A view of the site as it stands today.

Assistant Project Manager Aaron Noble trains the construction team on proper technique.

Electrical wiring is being installed in the hospital.

It has been a busy and productive week in Mirebalais.  The Construction Team began building the second floor of the Women’s Health Building (Building 1.6), on the recently poured reinforced concrete deck. This will be the future home of the Medical School, Administrative Offices, and Dentistry. They also completed the foundation and began the block walls for Building 4, which includes an area for the Solar Electrical Equipment, the Kitchen and Laundry, and a large Mechanical and Electrical Area.

Extensive work has been done to the electrical systems and this process is moving along quickly and efficiently. The underground conduits for distribution of electricity around the campus have been installed and we have a large team cutting block and fitting boxes and conduit in the walls for electrical switches and outlets.

The drainage work is now in its final stages as special Vetiver Grass is being planted in order to prevent erosion on the steep slopes of the hill and around the drainage canals.   

We have ramped up the number of workers on site in the last week. With this comes safety concerns and we have intensified both training in safety practices and the enforcement of safety rules (i.e. the use of hardhats and safety glasses).

In the summer of 2009, Cassandra Peitzman, a student at Harvard Medical School, travelled with PIH to Chiapas, Mexico. There she helped implement a photovoice project—an initiative that placed cameras in the hands of illiterate women from five communities, giving each the chance to document her world and life through pictures.

Over the course of six weeks, Cassandra and PIH and EAPSEC staff in Mexico spent roughly one week in each of the five communities: Rancho Bonito, Cerro Perote, Cinco de Mayo, Honduras, Nueva Libertad, and La Laguna.

Images taken by women living in the mountain village of Cinco de Mayo.

The women met in groups of 8-12 to discuss their rights, health care, farming techniques, and their children and families. More than just sharing stories and ideas, the women talked about the ways they could work together to improve life in the community. They also received a crash course in photography.

	Click to see a slideshow of images from the women of: Rancho Bonito, Mexico.
	Nueva Libertad and La Laguna, Mexico.
	Honduras, Mexico.
	Cerro Perote, Mexico.

“This project sought to empower women in rural communities of the Sierra Madre mountains to analyze, document, and present the challenges that they faced as women and individuals,” recounts Cassandra. “It also attempted to facilitate organization between women by forming discussion groups, and to provide a supportive environment for the generation of specific, actionable goals for change.”

While the specific format of the workshops and home visits varied somewhat between each group, the overall structure of the project was consistent between communities.

“On the first day in each community, Lindsay [Palazuelos, PIH’s Mexico project coordinator] and I attended a meeting of local women,” says Cassandra. “We explained the intention and design of the photovoice project. We answered questions and invited the women to participate.”

During the second day of meetings, local women discussed the difficulties they faced in the community, the opportunities and resources available to them, and their ideas for positive change.

“We also taught the women how to operate digital cameras and distributed donated cameras,” remembers Cassandra.

Each woman had one full day to take pictures of whatever she wished, with an emphasis on things that she considered especially important, helpful, or difficult. At the end of the day Cassandra and Lindsay visited each woman’s home to discuss her pictures, her reasons for taking them, and her experience using the camera. 

Common themes emerged amongst the photographs. A surprising number of women took multiple pictures of wells, gardens, ovens, cleaned kitchens, and farm animals. There were far fewer pictures of family and friends than Lindsay and Cassandra had expected. And even fewer self-portraits.

Each woman documented her daily life, and for many of the women involved that meant capturing images of her daily labor—from baking bread to raising chickens.

“At this time, we also asked several directed questions about the challenges and resources that the women had in the communities and their opportunities for participation in decision-making,” says Cassandra.

“On the final day of the project, we held another workshop to show the participants’ pictures to the group, discuss the themes that had emerged in the pictures and conversations, and facilitate the generation of ideas for constructive change,” says Cassandra. “This final workshop often produced plans for small collaborations between the women, to cooperate in the planting of radish gardens, for example, or for broader-scale political action, organizing a group to inquire as to the whereabouts of government-promised resources.”

Cassandra worked closely with EAPSEC leadership, especially Leonel Gonzalez Ortiz, as she designed and implemented this project. PIH has accompanied the Chiapas-based nonprofit EAPSEC—El Equipo de Apoyo en Salud y Educación Comunitaria—since 1989.

As they moved between villages, Cassandra and Lindsay worked with and stayed in the homes of PIH/EAPSEC community health workers.

Before heading back to medical school in Boston, Cassandra printed all of the photos and made sure that each participant received copies of her pictures.

Learn more about PIH's work in Mexico.

	Rosali

By Ari Johnson

During the 22 years that Rosali has called Yirimadjo her home, people would come to her for help, and all she could do was to listen to their sad stories. She felt like she was stuck with her hands tied behind her back, because she did not have the resources to address the suffering around her.

Today, Rosali no longer has her hands tied, thanks to Project Muso, a PIH-supported organization that works to bring health care to the poor in Yirimadjo, a community of slums on the outskirts of the city of Bamako in the West African country of Mali.

She enrolled in Project Muso’s Education Program, where she graduated at the top of her class. She then went on to train as a community health worker. In this role, she now tests and treats children in her community for malaria, provides counseling and support to her neighbors, and works to ensure that everyone in her community has access to health care. She has the skills and resources to bring happy endings to sad stories she hears.

One such story is that of 4-year-old Amadou. During one of her daily outreach rounds, Rosali visited a family in her neighborhood and discovered that little Amadou had developed a fever two days before and had become very ill. The boy’s family had not sought care because they did not have the money to pay for health services. Amadou’s father, who had formerly worked at the mayor’s office, had been injured and permanently disabled in a car accident, leaving him unable to work.

Rosalie saw signs of severe malaria in the little boy. She quickly brought him to the health center supported by Project Muso for urgent care, where he was treated for free. She also encouraged the family to seek early treatment for malaria in the future, explaining that this was both for their safety and to protect other community members from being infected.

Recently, little Amadou came down with another high fever. This time, Amadou’s mother brought him to Rosali within the first few hours, and Rosali quickly accompanied him for treatment at the health center. Amadou was able to receive treatment early, before his malaria infection progressed to advanced stages, and he quickly recovered.

Rosali also helped Amadou’s family obtain a bed net and explained how to effectively use the net to protect the boy from malaria-carrying mosquitoes—potentially preventing future sickness.

Today, Amadou is healthy and attends kindergarten, and Rosali continues her daily rounds, reaching out to bring access to healthcare to her neighbors, and ensuring that there are fewer sad stories and more happy endings in her community.

Project Muso is currently facing an urgent cash flow crisis. Learn more and find out how you can help.

Ari Johnson is the co-executive director and co-founder of Project Muso. 

	Patients recuperate at a ZL cholera treatment center.

Zanmi Lasante-supported cholera treatment centers and treatment units in Port-au-Prince, the Lower Artibonite, and the Central Plateau regions are seeing a worrisome rise in cholera cases. 

Though official numbers won’t be available until next week, Dr. Maxi Raymonville, ZL’s Director of Women’s Health, reports that the organization’s hospitals and clinics experienced a significant jump in the number of people contracting cholera during the first weeks of April. At the ZL cholera treatment centers and units in Mirebalais, near the site of the original outbreak, numbers were roughly triple what they were just a few weeks ago.

In March, ZL saw a total of 5,136 patients presenting with symptoms of cholera across all 14 of its sites in Haiti. Of those patients seen, 2,459 required hospitalization for cholera.

To Dr Raymonville and his colleagues, the spike in cases comes as no surprise.

ZL knew that cases of cholera, like any waterborne illness or diarrheal disease, were likely to surge at the onset of the rainy season. While Dr Raymonville's team was prepared to treat more patients, he remains concerned that flooding will prevent people from accessing cholera treatment quickly. Since cholera often debilitates a person in less than 24 hours, it is critical that a patient be able to access medical care quickly.

The rainy season arrives as Zanmi Lasante is making a concerted effort to transition its cholera work from an emergency response posture to an integrated proactive and preventative approach in recognizing that the disease is now endemic to Haiti.

Yet, flooding at facilities in Boucan Carre and Thomonde is making it difficult to treat patients, and therefore inhibiting ZL’s ability to shift away from an emergency response mindset.

Having written one of the first cholera prevention and treatment training curricula for community health workers, Zanmi Lasante is focused on training more frontline health workers to educate their communities, identify cholera infections, and help those ill to quickly access care. In addition to education, the ZL team is working with communities to improve hygiene practices as well as access to potable water and latrines.

As Dr. Maxi notes, ZL staff are reminding communities that they must seek care quickly in order to treat the disease and protect family and friends from becoming infected. The organization’s cadre of community health workers have been educating a catchment area of 1.5 million people about the disease since the outbreak began last October.

On average, Haiti receives 452 mm (18 in) of rain between March and May—more than 40 percent of the nation’s annual rainfall. Years of deforestation and erosion have left the island’s soil so dry that it is non-absorbent in many regions. As the rains come, they cause dangerous flooding which leaves large pools of standing water—conditions ideal for waterborne diseases like cholera, or other illnesses like malaria. During last year’s floods, for example, ZL had to use UN helicopters to reach communities isolated by flooded roads and unstable bridges.

Other actions underway include evaluating the ability of cholera treatment facilities—which are housed in standalone tents—to withstand the current rainy season and upcoming hurricane season, which runs from June to September.

Understand how cholera spreads and why it disproportionately affects the poor.

	Tim poses with his new trophy.

In March, Tim Thayer, a first-year medical student at the University at Buffalo, sent an email to friends and family. The message: he would be fighting to support Partners In Health—literally.

Tim had signed up to compete in New York State's Golden Gloves Boxing competition. His goal was to support and advocate for PIH's work in Haiti.

According to Phil, Tim’s father, the story of Partners In Health cofounder Paul Farmer inspired his son to pursue medicine.

“I very well remember the phone call my son made to me early in his freshman year of college to let me know that he had read this book called Mountains Beyond Mountains, and as a result felt called to medicine,” recounts proud dad Phil. “He sent me the book and it’s is an incredible story of one man's passion making a difference.”

“What my father told you in his email about Dr. Farmer influencing my decision to go into medicine is true,” says Tim. “So I am honored to have stumbled across a way to help raise money for the incredible organization that has had such a monumental impact on my life.”  

“As for the tournament and fundraising, it couldn't have gone much better,” says Tim when asked about the Golden Glove competition. 

“I won my division to become the Sub-Novice 152lb New York State Champion,” reports Tim. “Through generous donations from friends and family I was fortunate enough to raise over $1,300 for PIH. My original ambition was to raise a few hundred.”

With the competition over, Tim is hard at work with his medical school courses. “I'm back to focusing on the renal module of my first year of medical school here in Buffalo, NY.”  

Aaron Noble is a 27 year old from Bozeman, Montana, who is working for Partners In Health at the construction site of Mirebalais National Teaching Hospital. Aaron works for Windover LLC, a general contractor in Manchester, MA, so he certainly has a diverse skillset to offer. He will be in Haiti until May—here’s what he has to say about his experience so far. 

Aaron completes some of the construction work himself.

He also frequently trains Haitian workers on new skills.

The Haitian workers can then take over some complex work themselves, with oversight from trainers.

How did you become involved with Partners In Health? 

Jim Ansara, the Mirebalais Director of Construction, reached out to the President of Windover Construction (Lee Dellicker) for help identifying an Assistant Project Manager that had the unique skill set that is required for this project. They were looking for a person who can speak Spanish, is adventurous, is willing to commit a good amount of time to the project, and wanted to do something to better Haiti. When I saw this opportunity, I immediately volunteered. I heard about Mirebalais on a Thursday morning, that Sunday I was on a plane down to Haiti to see the project first hand.

What is your role on site? 

My role changes daily. Currently, I am working on electrical rough in: cutting boxes, receptacles and switches, which will provide power and light to each room of the hospital. I have also been helping with the concrete pour for the roof slab

How have you liked working with the Haitian team?

It’s been really fun. I initially taught a team of six Haitians how to use a rotary hammer and grinder to chip and cut block. Now they have been able to teach another crew how to use the tools.  It was very satisfying to see how eager the workers on each team were to learn a new skill.  Hopefully in the future these skills will help these workers improve their country. 

My foreman here on the site is a Haitian who speaks Spanish like me, so we communicate mostly in Spanish. The language barrier in Haiti can be challenging but because we are doing construction, you can always show people how to do it. 

The best thing about working here is that the Haitian crew is really excited about working. In the United States, you often have workers complaining about their jobs, whereas here, you have a team working in the blistering sun and they are just plain happy to have a job and be working.

There is no need to be worried about working with the Haitian team. They are fun to work with and they really want to learn. They are really receptive and excited about learning how to use new equipment. Working with the Haitian team has been one of the most enjoyable parts of my experience here.

What was your first impression of Haiti?

My first impression is that life is challenging here. As an American visiting Haiti, you have to be accepting of the fact that things won’t always go your way, and they might not be as easy as they would be at home. But I love a good challenge, so that is good for me!

Where do you live?

We live in a simple house not too far from the hospital site in Mirebalais. We have everything that we need and have great Haitian colleagues and friends who help out if we need anything else. 

Were you nervous about coming to Haiti? 

No I wasn’t. I like adventure. I have lived in both Bolivia and Chile for six months each, so I probably felt more prepared then the average traveler coming to Haiti. 

That said, I would recommend this experience in a heartbeat. It makes you appreciate what you have. You may be eating the same things every day here in Haiti but you appreciate that you have it, because other people down the street might not have food to feed their families. It’s good to change your reality, even if it’s just for a week. 

Were you nervous about cholera? 

Cholera really isn’t an issue to worry about. Avoiding cholera is about washing your hands, using hand sanitizer. Just be aware of it, but don’t worry about it.

What would you say to someone who is thinking about coming to volunteer in Mirebalais?

Anybody who has the opportunity to come here won’t regret it. It’s fun and I love it down here. Just bring sunscreen!

For more information about helping with construction at Mirebalais Hospital, learn more about volunteering or contact Heidi Burgess, Mirebalais Volunteer Coordinator.

By Joia Mukherjee, PIH Chief Medical Officer

Each year as Mother's Day approaches, I stop to reflect on the strength and love of mothers across the globe, on our children, and on the joys of being a mom. My own son will be 5 years old in July.

Each year that joy is marred by the knowledge that nearly 350,000 women die annually due to complications from pregnancy and childbirth. The vast majority of these deaths occur in the developing world.

For the women in the countries where we work, pregnancy and childbirth pose significant risks of disability and 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.

Join me on April 27 at 7 p.m. EDT for a live webcast and discussion about the risks faced by millions of expectant mothers and what can be done to help.

Along with my colleague—Donna Barry, PIH Director of Policy and Advocacy—we'll discuss PIH's efforts to provide critical services to expectant mothers.

We'll take questions live via chat or Twitter (@pih). 

On World Malaria Day, April 25, PIH Chief Medical Officer Joia Mukherjee discussed how budget cuts in the U.S. and other donor countries could mean setbacks to the worldwide efforts to fight malaria. Listen to her interview with NPR's Michel Martin on the player below. 

This segment aired on NPR's Tell Me More. 

PIH Chief Medical Officer Joia Mukherjee delivers the Honorary Keynote Address at GlobeMed's 2011 Global Health Summit. 

2011 GlobeMed Global Health Summit Honorary Keynote: Dr. Joia Mukherjee from GlobeMed on Vimeo.

Partners In Health (PIH) and Zanmi Lasante (ZL) are deeply concerned about the insecurity in Belladère and elsewhere in Haiti and strongly condemn recent acts of violence. Beyond causing pain to our staff and the community we serve, these events have disrupted our ability to provide critical health care services to communities in the Belladère area. We call upon Haitian authorities to maintain security in the region to ensure that the people of Belladère and the surrounding communities have continued, uninterrupted access to health care. Moreover, we urge partisans to respect the neutrality of PIH and ZL in the political process.

Immediately following the publication of the second round legislative elections results late on April 20, violence erupted in Belladère where ZL has worked with the Ministry of Public Health and the local community since 2003. In the early hours of April 21, arson claimed the life of a beloved colleague Phyzeme Isly, who worked to provide health care to the people of the region for nine years. Other ZL staff and their family members were also wounded in the attacks.

In advocating for access to free services for the poorest and most vulnerable communities in Haiti, PIH and ZL work with the Government of Haiti to strengthen the public health care sector, in close partnership with affected communities and other local partners. While we work with democratically-elected officials and their appointed officials of the government, PIH/ZL neither participates in the electoral process, nor affiliates with any political party. Despite the recent acts of violence that have occurred, we remain committed to serving our communities in an impartial manner.

Read a tribute to Phyzeme Isly.

The Partners In Health/Zanmi Lasante family mourns the death of our beloved colleague, Phyzeme Isly, who was the victim of an arson attack on a ZL staff residence during the early hours of Thursday, April 21st. The attack came in the immediate aftermath of the announcement of final election results for local officials shortly after midnight in Belladère, a Haitian community near the Dominican border. During the attacks, government buildings and vehicles were also set ablaze.

	Phyzeme Isly
	Hopital de la Nativite in Belladère.

ZL staff across Haiti grieve the loss of their dearly loved colleague, Phyzeme (whose name means "beloved son" in Haitian Creole). Born in 1967 in Grand Riviere du Nord in the North of Haiti, Phyzeme worked for the last nine years as the head laboratory technician for PIH/ZL in Belladère, at the Haitian Ministry of Health’s Hopital de la Nativite. As one of the longest serving PIH/ZL staff in Belladère, Phyzeme was a key figure in improving the quality of care at this site by ensuring that patients had continued access to laboratory services. Before moving to Belladère, he completed his year of social service in the neighboring town of Lascahobas.

PIH/ZL expresses their sincere condolences to the family that Phyzeme has left behind, including his 10-year-old son, Wansly. PIH/ZL strongly condemns the violence that has occurred, which has not only taken the life of our beloved colleague, but wounded others.

"Our thoughts and prayers are with Phyzeme's family and all of our Belladère colleagues," says PIH Executive Director Ophelia Dahl. "Such violence is deplorable, and strikes a community already struggling with poverty and injustice."

PIH/ZL calls upon the Haitian authorities, with whom we are working, to pursue justice and restore peace in the city of Belladère; and calls on the UN to restore security in the area.

In a typical strong exhibition of solidarity, the ZL family across Haiti has united to show their support for their colleagues in Belladère. Immediately following the attack, the ZL team mobilized to secure the safety of all ZL staff in Belladère, resulting in their evacuation to our sister site in a neighboring border town in the Dominican Republic. PIH/ZL is providing psychosocial and financial support to the staff who lost most of their belongings in the fire. 

Details surrounding the motivations behind the attack remain unknown as political violence continues in Belladère. Gunshots and roadblocks are being reported as the story unfolds even now. 

Read PIH's official statement regarding the political violence in Belladère.

A post from Joia Mukherjee, PIH's Chief Medical Officer.

	Help us build a movement. Donate to Project Muso now.

Today, I was in touch with Ari Johnson, the founder of Project Muso in Mali, which I wrote about on April 15. While this wonderful, grassroots organization is doing tremendous work in building community, delivering of health care and supporting the public sector in Yirimadjo, Muso is facing challenges faced caused by an abrupt loss of a key funder.

Because of our collective advocacy for this important grassroots project and solidarity approach a generous, anonymous donor offered a $30,000 match if $30,000 dollars can be raised before May 13.  I am happy to report that, with your support, Project Muso has raised $26,000 toward this match.

But…we aren’t there yet.  Please pass the word to your friends, like minded people, to all those who believe justice and dignity will come by working alongside the poor to achieve human rights. That Project Muso, a young, small organization is doing phenomenal work in achieving this greater humanity.  Any amount goes a long way for this group.

Tax -deductable donations can be made through the website at http://www.projectmuso.org/donate or by sending a check or money order out to "Under the Baobab Tree" and mailing it to:

Under the Baobab Tree
1380 Monroe Street, NW Box 309
Washington, DC 20010 

Thank you for considering this urgent appeal on behalf of our friends and family at Project Muso.

In solidarity and with gratitude,

Joia

Through our work, we know that the natural environment directly affects the overall health of a community. April 22 is Earth Day. To commemorate the day, watch a slideshow featuring projects that work to improve and preserve the local environments of the communities we serve around the world:

View slideshow in full screen.

A family receives care in a Port-au-Prince settlement camp.

A rendering of the new Mirebalais Hospital.

An appeal from Ted Constan, Chief Program Officer

Dear supporters,

The earthquake on January 12, 2010 impacted millions of Haitians. But as a parent I can’t imagine the loss and fear that one woman, Rosalind, experienced that day.

Pregnant at the time, Rosalind saw her home destroyed and one of her children fatally injured. Nine days later she went into labor.

But the next part of Rosalind’s story gives me hope.

She came to a clinic at Dadadou—a Port-au-Prince soccer field converted to a muddy tent city with more than 10,000 residents. There under the watchful eyes of one of our nurses—Geneviève Joubert—she gave birth safely.

Thousands of earthquake survivors, like Rosalind and her baby, are alive today because you chose to donate to Partners In Health and Haiti in our darkest hour. I’m writing today because we need your help again.

Help us continue to save lives and invest in projects that put Haiti’s public health system on a course to recovery. Please donate now.

A year after the earthquake Partners In Health still serves more than 100,000 people in three settlement camps in Port-au-Prince and nearly 1.2 million people in the lower Artibonite and Central Plateau regions of Haiti.

Each day we make a real difference. We safely deliver babies. We help amputees walk again. We counsel those bearing emotional scars left by the earthquake. We treat and prevent the spread of cholera. But to help Haiti recover stronger from this disaster we need to do more. We need to build medical facilities capable of providing high-quality care and train more Haitian medical professionals to deliver that care.

Mirebalais hospital meets all of those needs and is the flagship project in our three-year plan to help rebuild and strengthen Haiti’s public health system.

Construction on this massive 320-bed hospital has already begun. Walls are quickly rising on buildings that will house state-of-the-art services not currently available in Haiti. Dorms are being built for the next generation of Haitian doctors, nurses and medical workers who will be trained there.

It’s our largest construction project yet, and we will need your help to open it in January 2012 as planned.

Please stand with Haiti today. Your donation will help save mothers like Rosalind and strengthen Haiti’s devastated public health system.

Sincerely,

Ted Constan
Chief Program Officer
Partners In Health

	Matt speaking to students before they start their walk.
	Signs welcoming people to the day's event.
	Carborro students posing before the walk.

In March, high school students in Matt Cone’s Global Issues class read Tracy Kidder’s Mountains Beyond Mountains, talked with Paul Farmer and Ophelia Dahl, and decided to get involved in a social movement aimed at improving life for thousands of people living in rural Rwanda. To meet this end, the students of Carrboro High—a suburb of Chapel Hill, NC—started a FACE AIDS chapter in their school and organized a fundraiser.

Today we received an update from Matt about his students’ efforts.

From: Matt Cone
Date: Wednesday, April 20, 2011 12:35 PM
Subject: Carrboro High School (NC) kicks butt for FACE AIDS!

Hello PIHers,

I have good news and I wanted to spread it to all of you with all deliberate speed. As many of you know, the students at my school, Carrboro High (CHS), just completed a fundraiser on behalf of FACE AIDS. The CHS students, who were led by four powerhouse 9th grade girls, established a goal of $20,000 and organized the event around a simple principle: each participant would ask 20 people to sponsor them for $20 to walk 20 miles on Sunday, April 17.

In the end, the students collected $21,000 and we know that we still have at least $2,500 that is scheduled to come in to us. The process of raising the money was exhausting, but the sight of so many students getting excited about global health, social justice, and activism was truly inspiring. In fact, we were so giddy at one point that we briefly fantasized about a 30-mile walk next year.

Best wishes.
Matt Cone

Read “Students join a movement for social justice in global health,” an earlier article about activities at Carrboro High.

	In Rwanda, a community health worker delivers medicine to a patient living with HIV.

Partners In Health was selected as a Devex Top 40 Development Innovator based on a poll of thousands of aid and relief workers from around the world.

Announced on April 18, the top 40 innovators include four types of international development organizations: donor agencies & foundations, development consulting companies, implementing NGOs, and advocacy groups.

The selection is based on a survey Devex emailed to more than 100,000 aid workers and international development professionals.

"Solving the big global challenges we face—from climate change to poverty—will require innovation,” Devex President Raj Kumar said. “We are proud to honor these 40 organizations that are leveraging innovative techniques and approaches to solve complex problems.”

All honorees will be recognized at a reception at the House of Sweden in Washington, DC on April 21 with Chris Thomas, Chief Strategist at Intel and Sonal Shah, White House Director of Social Innovation as featured speakers.

Other top 40 development innovators include Doctors Without Borders (MSF), William J. Clinton Foundation, The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Bill and Melinda Gates Foundation, and Oxfam.

See a complete list of this year’s Devex Innovators.

	An infected patient's lungs are filled with liquid.
	Alcoholic TB patients disproportionately live in rural areas.

In the district of Tomsk, Russia, between one-half and one-third of people living with tuberculosis (TB) suffer from alcoholism, with a majority of these people binge drinking alcohol upwards of three or more times a week. For people suffering from a potentially fatal and highly contagious disease, addiction manifests in irregular medication use--which can lead to drug-resistant strains of TB--and an increased risk of HIV co-infection. All of these factors have left this Siberian region of just over a million people with the unfortunate distinction of having some of the world’s highest TB and alcohol consumption rates.

In response, PIH-Russia, Brigham and Women’s Hospital’s Division of Global Health Equity, McLean Hospital, and the Tomsk TB-Alcohol Working Group implemented an initiative aimed at curbing those numbers. The six-year clinical trial—called IMPACT—will conclude in June 2011.

Treating tuberculosis and preventing its spread in this isolated region historically posed seemingly insurmountable challenges for health care workers in Tomsk. In 1998, the government of this remote Russian province partnered with PIH to bolster the efforts of the local health system. With proven results treating TB in Peru, PIH was well equipped to meet a similar challenge in central Russia.

While TB rates in the region have continued to decline in the past decade, shockingly widespread alcoholism rates threaten to reverse those trends.

Even without the factor of TB, alcoholism is a major concern. According to “Alcohol and cause-specific mortality in Russia,” an article published in the medical journal Lancet in 2009, 52 percent of deaths in people aged 15-54 are associated with alcohol abuse. In fact, twelve of the top 20 causes of death in Russia are alcohol related, killing more than 300,000 people in the country annually.

“Heavy drinking has a long tradition in Russia. This has led many commentators to argue that it is so deep-rooted as to be impossible to tackle,” writes Dr. Namvar Zohoori, lead author of Monitoring Health Conditions in the Russian Federation. “Roughly 70 percent of men and 45 percent of women drink alcohol,” he states in the report.

Roughly 20 percent of men binge drink more than 100 grams (3.5 oz, or roughly seven mixed drinks) of alcohol per day.

The problem is so pervasive that between 1991 and 2001 life expectancy among men fell from 63.5 years to 58.9 years. To put that in perspective, men in the US live to 75 on average. Estimates associate Alcohol with approximately one-third of all deaths in the country.

Prior to this intervention, surprisingly little to nothing was being done in the public sector to address this crisis.

“The longstanding failure to integrate treatment for alcoholism into the primary care of TB patients suffering from both diseases represents a missed opportunity with serious clinical and public health implications,” says PIH’s Dr. Sonya Shin.

In 2007, PIH’s Russia-based project, Партнеры во имя здоровья, began integrating alcohol treatment into 200 patients’ tuberculosis regimens. Since TB treatment requires between six and 24 months of daily doses of medication (depending on the severity of the case), the time and effort required to provide treatment is enough to also simultaneously address alcohol addiction.

Because patients with aggressively contagious strains of TB are often quarantined for the first few months of treatment, PIH-Russia and Tomsk’s TB-focused clinicians created treatment communities within the hospital setting. 

“To our knowledge, this is the first study to examine the feasibility of delivering alcohol treatment as part of routine TB care and to assess this treatment model’s impact on both TB and alcohol outcomes,” says Dr. Shin. “If proven feasible and effective, this treatment model could be adapted for alcohol dependant TB patients.”

In order to determine how best to confront TB infections induced or worsened by alcohol, clinicians tested to see if patients addicted to alcohol were more likely to complete an anti-TB drug regimen if they were also taking an opioid that reduces a patient’s craving for alcohol called naltrexone.

Patients were given one of four randomized treatments:

1. Oral naltrexone + Brief therapy during treatment + TB medication regime
2. Brief counseling intervention + TB medication regime
3. Naltrexone + Brief therapy and brief counseling during treatment + TB medication regime
4. TB medication regime

Under the watchful eye of nurses or clinicians responsible for supervising the administration of TB drugs, patients received naltrexone for six months in conjunction with directly observed therapy for tuberculosis.

Although naltrexone is approved for the treatment of alcoholism in Russia, access to this medication is scarce and primarily used for heroin addiction.

	Staff take samples from TB patients regularly.
	Nurses and clinicians examining TB patient's x-rays.

“At the time of signing the consent form, none of the 200 patients knew which group they will be assigned,” says Viktoriya Livchits, PIH-Russia’s research coordinator. “A number of the patients had some experience being treated for alcoholism.”

“In the end, all of the patients liked talking to their doctors and would recommend counseling interventions to other patients.”

While researchers will continue working with the data for months before publishing, it is safe to say that the program was a success—both for the patients who received care and for the cadre of health care workers trained to simultaneously address TB and alcoholism.

That is not to say the program did not run into a few glitches. Local physicians were initially worried about an increased work burden, while patients were hesitant to participate.

In Russia, patients pay out-of-pocket for drug and alcohol addiction services and they are required to register with the government’s Narcology Services department upon entering rehab. Registration can result in difficulty seeking employment, employment loss, and restrictions in owning or driving a car.

Men and women enrolled in this clinical trial were not registered with the government’s narcology department. 

“Suffering from alcoholism and chronic medical illness further contributes to a cycle of poverty, displacement and socioeconomic disempowerment that often makes recovery unattainable, even for the most motivated patients,” says Dr. Shin.

“The decrease in overall alcohol consumption will improve TB outcomes and decrease HIV risk behavior,” continues Dr. Shin. “Ideally the patient is able to break his or her dependency on alcohol as well.”

In the end, nearly all 200 participants saw the program through from beginning to end.

“The study was challenging,” says Dr. Shin. “Nonetheless, our experiences implementing this care taught us the necessity of working within cultural contexts, delivering services as an integral component of treatment for other chronic medical conditions, employing community health workers, and accompanying our patients through each step of alcohol treatment.” 

Learn more about PIH's work in Russia.

Visit PIH's Russian language website.

By Meredy Throop, Policy and Advocacy Coordinator at PIH

“User fees raise less than five percent of a health sector’s budget… most of that income is lost to administrative costs. To be short: fee-based health care is inequitable. If we were to remove these fees, 233,000 children in 20 African countries would be saved from preventable deaths this year.”

                                                                                    - Robert Yates, UK DFID

	A mother and her baby visit a clinic in Rwanda, where PIH covers user fees for poor patients.

Nobody believes that a woman should die in childbirth or that anyone should suffer from a debilitating disease simply because they are too poor to afford health care. Yet this is precisely what happens when small point-of-service fees are charged at public health facilities in low-income countries. 

On April 7, 2011 Partners In Health co-hosted a seminar titled “Health Financing for Universal Access” at the Harvard Kennedy School of Government’s Institute of Politics with Dr. S.A.S. Kargbo from the Sierra Leone Ministry of Health, Robert Yates from the UK Department of International Development (DFID), and Dr. Cristian Baeza from the World Bank.

The event was moderated by Dr. Paul Farmer and Dr. Agnes Binagwaho, Rwanda’s Permanent Secretary of Health. Other co-hosts included the Department of Global Health and Social Medicine at Harvard Medical School, the Center for Global Health at Massachusetts General Hospital, and the Francois-Xavier Bagnoud Center for Health and Human Rights at Harvard University.

The seminar sent a strong message to attendees: the time to abolish user fees is now.

When Robert Yates first began working in Uganda’s Ministry of Health in the 1990s, development discourse mandated user fees for health and education. Yet when Uganda abolished user fees at public health facilities in 2001 against the advice of its donors, outpatient visits nearly doubled.

Within weeks hundreds of thousands of people emerged from the shadows of their deathbeds with a powerful lesson for Yates: it is better to have people waiting in line for treatment than waiting in their homes to die. A decade later, Yates’ research proves that user fees are not only inequitable, but they are also ineffective at raising revenue for the health sector.  

	Lines outside a clinic the first day user fees were eliminated for mothers and children in Sierra Leone.

In 2008—facing the highest rate of infant mortality at 123 per 1,000 live births and one of the highest rates of maternal mortality in the world—the government of Sierra Leone asked Ministry of Health official Dr. Kargbo to investigate the impact of user fees in the country. 

An overwhelming 88 percent of survey respondents determined cost to be the biggest obstacle to accessing health care, followed by distance/lack of transportation (six percent), lack of staff (two percent), lack of drugs (two percent), and inadequate or no health facility (one percent). On April 27, 2010, Sierra Leone took decisive action and eliminated user fees for children and for pregnant and lactating women. Clinic-based births increased more than five-fold, raising the bar on what is possible for the mothers of Sierra Leone.

Evidence emerging from Sierra Leone and other African countries demonstrates that with support from donor agencies, governments can improve health outcomes for the poor by abolishing user fees. But targeted financing is necessary. These concurrent reforms, such as increasing health workers’ salaries and benefits, procuring additional medicines and supplies, and increasing financial flows to front line services, are requisite to ensuring effective and equitable health services.  

Today the international community increasingly recognizes that user fees discriminate against the poor. But reform has been slow. It is time for all international donors to commit to supporting poor country governments which choose to remove user fees from public health facilities.  

Learn more about PIH's advocacy work.

On April 1, 2011, PIH-Lesotho eliminated user fees at Mamohau Hospital after agreeing to support the facility with the Government of Lesotho and the Christian Health Association of Lesotho. PIH staff members worked to make the hospital a cleaner and more dignified place for patient care before reopening.

 
By Andrew Marx, PIH Director of Communications

Some striking data on what happened on the first two days after we eliminated user fees at Mamohau on April 1. In just two days, without our having yet done any community outreach or having had time to dramatically improved services at the hospital, the number of patient visits per day more than tripled, from 55/day to 175/day. 

Some numbers:
 
Before April 1, Mamohau was seeing an average of 55 patients per day.

Starting April 1, we eliminated charging user fees at the hospital. That's all we did, aside from a one-day work party that included a thorough cleaning and paint job.

For the first two days after we got rid of user fees, Mamohau treated an average of 175 patients a day. That's an increase of 120 patients each day.

For those looking for more data on costs and benefits:

• Mamohau will lose $4500/month from not charging user fees.

• If the hospital continues to see an additional 120 patients a day, that means they will see over 3,600 more patients each month.

• So to collect $4500/month, user fees were discouraging at least 3,600 patients each month from receiving care.

If PIH-Lesotho’s estimates of eventually seeing 400 patients/day are right, that number will increase from 3,600 to over 10,000 additional patients a month who will be receiving care—all just by eliminating user fees.

Read why user fees discourage patients from visiting health clinics.

Find out more about PIH's work in Lesotho.

The Mirebalais Teaching Hospital has come a long way since breaking ground on July 2, 2010.

Concrete is being poured for the first two buildings.

Site Supervisor Larry Nicholls gives a tour to an American structural engineering surveyor.

Haitian workers lay cement for the roof.

The excavation and leveling of the site is complete. In total, over 4,387,989 cubic feet of dirt was moved and the base of the building was raised 10 feet for protection against flooding. We have made rapid progress on the foundation and walls of the first five buildings—about 60% of the hospital footprint. 

The concrete has been poured for first two roof slabs of the Womenʼs Health and Ambulatory Care buildings, which are by far the most structurally complex on site. We expect to move more quickly on forming and pouring the roof slabs on the following four buildings. Construction is progressing on the underground plumbing and electrical work, staying just ahead of the excavating and foundation crews.

In the last week of March, we successfully completed the extensive system of drainage canals, culverts, and spillways that handle rainwater. This was a crucial milestone, as the Haitian rainy season begins in April, bringing brief but torrential rainstorms each afternoon for the next six months. With this accomplishment, we will be able to protect the buildings that are currently under construction from flooding and possible damage, and we hope to lose less time due to extremely muddy and wet conditions.

Over the next 120 days, the construction crew hopes to complete the concrete on the first four buildings, allowing work to begin inside with the installation of the interior systems and finishes.

In-Kind Donations

In March, Mirebalais Hospital received very significant in kind donations. Stanley Black & Decker donated all door hardware, locks,and keying from their top of the line, heavy-duty commercial door levers and lock series for the 410 doors in the hospital.

Led by Hubbell CEO Tim Powers, three of the largest electrical equipment manufacturers—Hubbell, Southwire, and Thomas & Betts—have donated all the electrical equipment, light fixtures, ceiling fans, and wire for the entire project.

by Joia Mukherjee, PIH Chief Medical Officer

A Project Muso community health
worker conducts a home visit.

As many of you know, PIH—working with Still Harbor, a Boston-based social justice organization—has made a conscious decision to support and foster the success of small, start-up, grass roots organizations that are trying to bring about health equity around the world.

Project Muso in Mali is one of these organizations—a small group, working with local communities to improve the lives of the least fortunate. The organization, just 2 years old, is making incredible progress demonstrating real reductions in child mortality, tangible empowerment of women and a massive increase in access to health care. Yet, after a key funder underwent a strategic reorganization of funding priorities, Project Muso is facing an urgent cash flow crisis and needs your support. Thankfully, with this threat has come opportunity and a generous supporter has agreed to match up to $30,000 of what is given over the next 30 days to help ensure Project Muso's patients continue to get the care they need.

Partners In Health and those who support us know that real, sustained change will only come from the grass roots. The solution to the problem of global inequity, poverty and injustice is pragmatic solidarity—working alongside the poor, oppressed and marginalized to achieve change. Solidarity is the tie that binds us to one another in the struggle. It is the special force—spiritual in nature—that connects us to other human beings, particularly to those striving to bring basic dignity to all, to remediate injustice everywhere. Solidarity goes much beyond social theory: It is faith, it is religion, it is connectedness.

For me, Project Muso in Yirimadjo, Mali is one of the faces of solidarity. The team of Project Muso has used malaria prevention and treatment as a battle horse to enter into the larger battle against poverty, structural violence and ill health. Founded in 2005 by Harvard Medical Student Ari Johnson and his wife Jessica Beckerman—a medical student at UCSF (and former PIH-PACT worker!), Muso team members have shown that even in a desperately poor place, community engagement in health, removal of user fees and other barriers to health care, and the assistance of the public sector in delivering care can have transformative effects on health and society.

Project Muso has achieved some of the most remarkable, tangible results a very short time—in the first 2 years (2008-2010):

  •    Fever prevalence in children younger than five years decreased from 46% to 26%;

  •    The percentage of children treated for malaria within 24 hours of their first symptom tripled from 14% to 45%;

  •    Health care use increased 136%, from 11,056 to 26,135 health center visits/year;

  •    Child mortality has DECREASED—in just two years!!!!! (full report and validation in process).

We can't give up on our community anywhere. Closing down Project Muso is not an option. It would mean turning away critically sick and destitute poor patients from care, which they would have no other way to access.

Project Muso urgently needs to raise $30,000 per month for the months of May and June to ensure that they can reach thousands of patients in urgent need of care. If we can raise $30,000 by May 13th, the funds will be matched dollar for dollar by a generous donor.

Right now the team is looking for some immediate heroic gifts to reach the match, as well as a movement of people to spread the word about their important work. We are also working to create a network of individual supporters and advisors who would like to make a longer term commitment to Project Muso's work and to the people of Mali. As a young organization with very limited staff, a little goes a very long way.

Tax-deductable donations can be made through the website at http://www.projectmuso.org/donate

or by sending a check or money order out to "Under the Baobab Tree" and mailing it to:

Under the Baobab Tree

1380 Monroe Street, NW Box 309

Washington, DC 20010

Thank you for considering this urgent appeal on behalf of our friends and family at Project Muso. As Martin Luther King, Jr. said,  “Injustice anywhere is a threat to justice everywhere.” At this critical juncture, every bit will make a real difference in the lives of the patients, their families and the community of Yirimadjo.

	SES staff train college students about HIV and STDs.
	Local officials participated in the day's events.
	Prizes were awarded for students who answered questions correctly.
	Entertainment included music, games, and contests.

On April 14th, Socios En Salud—PIH’s sister organization in Peru—participated in the “2011 Healthy Universities Campaign” at the National Agrarian University in La Molina, Lima. The event trains students how to help stop the spread of tuberculosis, HIV, and sexually transmitted diseases. Students also learn about mental illness.

There were 15 institutions that participated in this event, including NGOs, hospitals, and the Peruvian Ministry of Health, which provided interactive and engaging information on ways of preventing different illnesses with the university community.   

By 10 a.m. hundreds of students had came out to participate in games, contests, talks, and short-film viewings related to tuberculosis at the Socios En Salud tent.

More than 50 young people enthusiastically competed in responding to questions about the TB prevention. Winners were rewarded with books, stuffed animals, and t-shirts.

This campaign was carried out under the Health Universities Program created by the Ministry of Health to drive promotional and preventative activities in the Universities in Peru.

Learn more about Socios En Salud.

--

Socios En Salud contribuye a la prevención  y promoción de la salud en las “Universidades Saludables” – Universidad Nacional Agraria

Hoy jueves 14 de abril Socios En Salud Sucursal Perú participó en la “Campaña Universidades Saludables 2011” realizada en la Universidad Nacional Agraria de La Molina (UNALM) para la prevención de enfermedades como la tuberculosis, VIH, enfermedades de transmisión sexual y salud mental.

Este evento contó con la participación de más de 15 instituciones, entre ellas ONGs, hospitales, representantes del Ministerio de Salud (MINSA) y asociaciones civiles, las cuales difundieron lúdicamente formas para prevenir las distintas enfermedades dentro de la comunidad universitaria. 

Desde las 10 de la mañana cientos de alumnos se acercaron  para participar en juegos, concursos, charlas y visionado de cortometrajes en relación a la tuberculosis , dados en el stand de Socios En Salud. Más de 50 jóvenes mostraron mucho entusiasmo y concursaron respondiendo preguntas básicas sobre la prevención de la tuberculosis, con lo que se hicieron ganadores de libros, muñecos y polos.

Esta campaña se realizó en el marco del Programa Universidades Saludables, creado por el MINSA con el objetivo de impulsar actividades preventivo promocionales en las universidades de nuestro país.

Learn more about Socios En Salud.

By Lydia Flier, 2010 PIH Summer Intern

	Teboho talks with PIH-L social workers.

Before Partners In Health’s project in Lesotho (PIH-L) implemented a community-based multidrug-resistant tuberculosis (MDR-TB) program in 2007, Teboho Khophoche, a young teenager, lived in a village near the capital city of Maseru with his grandmother, mother, and three uncles. All members of this extended family had been treated for TB several times over the years, but it was not until his mother died of that same disease that Teboho was diagnosed with MDR-TB.

Shortly after his mother’s death, Teboho became one of the early patients at the newly renovated Botsabelo MDR-TB hospital in Maseru. After five months of treatment in 2008, he was discharged to the care of his aunt, and PIH-L provided him with a monthly food package as part of his MDR-TB treatment. But after falling ill and being readmitted several times over the next few months, the PIH-L medical team met with the family to negotiate who would take responsibility for him during the home-based part of his treatment. His grandmother, who had moved to South Africa, agreed to stay with him until he was well. After he recovered, Teboho’s grandmother stayed on, and was joined by his aunt.

Teboho is one of 40 million orphans living throughout all of Africa. Though children can be orphaned by disease, famine, war and other causes, the HIV/AIDS epidemic, paired with high rates of tuberculosis (TB), has exacerbated sub-Saharan Africa’s existing crisis: over 12 million- children in sub-Saharan Africa have lost one or both parents to HIV/AIDS.

Yet these statistics do not capture the full impact of the crisis. UNAIDS and UNICEF jointly reported that millions of non-orphaned children are also vulnerable if they live with a parent or family member who is ill and cannot care for them. Moreover, unless access to medical care in Africa changes dramatically in the coming years, the number of orphans will continue to grow.

Once orphaned, young girls and boys are forced to find work; they frequently become heads of households, suddenly responsible for the care of younger siblings. These children are placed at greater risk for abuse, malnutrition, illness, and psychological distress. Orphans are also more likely to fall behind in or drop out of school than their non-orphaned peers, according to UNAIDS and UNICEF.  Many orphaned children are sent to live with extended relatives – creating additional economic pressures on already strained family units.

In an effort to break the related cycles of disease and poverty, Partners in Health (PIH) has responded to the needs of these children at many of our sites, for example, by providing food packages and covering school fees so that they can finish their education. PIH runs programs for Orphans and Vulnerable Children (OVC) at our three African sites: Rwanda, Lesotho, and Malawi.

Rwanda

	IMB assists more than 700 orphaned children in Rwanda.

In 2007, UNICEF estimated that Rwanda was home to more than one million orphans. Inshuti Mu Buzima (IMB), PIH’s sister organization in Rwanda, assists more than 700 orphans and vulnerable children. Some of the orphans’ parents died of HIV or other illness at IMB facilities, while many others have been identified as needing assistance in concert with the Rwanda National HIV Associations Network and the local social affairs departments.

IMB supports these children by providing food packages, clothing, health insurance coverage, as well as emotional support. Long-term support includes paying for school fees and materials, and ensuring access to housing. Additionally, IMB holds a a three-day youth forum each year around World AIDS Day in December and invites most of these children to participate in HIV education workshops, as well as creative and cultural forums.

Additionally, IMB offers older children vocational training in sewing, carpentry, and welding – skills that give young people the possibility of supporting themselves and their families. Approximately 65 children graduated from IMB’s vocational programs in 2010.

One of these graduates is seventeen-year-old Claudine, who lives with her HIV+ mother and nine siblings. After losing her father to heart disease, she quit school to support her family. Her mother knew she needed a skill to find steady employment so she enrolled her daughter in IMB’s sewing school. Claudine is now looking for a job – a difficult task in rural Rwanda.

Today, she continues to receive support from IMB and is enrolled in a vocational cooperative where she is learning to sew.

Malawi

	More than 1.1 million orphans live in Malawi

UNICEF estimates that there are 1.1 million orphans in Malawi. Abwenzi Pa Za Umoyo (APZU), PIH’s sister organization in Malawi, currently supports 889 school-age children in the Southern region’s Neno District. The children are usually identified at an HIV clinic by filling out a referral form.

Children receive school fees, uniforms,shoes, writing materials, and if necessary, food packages and medical care. If the child and his or her extended family are homeless, APZU will work to find or build housing.

Beyond working with these children on a one-on-one basis, APZU funds the creation of community-based childcare centers, financially supporting income-generating activities through community-based organizations that train children in various job skills. 

When he was seven-years-old, Lowesi George lost his parents to Malawi’s HIV/AIDS epidemic. Raised by his elderly grandmother, he left school in 8^th grade when she was no longer able to afford his school fees. He was later identified by a PIH-affiliated organization, which taught him carpentry with financial support from APZU. Now 18, Lowesi plans to use the skills he has learned to support his grandmother and his younger sister, who is still in school.

Lesotho

	The first five orphans to receive care from PIH-L.

In terms of the AIDS epidemic, Lesotho is the third-hardest hit country in Africa: an estimated 23.2 percent of its 1.8-million adult population is HIV positive. UNICEF reported 160,000 orphans in the country in 2007, with 110,000 of those children orphaned by HIV/AIDS.

Lesotho presents particular geographic challenges, as many patients live several hours away from the nearest PIHL clinic, and most must make mountainous hikes to reach any medical services. In addition to the seven mountain clinics, PIHL runs both the national MDR-TB treatment program and Botsabelo hospital, which was renovated to provide state-of-the-art MDR-TB care in the capital city of Maseru.

All PIHL orphans are children of patients who died from HIV or TB. Some of these children contracted HIV or TB from their parents, though many are healthy.

The first five orphans served by PIHL were three sisters who lost their mother to TB, and a brother and sister whose father died of advanced HIV/AIDS and TB. These children moved to a house in Maseru in 2008, and continue to live there with a PIHL-supported foster mother. They receive PIHL support for school fees and supplies, food, clothes, and medical care, including counseling.

In 2010, PIHL scaled up its OVC program to include more than 100 children, with each of the seven mountain clinics now supporting at least ten children who live with relatives. These families are provided with food packages and support for school fees and uniforms to defray the economic burden of caring for additional children.

Teboho, having completed his full MDR-TB regimen in November 2009, came up with his own method for reducing the burden on the grandmother and aunt who took him in. He is a budding entrepreneur, bringing in money for his family by raising pigeons to sell. PIHL has also provided Tebohao with knitting materials, and he has begun to make ladies’ shawls and jerseys for preschool children on his aunt’s knitting machine.

In January 2010, the PIHL OVC program helped Teboho re-enroll in school. After ensuring that his teachers and peers understood he was no longer contagious, he began to be welcomed back into the social sphere and just finished his second term with high marks.

Read more about PIH’s work in Africa.

CNN’s Inside Africa produced a segment on maternal mortality in Rwanda that aired in early April. The piece focuses on Butaro Hospital, a facility in rural northern Rwanda, which was built and operated by PIH in partnership with the Government of Rwanda. Rwandan Permanent Secretary of Health, Dr. Agnes Binagwaho and PIH Country Director, Dr. Peter Drobac discuss the effectiveness of the hospital and the importance of public-private partnerships.

Learn more about Butaro Hospital.

By Aliya Aitpayeva, PIH-Kazakhstan Administrative Manager

	Tuberculosis patient receives examination.
	TB patients receive care in Kazakhstan prisons.
	Prisoners living with TB.
	PIH-KZ trained nurse brings medicine to a TB patient.

Though tuberculosis continues to be a major public health threat in Kazakhstan, especially in penitentiaries and rural areas, the number of new infections each year has slowed. According to the KZ Ministry of Health, roughly 240 Kazaks (per 100,000) were living with TB in 2009—a dramatic decrease from 2003, when the number was closer to 482.

Yet, Kazakhstan is far from eradicating the disease. Because of the long-term requirements and complexity of treatment, patients frequently fail to complete treatment, which only spreads the disease.

“Patients’ adherence to treatment is one of the main bottlenecks for successful completion of treatment for our patients,” says Dr. Maya Omarova, the PIH project coordinator in Pavlodar Oblast. “The majority of patients lack the resources needed to sustain their families while being on treatment, as they are the only source of income; thus, they abandon treatment to search for work and money.”

With the invitation of the Kazakhstan government, Partners In Health began providing technical and methodological assistance to the National TB Program of Kazakhstan in two territories with high rates of MDR-TB—the oblasts of Karaganda and Pavlodar—in April 2010.

Financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, PIH’s Kazakhstan project (PIH-KZ) accompanies the National TB Program as it scales up medical and program management MDR-TB services. This includes providing intensive MDR-TB management training to TB nurses and doctors, onsite technical assistance for medical management, monitoring the progress of each clinic, and assisting with operational research.

As PIH-KZ expands its services, it draws heavily on the lessons learned in neighboring Russia, where PIH has been working for in Tomsk Oblast for 15 years. To support their new colleagues, PIH-Russia staff presented four seminars on medical and program management of MDR-TB to the KZ team.

In Tomsk, PIH introduced the Patient-Centered Approach Initiative in order to provide patients with higher quality and more convenient access to treatment, to provide comprehensive socio-psychological support, and to reduce the stigma attached to the diseases in the region.

The PIH-KZ patient adherence program trains TB nurses to counsel, educate, and empower their patients. In addition, nurses guide patients through a 10-module program that includes information on patients’ rights, social support, and adherence.

To date PIH-KZ has conducted 6 sessions, training 107 civilian and prison TB nurses from Karaganda and Pavlodar.

“These seminars had showed the necessity of a person who act as counselor or supporter and provide education of patients at all stages of treatment,” says PIH-Russia’s Dr. Alexandra Solovyeva. “Patients must know their rights and responsibilities in order to act as equal partners in the treatment process.”

“I am certain that the initiative will improve patient adherence in Kazakhstan,” continues Alexandra. “PIH-Russia will replicate some of what we’ve learned in Kazakhstan back in the Russia program.”

Government-payed TB physicians in KZ have also received additional training. Two clinicians from PIH-Russia, Alexandra Solovyeva and Viktoriya Livchits, and a specialist from Tomsk TB Program, Tatyana Fedotkina, are acting as mentors to staff working with TB patients.

Beyond re-training staff, PIH-KZ is committed to shifting the country’s larger policy and advocacy conversations around tuberculosis.

PIH-Russia and PIH-Kazakhstan organized two international trainings for 21 leading Kazakh specialists and prison health authorities in Tomsk, Russia. Kazakhstan officials were impressed by PIH’s MDR-TB Program and have replicated the PIH-Russia model known as the “Sputnik” initiative. These initiatives are currently being implemented in the nation’s prison system, improving treatment for sick prisoners.

In early 2011, the government asked PIH-Kazakhstan to expand its services to four additional regions in Kazakhstan. 

Learn more about PIH's work in Kazakhstan.

Read about PIH's successes in Russia.

Visit PIH's Russian website.

Published in the April edition of Engineering News Record, Tom Sawyer’s article, “Construction Contributions Drive Hospital’s Rise in Haiti,” describes the difficulty of training Haitian construction teams to assist in building Mirebalais Hospital.
 
“The idea is to train the locals in a different type of construction than they are used to and to use as little material as we could,” says John Looney, the structural engineer of Mirebalais Hospital.

Mirebalais hospital is one of the first major public-sector projects to start in Haiti since the earthquake. Partners In Health is hiring Haitian workers both to decrease labor costs and to further develop the skills of workers in the Mirebalais community.
 
“The first day we started to lay block,” explains Jim Ansara, PIH’s director of construction, “we had 1,500 to 1,800 men line up to see if they could get jobs.”
 
Ansara hopes that the Engineering News Record article not only raises awareness about the hospital, but also encourages skilled tradespeople from America to volunteer with complex construction and the training the Haitian staff.
 
“We have people who are really good at stone, masonry and tile,” Ansara says, but not so skilled in electrical systems, control wiring, acoustical ceilings and millwork. “We are desperately trying to gather volunteers willing to go to Haiti and work for a week.”
 
To learn more about the construction, read the piece in Engineering News Record.
 
Find out more about volunteering to work on Mirebalais hospital. 

The 8th annual Urban Walk for Haiti took place April 2 in Cambridge, MA. PIH Chief Medical Officer Joia Mukherjee talked to supporters prior to the walk, and led the group as they sang "Tout Moun Se Moun," which, translated from Haitian Creole, means "Every Person is a Person."

Each year the Walk raises money and attention for PIH's work in Haiti. This year the Walk focused on malnutrition in post-quake Haiti. Funds raised during the day-long event will support PIH's agricultural program, Zanmi Agrikol.

“One thing that is so great about the walk, is that…people seem to just really be selfless, with volunteers helping out the day of with preparing, cleaning up and helping out where needed, says Karleen Porcena, Walk co-founder. “It's really a great event, with great energy and such a positive atmosphere.”

“The fact that so many people came out and financially supported the Walk this year, when we don't hear so much of Haiti in the news is so comforting because it shows that people still care regardless of media headlines, and people want to support organizations like PIH because they trust it and know about its wonderful history.”

“The cultural aspect of the day, with the wonderful food, beautiful artwork and crafts being sold, and people dancing in the courtyard to the band was wonderful and very uplifting,” continues Karleen. “We had families, college students, young professionals, politicians...everyone coming together for this great cause.”

The Urban Walk for Haiti has raised over $300,000 since 2004. 

Read more about this year’s Walk for Haiti.

Visit the Urban Walk for Haiti website.

On Sunday, April 10, over 11,500 people came to watch the Haitian national soccer team play—and defeat—the Harvard men’s soccer team. Students, Haitian-Americans, PIH-supporters, and local soccer fans were out in force. Many of the Haitian-Americans in attendance cheered for their native country from the start, proudly waving Haitian flags and giving Les Grenadiers—the name of the Haitian team—a standing ovation when the squad came out for the first time.

“It was only fitting that such a contest would come down to the most dramatic of finishes, with the 2007 Caribbean Cup winners pulling away to win 4-1 on penalty kicks after a scoreless 90 minutes,” writes Harvard Crimson’s Scott Sherman.

Proceeds from ticket sales are being split evenly between Partners In Health and the Haitian national team. In addition, Crimson coach Carl Junot presented a $2,500 donation to PIH on behalf of Harvard Soccer, Friends of Harvard Soccer, and Harvard Athletics, as well as a $2,500 donation to the Haitian Football Federation from Harvard Soccer, during halftime.

By Sarah Arnquist, GHDonline

While nurses in high-income countries benefit from many additional resources compared with their colleagues working in resource-poor settings, both groups confront challenges in promoting adherence to HIV treatment, particularly among patients with numerous complex needs. Through a virtual discussion this week on GHDonline.org, nurses working globally are exchanging tools and strategies to promote patient adherence.

	Christopher Shaw

Christopher Shaw, a nurse working at Massachusetts General Hospital’s infectious disease clinic, is leading the discussion in GHDonline’s nursing community, one of nine public virtual professional communities developed by a team at Harvard University and the Brigham and Women’s Hospital. Through the GHDonline community, Shaw is connecting with hundreds of health care implementers worldwide to share proven practices and resources to improve patient care quality. Shaw has posted two short case descriptions of immigrant patients struggling to adhere to their HIV treatment.

 In response, expert panelist and veteran nurse Pat Daoust wrote, “One of the advantages I had while working in other countries was learning first-hand from my in- country nursing colleagues just what many of the cultural, religious and lifestyle challenges existed for our patients which would impact their ability to successfully or unsuccessfully adhere to ARVs. As we work more and more with the immigrant population here in the U.S. I think it really becomes our responsibility to investigate and learn from our patients about those barriers.”

Dehne Mengiste, the nursing director at I-TECH Ethiopia, trains cadres of adherence case managers and adherence supporters that work directly with patients to improve adherence. Mengiste offered suggestions to manage Shaw’s complex patients and then recommended connecting these patients to groups. “Joining the Association of People Living with HIV/ADIS,” she wrote, “brings a difference in the life of such cases, especially with those who speak same language and share some aspect of culture and religion.”

	Sheila Davis

Sheila Davis, GHDonline moderator and Partners In Health Nursing Director, frequently says global health begins at home in our own backyards. Moreover, she says, nurses and anyone else going to work abroad should not go with the mindset of wanting to teach, but rather to listen and learn.

Through this GHDonline panel discussion, nurses can begin participating in global health and learning from their colleagues worldwide.

To participate in the discussion, sign up for GHDonline’s Global Nursing & Midwifery 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.

Arcade Fire performs outside PIH's hospital in Cange, Haiti.

	Arcade Fire performs for patients and staff.
	The band tours Mirebalais Hospital construction site.

Members of the rock band Arcade Fire, winners of this year’s Grammy for Best Album, visited PIH projects throughout Haiti last week. In addition to performing informal concerts for patients and staff, the musicians came to learn more about PIH’s work and the issues faced by the communities PIH works with.

Arcade Fire has supported PIH since 2007. During that time the band has raised over $1 million for PIH’s work in Haiti. More than that, they have introduced thousands of their own supporters to PIH. 

After reading Tracy Kidder’s book Mountains Beyond Mountains, the group contacted PIH to ask how they could help. Since then, their support has included organizing special fundraising events and donating a portion of ticket sales from recent concert tours to support PIH’s work. Last year, they licensed their hit song “Wake Up” to the NFL for a series of commercials, donating all proceeds to PIH’s work in Haiti. 

In addition, the band’s relationship with Haiti runs deep. Cofounders Win Butler and his wife Régine Chassagne have always remembered Régine’s Haitian roots; her family emigrated from Haiti to Canada before she was born. Fans know that Win sometimes decorates his guitar with the Haitian proverb “sak vide pa kanpe”—“an empty sack cannot stand up”—as a reminder of the crushing poverty that afflicts Haiti.

Chassagne and Butler, along with the rest of the band—Richard Reed Parry, William Butler, Tim Kingsbury, Sarah Neufeld, Marika Shaw, and Jeremy Gara—have supported relief work in Haiti through donations and, equally importantly, by spreading the word around the world about Haiti and PIH’s work.

PIH Chief Medical Officer Joia Mukherjee discusses how an early childhood memory helped inspire her current efforts to promote social justice in health care. The above video was produced by Two Degrees, a company that manufactures nutrition bars. For every bar sold, a nutrition packet is given to undernourished children in poor communities around the world, including communities that PIH serves. Learn more about Two Degrees.

By Grace Ryan, Department of Community Health, Inshuti Mu Buzima/Partners In Health

The world’s first international conference on community health (ICCH) was held in Kigali, Rwanda, from 25-28 January 2011 on the theme: “The Role of Community Health in Strengthening Health Systems”. ICCH represents a collaborative effort between Rwanda’s Ministry of Health and its development partners, including Partners In Health. The conference brought 500 participants from 13 different countries to Kigali to share lessons, best practices, and research in community health. 

The ICCH was organized into nine sessions based on WHO building blocks for health system strengthening. Session themes ranged from equitable access to essential medical products, to community health financing, to the role of good governance in strengthening the community health system. Overseas participants from India, Afghanistan, Pakistan, Timor, and the United States presented alongside representatives of community health programs in North, East, South, West, and Central Africa. Each session concluded with a lively discussion on the unique challenges of service delivery across the globe, as well as potential applications of presenters’ findings to inform program development internationally, building up to the ratification of an ICCH Consensus Statement.

Highlights included inaugural and closing addresses by Minister of Health Dr. Richard Sezibera and remarks by Permanent Secretary to the Ministry of Health Dr. Agnes Binagwaho, setting the tone for the conference as an important milestone in the history of community health in Rwanda and around the world. Keynote speeches from Professor David Sanders of the University of the Western Cape School of Public Health in South Africa and Partners In Health’s own Dr. Paul Farmer underlined the importance of significant investment in community health programs in order to improve national health indicators. A field visit to the Musanze District community health program  showcased Rwanda’s performance-based financing system for community health worker (CHW) cooperatives, as well as the work of its maternal, pediatric, and chronic disease care CHWs, and the new Rapid SMS program that allows pediatric CHWs to communicate data to health centers in real time. Finally, a trip to the Gisozi genocide memorial underscored the changes seen in Rwanda over the past seventeen years through strong leadership and an emphasis on human resource and infrastructural development.

The ICCH steering committee chaired by Dr. Fidele Ngabo, Director of the Ministry of Health’s Maternal and Child Health Unit, and Kathy Mugeni, Coordinator of the Community Health Department, is now designing a web-based community health forum in order to harness the spirit of intellectual curiosity and exchange that made this conference a success. Visitors to the ICCH website can already view the summit’s consensus statement and download presentations of summit participants (including lectures by PIH Rwanda’s Director of Community Health Didi Bertrand Farmer and Director of Research Dr. Michael Rich). Soon visitors will also be able to post short articles, comment on presentations, and discuss important themes in community health on the forum page. Steering committee members are working to make this forum a place where everyone with a stake in community health, from international health experts and governmental representatives to village leaders and CHWs, can learn from one another to build better health systems worldwide.  

The following email was sent this morning from Anne Stevenson in Rwanda.

As most of you know today is the first day of the Genocide Memorial Week. To turn all of that sadness and loss on its head, the sister of one of our local staff gave birth today to a beautiful 6 pound girl at Rwinkwavu Hospital.

What I think is the most amazing part about this is that the baby was turned sideways, so the mother had to have a cesarean section. I immediately thought about how lucky she was to be near a hospital like Rwinkwavu that actually had a surgeon and an anesthesiologist and a functional supply chain to have what they needed to perform the operation safely. A true testament if there ever was one to what PIH/IMB are doing here!

Anne Stevenson is a program manager at the Harvard School of Public Health. She is currently working with PIH’s sister organization Inshuti Mu Buzima (IMB) in Rwanda.

Learn more about efforts to strengthen Rwanda’s health care system.

	HIV/AIDS affects all members of a family, not just the patient.

“The support groups have given me strength, they have helped me know how I can better relate to my children,” said one parent participating in Partners In Health/Zanmi Lasante’s “Tout timoun se moun” (All Children are People), a five-year old support program for Haitian families affected by HIV/AIDS.  “In the exchange of ideas we’ve had I’ve come to realize that it is not only me who lives like this. The groups have helped me in how I relate to my children,” she continued.

A new study by PIH/ZL researchers and health care providers powerfully documents the transformative experiences of some “Tout timoun se moun” participants, who, like this parent, face stigma and other significant challenges while juggling the pressures of family life, and the demands of managing a chronic illness. Last year, PIH/ZL published preliminary research about the program in the journal AIDS Patient Care and STDs. And Father Eddy Eustache, Director of Psychosocial Services for Zanmi Lasante, presented some of PIH/ZL’s findings at the International AIDS Conference in Vienna in 2010. 

The forthcoming article, “Psychosocial support intervention for HIV-affected families in Haiti: Implications for Programs and Policies for Orphans and Vulnerable Children” presents new data that quantifies the impact of psychosocial support groups on HIV-affected families in a low-income country, and may be the first published in a peer-reviewed journal to do so.  

The paper is based on data collected from almost three hundred people (168 youth and 130 caregivers), at six Partners In Health-affiliated sites, who completed a baseline questionnaire about psychological symptoms, psychosocial functioning, social support, and HIV-related stigma prior to participating in the psychosocial support group. One year later, ninety-five percent of these families completed a comprehensive questionnaire, with PIH/ZL staff also interviewing participants to better assess their perspectives of the intervention, and researchers found a meaningful reduction in depressive symptoms and stigma, and a marked increase in social support.

“Reduction in depressive symptoms among HIV-positive patients may improve adherence, reduce morbidity, and increase survival,” said Mary Kay Smith Fawzi, an associate epidemiologist for Partners In Health and the Department of Global Health Equity at Brigham and Women’s Hospital, who was a co-principal investigator on the study.  “A significant reduction in depressive symptoms, if sustained, can improve the prognosis of HIV disease in resource-limited settings,” said Smith Fawzi.

Until recently, most of the programming for families in the developing world affected by HIV/AIDS targeted orphans and vulnerable children, or “OVC.”  (OVC are generally defined as young people who have been affected by the illness they have, or had, an HIV-positive caregiver or parent/s.)  Given the devastating and multigenerational impact of the pandemic, these efforts are essential: UNICEF estimates that there are 16.6 million children who have been orphaned by HIV/AIDS, as of 2010.

But this approach to psychosocial support in the developing world dates back to the pre-antiretroviral (ART) era, before 2001, when programs focused on supporting “children who were abandoned, ill-cared for, or grieving,” according to the study. As access to these drugs for people living in the poor world has slowly begun to improve – due in part to the proven interventions of progressive, grassroots like organizations PIH/Zanmi Lasante in Haiti – the needs of patients and their families have also begun to change and evolve.  For instance, in 2001 the World Bank estimated that there would be 35 million children orphaned by HIV/AIDS worldwide by 2010. Instead, there were 16.6 million in 2010, due in large part to greater access to better medicines.

Within PIH/ZL facilities in Haiti, where access to HIV/AIDS treatment was initiated in 1998, more caregivers and children now need support to cope with managing chronic illness. “Children affected by HIV often face significant uncertainty about their parent’s disease, having concerns about the recurrence of significant and life-threatening symptoms or premature death,” according to the PIH/ZL study. “Girls in particular may take on the role of caregiver in the household, caring for their ill parent or assuming greater responsibilities in supervising younger children in their family.” Not surprisingly, children living with parents with HIV disease may have symptoms of depression and anxiety, and are more likely to engage in “high-risk behavior related to problems with conduct, unprotected sex, and substance abuse.”

	Support groups can help those affected by HIV/AIDS.

Likewise, caregivers living with HIV/AIDS reported feelings of hopelessness, worthlessness, and loneliness. Among HIV-positive people, depression has been shown to be associated with poor treatment adherence rates, increased progression of HIV, and mortality.

Many of these psychological symptoms – among children and adults – improved markedly after 12 months attending two times per month PIH/ZL-run psychosocial support groups.  Said Smith Fawzi, ”Providers working with HIV-positive patients may consider a broader, family-focused approach that addresses the psychosocial dimensions of HIV, such as feelings of isolation, depression, anxiety, and HIV-related stigma. In particular, we observed that reductions in depressive symptoms provided an increased capacity of patients to face HIV-related stigma in a positive manner, gaining confidence to live positively with the disease.”

“I used to treat my children very badly,” said one parent who was interviewed by PIH/ZL. “I would hit them…and yell at them. But now, thanks to our good God, the support groups have brought a different feeling to me, and my children are now my friends because I treat them much better.”

And children reported benefiting from the groups in a number of ways. “The support groups did a lot for me. The transport money I received – my mother put together with hers – and helped me go to school…As a teenage girl, I learned how to protect myself and cope with things on my own and continue with school,” said another Tout timoun se moun participant.

View the International AIDS Conference poster presentation.

View the abstract from the paper published in AIDS Patient Care and STDs.

By Bibhav Acharya, Nyaya's Executive Vice President

	Patients waiting outside Bayalpata Hospital.
	Community health workers survey people living in Ridikot. One of the CHW's objectives is to locate community members who might need medical help.

Dr. Arunima Rajbhandry, a volunteer clinician working at Nyaya Health’s Bayalpata Hospital, recently recounted her experiences treating a mother suffering from mental illness on our blog:

Bayalpata Hospital outpatient department was crowded with patients, all lined up eagerly to be seen by a clinician. I was done seeing my first few and rang the bell to call for the next patient. A thin, nervous looking middle-aged woman walked in, along with her teenage daughter.

“I have a headache,” she said looking down, avoiding my eyes.

“Okay, tell me more about it,” I said as I lowered my head to get a good look at her face.

She paused for a few seconds, then, hesitantly uttered, “I see normal people as if they have long teeth and long bushy hair, like a demon.”

It took me a few seconds to comprehend what I had just heard. “Normal people walking down the street…they appear like demons. And I am afraid I might attack them like I did before.  I am scared I might go crazy again like I did before,” she blurted out in a single breath.

“I don’t want to go crazy again because it hurts me a lot. Last time, when I went crazy, people tied both my hands. Then they hit me. They hit me so hard on my head that my head still hurts. Then they locked me up in a dark room for days. Please give me some medicines so that I don’t go crazy and I don’t get beaten up again,” she said.

Continue reading Arunima’s blog post.

This moving story of a mother dealing with stigmatizing condition reminds us how much clinical and advocacy work still needs to occur in Nepal around mental health.

Only 0.8% of the total healthcare budget of Nepal is allocated for mental health. There is only one public psychiatry hospital and it is located in Kathmandu, the capital. There is one psychiatrist for every 1 million people, and most of the psychiatrists practice in the capital city. 

A government study funded by multilateral donors found that in 2008/2009, the number one cause of death among women aged 15-50 years old was suicide. The clinicians at Nyaya Health are constantly seeing patients that have received absolutely no treatment despite severe and persistent signs of mental illness. Patients and their families have narrated stories of neglect, shame and abandonment that range from verbal and physical abuse to murder attempts like the patient that we have featured in Dr. Arunima’s blog. 

Nyaya Health has been working with a team of psychiatrists based in Nepal and abroad to provide support to our primary care clinicians at Bayalpata Hospital. The psychiatrists provide assistance in several ways. They have helped write protocols on management and they provide case-specific advice for clinicians at Bayalpata Hospital via email. 

The treatment gap is large and in addition to availability of treatment, which we are providing as a part of primary care, significant steps need to be taken to address stigma so that we can not only provide treatment but also restore the dignity that our patients deserve.

Read Arunima Rajbhandry’s article in its entirety.

Learn more about Nyaya Health.

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.

Guest blog post by Arcade Fire violinist Marika Shaw. Marika and the rest of the band recently spent four days in Haiti visiting various PIH sites.  

I am writing to you, our friends and supporters who signed up to Stand with Haiti at an Arcade Fire show within the last year.  We recently returned from a trip to Haiti, my first, and I learned so much and was so moved by the experience that I want to share some of it with you. 

As we flew into Port-au-Prince, and while I tried to prepare myself for a city in ruins, devastated by the January 12^th 2010 earthquake, I looked out my window, surprised and totally overwhelmed by beauty. On one side, a sprawling mountain range surrounding the city and on the other, quintessential crystal blue Caribbean waters. This view was the first example of something we found each day in Haiti: that struggle and vitality go hand in hand.

In Port-au-Prince, the suffering we saw was incomprehensible. People are living in, at most, real tents, but often under only a clothing line with a tarp drawn over it, on top of or around semi-fallen abandoned buildings, on what might have been the sidewalk only a couple of years ago. There are people living in ditches and drains. Garbage is everywhere.

Arcade Fire performs outside PIH's hospital in Cange, Haiti.

The city is also made up of “spontaneous settlement camps” which, 15 months after the earthquake, seem far more “settlement” than “spontaneous”, as over 1 million Haitians are still homeless. Dr. Louise Ivers, Head of Mission for PIH in Haiti, shared with us her experiences of working in these camps. There are over 80,000 people living in the largest camp (there are MANY of these camps throughout the city and beyond) who share 200 latrines and 10 showers.

Down the road, in another camp, I spoke with a Zanmi Lasante nurse, Genevieve Joubert. [link] She lost everything in the earthquake, and lives in the settlement camp while providing care for her patients, patients who are also her neighbours, sometimes living with up to 15 people per tent.

But, no-one we visited—not the Haitian doctors, nurses, midwives, or community health workers, many of whom, like Genevieve, had also lost everything in the quake and were also living in the camps - were defeated. Quite the opposite. What was most poignant and lasting about our time in Port-au-Prince was that despite all the devastation, sorrow, and sickness, the teams of people working together are undeterred; approaching every challenge with commitment, positivity, and tenacity.

After Port-au-Prince, our PIH hosts brought us to several communities in the central plateau, where PIH started its work 25 years ago. Due to the road conditions (MASSIVE jagged rocks jutting out onto one-lane/half-lane trail traversing over mountain tops and through rivers), we piled into separate 4x4s to visit Bay Tourib, a village area of about 5,000 people. Our ride was 2 hours long, but put into stark perspective when we were told that the residents of Bay Tourib must walk 5-6 hours to the nearest health center; often carrying family on their backs or make-shift stretchers from old doors. During the height of the cholera epidemic, this walk proved too long for many who passed away before ever arriving at the clinic. When we arrived, it appeared that the entire village had come out to greet us.  The schoolchildren sang for us. (The echo of this song still resonates in my ears …I don't know if it's possible to convey the magic of that sound, the thunder in their voices...) The entire village walked us through a tour of their community: a church, a two-room school house, and an empty building. We were told that this building was erected to be a health clinic, but the organization that had come in to build it abandoned it before the money for services and equipment could be raised. This village is where KANPE, in partnership with Partners In Health, will begin its work.

Our trip ended at the PIH/ZL flagship hospital in Cange, a place which 25 years ago, like Bay Tourib today, was a squatter settlement, not even on the map. The people were living on land that had been completely deforested, with no agriculture, and no access to healthcare or education. They had been displaced, had “settled” and were barely surviving. And in just one generation, Cange is a vibrant community of Haitians, running arguably the best hospital in the country, with an educated, tri-lingual, healthy generation of youth. There are trees and agricultural programs. There is even a marching band.

That night, with the Haitian band, RAM, we played music.  It felt like the entire community came out to celebrate; to celebrate Haiti. The marching band welcomed our set with proud versions of both the Canadian and Haitian National anthems, then we played and sang for the community, the patients, and our hosts.  As RAM’s set started, and as more dust was kicked into the air by the hundreds of dancing feet, the exuberance was a powerful reminder of what is possible.  Our final night in this Haitian village which had transformed so beautifully, turned into one of the best musical experience of our lives.

While I still find it challenging to fully process and digest what this extraordinary country and its people have gone through, and what they continue to face, it's the resilience, perseverance and commitment of PIH and their Haitian colleagues in ZL who continue to do "whatever it takes" that re-affirms the commitment I made to Stand With Haiti. It is a long and challenging road ahead as Haiti rebuilds itself, but there is also incredible potential and there is work to be done.

Thank you to all the incredible people we met in Haiti who shared their country and their lives with us. I would especially like to thank Partners In Health/Zanmi Lasante for hosting us: Ali, Jon, Joan, Cate, Louise, Bec, Kathryn, Robinson, Domec, Dr. Almazor, Dmitri, Genevieve, Joel, John, Marie-Flore, the amazing cooks, the doctors and the nurses who met with us, and everyone else. We are truly inspired by the important work you do and the generosity of heart with which you do it.

And thank you to you—our fans and supporters who also made the commitment to, and who continue to, Stand With Haiti.

Love,

Marika
Arcade Fire 

Guest blog post by Arcade Fire violinist Marika Shaw. Marika and the rest of the band recently spent four days in Haiti visiting various PIH sites.

By Peter Luckow, Tiyatien Health Director of Operations

Tiyatien Health is one of PIH’s six supported projects that are endeavoring to implement a philosophy of  social justice in health care on a global scale by forging long-term partnerships with local communities and governments to create change.

ZWEDRU, LIBERIA -- More than 30,000 Ivorian refugees have fled to Liberia’s Grand Gedeh County as political violence has intensified in the neighboring Ivory Coast.  In collaboration with the public health sector, Tiyatien Health is providing emergency health outreach to the growing number of refugee communities in southeast Liberia.

Escalating violence in the Ivory Coast has forced more than 100,000 Ivorians to seek safety by fleeing west across the Liberian border. As violence has progressed south toward Abidjan, an increasing number of refugees have crossed into border towns in Grand Gedeh County, home to Tiyatien Health. 

The conditions in the refugee communities are rapidly deteriorating as Ivorians continue to pour into Grand Gedeh County. Many refugees have been forced to take shelter in overflowing churches, schools, and homes in these communities. Meager resources, poor sanitation, and shortages of food and clean drinking water threaten the health and well-being of the refugees and the Liberian hosts who have opened their doors to the Ivorians. 

The influx of tens of thousands of refugees into Grand Gedeh County has placed significant strain on the already understaffed and overstretched health system.  Refugees have been admitted to the clinics and hospital in the region for severe malaria, diarrhea, malnutrition, and bullet wounds, among other injuries and diseases. Food shortages and dwindling stocks of blood reserves are threatening the lives of patients at Martha Tubman Memorial Hospital, where nearly one-third of the patients are Ivorian refugees. Dozens of refugees have been found to be HIV-positive, some of whom were on treatment in the Ivory Coast. Stock outs of condoms threaten to reverse many of the gains made in Liberia to reverse the spread of HIV/AIDS over recent years. 

Over the past several weeks, Tiyatien Health (TH) has been mobilizing our health workers -- many of whom were refugees in the Ivory Coast during Liberia’s civil war -- to improve health care services for the refugee population in Grand Gedeh County, where TH was founded four years ago. TH has been focusing our health outreach in seven refugee communities: Zwedru, Janzon, ZiaTown, PouhTown, ZlehTown, ToeTown, and Tempo. 

In these communities, TH teams are actively promoting health and sanitation awareness, and our community health workers are ensuring that HIV patients continue receiving the courses of antiretroviral treatment that some began while in Ivory Coast.  We are also beginning to assess emotional trauma among the refugees and conduct psychological first aid.  With advice from Partners In Health, TH is building a comprehensive mental health and psychosocial response, rooted within the communities of displaced people.

Importantly, TH leadership in Zwedru has facilitated greater coordination among health partners in Grand Gedeh County, including the Ministry of Health and Social Welfare’s County Health Team, UNHCR, Merlin UK, and Médecins Sans Frontières, among others. Through the strength of our existing community connections, TH outreach teams have already helped identify acute water, sanitation, and food shortages, and are working with partners to facilitate delivery of these critical services.  TH has also begun operating referral and ambulance services throughout the county.  Through active surveillance, TH is bringing the sickest, most vulnerable people to receive lifesaving care.

TH aims to mobilize additional funds in order to continue providing essential health services to the refugees. This week, we will announce a call for three-month health professional volunteers to assist TH in our response to the refugee crisis.

For more information, please visit TH's website: www.tiyatienhealth.org.

About Tiyatien Health: Founded in 2007 by survivors of Liberia’s civil war, Tiyatien Health (TH) is an innovative social justice organization partnering with rural communities and the Liberian government to advance health and the fundamental rights of the poor. Our model features a backbone of community health workers trained to accompany patients through their illnesses and beyond -- linking the destitute sick to jobs, agriculture and economic empowerment programs. This approach fills a crucial gap between health centers and the community, allowing the public sector to provide comprehensive care for people with complex illnesses like HIV and epilepsy that previously went unaddressed.

The Harvard men's soccer team will host the Haitian National Soccer Team on Sunday, April 10 at 5pm to benefit Partners In Health's work in Haiti.

Tickets to the game for the general public will be $10. Admission for the game will be free to Harvard undergraduates, but donations will be accepted for this worthy cause will all proceeds being split between Partners In Health and the Haitian National Soccer Team.

Haiti is currently the 99th ranked team in the world out of the 202 FIFA nations.

"We are thrilled to host our friends from Haiti," said head coach Carl Junot. "Together with Partners In Health and the administration at Dartmouth, we hope that this extended weekend of games will be a large benefit to Partners In Health's work in Haiti."

Prior to the game, Harvard’s Athletics Department will be hosting a “FanFest” starting at 3 p.m. on the lawn outside the Harvard stadium which is open to the public with food and entertainment. Between 3 - 3:30 p.m., several members of the Haitian National team will be signing autographs.

The Haitian team will be hosted by the Dartmouth men’s soccer team on Friday, April 8 at Dartmouth in New Hanover, NH. The events at both Dartmouth and Harvard will raise money to support Partners In Health and its relief efforts in Haiti, which is still recovering from a catastrophic 7.0M earthquake that struck on Jan. 12, 2010.

Watch the game live @ 5 p.m. on April 10, 2011

With English audio

With Haitian Creole audio

By Paul Farmer, PIH co-founder

Dr. Farmer presented this speech at the 2011 Skoll World Forum On Social Entrepreneurship. 

When Mabel and Sally asked me to participate on this panel, I said yes—I am fundamentally obedient when they are concerned—but with anxiety. It wasn’t the large-scale change part that worried me. That’s why we’re here at Skoll. But “interior dimensions” often leads to dismissive comments about singing Kumbaya. This year is different for many reasons. One stems from having worked in the “quake zone” in Haiti this past year. Another is the presence of “the Arch”—Desmond Tutu—who is no stranger to struggles for large-scale change, or for understanding its interior dimensions. My admiration for the Archbishop comes not so much from his Nobel Prize or other honors, but from his decades of humble service to the poor.

What is there to say about “deep leadership and the interior dimensions of large-scale change” when we’re talking about disasters natural and unnatural—from the Haiti earthquake to apartheid? One thing we can do here, in the city of dreaming spires, is to bear witness to difficult times—and the quake was the most difficult time I’ve been through. Another task, to paraphrase Haiti’s former President, who himself found shelter in South Africa for years, is to “echo and amplify” the voices of the poor majority and those who support them in their struggle for survival and for dignity. After the quake, this diverse group included local women’s groups, international teams of trauma surgeons, Cuban caregivers, and community health workers in the country’s rural reaches. It included so many of you gathered again at the Skoll Forum. Together, we can try to honor the voices silenced on that night fifteen months ago. This is, I believe, the most important kind of “deep leadership”—witnessing, building partnerships, and promoting collaboration rather than competition.

Alas, this has not been easy. Deep leadership will require social entrepreneurs to rethink siloed approaches to “branding,” innovation that is deemed proprietary, as if worthy of patent. It requires not that we reject these notions, but rather that we interrogate them whenever our humanity and dignity are under fire.

Let me describe the events of a single night at the General Hospital, Port-au-Prince’s largest. It was just after the quake. Although there were, in those days, never enough supplies or staff or space for the patients streaming in, expert mercy was not in short supply. Trauma teams from all over had set up tents throughout the damaged hospital. (There were even Scientologists in bright yellow t-shirts, though I didn’t know how to explain to my Haitian colleagues what they were doing, because I hadn’t a clue.)

In one tent, I spied a Haitian doctor standing anxiously over a thirty-four-year-old man who thought he’d escaped serious injury when his parents’ house collapsed around him but now presented in respiratory distress. He looked whole but was gasping for breath. I gave him morphine. His story came tumbling out in shreds: part of a wall had fallen on his legs; it took him an hour to free himself, but he was soon up and helping others in the neighborhood. A physical exam revealed a high fever, but only minor abrasions on his legs. He’d been treated with antibiotics in another facility (the General Hospital was the third one in which he’d sought care), but an X-ray suggested severe pneumonia. We gave him a broad-spectrum antibiotic, and tried to treat him for blood clots that might have traveled from the large veins in his legs to his lungs, but we didn’t have the right formulation of blood thinner on hand.

In a few minutes the morphine kicked in and he was feeling well enough to ask, in one of his first complete sentences, for something to eat. We knew the morphine was responsible for his improvement, but morphine doesn’t last long, nor does it treat problems at their root. Fearing that he wouldn’t survive the night without mechanical ventilation, we tried to transfer him to the USNS Comfort—a navy-ship-turned-hospital steaming, that day, toward Port-au-Prince.

We had many other patients to see that night. A slight elderly woman at the other end of the tent was wracked by the spasms of tetanus—the first of many cases we would see that week and the next. White-haired and weighing about ninety pounds, she had tears rolling down her cheeks. Every few minutes she would go rigid with potentially bone-breaking and suffocating spasms. The slightest stimulus triggered them; she needed to be in a dark, quiet room—but that would move her far away from medical care because, with frequent aftershocks shaking the foundations of the hospital, no one wanted to work inside.

With all this suffering hemming us in from every side, what was there to be said about our own “interior suffering”?

At one point, I ducked outside for a breath of fresh air, and saw a young woman, perhaps twenty-five, lying on a stretcher outside, all alone in the pitch dark. Had she died? No, she was breathing and warm to the touch. I said hello and asked her how she was; she raised her hand and said, simply, “I think my legs are broken.” I looked at an X-ray that had been tucked under her feet: both of her femurs were fractured high up, near the pelvis. I asked if she’d received anything for her pain; she had not. She had no family present; that was clear. She feared that her parents and infant daughter had perished. “The roof fell on us,” she said and began to weep quietly. The best feeling I had during that wretched evening was bringing her pain medications, which soon led her to what might have been her first sleep in days.

As with every night those days, there was no shortage of work and no reason to leave, except that we would be exhausted and useless the next day if we stayed. I tried to corral my coworkers into rest—it was almost midnight, and we’d made some progress: we’d secured for the young man in respiratory distress the promise of a transfer to the floating hospital by helicopter at daybreak; the old woman with tetanus had received antibiotics and heavy doses of diazepam; a number of patients with major trauma were now, like the young woman alone in the dark, resting thanks to pain meds.

We finally left the hospital for houses up the hill, away from the worst damage. We were spent. As our car climbed through a wrecked and darkened neighborhood, a dog darted in front of us and we heard a thud. No one said a word. I got to sleep in the wooden (and thus safer) house of some close friends, far above the heat and stench of the vast, blacked-out city below. There was a bottle of water by my bed and blessed silence.

But I couldn’t sleep. In the dim reaches of misery, insomnia is a constant companion, especially wherever twenty-first-century people die of nineteenth-century afflictions—minor injuries and simple fractures as well as pneumonia, tuberculosis, and other infections, such as tetanus, that are preventable with a vaccine available for pennies. Archbishop Tutu knows exactly what I’m talking about. I was pursued by the sights and smells and sounds of the day: the unrelieved pain; patients and doctors sprinting outside during an aftershock; phone calls from people trapped under rubble; the charnel-house odor from the morgue and from under the rubble. Counting sheep kept turning into the grim process of counting the dead. I even thought of the hapless dog. Was I praying, or fretting, or what? The image of the man who couldn’t breathe was still with me as dawn approached—had he survived the night? Surely the floating hospital could save him.

Hanging on to this hope, I fell into a deep sleep. But after an hour or so, I was shaken alert by a large aftershock. The wood of the house strained and creaked; the paintings in the room tilted; the plastic water bottle at my bedside started to tremble. My host yelled for us to “get out of the house right now!” The sun was coming up, and I watched impassively as the water bottle fell to the floor. I heard people in the house scrambling to get out, and saw, in my mind’s eye, the crushed limbs of people trapped in countless other houses during the quake. I knew I should move and thought of my children, who had spent the recent holidays in Haiti but, by the grace of God, had been spared the fate of so many a few days after they left. It would’ve been prudent to bolt down the stairs and into the street. But I didn’t move a leaden muscle and did not wake again until the sun was high in the sky.

Watch Dr. Farmer on a panel at the Skoll Forum with Archbishop Emeritus Desmond Tutu, Joe Madiath, and Cecilia Flores-Oebanda.

Dr. Paul Farmer is a co-founder of Partners In Health; Kolokotrones University Professor, Harvard University; Chief of the Division of Global Health Equity at Brigham and Women’s Hospital; and UN Deputy Special Envoy for Haiti.

PIH co-founder Paul Farmer, Archbishop Emeritus Desmond Tutu, Joe Madiath, and Cecilia Flores-Oebanda spoke on a panel at this year’s annual Skoll World Forum On Social Entrepreneurship on March 31. The panel, “Deep Leadership: Interior Dimensions of Large Scale Change,” focused on unconventional leaders and the ways that their social visions have impacted the lives of millions confronted by poverty, pandemics, conflict, and injustice. Watch the full discussion on the player below.

Read the full text of Dr. Farmer's speech from the 2011 Skoll World Forum.

Read a thoughtful response about the panel from the organization Still Harbor.

Archbishop Emeritus Desmond M. Tutu is current Chair of The Elders, an independent group of eminent global leaders, brought together by Nelson Mandela, who offer their collective influence and experience to support peace building, help address major causes of human suffering and promote the shared interests of humanity.

Joe Madiath is Executive Director of Gram Vikas, an organization that has been working since 1979, to bring about sustainable improvement in the quality of life of poor and marginalised rural communities in Orissa, India.

Cecilia Flores-Oebanda is the Founding President and Executive Director, Visayan Forum Foundation, a Philippine-based NGO known for its innovative work for empowerment of vulnerable migrants especially victims of human trafficking, domestic servitude and other forms of exploitation.

Paul Farmer is a co-founder of Partners In Health; Kolokotrones University Professor, Harvard University; Chief of the Division of Global Health Equity at Brigham and Women’s Hospital; and UN Deputy Special Envoy for Haiti.