recommendations to Global Alliance for Vaccines and Immunization (GAVI) leadership in three vital issue areas: GAVI’s mandate and business model; its financing strategy; and the GAVI Secretariat and partners’ capacities.

***Going Horizontal – Shifts in Funding of Global Health Interventions (New England Journal of Medicine, Till Bärnighausen, David Bloom and Salal Humair, June 9, 2011)
PEPFAR, GAVI, and the Global Fund have recently prioritized more horizontal approaches to global health interventions that do not isolate critical human and financial resources from general health care systems. This shift carries the promise of improving health care delivery in developing countries if global health organizations work side-by-side with in-country policymakers.

HEALTH SYSTEM STRENGTHENING

Ethiopia gears up for more major health reforms (The Lancet, John Donnelly, June 4, 2011)
After five years of strong support for community-based health care programs, Ethiopia’s Federal Ministry of Health has announced that it will create a Health Transformation Army. Though this army will take years to build, Ethiopia is focused on primary health care and being able to help communities help themselves by expanding public health services in villages.       

FOOD SECURITY

Micronutrient Deficiencies and Protein-Energy Malnutrition (The Social Medicine Portal, Claudia Schuftan, May 2011)
Addressing malnutrition cannot be accomplished by focusing on high-tech micronutrient interventions alone. There must also be a focus on empowering people and communities to address the underlying determinants of protein-energy malnutrition, including issues of equity, participation, wealth distribution, and access to health and education services. 

MULTIMEDIA

2011 High Level Meeting on AIDS: Silvia Petretti, Global Network of People Living with HIV (UN, June 10, 2011)
In her statement at the 95th Plenary Meeting of the UN's 2011 High Level Meeting on AIDS, Silvia Petretti emphasizes the importance of involving people living with HIV–and women living with HIV in particular–to be at the center of the response to HIV/AIDS. Petretti clearly explains how this involvement is crucial for historical, political, economic, and health reasons.

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Construction on the new national teaching hospital in Mirebalais is over halfway complete and continues at a rapid pace, despite the onslaught of the rainy season. View a gallery of recent photos below. 

View full screen. 

	A clinician attends to a severely malnourished child at Neno's new Nutritional Rehabilitation Unit (NRU).
	A nurse prepares a feeding for a child at the NRU.

On May 26, Neno District Hospital admitted its first patients into a new Nutritional Rehabilitation Unit (NRU) — the first of its kind in the rural Neno district of southern Malawi.

The NRU, which provides specialized care to dangerously malnourished children, is supported by a partnership between PIH’s Malawian sister organization Abwenzi Pa Za Uyomo (APZU), the Malawian Ministry of Health, and the Clinton Health Access Initiative (CHAI).

The three young children admitted were all dangerously malnourished, reported Dr. Jonas Rigodon, PIH/APZU Country Director for Malawi. Previously, such cases had to be referred to a NRU in the neighboring Mwanza District, which is hours away for many of the patients served by APZU in the Neno district, added Dr. Rigodon.

In a country where roughly one in five children under the age of five is moderately or severely underweight, and over half suffer from moderate or severe stunting due to chronic malnutrition*, the APZU team believes that they will very soon be admitting many more children as the word of the new facility spreads. In addition to the Neno District, the new NRU will also likely serve patients in the neighboring Ntcheu District, as well as Mozambique, a country that borders Neno to the west.

The new NRU is part of APZU’s comprehensive Community-based Therapeutic Care (CTC), which identifies and treats malnourished children under the age of 12 in the district, as well as pregnant and lactating mothers. The other components of CTC — community outreach, out-patient therapeutic care, and supplementary feeding — bring services even closer to patients, allowing for better access to health care for those most in need.

“The components are designed in a decentralized manner, with multiple distribution points,” explains Dr. Rigodon.

Village Health Workers play a vital role in supporting CTC. They provide community outreach services, which include sharing information about malnutrition with their neighbors, identifying likely cases, referring and accompanying patients to the hospital, and following up with them when they return home to help ensure that the children do not relapse.

Once at the hospital, only the most severe cases, or cases with additional medical complications such as severe dehydration or vomiting, are admitted to the NRU. The swelling of the soft tissues known as bilateral oedema is the most common criteria the hospital uses to determine whether the patient should be admitted to the NRU or treated as an outpatient, adds CTC Coordinator Blessings Banda.

The majority of patients referred for malnutrition are able to be treated as outpatients, using Ready-to-use Therapeutic Food (RUTF), which can be administered at home. Currently, there are 37 children in CTC's out-patient therapeutic program. A partnership with the company Two Degrees helps supply RUTF for this program. 

In addition to the RUTF distribution, CTC's supplementary feeding program provides take-home food rations to children suffering from malnutrition, as well as at-risk pregnant or lactating women, and patients who have been discharged from either the NRU or the out-patient program. There are currently 275 patients in this program.

Dr. Rigodon reports that two of the first three patients admitted to the NRU have already been discharged.

*According to World Health Organization 2009 estimates.

By Kaitlin Keane

	PIH Interns Allie Broas and Nina Skagerlind have a discussion in a hallway at PIH's Boston office. Allie is working with PIH's Communications team, and Nina is interning for PIH's Lesotho team.
	Intern Sika Holman works with PIH's partner organizations in Mexico and Guatemala.
	Several PIH Summer Interns bond over lunch outside the office.

The paths that led the Institute of Health and Social Justice interns to Boston this summer are varied, and our future plans span a wide range of careers and specialties — but as an international group of students, clinicians and young professionals, we share a common commitment to fighting poverty, social injustices and health inequities.

Jill Shah discovered her passion for public health and social justice early on, growing up amid the bustling streets of Mumbai. For Peter Kaminski, it was work as an EMT that highlighted the country’s health disparities and placed him on the road to medicine. Sika Holman was drawn to public health after years as an RN and a stint in the Peace Corps, while Brittany Powell found passion in the classroom, learning about global health disparities firsthand from PIH co-founder Paul Farmer during a course at Harvard College.

Our group of 27 started the summer at PIH last week with the promise of working on projects and initiatives that matter both to us and people around the world. Through specific project work paired with lectures and discussions, the program will also provide exposure to global public health issues that many of us have long been hungry to learn more about.

“Global Health has always been my passion, before I even knew it had a name,” said Sarah Phillips, a Colorado College student working on the Right to Health Care team, which transports patients to the US to receive care unavailable in their home country, with the help of collaborating hospitals and clinicians. Like many of us, Phillips began following PIH’s work after reading about Paul Farmer and fellow co-founder Ophelia Dahl in Tracy Kidder’s “Mountains Beyond Mountains,“ and relishes the opportunity to learn more about her mentors’ efforts to bring integrated comprehensive health systems to the poor.

As we work on various projects and find our way around PIH, we will be writing about new experiences, interesting stories and people and new knowledge gleaned from meetings, lectures and interactions. Watch for reflections on meeting local patients, interviews with longtime employees working in the field, and details about the projects in which we are involved.

For many of us, the work we are doing will builds on previous experience or fields of study, and we hope to utilize PIH’s successful model and resources both to get better at what we do and make a valuable contribution here.

For example, Xeno Acharya, originally from Nepal, will work with in Boston with Dr. Edward Nardell on tubersulosis research, building on his previous work with infection prevention at a hospital in Ethiopia. Kate Glynn will bring both non-profit experience from her time at The American Cancer Society and skills gleaned as an MBA candidate at the Boston University to her internship with PIH's development team. And as a fourth year medical student, Donal Hanratty will travel from Ireland to Boston to support research studies in Haiti, which will expand upon skills he learned while organizing an AIDS awareness campaign in Andhra Pradesh, India.

From Boston to Rwanda

In addition to our local Boston IHSJ interns, this blog will include posts and updates from a younger group of interns who are farther away. Three local high school students -- Becca Nova, Danny Davis and Nikki Philip will fly to PIH’s site in Rwanda this month to spend a month documenting patient experiences and progress at Rwinkwavu Hospital, teaching English to eager staff and assisting employees in both the pediatric ward and agricultural fields.

Nova, who has previously traveled to the Rwanda site four times, said the chance to live and work among the people she has previously only met in passing will offer a chance at greater fulfillment and the opportunity to help.

“Each time I go there I’ve been able to connect more with the people and the country, and living there will give me a chance to really feel like I’m a part of what’s going on,” she said. “I won’t just be hearing about people doing good things but actually doing them.”

Kaitlin Keane is an IHSJ Summer Intern with PIH's Communications Team. 

US [government] Sponsors Ambitious Study of TB Transmission in Peru

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

Wednesday August 3, 2011 – 12:32 p.m.

RONNY ISLA ISUIZA

Online Edition

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

“We want to understand why some people contract tuberculosis while others who live in the same home and eat the same food don’t; why some appear to have greater resistance [to the illness] than others; why some don’t become sick for one to two years while others have TB symptoms just weeks or months after their first contact with an infected person,” explains Dr. Leonid Lecca, the study’s Principal Investigator in Lima. The need to find answers to these questions is the basis for this project, which is financed by the US National Institutes of Health, specifically by the Division of Microbiology and Infectious Diseases of the National Institute of Allergy and Infectious Diseases. The project’s Principal Investigators are Drs. Megan Murray and Mercedes Becerra of Harvard University, who proposed conducting the study in Lima, Peru and secured the multimillion-dollar grant to fund it. Socios En Salud has received six million dollars to carry out the project. 

WHY PERU?

With 32,000 new TB infections, Peru has one of the highest burdens of the disease in Latin America. Although it is painful to admit this, the country is therefore the ideal environment in which to conduct such an ambitious study (El Comercio has published multiple reports on TB in Peru).  Dr. Lecca asserts that measured by the numbers of subjects to be enrolled, the size of the project’s staff and its funding, this is the largest TB study ever conducted anywhere in the world.

“We are attempting to enroll 4,000 TB patients and everyone who lives in their households in the study. Patients may live with as many as five people, so we’re talking about a study of more than 15,000 people,” he explained. The project’s staff consists of nearly 200 people, among them doctors, nurses, nursing and lab technicians, etc.

THE STUDY

The study’s objective directs its focus not to TB patients, but rather to the people who live with them since the goal is to learn which factors contribute to infection and which confer greater resistance [to the illness]. To that end, study teams contact patients through health centers run by the Ministry of Health, which serves as a partner in the project, and then visit their homes to enroll them and other household members in the study.

Dr. Lecca elaborated, “We need to find answers that help us understand TB transmission. The only way to do this is through prospective follow-up of TB patients and people who live with them (following them over time). So when the Ministry of Health diagnoses a TB case in a health center, we look for that patient’s household members. We find healthy people who have been in contact with the TB bacilli, or others who have symptoms; the latter then require a thorough evaluation to diagnose if they have TB. The goal is to identify when these healthy people are infected with TB and with what type of TB.”

SOLIDARITY IN ACTION

However, this project serves not merely as a witness to TB transmission. When a person who may have TB is identified, he or she is referred to a health center to screen for infection and the disease (which are two distinct stages). The Socios En Salud study team also screens for TB infection using PPD testing and requesting sputum specimens from people with respiratory symptoms so that the TB bacilli may be isolated and tested. The study also provides chest x-rays to screen for disease and offers HIV testing to all subjects.

“The study works with the Ministry of Health to identify people in the community with respiratory symptoms and helps achieve timely diagnosis of TB. People go to a doctor as soon as they feel sick, but this study speeds up the identification of these people by referring them promptly to health centers for treatment. This study encompasses service, training, and research,” Dr. Lecca explained.

STUDY AREA

The study is being conducted in the DISA V region of Lima, in districts that include Rímac, San Martín, Los Olivos, Cercado, La Victoria, Lince, San Luis.

When data collection is completed, the researchers will conduct an analysis and publish their conclusions, sharing them with the global scientific community in the hope of reducing the spread of this disease that affects millions of people around the world.

Oswaldo Jave Castillo, who directs Peru’s National TB Program, believes that this study, “will add to the knowledge” that his institution uses to carry out its mission. He explained, “Knowing how frequently contacts (of TB patients) are infected and at what point will allow us to adapt some of our interventions, such as how many times a year we should test the household contacts of TB patients for the disease.

KEY INFORMATION

The areas in metropolitan Lima with the highest number of TB cases are La Victoria (San Cosme, El Pino), Cercado de Lima and San Martín de Porres.

There are three types of TB: simple or drug-susceptible TB, multidrug-resistant TB (MDR-TB), and extensively drug-resistant TB (XDR-TB). MDR-TB is resistant to two drugs used to treat the disease. Eighty-two percent of MDR-TB cases in Peru are in Lima. Nearly all the drugs used to treat MDR-TB are imported. XDR-TB is resistant to five anti-TB drugs. Ninety-three percent of XDR-TB cases in Peru are in Lima. The first XDR-TB cases in Peru were detected in 1999 and today number 341.  According to the World Health Organization, in 2009, TB killed 1.7 million people (380,000 of whom had HIV). 

The main hospital electrical room and vault are being prepared.

Dr. David Walton (Project Director for Partners In Health), Myk Manon (Haiti Country Director for NRECA) and Omar Tejada (Head Engineer for COAMCO) look over the site.

The beginning of June has been especially productive at construction site of the National Teaching Hospital at Mirebalais, Haiti. Our construction team has prepared the roof of the Building 4--housing the mechanical and electrical equipment, laundry facilities and kitchen--with steel reinforcements so that they can pour the concrete slab in the next couple of days. The construction team has been quickly installing the electrical and plumbing, stuccoing, and laying concrete block in all four buildings currently under construction. 

Partners In Health has recently agreed to a partnership with the National Rural Electrical Cooperative Association (NRECA). Engineers from NRECA, a US-based company, brought crews of volunteer electrical linemen to the site last week to begin making improvements to electrical grid and transmission lines. The NRECA is also working as consultants with EdH, the Haitian national power company, to help them to improve the electrical transmission and infrastructure of the country. 

This coming week we look forward to pouring more concrete and starting the walls of the Men’s, Women’s, and Children’s Wards. 

Additionally, the Interim Commission for the Reconstruction of Haiti (IHRC) held a press conference on May 27 to announce that Mirebalais Hospital--the largest IHRC-approved public construction project in Haiti--is 50% complete. This milestone has been covered by a variety of journalists around the globe, including stories in the following publications:

Teaching Hospital on Haiti’s Central Plateau Over 50 Percent Complete
(picked up from PR Newswire, similar stories in WN.com, KOLD, Bioportfolio, Yahoo, Herald Online, India Times, MedIndia, Haiti Live News)
The PIH/ZL-MSPP Teaching Hospital of Mirebalais, a major public health services and medical training facility in Haiti's Central Plateau approved by the Board of the Interim Haiti Recovery Commission (IHRC) in August 2010, is quickly moving toward completion, having passed the 50 percent completion point this May.  

Bellrive rechaza la propuesta de Rouzier de eliminar comision de reconstruccion
(similar story in Yahoo, El Nuevo Diario, Informador, Univision, SDP Noticias, Terra, MSN, 123.cl, EFE)
El primer ministro saliente de Haití, Jean-Max Bellerive, se mostró este jueves opuesto a la eliminación de la Comisión Interina para la Reconstrucción del país (CIRH), como lo planteó ayer el candidato a sucederle en el cargo, el economista Daniel Gerard Rouzier.

By Kaitlin Keane

A decade ago, the international health community, prompted by activists including persons infected with HIV, came together to establish fundamental treatment and prevention goals that shaped the past decade's approach to curbing the AIDS epidemic. From that landmark meeting, the United Nations' first ever Special Session on HIV/AIDS, came a declaration calling for universal access to prevention, treatment and care.

Ten years later and just days after the 30th anniversary of the first reported cases of HIV/AIDS in the United States, the international community has again converged in New York for the second high level meeting on the disease — and debate continues to rage over the expected outcome of the meeting and the potential effects of the resulting declaration.

Prior to the completion of the three-day conference, discussion among the health community has focused on the language of the document expected to come out of the meeting. Partners In Health has worked with other organizations to keep concrete timeline and funding goals in the declaration, while cutting references influenced by moral and political ideas rather than evidence and human rights.  

Among the most pressing priorities are:

• Holding the international community accountable to time and funding goals by adding the goal of "15 by 15" — providing necessary treatment to 15 million HIV/AIDS patients by 2015. The goal, deemed overly ambitious by some first-world nations, would still treat less than 80 percent of the patients in need. 
• Advocating for "treatment as prevention," a strategy bolstered by results released last month from the HPTN 052 study, which confirmed the Partners In Health approach that putting patients on antiretroviral therapy early drastically reduces transmission. The results — a 96 percent reduction in transmission among the group given early treatment — should mean more funding directed at putting patients on treatment much earlier than has been standard practice for the last decade.
• Capitalizing on recent announcements of significant price reductions on antiretroviral drugs for HIV/AIDS patients in the developing world.
• Recognizing both the crucial link between AIDS-related deaths and tuberculosis — the leading killer of people living with HIV/AIDS — and the feasibility of saving lives lost to the fatal combination. One million lives could be saved by 2015 if world leaders commit to efforts to prevent and treat tuberculosis among people living with HIV/AIDS.

Dr. Wesler Lambert, who works with PIH’s sister organization in Haiti, Zanmi Lasante, is attending the meeting and said he was encouraged by the support professed for earlier ART from speakers and other attendees. There was also support for integration of HIV treatment into comprehensive health care alongside programs for nutrition and TB — a strategy that improves chances of success, he said.

As the high level meeting continues, Partners In Health strongly advocates for world leaders to adopt an integrated approach to HIV/AIDS support and care programs, including the accompaniment model that continues to prove successful in countries where community health workers care for the local patients and through which stronger health systems in resource-poor countries are developed to increase the capacity of existing healthcare systems to treat other diseases and conditions.  

As part of their final project of the semester, students of a Global Issues class at Carrboro Hogh School in Carrboro, NC, organized and led a public forum about Haiti’s reconstruction efforts following the January 2010 earthquake. These young social justice warriors presented information on large posters, answered questions, and moderated a dialogue among more than 100 community members.

During the event, the student explained the importance of building roads and providing free education as Haiti continues to build back.

“[The students] worked far harder than they expected to when they signed up for this class,” says Global Issues teacher Matt Cone.

While the students may agree with that statement, they also recognize the impact and scope of what they've accomplished over the past 5 months.

“When I started in the class I had no idea what we were doing,” says one student. “It was global issues, in the plural… I wasn’t expecting it to be so direct, so narrow about Haiti. But, now I’m glad that it was, I learned so much about it. I’m so proud of myself for learning all of this.”

Students spent much of the semester preparing for this culminating event. They read Tracy Kidder’s Mountains Beyond Mountains, talked with Paul Farmer and Ophelia Dahl, started a chapter of the student health organization FACE AIDS, and raised tens of thousands of dollars for PIH’s work in Rwanda.

As the school year draws to a close in this suburb of Chapel Hill, NC, Mr. Cone sent one final update. 

The colloquium was a hit! Parents, community members, and fellow students learned about Haiti and the importance of social engagement. 

“I think this is great. The students just didn’t learn, they learned to think,” says a community member who attended the May 23 event.

“I saw more than just content… but enthusiasm. I could see these guys and girls take that forward and really do something in the world,” comments another attendee.

The students are excited to continue this conversation next year and bring in another round of influential speakers. If you are interested in helping the students of Carrboro High, send an email to haititalks@gmail.com.

Students raise over $23,500 for PIH’s work in Rwanda.

Carrboro students advocate for social justice in developing countries.

The Carrboro press covers the startup of the FACE AIDS chapter.

The walls of isolation wards for patients with highly infectious diseases went up rapidly this past week.

The rainy season is in full swing, which can often make construction very challenging.

Scope of hospital as of June 6^th, 2011.

We’re very happy to report that since our last donor update, we have received a very generous donation from Boston’s own Marr Scaffolding Company. They are supplying us with scaffolding to be used on the construction site. This donation makes the site a much safer place for each and every worker. Thank you to everyone at Marr Scaffolding Company, it is because of companies and people like you that this project is achievable.  

We’d like to take this time to mention that the Mirebalais Hospital Project is still in need of many refurbished materials, tools and equipment.  One small tool can go a long way! If you’d be interested in donating or seeing a list of needed materials, please contact Heidi at hburgess@pih.org. 

Check back next week for a construction update from the National Teaching Hospital! If you’d like to view more photos on the hospital progress, please visit our photo gallery.

	A cholera treatment center in Haiti.
	Paul Farmer at a cholera treatment center in Haiti.
	Community health workers educate their neighbors about cholera prevention.

As Haiti’s cholera epidemic enters its ninth month, the country’s rainy season has begun, further stressing and disrupting the country’s woefully inadequate water and sewage systems. According to the World Health Organization (WHO) and Haiti’s Ministry of Health, increasing numbers of people are falling ill and dying from the illness.

Debate about the public health response to the crisis has also been under way, with some experts arguing that a vaccination campaign in Haiti would be neither feasible, nor cost-effective. But a coalition of medical and public health researchers, policymakers, and practitioners, led by PIH co-founder Paul Farmer, argue that a universal vaccination campaign is essential to ending the crisis in an article published in the May 31 issue of the open-access journal PLoS Neglected Tropical Diseases.

“Vaccination has a significant role to play in Haiti given the vulnerability of the post-earthquake health, water, and sanitation systems and the observed virulence of the El Tor strain,” write the 44 authors of Meeting Cholera’s Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care. “The MSPP (Haitian Ministry of Health) has called for nothing less than a universal vaccination campaign — an end goal this document endorses.”

In addition to universal vaccination, the statement endorses three primary goals: aggressive case finding and scaling up of all treatment efforts; strengthening Haiti’s water and sanitation infrastructures; and linking prevention to care by bolstering surveillance, education campaigns, and water, sanitation and hygiene (WASH) efforts. “[I]n the face of cholera’s challenge to Haiti and the world, we can accept nothing less than complementary and comprehensive prevention and care,” writes Farmer, who is also the Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, and his coauthors.

There are currently fewer than 400,000 vaccine doses ready for shipment, but the PLoS consensus statement asserts that advance purchase commitments could significantly increase availability, perhaps to several million doses. In the past, bulk purchases have expanded vaccine access by boosting production and lowering prices. Economies of scale contribute to lower production costs, as observed during the scale-up of antiretroviral therapy for HIV/AIDS.

Furthermore, scaling up efforts in Haiti would also create momentum to prevent similar vaccine shortages during future outbreaks. For example, Farmer and his coauthors say that neighboring countries in the Caribbean and Latin America also lack strong public health, water, and sanitation systems, so the threat of a multi-country epidemic is real.

Farmer and some of his coauthors drafted a vaccination proposal to present at the World Health Organization (WHO) meeting ("Integrated Response to Cholera Outbreaks in Large Scale Humanitarian Crises") in May. As a first step in a Haitian vaccination campaign, they called for the WHO to endorse the development of a two-million dose stockpile for Haiti, coupled with a large-scale pilot in Haiti comparing the effectiveness of cholera control efforts with — and without — mass vaccination. If this pilot were successful, they would suggest that production be ramped up so a global stockpile of 10 million doses could be developed.

Before last October, cholera had never been reported in Haiti. Largely because Haiti’s population was “immunologically naïve,” initially the outbreak exhibited a 7 percent case-fatality rate — among the highest recorded in recent history. In just 40 days, there were over 2,000 reported cholera-related deaths — nearly half the number of total deaths registered in Zimbabwe’s yearlong epidemic, which started in 2008, and the Haitian figures are likely underreported in many rural areas. 

	Settlement camps for displaced earthquake survivors are vulnerable to cholera outbreaks.

Another factor that has exacerbated the Haitian epidemic includes the large number of people left homeless and displaced by the 2010 earthquake who have been living in rural areas or large rural slums, where the epidemic has been most severe. “These communities were charged with hosting hundreds of thousands of displaced people after the earthquake, placing greater demands on their already-scarce resources, including water,” write Farmer and his coauthors.

A cholera vaccination campaign could leverage existing health worker networks without taking doctors and nurses away from providing more acute care. Unlike more complex medical interventions, community health workers can quickly and effectively administer oral vaccines. And existing vaccination and treatment delivery infrastructure — such as the cholera treatment units (CTUs) and cholera treatment centers (CTCs) created during the crisis — may provide sites for vaccine administration.

Paul Farmer is the United Nations Deputy Special Envoy to Haiti, and Chief of the Division of Global Health Equity at Brigham and Women's Hospital. The other coauthors of the article represent organizations including the Haitian Medical Association, GHESKIO Centre, the Earth Institute at Columbia University, the Global Health Program or the Bill & Melinda Gates Foundation, the International Vaccine Institute, the American Society of Tropical Medicine & Hygiene, and the International Centre for Diarrhoeal Disease Research in Bangladesh.

Read the entire article "Meeting Cholera’s Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care."

IHSJ Reader     June 2011     Issue 2          

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

HIV/AIDS

Clinton Health Access Initiative, UNITAID, and DFID Announce Lower Prices for HIV/AIDS Medicines in Developing Countries (Press Release - UNITAID, May, 17, 2011)
In the wake of groundbreaking HIV prevention results, the Clinton Health Access Initiative, UNITAID, and UK’s Department for International Development announced that their partnership achieved another round of dramatic price reductions in antiretroviral drug regimens. These price reductions will generate a global savings of $600 million to $1 billion over the next three years, making HIV treatment more widely accessible.

CHOLERA

Meeting Cholera's Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care (PLoS Neglected Tropical Diseases, Paul Farmer et al., May 31, 2011)
Debate about the public health response to Haiti's cholera epidemic continues as the crisis enters its ninth month. In a viewpoint article published on May 31, 2011 in the open-access journal PLoS Neglected Tropical Diseases, a coalition of medical and public health researchers, policymakers, and practitioners argues that a universal cholera vaccination campaign along with standard cholera prevention and strengthened treatment methods are essential to ending the crisis.

GLOBAL HEALTH FUNDING

G8 Declaration Renewed Commitment for Freedom and Democracy (G8 France 2011, May 26-27, 2011)
Though global health took a back seat at the 2011 G8 Summit, in the final Declaration, G8 leaders commit to continue to support the Global Fund to Fight AIDS, Tuberculosis and Malaria; reaffirm their commitment to maternal and child health through the Muskoka Initiative; recognize the impact of the GAVI Alliance, and “strongly welcome” its efforts to expand access to new and under-used vaccines in the poorest countries through tiered pricing and innovative financing mechanisms; and stress their continuing commitment to the eradication of polio.  However, without specific targets, it will be difficult to hold G8 leaders accountable to delivering the investments needed to advance the fight against global hunger and premature death.

A Special Relationship to Save Lives (Huffington Post, Joanne Carter and Aaron Oxley, May 25, 2011)
On June 13^th, President Barack Obama and Prime Minister David Cameron will meet for the Global Alliance for Vaccines and Immunization (GAVI Alliance) pledging conference. With nearly 40 percent of the 8.8 million child deaths in developing countries due to preventable and treatable conditions, both governments need to commit to funding GAVI’s immunization of 240 million children.  

Rhetoric versus Reality: The Best and Worst of Aid Agency Practices (William Easterly and Claudia Williamson, May 11, 2011); IHSJ Review of Easterly/Williamson Report (PIH Blog, Meredy Throop, May 31, 2011)
Have international aid donors delivered on their promises to improve aid practices? For the most part, no, according to a new piece about aid effectiveness by William Easterly and Claudia Williamson of the Development Research Institute. The IHSJ’s Meredy Throop provides a summary and analysis of the 78 page report by Easterly and Williamson.

HEALTH SYSTEM STRENGTHENING

Task Shifting in HIV Care: A Case Study of Nurse-Centered Community-Based Care in Rural Haiti (PLoS, Louise Ivers, Jean-Gregory Jerome, Kimberly Cullen, Wesler Lambert, Francesca Celletti, Badara Samb, May 6, 2011)
Good clinical and program outcomes demonstrate that task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services. The authors reveal how community health workers provide essential health services that are otherwise unavailable in poor, rural areas.

***Strengthening the Health System While Investing in Haiti (American Journal of Public Health, Louise Ivers, June 2011)
In this editorial, Dr. Ivers explains how disease-specific funding can be used to strengthen comprehensive health services and public health systems. In this way, a program created to respond to the HIV crisis has the breadth and flexibility with which to respond to a totally different kind of crisis—mass earthquake causalities.  

HEALTH AS A HUMAN RIGHT

***Human Rights in Global Health Diplomacy: A Critical Assessment (Journal of Human Rights, Michelle Gagnon and Ronal Labonté)
What arguments exist for why health (and notably health equity, the reduction of preventable inequalities in health within and between nations) should be a prominent foreign policy concern? Within the polyphony of possible arguments, where is there reference to human rights and have invocations to human rights by governments with stated commitments to health in their foreign policy mattered in how they actually behave? This article begins to address these questions.

FOOD SECURITY

Malnutrition: Child Mortality Observed 50% Lower With Better Food (Press Release – Medecins Sans Frontieres (MSF), May 24, 2011)
A study conducted  by MSF in Niger in the fall of 2010 found a 50 percent drop in mortality among young children who received a ready-to-use supplementary food (RUSF), compared to those who did not. This outcome reinforces the need for complementary RUSF for young children in countries where malnutrition remains high. 

Chicago Council Releases 2011 Progress Report on U.S. Leadership in Global Agricultural Development (Press Release - The Chicago Council on Global Affairs, May 24, 2011)
The Progress Report on U.S. Leadership in Global Agricultural Development was released, giving the U.S. government an overall grade of B minus for its efforts to reassert leadership in global agricultural development. The report emphasizes that little progress has been made on several structural and economic barriers including: how food aid is administered; rules against working on specific commodities; opposition to input subsidies or vouchers as a development strategy; failure to complete negotiations to lower world trade distortions; and the use of corn for fuel instead of food.
 

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By Meredy Throop

Have international aid donors delivered on their rhetorical promises to improve aid practices? For the most part, no, according to a new piece about aid effectiveness—or perhaps more aptly, aid ineffectiveness—by William Easterly and Claudia Williamson of the Development Research Institute.

Their paper, Rhetoric versus Reality: The Best and Worst of Aid Agency Practices, measures donors’ adherence to five “best practices” that have been prominently featured in the Paris Declaration, aid agency documents and academic literature alike. These include: (1) maximum transparency; (2) minimal overhead expenses; (3) specialization of programs by sector or country; (4) delivery through more effective channels; and (5) selective disbursement of aid based on poverty and good government. The findings for each of the five indicators are summarized below and explained in great detail in the paper.

Although the paper finds poor overall performance and little to no evidence of improvements in specialization, fragmentation and selectivity, the Global Fund to Fight AIDS, TB and Malaria was a real outlier, scoring highly across all indicators and donor categories. Not only is the Global Fund leading the aid community on transparency, specialization, and selectivity, but it has the lowest overhead costs for any multilateral or UN agency. For every employee, the Global Fund disperses over $5 million of highly specialized aid dollars to low income, less corrupt recipients.

The UK performs best among bilateral agencies, followed by Japan, New Zealand and Germany. The US falls below average, and the Scandinavian agencies rank surprisingly low. The UK disperses $4.4 million aid dollars per employee, publishes budget and staffing information on the website, fully reports aid flows to the Organisation for Economic Co-operation and Development (OECD), and does not tie any of its aid. (In 2001, the UK set an important precedent for the donor community by untying all development assistance.)

The worst performing agencies are all bilateral donors: United States, Portugal, Sweden, Switzerland, Spain, Belgium, Finland, and finally Greece. The US ranks highly on transparency, but, despite decades of criticism, still ties a quarter of all foreign aid, is a leading exporter of food aid, and does not select recipient countries based on poverty or good governance. Given this poor performance on ineffective channels on selectivity, Easterly and Williamson hypothesize that domestic lobbying and national security interests “dominate the politics of American aid.”

Transparency

Easterly and Williamson use two indices to measure transparency. The first transparency index is based on the extent of data reported directly to the OECD in 2008. Bilateral agencies reported more data to OECD than both multilateral and UN agencies.

The second transparency index, overhead costs, measures four categories of overhead costs including: international staff, administrative expenses, salaries and benefits, and total development assistance disbursed. The study found that despite rhetoric surrounding the international aid transparency process, most bilateral agencies fail to report budget and operations data, and few responded to the researchers’ direct request for information. Two agencies (MOFA Japan and France’s DgCiD) failed to report any data whatsoever and three other agencies, all Scandinavian, fall below the half-way benchmark. Though multilateral agencies made the most non-OECD development assistance data publicly available, the UN agencies performed the worst, with zero reporting for the UNDP.

In total, five bilateral agencies—including the US and UK--got a perfect overall score on transparency, as did four multilaterals and one UN agency. The worst performers were all UN agencies: the FAO, UNDP, UNTA and UNIFEM. One of the few positive trends emerging from the study was the indication that both bilateral and multilateral agencies are becoming more transparent over the long-run. However, the authors still claim that transparency is “shockingly poor” in most aid agencies.

Overhead

The second best practice, low overhead costs, was measured according to: (1) ratio of administrative costs to ODA (official development assistance) or ODF (official development financing); (2) ratio of salaries and benefits to ODA; (3) and the level of ODA or ODF disbursed divided by numbers of employees. Bilateral agencies were found to have lower salaries and overhead costs relative to lending than multilaterals, which in turn have lower cost rations than UN agencies. The worst performers were the UNDP and UNFPA, which were found to spend more on administrative costs than on aid disbursements.

Specialization

Specialization, the converse of fragmentation, has been a key area of reform to emerge from the Paris Declaration and Accra Agenda for Action. According to Easterly and Williamson, “Most agree that there have been too many donors in too many countries, stretched across too many sectors or projects.”

Given its mission (Palestinian refugees), UNRWA ranked at the top of specialization by country, as did all regional development banks, potentially distorting their overall scores. Similarly, some agencies that specialize by sector, like the UNFPA (population and reproductive health) or the WFP (food aid) received high ratings. However, fragmentation was rampant among bilateral agencies that lack a specialized mission. The political economy incentives for fragmenting aid, such as appeasing sector and country lobbies, are likely responsible for the stark lack of progress in this area.

Selectivity

The fourth measure is selectivity. To measure selectivity, the researchers positively scored aid to low-income countries, and negatively scored aid to corrupt or “unfree” countries. Countries were classified as free if they received a Polity IV democracy score equal to 8, 9, or10, where 0 represents autocracy and 10 is fully democratic.

The World Bank received the top score on selectivity, closely followed by the Asian Development Bank and the Global Fund. These scores reflect a commitment to mobilizing aid primarily for “non-corrupt” poor countries. Thought the jury is still out on how to support impoverished citizens in corrupt societies, UN agencies such as the UNDP and UNICEF were penalized for prioritizing poverty selection criteria above good governance. At the other extreme, Japan and the Caribbean DB channel aid exclusively to non-corrupt democracies, regardless of economic need. The United States is one of the biggest losers on the selectivity measurement, doing badly on both poverty and governance scores. This likely reflects the primacy of narrowly-defined foreign policy objectives when determining aid recipients.

Findings confirm that donors did not substantially change aid disbursement in response to democratization. Instead, the significant decline in the share of aid to autocratic countries after 1990 is driven by governance transformations within recipient countries. Easterly and Williamson find that the negligible changes in aid shares to corrupt countries reflect the most egregious contradiction between rhetoric and actual outcomes.

Ineffective channels

The final measure used is ineffective channels, which are defined as the share of aid that is tied, food aid, or allocated as technical assistance. Tied aid--when a certain percentage of aid must be spent on the donor country’s goods or services--and technical assistance are widely seen as a way for donor countries to promote their own commercial interests above the development needs of recipient countries. Food aid is also recognized as an inefficient way to provide assistance, as it frequently undermines local and regional agricultural markets.

Perhaps most disquieting, new data reveals that the US still ties a quarter of all foreign aid.  The US is also one of the three largest donors of food aid, along with the EC and Australia. Though there is a positive long-run shift away from food aid and instead towards cash for local and regional purchase, the US agricultural lobby continues to resist this change. Globally, food aid has gone from 9 to 1 percent of aid from 1979 to 2008. Thus, the combined reduction in food aid and tied aid constitute the most positive reform trend overall.  

In conclusion authors find that not only does donor rhetoric fail, by and large, to match reality, but there is little to no evidence of improvement in doing so.

Meredy is the Policy and Advocacy Coordinator for Partners In Health's Institute for Health and Social Justice. 

Stucco work inside the future outpatient clinic.

Director of Construction Jim Ansara is speaking with the engineers and foreman.

The scope of the construction site as taken on May 21, 2011.

The hospital site was partially shut down on last weekend, May 27-28, so that the Dominican construction workers could celebrate their Mother’s Day. However, two hundred non-Dominican workers continued the construction throughout most of the 14-acre site.

The first two buildings – the outpatient building and community health center – are coming together nicely. The stucco on the first floor interiors has been completed and work on the exterior has begun. Plumbing continues with the installation of water piping to the sinks and toilets.

Soon they will complete the walls on the second floor above the community health center, and that area will contain administrative offices, dental suites, and medical education classrooms.

The masons are hard at work, finalizing the walls of the building that will house the laundry facilities, the kitchen, and the mechanical and electrical equipment for the campus. They are also building the walls for the isolation wards, which will accommodate patients with airborne infectious diseases such as tuberculosis.

The construction team has begun laying the foundation for a new building that will house the children’s and women’s wards.

The electrical crew is almost finished putting electrical boxes and conduit in the walls of each building that is under construction.

Work continues on the campus-wide surface drainage system, as the central drainage trench has been completed. The Vetiver and Bamboo planted in May for erosion control has taken well and is stabilizing the soil on the steep slopes on the perimeter of the site.

PIH's Dr. Evan Lyon discusses the cholera epidemic in Haiti on Neighbourhood Watch, a program on Sydney Educational Radio in Australia. Listen to the interview on the player below.

Enrollment has opened for Beyond the Biologic Basis of Disease, an annual four-week immersion experience in northern Uganda for medical students. Offered by physicians affiliated with the Division of Global Health Equity at Brigham and Women's Hospital, this course links clinical tropical medicine with social medicine.

"Our social medicine course works to build deeply personal partnerships that teach us all critical lessons for advancing global health equity," says Dr. Michael Westerhaus, one of the course organizers and instructors.

The course, which lasts from January 9 to February 3, 2012, merges a number of unique pedagogical approaches including field visits, classroom-based presentations and discussions, group reflections, student presentations on previous international work, films, patient clerking and presentations, and bedside teaching. These approaches are utilized to create an innovative, interactive learning environment in which students participate as both learners and teachers to advance the entire class' understanding of the interactions between the biology of disease and the social, cultural, economic, political, and historical factors that influence illness presentation and social experience.

"I honestly think that it will forever change how I view and practice medicine," writes a participant who took the course last year.

"I've learned that although battling the factors that contribute to poverty and health care inequities is difficult, it is doable," writes another.

Learn more about this course and how to apply.

In addition, the course is also seeking an intern to help with logistics and administration. 

	PIH co-founder Paul Farmer addressing graduates at Harvard's Kennedy School. Click to watch the speech.

On Wednesday, May 25, PIH co-founder Paul Farmer gave a commencement address to students and families at the Harvard Kennedy School. His talk challenged graduates to find ways to incorporate compassion and persistence into the development of future public policies.

Read more about Paul’s commencement address. Or, watch a video.

In an editorial published in the Harvard Crimson the following day, Paul went further and outlined the ways a research university can address problems of health-care delivery in developing countries. 

Paul argues that “from undergraduates to emeriti, the college to the professional schools, and the alumni to administration – [we all] have something to offer.”

More Than Just a Hobby
What Harvard Can Do to Advance Global Health

How can a research university address problems of health-care delivery, especially for the poor or otherwise vulnerable? The possibilities are, as we say in a clinical lab when counting blood cells, “TNTC”—too numerous to count. But for those who wish to build robust academic programs in global health, there are three chief categories of action: research, training, and service. This triad is familiar to anyone who works in a teaching hospital. However, problems as significant as health-care delivery cannot be solved by medical schools, teaching hospitals, or schools of public health alone. All parts of the university—from undergrads to emeriti, the college to the professional schools, and the alumni to administration—have something to offer. Harvard’s global health agenda is ambitious, and its time has come.

That agenda has been transformed in recent years, as I know from personal experience. In the fall of 1984, newly arrived to Harvard Medical School after a year volunteering in a rudimentary clinic in central Haiti, I knew I wanted to work in what was then called “international health.” Even then, it was obvious that Haiti needed not only improved infrastructure and personnel but also new ways of delivering services. With the help of friends, the NGO Partners In Health was founded to help build delivery systems in Haiti and elsewhere. But what sort of training should someone with my interests pursue here at Harvard? It wasn’t a propitious time: there was not, at one of the world’s best medical schools, a formal training track for someone with such interests, nor were there many students in my class with similar aspirations.

Much has changed since then. Many of our small cohort of students did pursue careers in “global health equity,” the next and better iteration of international health. We had a lot of help along the way, but not because there were a plethora of career ladders in global health. I studied medical anthropology and trained in infectious disease, but these were not global health training programs. In fact, there were no such programs, in large part because global health is not a discipline or a field but rather a collection of problems.

These problems—which range from the grotesque absence of basic services for the world’s bottom billion to the poor quality of delivery of care in some more affluent nations—are increasingly recognized for what they are: a rebuke to our unequal world and a source of unnecessary suffering and social instability. This is obvious to poor families facing catastrophic illness, the leading cause of destitution in many nations; it is recognized by the citizens and leaders of countries still struggling to break the cycle of poverty and disease.

I am glad to see that U.S. research universities, too, now all seem to boast programs in global health. But claiming to have programs in global health is not the same thing as creating programs that can make a difference to populations facing poverty and ill health; nor is that the same as having career pathways and sound training programs, not just for our own students and faculty, but for students and colleagues in the places we work. Harvard needs to accompany its students and faculty and alumni by tackling the big three problems—building sound platforms for research, training, and service delivery—with all of the resources at our disposal.

This should be easier at Harvard than at any other American university for at least three reasons. First, because so many faculty are already working on the health problems that plague the most vulnerable in countries rich, poor, and in between. Second, because so many of our students and trainees wish to work in this arena, which wasn’t true not long ago. And third, because the university’s leadership, from President to Provost (both outgoing and incoming are doctors interested in global health) to Deans, all believe in moving global health forward as a serious academic enterprise.

How do we advance the research agenda when it must reach from bench science to the social sciences and humanities and every field in between? Sue Goldie, who leads the Harvard Global Health Institute, has worked with others to compile a directory of what’s going on here already, and it’s a long and impressive list. Both volume and quality will continue to increase with even a modicum of support, and will increase more rapidly with greater investments and support for junior faculty seeking to make global health the focus on their work rather than a hobby.

Tackling the training challenges in an equitable way is a thornier problem. According to the Consortium of Universities for Global Health, seventy American universities have formal academic programs in global health, almost all of them developed within the last several years; of the 131 U.S. medical schools, over a hundred have programs in global health. But, again, the “hobby” approach differs from true accompaniment. We’ve started, with the help of undergraduates and Partners In Health sites in Africa, a global health study abroad program (GEO-Scholars), and similar programs are flourishing at the Medical School. Well mentored opportunities are rarest in the poorest countries—the places to which most students are drawn.

Funding post-graduate medical education is a much more resource-intensive affair. Almost a decade ago, we started the country’s first residency in internal medicine and global health equity, with the expectation that private philanthropy and support from the Brigham and Women’s Hospital would be followed by support from public sources: global health initiatives like the President’s Emergency Plan for AIDS Relief have proven their worth and should be complemented with rigorous training and research. But the training of U.S. doctors does not include public financing of their training when outside the United States, or for that matter in poor regions outside the teaching hospital but within the borders of the country. We still don’t have federal support for residency programs in global health. Training specialists in medicine—fellows in cardiology, say, or the surgical specialties—also takes a lot of resources, and these typically come from the federal government in the form of large training grants. But federal training grants in global health, though cheered by many leaders and perhaps right around the corner, are stalled by the financial crisis.

And every training program at Harvard should be “mirrored” by similar commitments to help our host countries address their own training needs, since in each of these countries there are talented students and trainees who would also like to devote themselves to improving the health of their fellow citizens. Consider Botswana (which has no school of public health), Rwanda (not a single oncologist but plenty of cancer), Haiti (which lost its nursing and medical schools to a devastating earthquake) and Lesotho (which doesn’t have a single medical school but does have enormous need for physicians and plenty of talented young people). “Aid” to people in such countries—and I’ve just mentioned a few in which Harvard students and faculty work—cannot consist only of exporting our research and our training. This model of assistance has been long discredited.

A better term for what Harvard might do to help build a proper field of global health is “accompaniment.” To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. As at a commencement like the one we celebrate this week, we’re not always sure where the beginning and end might be. In this accompaniment, America’s universities can line up with many worthy partners. For example, the Clinton Health Access Initiative is advancing an ambitious program to allow faculty members from a half dozen American universities to support medical training in Rwanda; similar efforts are needed in dozens of countries.

Research and training in global health are for naught if they fail to improve the delivery of health services or if we fail to train, and learn from, our peers and partners. The word “global” shouldn’t deceive us: Boston is on the globe, too, and some people in the United States suffer from deficiencies in infrastructure and personnel not all that different from what I saw in rural Haiti in 1983. One thing we’ve learned in the United States is that it’s very expensive to give poor-quality health care to poor people in a rich country.

Taking global health from a hobby to a serious pursuit is well within our reach if we commit adequate resources to a series of tasks that include research, training, and improved delivery of quality care. Harvard can’t do this alone, but working with the right partners—including those laboring in places far from Cambridge—we can forge ethically sound endeavors in which we generate new knowledge while saving lives and improving the quality of many more.

Farmer is the Kolokotrones University Professor, chair of the Department of Global Health and Social Medicine at Harvard Medical School, chief of the Division of Global Health Equity at Brigham and Women’s Hospital, and founding director of Partners In Health. 

Read Paul's editorial on the Harvard Crimson website. 

Watch Paul's commencement speech.

	Patients waiting outside a PIH/ZL clinic in central Haiti.

Within weeks of the earthquake on January 12, 2010, the Haitian Ministry of Health’s national HIV program went to work ensuring that thousands of patients living with HIV continued to receive medications and care. Supported by two of Haiti’s largest HIV care providers – Partners In Health/Zanmi Lasante and GHESKIO – the program was able to quickly account for more than 95 percent of existing HIV patients. In many instances, investments that had been made in the HIV program provided a platform to respond rapidly to the needs of mass casualties after the disaster.

This feat was not the product of chance or luck, but the result of a decade-long initiative aimed at expanding and integrating HIV services into existing health systems.

“[T]he lesson is simple,” writes Dr. Louise Ivers, PIH’s Senior Health and Policy Advisor, in her recent editorial in the American Journal of Public Health. “[A] program with sufficient human resources, a functional medical records system (with electronic back-up), and a working coordination mechanism pre-earthquake was able to recuperate rapidly and to work on implementing a plan for its own needs going forward.”

Haiti’s largest and most successful national HIV programs have long focused on system-wide health care strengthening.

“[H]ealth care programs can and should be made with the system as a whole in mind, carefully constructed within the context of national plans and avoiding the errors of vertical projects,” writes Dr. Ivers. “In this way, a program created to respond to one crisis (HIV) has the breadth and flexibility and substance with which to respond to a totally different kind of crisis (mass casualties).”

Integrated care results in healthy patients.

In the early 2000s, with support from the Global Fund for AIDS, Tuberculosis, and Malaria and later from the President’s Emergency Fund for AIDS Relief (PEPFAR), PIH/ZL collaborated with the national HIV program to significantly bolster services and programs by intertwining health programs and developing an electronic patient record system.

The effects were immediate and substantial.

“In PIH-supported programs…pediatric consultations [between 1998 and 2008] increased by more than 500 percent after Global Fund and PEPFAR funding began, as did the number of pregnant women seeking services,” writes Dr. Ivers. “This increase was compared with an average 1 percent increase for pediatrics and 56 percent increase for pregnant women seeking services at a large general hospital also with Global Fund and PEPFAR funding over a similar timeframe.”

These lessons can serve as a guide to other health organizations working in developing countries.

“[H]ealth programs that were successful before the disaster provided both a platform from which to respond [to both the injured and people living with HIV] and a lesson on how to strengthen the country’s health system,” writes Dr. Ivers. “The opportunity now for Haiti in the context of so much interest and funding and so many organizations involved is for us all to put our shoulders together to create a health system that is greater than the sum of its potentially disparate parts.” 

Dr. Ivers’s editorial, “Strengthening the Health System While Investing in Haiti,” can be found in the June 2011 edition of the American Journal of Public Health. 

Jeff Gordon’s charitable foundation has committed to donate $1.5 million over three years to help children fight cancer in Africa. Partners In Health and the Dana Farber Cancer Institute are currently working together to develop a comprehensive cancer program in Rwanda. Funding from Jeff Gordon’s charitable foundation will help with prevention, diagnosis, chemotherapy, radiation, surgery and follow-up care for kids in one of Africa’s most densely populated country.

While the scope of the cancer burden within Rwanda remains poorly defined, in 2002 the World Health Organization global cancer database estimates that approximately 650,000 new cases of cancer are diagnosed annually in Africa. By 2020, more than 1 million new cancer cases will be in sub-Saharan Africa.

At the 2010 Clinton Global Initiative, PIH co-founder Paul Farmer discussed the need for cancer care in developing countries.

In spite of the growing needs, there are currently no practicing oncologists in Rwanda, and financial, geographic, and logistical barriers limit the accessibility of the few services that exist. 

To address this growing problem, PIH and our Rwandan partner organization Inshuti Mu Buzima (IMB) have been offering pediatric cancer care – despite a lack of oncological treatment infrastructure within the country – at our project sites in rural Rwanda since 2007, two years after we began working there.

Listen to Paul Farmer, Julio Frenk, Felicia Knaul and Lawrence Shulman’s call to action.

Having successfully provided high quality cancer care to a cohort of patients in rural Rwanda, PIH and IMB, are now committed not only to maintaining and expanding our program but also to participating in the development and implementation of a national cancer strategy. 

In collaboration with Harvard Medical School and the Dana-Farber Cancer Institute, and with the support of Brigham and Women’s Hospital, which has committed pathology services, personnel, and training, we are eager to work with our partners in the Rwandan Ministry of Health to develop a comprehensive national program to address all components of cancer care: prevention, diagnosis, chemotherapy, radiation therapy, surgery, survivor follow-up, and palliative care.  

Learn about PIH’s commitment to providing cancer care in developing countries.

Based on the Jeff Gordon Children’s Foundation’s history of supporting cancer treatment and research, PIH/IMB’s commitment to improving pediatric oncology in Rwanda, and DFCI’s commitment to supporting this work with key personnel, technical assistance, and medications and materials, we believe that these partnerships will have a great impact on pediatric cancer care in Rwanda and throughout the developing world. 

Learn more about PIH’s work in Rwanda.

Our organizations’ shared vision of making high quality cancer care accessible to all children, and to ensuring that their care includes not only attention to their clinical needs but also to their psychosocial and educational ones, will make this an ideal partnership.

The four-time Cup series champion formed his foundation in 1999 to support children fighting cancer. It also helps fund the Jeff Gordon Children’s Hospital in Charlotte.

	John Chew in front of the future site of Mirebalais Hospital Photo credit: Tony Cece, Operation Blessing

Every evening at sunset, Mirebalais Hospital Project Coordinator, John Chew, hikes the rocky hill that overlooks the site of Haiti’s biggest construction project since the January 12^th earthquake to witness the fruits of his labor. Oftentimes, he’ll snap a photo, or just simply reflect on the day's work and the progress made. To him, it’s a ritual that reminds him of how he feels each day on the site.

“This is a project that shows hope and gives me hope,” says John in the site’s office shed one humid morning. “After the earthquake, everything was discouraging. There were so many small-scale, temporary projects going on in Port-au-Prince. But here in Mirebalais, I am now able to work on something that is long-term for Haiti, something that is going to make a huge difference.”

	John takes a walk through the site every evening. Photo credit: Tony Cece, Operation Blessing
	The site has office and storage space where plans can be reviewed and staff can take temporary solace from the midday heat. Photo credit: Tony Cece, Operation Blessing
	While giving a tour of the facility, John explains the importance of the hospital's cistern in light of waterborne illnesses like cholera. Photo credit: Tony Cece, Operation Blessing

Since October 2010, John has been working for Partners In Health managing the construction of the future national referral and teaching hospital 30 miles north of Port-au-Prince. With over 200 Haitian construction workers on site six days a week to build the 180,000 square foot, 320-bed facility, John has a lot on his shoulders.

But if anyone can make this happen, John is definitely the guy.

John first set foot in Haiti on a church trip 25 years ago. Alongside his three sisters and a nun from his San Francisco-based church, John came for a two-week trip as a college student to work in a professional training school in the Port-au-Prince neighborhood of Carrefour. Six months later, he read a church newsletter soliciting long-term volunteers to help build schools, churches, and health clinics in Haiti. John and a college buddy soon boarded a plane to Port-au-Prince to spend the next year doing construction around the island.

A year later, the night before their flight home, his friend noticed that John’s bags weren’t packed. While he thought that John was simply feeling emotional after one year of life-altering service, he hadn’t guessed that he would be boarding his return flight home alone.

He also wouldn’t have thought that John wouldn’t return to the United States for another twelve years.

John says you should be careful in Haiti, or you might get bitten by the same Haiti bug that convinced him to stay. John’s humility prevents him from frequently talking about the myriad projects he has worked on over the last twenty-five years in the Lower Artibonite and Central Plateau -- some of Haiti’s poorest regions. It was during these years, many spent working in at a self-sustaining trade school, that he met his future wife who was the head of community development at Albert Schweitzer Hospital in Deschappelles. 

After the earthquake struck Haiti in January 2010, John spent more than eight months in Port-au-Prince conducting search and rescue missions and procuring equipment, supplies, and food for desperate hospitals. One morning, while at the Toussait Louverture Airport picking up supplies, he ran into Loune Viaud, PIH/ZL Director of Operations. She informed him of the ceremony that was to take place in Mirebalais – a groundbreaking for the biggest construction project in Haiti since the earthquake. While he agreed politely to attend the event, he wasn’t aware of the scope of the project. 

Following the ceremony on July 3, 2010, John was introduced to Dr. David Walton, the hospital’s Project Director, and Jim Ansara, PIH’s Director of Construction. And the rest is history.

For the past eight months, John has been working to build a facility that is more than twice the capacity of PIH’s largest existing hospital in Haiti. With the capacity to see more than 500 patients a day, the Mirebalais Hospital will provide Haitians access to clinical services that are not available in any other public hospital in the country. John is confident that not only will the hospital save lives, but it will also provide jobs so that families can send their kids to school, as well as attract other business to Mirebalais.

Once operational, the hospital will be a national training hospital providing educational opportunities for medical and nursing students. For John, the hospital will be a place that will connect Haiti to the world and will be a place where both Haitian and foreign doctors can learn from each other. But the training has already begun on the construction site. “I love the training aspect of my job,” says John. “Every day, I’m involved in training people to use power tools or to read blue prints, which are new skills for many Haitian workers on the site. By acquiring new skills, these workers will be able to go out and get good jobs and become better bosses.”

John currently lives in Cano, a small village outside of Verrettes, located more than 50 kilometers from Mirebalais, with his wife and three sons aged 17, 16 and 13. John is grateful for how supportive his family has been given he demanding hours of his job—he works sunrise to sunset six days a week. His sons often come to the site on Saturdays to volunteer their time; they see it as an opportunity to give back to their country.

Atop the hill overlooking the site, John expresses how beholden he feels to Haiti, the place he has spent much of his adult life.  “I feel indebted to this country for what I have learned here,” says John.  “Everyday I learn something. I am indebted to the people and to their love. It has been humbling twenty-five years and I am most grateful to Haiti.” 

“This isn’t just a job, it’s a vision,” John continues. “It’s a dream that is coming true right before my eyes. Whatever it takes to get it done, let’s do it.”

For millions of women in the developing world, pregnancy and childbirth pose significant risks of disability or death. Partners In Health strives to provide expectant mothers with critically important health services to make pregnancy and giving birth an occasion to celebrate life and hope. 

On April 27, 2011, PIH hosted a live webcast to discuss these issues. Panelists included PIH Chief Medical Officer Joia Mukherjee, Director of Policy and Advocacy Donna Barry, and Director of Communications Andrew Marx. Hundreds of people logged on and submitted questions, which the panelists answered in real time. 

Submit ideas for PIH's next webcast or ask questions on Twitter with #pihtalks.

In the early hours of April 21, arson claimed the life of a beloved colleague Phyzeme Isly, who had worked with PIH's Haitian partner organization Zanmi Lasante (ZL) for nine years as a laboratory technician to provide health care to the people of Haiti. ZL senior midwife Claudine Jean Gilles and her ten-month-old daughter both sustained life-threatening injuries in the fire, and are still battling to survive. Tragically, her three-year-old son, did not survive his injuries.

The arson attack occurred immediately following the publication of the second round legislative elections results on April 20 as violence erupted in the town of Belladere.

"All of us at Partners In Health and Zanmi Lasante are devastated by the tragedy in Belladere," says PIH Executive Director Ophelia Dahl. "We are keeping those lost and wounded by the violence in our thoughts and prayers--Phyzeme, Claudine, and two young children whose regular presence at the hospital had brought much joy and light. We will honor them by pursuing justice and remaining committed to serving the poor."

Welcome to the inaugural edition of the Institute for Health and Social Justice (IHSJ) Reader – a compendium of global health pieces which highlight important research and policy in the field. Through this bi-weekly reader, we at the IHSJ will share the news, policy and research articles, statements and reports that influence and inform our advocacy efforts. As the policy and advocacy arm of Partners In Health, the IHSJ is committed keeping you—students, academics, policy-makers and PIH supporters—informed about global health issues. This Reader is meant as a space to present various perspectives; as such, the views in these materials are not all endorsed by Partners In Health. To keep this dialogue alive, please comment on the blog to let us know what you think of the articles as well as what topics you might like us to include in future posts.

Let us know that you’re interested in learning more about PIH’s advocacy and policy efforts by signing up. 

In solidarity,

The IHSJ

IHSJ Reader     May 2011     Issue 1            

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

HIV/AIDS

Initiation of Antiretroviral Treatment Protects Uninfected Sexual Partners from HIV Infection (HPTN Study 052) (HIV Prevention Trials Network Press Release, May 12, 2011)
This comprehensive study provides the first evidence that early treatment with antiretroviral therapy for HIV infected individuals results in a 96% reduction in transmission. Additionally, the study found equally significant evidence that early ART resulted in drastically lower rates of tuberculosis.

GLOBAL HEALTH FUNDING

Crenshaw, Smith Launch Congressional Caucus for Effective Foreign Aid (Press Release, Representative Ander Crenshaw, May 12, 2011)
Congressmen Ander Crenshaw (R-FL) and Adam Smith (D-WA) formally launch a bipartisan group, the Caucus for Effective Foreign Assistance, to improve aid effectiveness to further national security and foreign policy objectives.

Barbara Lee Leads House Passage of Legislation to Ensure Support for Victims of Devastating Earthquake in Haiti (Press Release, Representative Barbara Lee, May 10, 2011)
The House of Representatives passed H.R. 1016, led by Representative Barbara Lee. The legislation directs the U.S. government to report on the status of humanitarian, reconstruction, and development efforts in the aftermath of the earthquake in Haiti.

Healing the World: Part 1 (GlobalPost, John Donnelly, May 9, 2011)
Though the Global Health Initiative (GHI) has incredible potential with a more comprehensive approach to health care, little has happened since President Obama launched the GHI two years ago. Over the next few months, GlobalPost will examine behind the scene decisions in the Obama administration, as well as what diplomats and health experts are doing to make what they’re getting out of GHI work for their countries.

Global health aid: raise more, spend better (The Lancet-Moussa Fatimata and David Hercot, April 23, 2011) 
Increased multilateral funding (from global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, and UNICEF) should reinforce the ability of governments to engage in health systems strengthening activities rather than earmarking funding for short-term solutions that fail to improve the long-term capacity of the system.

U.S. foreign aid is not a luxury but a critical investment in global stability (The Seattle Times-U.S. Reps. Adam Smith and Jim McDermott, and Bill Clapp, April 17, 2011) 
The maintenance of current foreign assistance levels is critical to America’s global stability. Demands for cuts to foreign assistance are driven by widespread misconceptions about how much of the budget is actually devoted to international investments.

HEALTH SYSTEM STRENGTHENING

(Equal) pay for (equal) work (Global Health-Julia Robinson, April 22, 2011)
Though the continuing trend has been to keep community health workers (CHWs) as volunteers, fair compensation is a moral and economic imperative. Many donor and host governments haven’t caught on to this idea, long championed by Partners In Health.

How did Sierra Leone provide free health care? (The Lancet-John Donnelly, April 23, 2011)
On April 27, 2010, Sierra Leone eliminated health user fees for pregnant women, new mothers, and young children. Results after one year show that Sierra Leone’s free health-care program has substantially increased service utilization. The president’s political leadership was the key factor in ensuring free healthcare for the women and children of Sierra Leone.

HAITI

Haiti and the international aid scam (The Guardian-Mark Weisbrot, April 22, 2011) 
American politicians are quick to blame corruption in Haiti for lack of progress since the earthquake, and corruption is often assumed to be exclusively a Haitian problem. But it is clear that some of it--maybe a lot--comes from the outside. It is time for the so-called international community to clean up its act.  

WOMEN’S HEALTH

Rwanda launches Africa’s first nationwide cervical cancer vaccination, detection program  (New Times-Edmund Kagire, May 9, 2011) 
Rwanda became the first African state to have a comprehensive, coordinated plan to eliminate cervical cancer by using the Human Papilloma virus (HPV) Vaccination for girls and screening for women. The vaccination, screening and treatment of cancer is crucial in protecting the lives of women.

VIDEO: Dr. Joia Mukherjee delivers keynote address at GlobeMed Summit (PIH Talks, April 27, 2011) 
Health care: a privilege, or a fundamental human right? Dr. Joia Mukherjee, Chief Medical Officer for Partners In Health, delivered a keynote address about public health and social justice to more than 300 students at GlobeMed’s national summit.

VIDEO: Reducing maternal mortality: a webcast discussion with PIH (PIH Talks, April 27, 2011) 
For millions of women in the developing world, pregnancy and childbirth pose significant risks of disability or death. PIH strives to provide expectant mothers with critically important health services to make pregnancy and giving birth an occasion to celebrate life and hope.

NON-COMMUNICABLE DISEASES 

***Health ministers pledge to tackle non-communicable diseases with global action (British Medical Journal-Richard Smith, May 4, 2011)
Non-communicable diseases (NCDs) are largely treatable and preventable, yet the WHO predicts that global mortality from NCDs will increase by over 24% in Africa from 2006-2015. Governments worldwide have yet to prioritize the fight against NCDs in low-resource settings.

Stay connected with the PIH Blog, Facebook, Twitter, and YouTube pages.

By Dana Raviv

	Catherine selling some of her produce in a local market.

When Catherine tells her life story, she begins in the year 2009. "Life changed with the clinics," she says. It was in 2009, at the age of 31, that she began the anti-retroviral treatment that would reduce the toll HIV was taking on her life. But she soon learned that access to drugs is not a cure-all for a diseases rooted in poverty, and comprehensive health care means more than just treating illness.

Not long after starting anti-retroviral treatment, Catherine was admitted to the hospital with tuberculosis. For two weeks, she remained glued to her hospital bed, a foreshadowing of the six-month convalescence that would follow. Her father cared for her during this time, while her seven children— four of her own, and three adopted from her deceased brother— were forced to learn how to care for themselves.  

With no money to pay for school fees, and no provider to supply food, Catherine's children went to the fields. They asked neighbors for ganyu, piecemeal work that would earn them a little money. Each day, they hoed others' land and gathered wood for others' fires — children as young as eight and ten laboring to support their family. Meanwhile, Catherine mustered what strength she had to grind discarded maize husks into a powder fit to cook. Doctors could prescribe medication for her HIV and TB, but no pill could cure her family's hunger.

Catherine is only one of many patients facing this problem in her community. PIH's sister organization in Malawi, Abwenzi Pa Za Umoyo (APZU), implemented the Program on Social and Economic Rights (POSER) to address the poverty — including lack of housing, clean water, food, and education — that so often causes and exacerbates poor health for its patients. In 2010, APZU and its POSER team piloted the Model Permaculture Farmer program as a way to tackle poverty and hunger. As Catherine recovered from her debilitating TB, she became a Model Permaculture Farmer.

Permaculture is a style of farming that eliminates the need for harmful and expensive fertilizers while improving the quality of the soil for future seasons. The Model Permaculture Farmer program aims to help patients provide for their families in the long-term, and to prevent the malnutrition that could make someone like Catherine more susceptible to TB and other opportunistic infections. As part of the project, participants received vegetable seeds along with weekly lessons on how to use sustainable agriculture techniques to improve crop yields. They learned how to stretch scarce water resources, increase the diversity of their crops, and grow vegetables without the use of foreign chemicals that deplete the soil over time. Catherine quickly became an expert in permaculture practices.

Leaning over her vegetable stand in the market, Catherine now smiles proudly. She points to the piles of tomatoes, okra, and eggplants, colorful symbols of surplus after such a dark tale. The seeds and training she received have allowed her to grow more food than her family can eat. She sells what's leftover in the outdoor market, earning money for maize and bread. In addition, her children are now able to go to school, as there's enough income to purchase uniforms and shoes, and pay the fees necessary for them to attend class. Through her training, Catherine has learned how to save seeds from her best crops so that she can continue to feed her family in future seasons.

As Catherine tells it, her story starts in the health clinic. But it doesn't end there. It continues in the community: in the home where she raises her children and the farm where she grows her food. Providing comprehensive healthcare means more than having the hospitals, doctors, and medications necessary for treating illness. It means going out into villages to tackle root causes of disease, like Catherine's hunger, and the cycle of sickness that would otherwise keep her from supporting her family.

Catherine (center) and other Model Permaculture Farmers in APZU's new project.

Dana Raviv served as the Volunteer Training Coordinator for APZU in Malawi.

“When unjust systems or structures prevent people from achieving good health, and from achieving good lives, this is structural violence in action,” says Donna Barry, Director of Policy and Advocacy for Partners In Health (PIH). 

In an article entitled “Structural Violence: A Barrier to Achieving the MDGs for Women,” published recently in the Journal of Women’s Health (JWH), PIH Medical Director Joia Mukherjee, Barry, and several other co-authors argue that maternal mortality continues to plague poor women in poor communities because public health interventions have not addressed the impact of structural violence. Drawing on examples from PIH’s work in Haiti and Lesotho, the authors also clearly demonstrate how women’s lives can be saved and transformed by programs that combine quality health care with determined efforts to uproot structural violence and the social determinants of disease, especially poverty, sexism, and gender-based violence.

In the late 1980s, 99 percent of the half million maternal deaths occurring each year took place in poor countries. Nearly a quarter century later, 350,000 women still die every year from pregnancy-related causes, the vast majority in the poor world. In a 2010 report on maternal mortality, the United Nations Population Fund (UNFPA) found that complications from pregnancy and childbirth are the leading causes of death for 15-19 year old women and adolescent girls in developing countries.

”Structural Violence” assesses the status of the United Nations Millennium Development Goals (MDGs), unanimously set by 191 UN member states in 2000. Three of the eight MDGs deal directly with women’s health: to promote gender equality and empower women (MDG-3); to reduce child mortality (MDG-4); and to improve maternal health (MDG-5). “[But] while elevating the status of women is intimately connected to achieving these goals…structural violence – in terms of gender inequality and the feminization of poverty – serves as a barrier to achieving the MDGs,” write Mukherjee and her co-authors.

	Women in the waiting room of a clinic in rural Lesotho.

“When we focus only on providing new facilities and services, and we don’t remove the real barriers to utilization, we fail,” says co-author Sarah Marsh, former Director of Women’s Health Programs for Partners In Health in Haiti, in an interview about this article. “We have to understand that women may have other reasons for being intimidated from the formal health care system.”

Undoubtedly, the most substantial barriers to health care for poor women have been the costs – including user fees charged by health facilities, the high costs of transportation, and lost work time traveling to the nearest clinic. Women are also frequently inhibited from accessing health care by social and cultural factors, including stigma, reticence to expose highly personal matters to medical attention, and intimidation by their husbands and families.

PIH has found that one way to overcome the structural violence in this system is by changing how facility-based health care is delivered. For example, in most developing countries, family planning services are “vertical” within the health system: a woman sees a family planning nurse in a separate room from routine care, with separate registration and waiting lines. Not only can this eat away at precious time the woman could be using to care for her family or earn income, the separate waiting line may carry stigma within her community.  

PIH works to combat this trend. Nurses at our rural clinics in Lesotho offer to discuss  family planning at each visit a woman makes to the facility, regardless of the focus of her visit. This is one example of how PIH has systematically used lessons learned in Haiti, where Zanmi Lasante overcame the stigma and additional wait associated with HIV testing by offering it routinely with each health system contact – from check-ups to malaria treatments.

Additionally, pregnant women are offered transportation money and logistical assistance to reach clinics for prenatal care. Delivery plans are coordinated with the woman and her relatives, and women who live too far from the clinic are provided beds and meals at a lying-in center for the two weeks before their due date.

	Pregnant women outside a lying-in center in Lesotho. These centers allow women to make the long journey from their homes to the health center before they go into labor.

“Meeting women’s family planning needs by reducing waiting times in clinics, increasing the number of providers delivering family planning methods, and improving access by delivering services in the communities helps overcome structural barriers to family planning and improves a country’s overall ability to provide universal access to reproductive health services,” write Mukherjee and her colleagues.

Another approach that directly addresses structural violence is the recruitment, training, and employment of local women as health agents. The majority of community health workers (CHWs) employed by PIH are women; in the countries profiled in the article, Lesotho and Haiti, more than 90 percent and 80 percent of CHWs, respectively, are women. Providing village women with paying jobs that are valued in the community improves the status of women in several ways.

“First, this values their knowledge of the local population and conditions,” write Mukherjee and her co-authors. “Second, it puts cash in the hands of women, which is known to improve the health of women and children. In addition, some of these CHWs were traditional birth attendants, but have now been trained and compensated to be more general community health workers and to accompany pregnant women.”

	A training for maternal health workers in Lesotho.

In Lesotho, for example, hundreds of traditional birth attendants (TBAs) who had previously delivered babies in women’s homes have been trained and employed to reach out to all women of childbearing age in their villages. These maternal health workers provide community education, and help pregnant women and their families secure access to health services before delivery. As part of the program, both the maternal health workers and the pregnant women they work with are offered incentives to attend prenatal visits, deliver at the clinic or hospital, and receive postnatal care.

The JWH authors hope their article will increase awareness of practices that neutralize structural violence, and positively impact the well-being of poor women. “Although sound evidence has long existed for improving women’s survival, the will to address women’s health concretely and holistically is only recently gaining the advocacy needed to change policy,” they write. “There needs to be a global social strategy to fight for women’s lives that is inclusive of the risks imposed by structural violence and the delivery of care.” 

By Peter Luckow

In recent months, more than 170,000 Ivorian refugees have fled into southeastern Liberia, home to PIH's partner project, Tiyatien Health. 

Yesterday, Dr. Raj Panjabi of Tiyatien Health wrote an urgent call to action in a Huffington Post Op-Ed, which was co-authored by Liberian peace activist Leymah Gbowee:

Writing, respectively, as a doctor and peace activist who have worked on the front lines of war, it is clear what's needed now is justice and aid. The international community should support justice on both sides of the border for the women and children who have suffered physical and sexual violence.

But, justice for the victims also requires meeting their basic needs. The international community must fill the UN's current $300 million emergency humanitarian appeal for food, shelter and medical assistance for the 170,000 Ivorian refugees in Liberia and the other million displaced within Ivory Coast. Thus far, only a fraction of the funds have been pledged. But individual Americans can do something too. Combined together, even small donations ($20 or $50), critical in relief efforts in places like Haiti and Japan, will help Ivorian refugees like Marie and her girls receive needed shelter, food and medicine. Simply put, dollars will save more lives.

Read the full op-ed. 

Tiyatien Health is bolstering the health system in Grand Gedeh County to treat and care for the growing number of refugees.Their work was recently profiled on PRI's The World radio broadcast and the PBS Need to Know blog.

Peter Luckow is the Director of Operations at Tiyatien Health. 

	Frank in his new wheelchair.
	Before receiving a wheelchair, Solange used to drag herself using a make-shift knee-pad.
	Solange tries out her new wheelchair.

There’s a Kinyarwandan phrase that Carolina Gonzalez-Bunster and her team from Walkabout Foundation will never forget: “seka cyane,” which means “big smiles.”

“Big smiles were exactly what we were greeted with everywhere we went,” says Carolina.

Carolina and the Walkabout team visited Rwanda to deliver 250 Rough Rider wheelchairs to patients living with disabilities that impact their mobility, in partnership with PIH’s Rwandan sister organization Inshuti Mu Buzima. These durable wheelchairs were designed especially for use in developing countries, with knobby tires for rough terrain and easily replaceable parts. The delivery was Walkabout’s second at a PIH site, following a distribution in Haiti last year. 

Read an excerpt from Carolina’s blog below. 

We started our trip at Rwinkwavu Hospital (which is operated in a partnership between PIH and the Government of Rwanda) on April 27th, 1.5 hours from Kigali, with a two and a half day training program that taught seven PIH therapists and doctors from different districts how to fit and adjust the Rough Rider wheelchairs and how to give the best care to patients with physical disabilities, particularly spinal cord injuries. 

Word spread around the villages and communities that Walkabout was at PIH distributing and donating wheelchairs. Before we knew it, we had lines of people showing up that had traveled hours and hours to be fitted into their new wheelchairs. 

One of those visitors was Frank. Frank has the biggest smile you've ever seen. He was born with a congenital birth defect which left him without the use of his legs. With no access to a wheelchair, Frank has spent years dragging himself along the ground in order to attend school. 

Despite such hardship, Frank wears a constant grin on his face and has an infectious giggle. Once fitted in his wheelchair, Frank proved to be a natural at pushing himself around. Having discovered the extraordinary freedom of mobility that his first wheelchair can bring him, the joy and hope on his face was overwhelming and priceless. 

Another patient that came that day was Solange. The first thing that struck us about her was how neatly and professionally dressed she was, which is no small feat for a woman who arrived at PIH dragging herself along the dirt road. Her left knee had a make-shift pad strapped around it to soften the impact of the ground as she dragged herself on the street.

Solange was also born with a congenital birth defect that led to a large growth protruding from her left leg as you can see in the photo. Furthermore, her legs never actually grew and have no strength or muscle, which has left her unable to walk. 

Solange was shy at first but once in her wheelchair, she could not contain her delight, and when she finally headed home in her new chair, she turned back over and over again to smile and wave and thank us. 

Butaro Hospital is an extraordinary new hospital built by Partners In Health. Walkabout's visit to Butaro turned into our busiest day with 12 individuals receiving their wheelchairs. 

Read more about Carolina’s time in Rwanda. 

Learn more about Walkabout Foundation.

PIH already has a history of implementing green technology, such as these solar panels at our Boucan Carre site.

This group of people are planting Vetiver grass to prevent soil erosion.

Everyone gets involved in the planting, even the kids!

The most recent studies estimate the extent of Haiti’s deforestation to be between 96 to 98 percent. Port-au-Prince is the largest city in the Western hemisphere without a central municipal wastewater and sewerage treatment facility, a reflection of the lack of sanitation infrastructure of the entire country. Electricité d’Haïti (EDH), the state-owned electrical company in Haiti, is characterized by dramatic shortages of service and provides intermittent access to electricity to only 12.5% of the population. Given these constraints and Partners In Health’s commitment to the environment and sustainability, the Mirebalais National Teaching Hospital was designed to minimize its impact on the environment and maximize our ability to harness natural resources. 

The major features of the green technology plan include electricity conservation, water conservation and treatment, and sustainability initiatives. In order to maximize and exploit solar energy, 500 kilowatts of photovoltaic solar collectors will be mounted on the roof to provide power to the hospital, and solar powered streetlights will be installed to illuminate the campus at night. The power collected from these solar panels will generate enough electricity to power the entire hospital campus on all but the cloudiest days. Hot water will also be powered completely by solar energy. In order to lower the overall electrical load and increase sustainability, high efficiency light fixtures and ceiling fans will be in operation throughout the entire hospital. To reduce the need for air conditioning, PIH has implemented natural ventilation systems through high ceilings and windows and has equipped ORs with insulation, fans and filters. 

Water conservation and waste management systems, virtually non-existent in Central Haiti, have been a major focus of our overall sustainability efforts. The hospital will be equipped with water saving toilets, faucets and showers; public drinking stations with self-closing spigots; and rainwater capture systems to preserve and provide clean water. Engineered by a team in Boston, a proper waste treatment system will be built that aerates and cleans wastewater and allows leftover sludge to be recycled at local farms. This sewerage system will protect against the spread of water-borne disease, such as the recent cholera epidemic caused by the runoff of untreated wastewater into the Artibonite River.

The hospital site was raised by over 10 feet to prevent flooding of the hospital campus. As a result, the edges of the property are characterized by steep grades of exposed soil.  To prevent erosion, the construction team has employed a local Haitian team to design and implement an erosion control strategy. These local experts are planting Vetiver grass (a local plant) and bamboo to provide stability to the soil in addition to other soil conservation methods.   

Several individuals and companies have been instrumental in the implementation of these green initiatives at the Mirebalais Hospital, including:

• • The Barr Foundation
• • Hubbell Incorporated
• • J.C. Cannistraro, LLC
• • Dr. Michael Siminovich, University of California Davis
• • Dr. Edward Nardell, Harvard School of Public Health

Partners In Health is grateful to these construction and design experts who provided their assistance in the strategy and implementation of these green technologies. It is our hope that the Mirebalais Hospital can serve as an example for future building projects in Haiti to adopt similar sustainable technology.

By Ashley Ahlholm, Institute for Health and Social Justice Program Assistant

On Thursday, April 12, 2011, results were released from a large multinational clinical study, HPTN 052, conducted by the HIV Prevention Trials Network that show a 96 percent reduction rate in transmission of HIV when antiretroviral therapy (ART) is initiated early.

The decision of when to start ART has been the subject of great debate in poor countries. The patient benefits are obvious, but these have been weighed against life-long cost of treatment and medications, and challenges to adherence. In Haiti, through the HIV Equality Initiative, Partners In Health and its Haitian sister organization Zanmi Lasante (ZL) began providing ART to people living with HIV in 1999. At that time, prevailing wisdom in public health claimed it was impossible to provide high-quality treatment and follow-up for people living with HIV in developing countries. But the success of ZL’s patients proved otherwise. For over eight years, Partners In Health has been providing HIV infected patients with free  ART when the patient’s CD-4 count reaches 350 because it was the standard of care in the United States.  PIH has gone on to implement successful, early initiation HIV treatment in Rwanda, Lesotho and Malawi. Once again, PIH has pushed the global health boundaries to extend the latest medical discoveries to the poorest patients around the world based on current science, not what was “acceptable” to implement in resource poor settings. 

HPTN 052 is the first clinical trial to show how dramatically early ART affects transmission, and as such, should significantly shift the debate around and funding for HIV treatment and prevention policy.

In the study both groups received the same level of HIV-related care, including counseling on safe sex practices and regular HIV testing. The couples in the delayed ART group received traditional treatment, beginning ART when his or her CD4 count fell below 250 cells/mm³ or if he or she developed an AIDS-related illness. The participants in the early ART group received the same level of counseling, but started ART when they had a CD4 count between 350-550 cells/mm³. Among the 877 couples in the delayed treatment group, 27 HIV transmissions occurred. In contrast, only one transmission occurred in theearly ART group. This difference represents a 96 percent reduction in HIV transmission.

Partners In Health has always recognized that ART also results in a reduction of active tuberculosis cases among HIV infected patients. This study found that out of the originally HIV infected patients, 17 developed extra pulmonary tuberculosis in the delayed ART group, compared with three cases in the early ART group.

Treating people with HIV earlier can have a dramatic impact on their health, their partner’s health, and the epidemic as a whole. This is just one step in shifting the international lens of HIV treatment, we need to continue to advocate for ART as a solution to treating and preventing transmission of HIV and drastically reducing  rates of tuberculosis.

Learn more about the Randomized Trial To Evaluate the Effectiveness of Antiretroviral Therapy Plus Primary Care versus HIV Primary Care Alone to Prevent the Sexual Transmission of HIV-1 in Serodiscordant Couples (HPTN 052).

	Nurses in Cange, Haiti, singing at a special event commemorating International Nurses Week.

Yesterday, May 12^th, was Florence Nightingale’s Birthday and nurses around the world ended our week-long celebrations for International Nurses Week.  Nurses at Partners In Health (PIH) sites in many countries took part in national, district and site celebrations.

An estimated 35 million nurses and midwives make up the greater part of the global health-care workforce and International Nurses Week is a time to celebrate nurses worldwide.

PIH, in solidarity with all of our sister organizations, want to take this opportunity to thank all of our nurses who work tirelessly every day to provide excellent nursing care to our patients. We are proud of each and every one of the over 1,200 nurses working with PIH, and the compassionate care they deliver in some of the poorest communities in the world. From Haiti, to Lesotho, to Rwanda, to Malawi, to Peru, to Boston, and at all of our other sites, nurses work in collaboration with the entire health care team to make sure our patients receive quality health care. Please take time today, and every day, to thank a nurse!

The materials before they were loaded onto the sea container.

This group of supplies will be delivered to the hospital site in June.

Loading up the equipment onto the sea container.

Numerous crucial donations have been given to the Mirebalais Hospital Project in the past month. Our first two shipping containers of donated construction materials will arrive on site in early June. Please check back then for pictures of the deliveries-this will be a major development for the Construction Team and it’s certain to be very exciting! Here are the donations we have recently received:

Laticrete International – Donation of adhesive, grout and necessary tools for installation of tile and seamless flooring

Legacy Office Solutions – Office partitions 

Lumalier – UV Lights for OR’s

Royal Adhesives & Sealants – Mastic and tools 

Stanley Black & Decker – Locks, interior hardware and small tools

Hubbell Incorporated – All light fixtures/ceiling fans and all electrical devices

Southwire – All electrical wire and cable for hospital

Thomas & Betts – Electrical materials including boxes, connectors, ENT, pipe hangers, grounding rods and lightning protection. 

All of us at Partners In Health and those working on site in Haiti are extremely gracious for these extraordinary donations. The Construction Team is anxiously awaiting the arrival of these contributions so they can begin the next phase of the hospital! 

By Sophie G. Beauvais, Communications & Web Content Manager, The Global Health Delivery Project at Harvard University

	Chris Gilpin, WHO, is leading the May 9-20 online event.
	Xpert MTB/RIF demonstration studies in Peru (2009) © FIND.

Since the endorsement of the Xpert MTB/RIF Diagnostic Test by the World Health Organization (WHO) in December 2010, implementers around the globe and especially those in areas with limited resources have been trying to figure out how they will be able to use this new tool in their settings. In an effort to address this, GHDonline.org is hosting an expert panel starting today, May 9, until May 20. Panelists will include:

• Christopher Gilpin, a member of the WHO’s Stop TB Department and part of the team leading the rollout of the Xpert MTB/RIF assay

• Dr. Daniela Cirillo, from Italy’s San Raffaele Scientific Institute

• Dr. Gerrit Coetzee, from South Africa’s National TB Reference Laboratory of the National Health Laboratory Service, one of the countries planning widespread roll-out of the diagnostic test

• Dr. Eduardo Gotuzzo, from the Instituto de Medicina Tropical Alexander von Humboldt at the Universidad Peruana Cayetano Heredia in Peru

• Dr. Mark Perkins from FIND Diagnostics

“In April 2011, we hosted a training workshop for Early Implementers focused on the practical application of the Rapid Implementation document. The conversation covered test and site selection, patient selection and management, interim case definitions and operational considerations,” says Gilpin, who will be hosting the event, which runs from May 9 to May 20. “This forum will address challenges related to implementing this transformational technology.”

The online event will cover topics such as:

• Factors and strategies to consider when integrating the Xpert MTB/RIF Diagnostic Test and GeneXpert system into current TB diagnosis and treatment plans, especially limited resource communities

• The appropriate placement of Xpert MTB/RIF Diagnostic Test in the health care system, taking into account operational considerations, burden of disease, human resources, supply chain management, and existing TB diagnostics

• Evaluating how countries can monitor the impact of implementing the Xpert MTB/RIF Diagnostic Test and generate evidence for scaling-up

GHDonline.org is a free platform of expert-led communities with thousands of members from more than 1,500 organizations worldwide.

Expert panels are a convenient and low-cost way to share lessons learned and know-how on a specific topic with a community of professionals. If you are not a member yet, we invite you to sign up for GHDonline’s MDR-TB Treatment & Prevention Community and set your email notifications to “per post” for instant participation via email or “daily digest” to reply on the web. Then jump into the conversation and share your experiences, advice and resources.

If you are not a GHDonline member, sign up here: https://www.ghdonline.org/accounts/signup/?signup_community=drtb

The discussion--running May 9 through May 20--will be hosted here: http://www.ghdonline.org/drtb/discussion/ghdonline-expert-panel-challenges-in-rolling-out-t/

By Ruma Rajbhandari, Nyaya Health

	A mother and child at Nyaya Health's Bayalpata Hospital.
	A mother and child receive a checkup.

In 2007, after a long flight to Nepalganj, a 16-hour drive over muddy and rugged roads, and a two-hour hike, we arrived at the Bajhang district hospital only to find no doctors; the only staff nurse was preparing to quit.

The entire hospital was run by village health workers and auxiliary nurse midwives. A middle-aged woman with three children stood at the hospital entrance.

"Where were your children delivered?" I asked.

"In my goth [her shed]," she answered. ("Where else do you think, lady?" was her tone.)

"Did anyone assist you—a midwife, your mother-in-law?"

"No."

"How did you cut the umbilical cord?"

"With my hasiya [a sickle], of course."

She had had enough of my silly questions and hurried off.

Since 2007, there has been progress in maternal health in far western Nepal. In Bajhang, the Nick Simons Institute (NSI) supports the district hospital through the Rural Staff Support Program, providing an MDGP doctor who can carry out caesarian sections, training for anesthesia assistants and skilled birth attendants.

On 29 March, the first caesarian section ever was carried out in Bajhang, saving the life of a mother who would otherwise not have made the journey to the closest operating room in Dadeldhura.

In Achham, Nyaya Health's Bayalpata Hospital operates because of a unique public-private partnership with the Ministry of Health. In a district where there were no doctors in 2007, Nyaya now runs and maintains a hospital that serves hundreds of patients everyday--all for free.

Mothers and children, who account for nearly three-fourths of the patients, often walk upwards of two days for treatment. Since the government's Safe Motherhood Program started paying women Rs1000 [US$14] for in-hospital deliveries, monthly deliveries have more than doubled.

There are huge challenges due to the backlog of neglect over the decades. Achhami mothers try to leave the hospital two hours after delivery.

"I must get back to my children and animals," one of them told me.

Motherhood connects women all over the world. The joy and exhaustion of holding a beautiful newborn for the first time is shared universally, from Bajhang to Boston. But for women in far-Western Nepal, the stakes are far higher. Bayalpata still lacks an operating theatre, requiring dangerous transfer across mountain roads for more than seven hours for a caesarean section. It's not surprising then to hear of pregnancy still referred to as a 'gamble with death'.

NSI has recently pledged $75,000 in matching funds to support the construction of Bayalpata's surgical center to provide life-saving caesarean sections and other essential surgeries by late 2011.

Still looking for a Mother’s Day gift?  Donate in tribute to your mother and the Nick Simon’s Foundation will match your generosity, doubling your impact!

Established in 2005, Nyaya Health works with the Nepali Ministry of Health and Population to develop health care services in the impoverished western regions of the country. Working to advance the solidarity model of Partners In Health, Nyaya aims to scale-up not only medical services, but also services targeting other population-level interventions. 

Nyaya is one of PIH’s six supported projects, each dedicated to implementing the organization's philosophy on a global scale by working with local communities and governments to create change.

Ruma Rajbhandari is a physician at Brigham and Women's Hospital in Boston and volunteers with NSI and Nyaya Health in Achham. 

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In Lesotho, five children orphaned by tuberculosis and HIV/AIDS have found a new home and a new mother--PIH staffer Lomile September. Already a mother of three adult children (and a grandmother!), Lomile did not hesitate to step into the role of mother for these orphans in need. PIH's project in Lesotho also makes sure that the new family has medical care and food, and that the children attend school.

	Jelen and her two children walk through the Gamarra district in Lima, Peru.

Jelen is a fighter. As a street vendor she 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. 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). This struggle is now a closed chapter in her life.

After completing 18 months of treatment, Jelen’s life has begun to return to normal. With help from SES, she has returned to work as an entrepreneur. Every afternoon she goes out with more motivation than ever to sell her homemade curtains.

	Sewing curtains at home and selling them in Lima's shopping district has allowed Jelen to become her own boss.
	A now healthy Jelen stands in front of the hills of Lima.

“It’s made me stronger,” says Jelen. “To be sick isn’t just about taking medicines. It’s a really long, hard fight, both the treatment and the side effects from the medication. But finally I won.”

Jelen is part of a large group of vendors in Gamarra, a district of Peru home to roughly 90 thousand employees. The district’s economy is largely populated by people selling products they’ve made at home. The streets are their storefronts. 

“Now I am happy everyday,” says Jelen. “When I’d go out to work while I was in treatment, I didn’t like getting there. I took some of my medications in the mornings and then the other half in the afternoon which made me feel sick, and that’s how I’d go out to work. All the sounds and background noise were unbearable but that’s how I’d have go around offering my products so people would buy from me.”

Now Jelen is motivated to sell curtains and she has developed tools to improve her family’s financial situation.

“Before I’d sell about 40 to 60 soles a day (US$ 14-20), and now I sell between 80 and 100 (US$28-35),” says Jelen. “I’ve gotten better. Now with my sewing machine I can be making things at any time I want and can take orders.”

Part of this improvement has made it so she can live in a more comfortable home and focus on making sure she and her kids are able to buy nutritious food.

Jelen is just one of tens of thousands of Peruvians who sell wares on the street. Almost always these workers make inadequate incomes, work long hours, and lack access to medical insurance. 

“I’d been working before for a sewing shop,” recounts Jelen. “They’d give me 1,000 shirts to stitch and they’d pay me 1 sol (US$0.35) per shirt. But that would take me a long time. In just four days I’d have to hand back all those shirts, so I’d be up all night sewing, resting only 4 or 5 hours and I wasn’t eating well. All of that made me weak and I think that’s why I got sick.”

Since then, she has become independent; she makes better use of her time. She also hopes to grow and diversify her business. “My goal this year is to buy a couple more machines, rent a stand and sell wholesale. I could have more clients, making different styles of clothes for different seasons. In winter it would be sweatsuits that is what most people here wear. And in summer lighter weight items like blouses, shirts and shorts.”

Having overcome a deadly disease, Jelen says she is ready to face life again. “Now I am able to support my kids. My son Frank is in his 5th year of secondary school. He wants to be a policeman and so he’s already preparing to go to school for that. I’ve told him we’ll have to save up a lot of money for that. And we’re going to do it. One of my goals is to give 100 percent to my son, so that he becomes someone great.”

Six months after treatment, Jelen reflects on her fight often and never neglects her health. “I feel like a new person. I’ve come to life again. I won’t have a lot of economic resources, but they aren’t nothing. I don’t have money to waste on my kids, but they also won’t go without anything.”

Learn more about Socios En Salud.

Written by SES's Jose Alonso Valdivia.

--

Saliendo Adelante: La historia de una luchadora
“Es una lucha muy dura, tanto con el tratamiento y con el trabajo. Pero finalmente le gané”

Jelen es una luchadora. Como comerciante ambulatoria lucha cada día contra los municipales, la competencia y la calle. Como madre soltera lucha por darle lo mejor a sus dos hijos. Como persona luchó y ahora la tuberculosis resistente es un capitulo cerrado en su vida.

Después de 18 meses de tratamiento, cada día a las 6 de la tarde Jelen sale a vender sus cortinas que ella misma confecciona con más ánimo que nunca. “Me he vuelto más fuerte. Estar en la enfermedad no es solo tomar los medicamentos. Es una lucha muy dura, tanto con el tratamiento y con el trabajo. Pero finalmente le gané”

Ella es parte de un gran grupo de vendedores en Gamarra, zona comercial en la que trabajan 90 mil personas aproximadamente. Muchos de ellos por la dificultad para conseguir un buen trabajo o formalizarse tienen que vender productos por su cuenta y hacen que su tienda sea la calle. “Hoy salgo cada día feliz. Antes cuando iba a trabajar y estaba con el tratamiento, no quería que llegue las 6 de la tarde. Tomaba el medicamento en la mañana y luego en la tarde la otra mitad, lo que me producía mucho malestar y así salía a trabajar. Los ruidos y el sonido eran insoportables y así tenía que ofrecer mis productos para que me puedan comprar.”

Ahora no solo tiene más ganas para sacar adelante su negocio, sino que tiene las herramientas que le han permitido mejorar su economía familiar. “Antes vendía entre 40 a 60 soles diarios (US$ 14-20), ahora vendo entre 80 y 100 (US$ 28-35) soles. He mejorado. Ahora con mi maquina de coser, puedo confeccionar en cualquier momento y puedo atender pedidos.” Parte de esta mejora ha hecho que pueda vivir en un lugar más cómodo y preocuparse por tener una mejor nutrición para ella y sus hijos, tema que nunca descuida.

El empleo informal en el que se encuentran aproximadamente 11 millones de peruanos, genera, en muchos casos, deficientes condiciones de trabajo, con excesiva carga laboral y sin contar con seguro de salud. “Antes trabajaba en un taller de costura. Me entregaban mil polos para coser y me pagaban 1 sol (US$ 0.35) por polo. Pero para eso me demoraba mucho. En cuatro días tenía que entregar esa cantidad y me tenía que amanecer, descansaba 4 o 5 horas nomás, no comía bien. Ahí fue que me puse débil y a razón de eso yo creo que me enfermé.”

Ella ha logrado en este tiempo ser independiente y disponer mejor de su tiempo. Su aspiración es crecer como comerciante y diversificar su negocio. “Mi meta de este año es comprar un par de máquinas más, alquilar un stand y repartir mercadería al por mayor. Yo podría tener más clientes, confeccionando diferentes prendas por temporadas. En invierno buzos de polar, que es lo que más usa la gente. Y en verano cosas delgadas, como blusas, polos y shorts.”

Con todas estas aspiraciones, experiencias y éxito frente a su lucha de todos los días Jelen se siente una mujer más fuerte para enfrentarse a la vida. “Ahora me siento más preparada para apoyar a mis hijos. Mi hijo Frank esta en 5to año de secundaria. Él quiere ser policía, así que ya se está preparando para ingresar a la escuela. Yo le he dicho que vamos a tener que juntar bastante dinero. Y lo vamos a hacer. Una de mis metas es dar el 100% para mi hijo, para que él sea alguien de bien.” 

Con casi medio año de alta ella está en una nueva etapa de su vida. Ahora reflexiona sobre su lucha y nunca descuida su salud. Esto mismo hace con sus hijos a quienes los tiene muy bien cuidados. “Me siento una persona nueva. He vuelto a vivir. No tendré muchos recursos económicos, pero tampoco son mínimos.  A mis hijos no les sobra, pero tampoco les falta nada.”

Jelen, así como quiso compartir su historia con nosotros, es algo que acostumbra hacer entre sus conocidos. Así, esta experiencia de luchadora es algo que no solo alimenta su vida, sino la de muchos más.

Learn more about Socios En Salud.

Written by SES's Jose Alonso Valdivia.

By Maxi Raymonville

	A midwife leading a training in Haiti.

To mark International Midwife Day, we would like to take the time to thank all of the midwives working in various Partners In Health sites in Haiti and in the world. We honor them for their expertise in the service of an important event for the families whom PIH serves: the birth of a child.

Working closely with women and families, midwives accompany pregnant women until delivery, and beyond—ensuring that babies come into the world under the best of conditions. Midwives play an indispensable role in the fight against maternal and neonatal mortality.

Today, we pledge to honor their work by providing them with the tools they need to continue to fight effectively for the collective well-being of women, children and their families. Please take a moment to thank the midwives you know and with whom you work for their incredible contribution to our work against maternal mortality.

On this important day, our thoughts turn to one of our most dedicated and senior midwives, Miss Claudine Jean Gilles, and her family, who are living through a particularly rough time right now.

Dr. Raymonville is the Director of Women’s Health for Zanmi Lasante, PIH's sister organization in Haiti. 

By Sophie Beauvais, GHDOnline

According to the latest figures that will be presented in The State of the World’s Midwifery report, more than 350,000 women and 4 million newborns die needlessly each year. Midwives are essential to the delivery of quality services before, during, and after childbirth for women and newborns. Despite this, recent analysis indicate that midwifery services are unequally distributed both between and within countries, states Assistant Director-General Family and Community Health at the World Health Organization Dr. Flavia Bustreo.

Today, May 5, is the International Day of the Midwife. On this day, many reflect on these critical issues and advocate for increased access to midwifery services worldwide, particularly in developing countries where 90% of maternal deaths occur.

Midwives and nurses make up the largest health care workforce worldwide. “Together, they bring unique experience and skill in delivering health care to individuals living in remote and under-resourced areas, navigating health care systems in their own regions, as well as understanding and addressing individual patients’ barriers to health," note the expert moderators of the Global Health Nursing & Midwifery community on GHDonline.org. "Their integration and active participation [in the health care system] is vital to the advancement of global health.”

Dire shortages in nursing and midwifery workforce is one barrier to access to needed services. Workforce shortages are symptomatic of other issues such as low salaries, lack of training, but also the isolation experienced by many health professionals in rural areas. Following a recent screening of No Woman, No Cry, a documentary that explores the risks of giving birth without adequate care directed by Christy Turlington Burns, maternal health advocate and founder of Every Mother Counts, panelists insisted that “a lot is going on that is hopeful and good, but there's not a lot of information sharing across countries and within countries. We need to connect and work together.”

Thanks to the Internet and a multitude of new platforms for nurses and midwives, sharing knowledge and connecting is only but a keyboard away. In addition to the Global Health Nursing & Midwifery community on GHDonline.org, which allows thousands of health implementers from more than 1,500 organizations across the globe to problem-solve in discussions and online expert panels, nurses and midwives can also find useful resources in Maternova.net, which provides training videos on DVD, simple obstetric kits, and small power paks, in the Global Alliance of Nursing and Midwifery communities, and in RH Reality Check, a comprehensive online community and publication serving individuals and organizations committed to advancing sexual and reproductive health and rights.

Read Sophie's full blog post on the GHD News Desk Blog. 

	Sutter Health employees trained St.Marc health care workers how to use the new sterilizer.
	The touch screen interface is easy to use.

By Meryl Glassman, PIH’s West Coast Regional Outreach Manager

Recently, the Sacramento-based Sutter Health donated an equipment sterilizer to Saint Nicolas Hospital, a hospital in St. Marc run by the Haitian Ministry of Health and Partners In Health. The sterilizer, manufactured by the Getinge Group, is a general-purpose vacuum steam sterilizer capable of decontaminating laboratory and medical equipment—an expensive piece of machinery that is very much needed in Haiti right now.

Sutter Health employees have traveled to Haiti with PIH six times since the earthquake in January 2010. Those same employees brokered the donation of a sterilizer.

Sutter Health employees then raised the money necessary to have the sterilizer shipped to Haiti, and a few weeks ago the Sutter Health team (led by Steve Lockhart) travelled to Haiti to help install the equipment and train the staff on how to use it.

As you’ll see from Steve’s description below, not only was the Sutter Health team able to use it in a number of surgeries, but the Haitian surgeons in St. Marc have been using it quite a bit since they left—which was of course the main goal all along.

Sutter Health’s Dr. Lockhart sent an email updating us on the sterilizer on March 26. 

From: Lockhart, Stephen, M.D.
Sent: Saturday, March 26, 2011
Subject: Sterilizer for Haiti…Thank you

Dear all,

We have returned from our trip and I wanted to update and thank you. The sterilizer arrived, is installed and is working extremely well. We had a lot of activity around installation and I wish to particularly thank Mark who placed and received calls at all times of the day and night to walk us through this.

The unit is now being used by local staff (Joan trained them) and everything is programmed in French. While we were there, we were able to do 50 cases, including hip implants for femur fractures, some of which were almost one year old!! Without the sterilizer, they would still be waiting. More importantly, it allowed us to do some training and Haitian surgeons performed 27 more cases the week after we left.
 
Here is a link to a brief video. I apologize that it is just an internal video for our staff, so I apologize for the narrator with a cold, the crooked tie, etc.

Again, thank you for this amazing gift. We will continue to update you on our progress.
 
Steve
 
Stephen H. Lockhart, MD,PhD
Regional Vice President and Chief Medical Officer
East Bay Region, Sutter Health

Learn more about PIH's work in Haiti.

	Dr. Louise Ivers examines a patient in Haiti.

PIH's Dr. Louise Ivers, a faculty member at Harvard Medical School's Department of Global Health and Social Medicine and at Brigham and Women's Hospital's Division of Global Health Equity, was recently honored as the 2011 Distinguished Graduate for University College Dublin (UCD) in Ireland. The award is presented annually to a UCD alumnus who has made an extraordinary contribution to medicine in their field. 

Currently PIH’s Senior Health and Policy Advisor, Dr. Ivers has focused her career on implementing health programs, and is interested in improving the delivery of healthcare in resource poor settings, the provision of care to the rural and urban poor, and patient-oriented investigation that offers solutions to barriers to healthcare. Dr. Ivers has been working with PIH in Haiti since 2003, implementing HIV and women’s health programs, and later serving as Country Director for PIH. Following the January 2010 earthquake in Haiti, she took on the role of Chief of Mission for PIH in Haiti, where she led PIH’s humanitarian assistance response and rebuilding efforts.

Past recipients of the UCD Distinguished Graduate Award include Dr. Hugh Brady, the current president of UCD.