By Sophie G. Beauvais, GHDonline

Participants from all over the world are currently debating paths to sustainable partnerships for surgical capacity in poor regions on an online forum. Questions they are grappling with include:

• What characterizes strong, egalitarian academic surgery and anesthesia partnerships, and how can groups get there?
• What key infrastructure must be enhanced to support such partnerships?
• What outcomes could be measured to evaluate the quality and sustainability of these partnerships?

These discussions are part of a GHDonline Expert Panel Discussion organized in collaboration with the University of British Columbia’s Branch for International Surgery right before the 2nd Annual Conference on Surgery & Anesthesia in Uganda starting Saturday in Vancouver. The panelists leading the discussion are experts working in Zambia, Canada, the United States, and Uganda.

Many patients in rural areas and in the developing world are not able to receive life-saving surgeries because of the lack of surgeons, anesthesiologists, or other clinicians that have had basic surgical and anesthesiology training. Building capacity on the ground and across the board is essential. The GHDonline community brings together surgeons, anesthesiologist, and a variety of health professionals to do just that.

	Dr. Nadie Semer

For one of the community moderators, Dr. Nadine Semer, a plastic surgeon who spends a portion of her time volunteering in rural areas of the developing world and also published two practical guides: The Help Guide to Basics of Wound Care and Practical Plastic Surgery for Nonsurgeons, it’s really about “opening up the potential for collaboration, offering fresh perspectives on recurring problems, and fostering the development of new innovative solutions.”

On the question of sustainable partnerships, Semer notes that “From my experience at a rural orthopedics hospital in South Africa […] local doctors felt they had no authority over the resident, nor did they have the time to try to exert any authority - they were working under incredibly difficult conditions to just keep things going.”

She concluded saying that there needs to be “a commitment to continuous evaluation of the ongoing partnership and programs, always looking for ways for improvement as well as looking out for the unintended consequences that can show up despite the best efforts of everyone involved.

What do you think? Sign up for free and join the discussion now!

The following post is by the team at Project Muso, a PIH-supported project in Mali.

	Dr. Ichiaka Koné of Project Muso (left) visiting an IMB hospital in Rwanda with Dr. Agnes Bingawaho, Permanent Secretary of the Ministry of Health in Rwanda.

Early this year, representatives from Project Muso traveled from the west African country of Mali to PIH’s project in Rwanda in east Africa. A partner project of PIH and its Rwandan sister organization Inshuti Mu Buzima (IMB), Project Muso made the cross-continent journey to learn how PIH/IMB has worked with the Rwandan government to scale up a community-based approach to health care, and to participate in a best practices exchange.

In 2008, Project Muso launched a partnership with the Malian Ministry of the Health to pilot a PIH inspired model for health-care delivery in Mali. With intensive technical support from the PIH team, Project Muso and its Malian Ministry of Health partners developed a health care delivery model focused on preventing and treating malaria while strengthening the accessibility and quality of the health care system as a whole. In the first two years of Project Muso’s intervention, access to care has more than doubled, and rates of early treatment of pediatric malaria have tripled.

After two years of piloting a PIH-inspired model, Project Muso team members Dr. Ichiaka Koné and Ari Johnson traveled across the continent to train with IMB and to share preliminary results of efforts in Mali. Through meetings with IMB team—including community health workers, stock managers, physicians, agronomists, supervisors, and administrators—Project Muso explored PIH strategies for community health worker outreach and supervision, health care quality improvement, accessible healthcare financing, and treatment of malnutrition, AIDS, and tuberculosis. These exchanges provided new insight and inspiration for Project Muso’s efforts in Mali.

The Project Muso team also met with PIH/IMB’s partners in the Rwandan Ministry of Health, Dr. Corine Karema, who has led Rwanda's malaria control efforts and is currently the Acting Director General of TRAC-Plus, and Dr. Agnes Binagwaho the Permanent Secretary of the Ministry of Health. Dr. Karema and Dr. Binagwaho discussed how the Rwandan Ministry of Health has been able to translate PIH-pioneered strategies into national policy, and shared strategies for how Project Muso can learn from this model and continue to deepen its collaboration with the Malian Ministry of Health.

Through the work of organizations like Project Muso, the scale-up of the community-based approach to health care is extending far beyond Rwanda’s borders, noted the Project Muso Team. Now back in Mali, Dr. Koné, Johnson, and their colleagues are continuing to work closely with the PIH/IMB team on the other side of the continent.

Learn more about Project Muso.

The following post was excerpted from a blog by Dr. Agnes Binagwaho, Permanent Secretary of the Ministry of Health in Rwanda. Read her full piece.

	Dr. Agnes Binagwaho

...[The] current top killers do not account for all of [Rwanda's] disease burden. Regretfully, there remains a serious gap in Rwanda’s current health care system. Noncommunicable diseases (NCDs)—probably accounting for about 25 percent of the national burden of disease—have yet to be addressed in a strategic and systematic way. These diseases include cardiovascular disease, cancer, epilepsy, pulmonary disease, and diabetes among others. These are global diseases and yet, more often than not, NCDs are thought to be problems of middle and high-income countries. In such countries, risk factors for NCDs include obesity, tobacco use, and other factors termed poor lifestyle choices. However, in Rwanda, and other developing countries, this is not the case. NCDs are instead linked to malnutrition, infection, congenital abnormalities, toxic environments, and lack of access to basic health care. These are all ultimately caused by poverty. And HIV/AIDS, tuberculosis, malaria and neglected tropical diseases—all diseases endemic to the poorest nations—further contribute to risk factors for NCDs whether treated or untreated.

Inshuti Mu Buzima (IMB)—the sister organization to the Harvard-affiliated non-profit, Partners in Health (PIH)—was invited to work in partnership with the Ministry of Health of Rwanda at the end of 2003. IMB-PIH has put itself at the service of Rwanda’s vision for health care by devoting itself to the needs of the entire populations of three districts. In particular, it has made a unique contribution in the area of chronic care and NCDs. This approach has led to a joint undertaking between the Ministry of Health and IMB-PIH, including a conference in January 2010, which was focused on how to tackle non-communicable diseases in Rwanda. Through such discussions, chronic care integration has been identified as a central unit of strategic planning to improve the health of the Rwandan population. Other units of planning for NCDs include gynecologic care at district hospitals; improving the quality of generalist physician care at district hospitals; histopathology; cancer care; cancer surgery; cardiac surgery and neurosurgery. Now, in January 2011, Rwanda finds itself equipped with a healthcare system capable of launching chronic care integration; and IMB-PIH finds itself prepared to advise, advance and support the effort.

Many Rwandans could afford the prevention and treatment of uncomplicated cases of common diseases such as malaria or pneumonia, but most could not afford the costs of chronic care of HIV/AIDS, heart disease, diabetes, epilepsy or cancer. Therefore, chronic lifelong treatment and managed care for NCDs must be rooted in a publicly-sponsored, tactical and efficient plan to achieve accessibility and affordability. Already Rwanda has taken steps to tackle some of the prevention issues unique to NCDs, including the improvement of household cooking stoves and access to treatment for streptococcal pharyngitis, among myriad other steps. But we have much work to do. And we implore other low-income countries to take seriously the non-communicable ailments of their patient populations—ailments which most of their citizens must simply endure, because they cannot pay for treatment. Rwanda has made great strides in combatting communicable diseases under the leadership of the Government. The Ministry of Health and our development partners affirm our unwavering dedication to preventing and treating noncommunicable diseases, and making chronic care available to all.

Read Dr. Binagwaho's full blog post.

By Natasha Arlyapova, PIH-Russia’s Moscow-based communications specialist

	James Nachtwey and Paul Farmer

	James Nachtwey standing in front of an image taken in Tomsk during the opening of the exhibit at Moscow Center for Contemporary Arts.

On March 24, 2011, Moscow Center for Contemporary Arts—M’ARS—opened a photo exhibition by James Nachtwey, a world famous American photographer and photojournalist, under the title “Fighting for life. Defeating tuberculosis.”

The exhibition includes photographs taken at the PIH-affiliated site in Tomsk, Russian, in 2008, when James Nachtwey visited the local TB Hospital and a Specialized TB Correctional Unit. The visit of James to Tomsk was a part of the TB project supported by PIH.

The opening of the exhibition was dedicated to the World TB Day, which is marked globally on 24^th March. The exhibition, called for highlighting a problem of tuberculosis in community, presents a collection of unique photographs that demonstrate patients suffering from TB. (The exhibition in Moscow is a part of an international project supported by Becton, Dickinson & Company).

Before the opening of the photo exhibition, James told the story of his work documenting wars, conflicts, famine, and critical social issues. The audience—mostly Russian photographers and photojournalists—were impressed by the collection of images documenting conflict in over two dozen of the world’s most volatile countries.

James Nachtwey has worked in hot spots around the world and witnessed horrible humanitarian disasters. His works are internationally recognized: he has twice received the World Press Photo award; he has been awarded the Overseas Press Club’s Robert Capa Gold Medal in 1983, 1984, 1986, 1994 and 1998. (This award recognizes the best foreign photojournalist who demonstrated exceptional courage). James Nachtwey has been recognized as one of the world’s best photojournalists and awarded as the Magazine Photographer of the Year seven times. He has also received numerous honors and medals.

See images from Nachtwey’s new exhibit. Images 46-48 are PIH-related.

Learn more about PIH’s work in Russia.

From Haiti to Boston, community health workers (CHWs) are playing an increasingly important role in international and local health systems. As health care in the US continues to evolve in the coming years, it’s very likely that CHWs will assist more and more patients. This will be the topic of WBUR’s Radio Boston program on Tuesday, March 29.

Host Anthony Brooks will talk with WBUR reporter Rachel Zimmerman, who recently filed a story about the CHWs working with PIH’s Boston-based program, the Prevention and Access to Care and Treatment project (PACT).

Zimmerman’s piece, From Haiti To Harvard: Crucial Foot Soldiers Of Health Make Housecalls, follows Fernanda Pereira, a native of Brazil, and her asthmatic son, Ycaro, as they attempt—and in many ways fail—to navigate the US health care system. That is until they are assisted by a community health worker from PACT.

PACT's CHWs help patients live healthier lives, while simultaneously cutting costs for health care providers. Speaking of the recent attention the project has received, PACT Executive Director Heidi Behforouz says, "We're thrilled our CHWs are finally getting the recognition they deserve for working every day to help their patients realize better health outcomes and more empowered lives."

Excerpted from Haiti to Harvard: Crucial Foot Soldiers Of Health Make Housecalls

Fernanda Pereira, a native of Brazil, had some basic misunderstandings about the U.S. health care system. Here are two:

1. She used to take her asthmatic son, Ycaro, to the emergency room every time he needed a refill for his inhaler. She didn’t know she could simply call the doctor for a prescription and pick it up at the pharmacy.

2. She was confused and anxious when Ycaro, 11, was diagnosed with childhood depression. “Here, it’s normal for kids to be in therapy; in Brazil it’s not normal, ” Fernanda said. So, she cancelled or skipped 10 pediatric therapy appointments.

Enter Erica Guimaraes, a community health worker, and part of an ambitious program here to provide better, more effective care to poor, chronically ill patients—some who cost more than $200,000 a year to treat.

Since October, Erica has visited the Pereira’s home at least twice a month to help them deal with their medical problems, mental health struggles, cultural challenges, and anything else that comes up. On a recent visit to the family’s tidy brick apartment above a pizza place in Medford, Erica taught Ycaro how to properly use his inhaler. She explained to his mom, once again, the difference between Flovent and Albuterol. And she set up in-home therapy sessions for Ycaro. The boy has not been to the ER since Erica started visiting. “This winter, with Erica, it’s better,” Fernanda says.

Read Zimmerman’s piece in its entirety.

March 24 marks World TB Day, a day to build public awareness about tuberculosis and celebrate acheivements to eliminate the disease. TB kills roughly 1.7 million people each year, mostly in the middle- and low-income countries, and is a major obstacle to improving the health of many of the communities where PIH works.

PIH sites around the world held community events to commemorate World TB Day. Below, staff from Malawi, Lesotho, and Peru report from the field.

An update from Malawi

	APZU informs and entertains local communities on TB Day.
	In Malawi, TB Day ended with a competitive soccer match.

By Jonas Rigodon, PIH’s Malawi Country Director 

On March 24, 2011, Abwenzi Pa Za Umoyo—PIH’s sister organization in Malawi—and the Ministry of Health (MoH) in Neno partnered to celebrate World Tuberculosis (TB) Day, using the event as an opportunity to raise public awareness about TB. 

The main venue was at Chiwale Secondary School, where thousands of people from everywhere in the district came to celebrate the event under the theme: “On the Move Against Tuberculosis: Innovation To Accelerate Action.” Our theme was also adopted nationwide by the government of Malawi.

Among the personalities presented at the event include the District Commissioner, District Health Officer and its District Health Management Team members, Traditional Authorities, other members from different government sectors—and of course PIH patients and staff. 

We think it was mandatory to join the world in recognizing this day because tuberculosis still kills two millions people every year worldwide, and 9 million people are newly infected every year. 

In Malawi roughly three thousand people die from TB each year. There were almost 25,000 new cases last year and almost half of them were HIV positive. We think this is not acceptable and as a social justice organization that promotes human rights, we think we should work hand-hand with local Ministry of health authorities to improve TB diagnosis, treatment and most importantly prevention.

Different activities took place on this day to spice up the event, including: speeches, traditional songs and dances, poetry readings, and drama. Each event was organized around the theme “On the move against TB.” A highlight was definitely the football tournament, which raised K100,000 (roughly $660 US).  T-shits and other gifts were distributed.

Find out what else the APZU team is doing to fight TB in Malawi.

Lesotho

	PIH-Lesotho organized a day of informational activities.
	In Lesotho, health professionals and advocates prepare to enter a TB ward.

By Archie Ayeh, PIH’s Lesotho Program Manager

Lesotho held its World TB Day events at the MDR-TB facility in Botshabello, Maseru.

It was marked by press conference by the Minister of Health and Social Welfare, Dr. Mphu Ramatlapeng. There were a number of journalists presents.

In her keynote address, the minister mentioned the need to raise more awareness of TB and also stressed the need to improve TB services and medication. She also mentioned the fact that it was expensive to treat TB, especially MDR-TB. Journalists were then taken on tour of MDR-TB facility.

PIH has done much to fight TB in Lesotho, last year PIH-L diagnosed 658 cases of TB and over 450 cases of MDR-TB. Over half of the people diagnosed with TB were also found to be HIV positive.

Despite this work, TB notification is still high in Lesotho. In 2008, the country had 640 incident TB cases per 100,0000 people. Lesotho is rated 5 out of the 15 countries of the world with the highest per capita incidence and has a very high rate of TB/HIV co-infection. In fact, in 2009, the proportion of TB patients who tested positive for HIV nationally was 78 percent.

Learn more about the work being done in Lesotho to fight TB.

And Peru.

	Lima's mayor leads a rally against tuberculosis.
	SES staff hold a rally to fight TB outside Lima's capital.

By Jonas Alonso Valdivia, SES communications team

On March 24, 2011, the Municipality of Metropolitan Lima and the Peruvian Ministry of Health carried out the “Breath Life. Together Against Tuberculosis” forum.

Presided over by Lima’s mayor and national health officials, most of the World Tuberculosis Day events were held at the capital’s city hall. A national event, mayors and representatives from various districts of Lima, as well as a variety of people associated with the fight against this disease, attended.

Socios En Salud (PIH’s sister organization in Peru), the NGO Pathfinder International, and the Center for Social Process organized the day’s events. Funding came from the Global Fund.

Read more about SES's day-long series of talks and events.

In Russia, longtime PIH friend Dr. Rostislav Mitrofanov reflected on the progress that has been made to fight tuberculosis in that country.

See images of patients living with TB from various PIH sites.

By Jose Alonso Valdivia

	SES staff welcome people to the day's events.
	Mayor Susana Villarán with patients and supporters.
	A patient recounts her struggle with tuberculosis.
	Gastón Acurio advocates for greater awareness.

On March 24, 2011, the Municipality of Metropolitan Lima and the Peruvian Ministry of Health carried out the “Breath Life. Together Against Tuberculosis” forum.

Presided over by Lima’s mayor and national health officials, most of the World Tuberculosis Day events were held at the capital’s city hall. A national event, mayors and representatives from various districts of Lima, as well as a variety of people associated with the fight against this disease, attended.

Socios En Salud (PIH’s sister organization in Peru), the NGO Pathfinder International, and the Center for Social Process organized the day’s events. Funding came from the Global Fund.

Today, Peru has one of the world's most successful tuberculosis (TB) programs, in part because of the widespread use of direct observational therapy, short-course (DOTS).

The World Health Organization reports that the decline in the incidence of TB in Peru almost doubled between 1991 and 1999 through the implementation of DOTS—preventing at least 70,000 cases and deaths. If this trend continues, the incidence of TB in Peru could be halved every 10 years.

A unique success story, Peru has met the WHO targets for TB control with a 70 per cent case detection rate and an 85 percent cure rate. Peru has one of the highest TB incidence rates in the Americas.

Sixty percent of TB cases and 80 percent of multidrug-resistant TB (MDR-TB) cases are concentrated in Lima. This situation demands that district authorities of Lima, the Lima provinces, and Callao not delay any longer in taking action to avoid the spread of the disease.

Today’s events focused on lowering these rates even further.

In an act of solidarity, the mayor of Lima, Susana Villarán, and the attending authorities signed an act committing to support detection, control, and preventative actions.

During the event, the renowned chef Gastón Acurio—owner of international restaurants, author of several books, host of his own television program, magazine contributor, and TB advocate—asked how Peru was experiencing its greatest economic growth in the country’s history and yet is unable to eradicate tuberculosis, a preventable and curable disease.

A number of people affected by TB, health promoters, authorities and people fighting against the disease, ended the day’s events by speaking on the main stage.

There was a prayer for those who’ve died from tuberculosis as well as those living with the disease, as they symbolically let go butterflies, alluding to the theme of the day’s event: “Breath Life. Together Against Tuberculosis.”

Learn more about Socios En Salud.

Visite el sitio web en español de Socios En Salud.

DÍA MUNDIAL DE LA LUCHA CONTRA LA TUBERCULOSIS

A medio día de hoy, la Municipalidad Metropolitana de Lima y el Ministerio de Salud realizaron el FORO RESPIRA VIDA, JUNTOS CONTRA LA TB. 

El acto, llevado a cabo en el municipio, fue realizado a propósito de la conmemoración del Día Mundial de la Lucha contra la tuberculosis y contó con la presencia de alcaldes y representantes de los distritos de Lima, y diversos personajes vinculados a combatir esta enfermedad.

En Lima se concentra el 60% de los casos de enfermos con tuberculosis simple y el 80% de tuberculosis multidrogorresistente.  Esta situación hace impostergable que las autoridades distritales y de las regiones de Lima Provincias y del Callao tomen acciones para evitar la propagación de la enfermedad.

Luego de las exposiciones, la Alcaldesa de Lima, Susana Villarán, y las autoridades asistentes firmaron un acta en la que se comprometieron a apoyar acciones de detección, control y prevención.

Durante la cita, el reconocido chef, Gastón Acurio dio un mensaje a los asistentes y cuestionó el tener el mayor crecimiento económico de nuestra historia, ser líderes culinarios y no ser capaces de erradicar la tuberculosis, una enfermedad que es prevenible y curable.

Finalizado el foro, en la Plaza Mayor de Lima, se realizó un acto simbólico con la presencia de personas que fueron afectadas por la tuberculosis, promotores de salud, autoridades y personas que luchan contra la enfermedad.

En este acto se realizó una oración en memoria de los fallecidos y los afectados, y de manera simbólica se soltaron mariposas que aluden al lema de la conmemoración del día: “Respira Vida. Juntos contra la Tuberculosis”.

Estas actividades, referidas a la sensibilización de la población y sus autoridades, son implementadas con el liderazgo de Socios En Salud Sucursal Perú en conjunto con la ONG Pathfinder International, y el Centro Proceso Social. Son financiadas por el Fondo Mundial, que ve en el Perú un modelo de lucha contra la tuberculosis que puede replicarse en otros países. 

Lima, 24 de marzo del 2011

Learn more about Socios En Salud.

Visite el sitio web español de Socios.

“For chronic disease, we need a community-based model," said PIH co-founder Paul Farmer during his keynote address at The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion conference. "We know that is the highest standard of care for a chronic disease.”

In early March, Dr. Farmer joined health workers and public health experts from around the world to discuss ways of increasing attention and resources for treating chronic, non-communicable diseases (NCDs)--such as cancer, heart disease, and asthma--among the world's poor. 

The new Butaro Hospital in northern Rwanda is an example of how to treat NCDs, explained Dr. Farmer. The district-level hospital is connected to a system of community health centers, which employ a cadre of community health workers (CHWs), who serve as a link between their villages and the medical services. If someone in a village is sick--whether from asthma or from an infectious disease, such as tuberculosis or HIV--the CHW can be there to deliver the needed medicine and social support on a daily basis; and if needed, refer and accompany the patient to the health center or hospital for more specialized care. 

Changing policies and reframing priorities 

Many public health leaders have chosen to focus policy and funding on addressing infectious diseases, like HIV and tuberculosis, which often sicken more people and incur a lower per-patient cost for treatment than NCDs. However, NCDs still afflict many people in poor countries. According to the Global Burden of Disease Study, these conditions--often linked directly to poverty and infection--account for more than a quarter of the disease burden in the very poorest populations.

"If you have a country that is deemed very poor... and you have an intervention like cervical cancer vaccinations, that could take up to half of all [that country's] health expenditures," said Dr. Farmer in an interview prior to the conference. "So then these vicious debates ensue--should we prioritize this, prioritize that. It's a very painful process for the public health leaders." 

There doesn't necessarily have to be a choice between treating either infectious diseases or NCDs, said Dr. Farmer. “You can use vertical programs like an AIDS program or even a cardiac surgery program to strengthen health systems in general. For example: A good cardiac surgery program would improve the quality of surgical care in general. Not just for one disease," he said. "If you have a good vaccination program that you use to vaccinate for polio, measles, or tetanus, it is a delivery system for the cervical cancer vaccine, Gardasil."

In order to change current policies, concrete data from research is needed to prove the effectiveness of such programs, added Dr. Farmer during his conference address. This research would then need to be shared with "a whole generation of people anxious to not be told they can't intervene effectively against NCDs among the bottom billion."

Driving policy on a world scale

The March conference, held in Boston at the Harvard School of Public Health, was the first in a lineup of discussions leading up to the UN General Assembly on September 19-20. UN discussions about global health, and the allocation of global health funding, will offer “a huge opportunity for the world to unite about non-communicable diseases, we are focusing on non-communicable diseases affecting people around the world living on less than a dollar a day—the world’s bottom billion,” said PIH physician Gene Bukhman, who organized the conference. 

The UN’s high-level meeting on NCDs will be only the 29th such meeting that the UN has ever held, and just the second pertaining specifically to a health issue. 

Watch Paul's keynote speech in its entirety.

Learn more about treating NCDs in poor communities in the video below.

Learn more about treating non-communicable diseases in poor communities.

On January 24, Partners In Health officially opened Butaro Hospital in Rwanda’s Northern Province. Built in just two years, the world-class, 150-bed Butaro District Hospital represents a major milestone in high-quality medical care for over 320,000 people. Our vision is that Butaro will not only provide medical care, but also serve as a flagship medical education and innovation center for Rwanda and the region.

On Saturday, April 2, and on the subsequent days, CNN International’s “Inside Africa” will feature Butaro Hospital and our collaboration with the Rwandan Ministry of Health to strengthen the health system in Rwanda’s rural northern Burera District.

We hope you will be able to tune in to "Inside Africa," a half-hour news magazine, that airs worldwide (but not in the US) seven times in the next week. Air times (all GMT) are:  Saturday at 0330, 0900, and 1630; Sunday at 2330 and 1430; Tuesday at 0730; and Wednesday at 0330. Visit "Inside Africa’s" website for more information about air times.

In his remarks at the hospital’s opening, President Paul Kagame of Rwanda said, “Butaro is more than a hospital. It is a unique story of exceptional people with the desire to see positive change in the world and in communities like the one hosting us today ... It is also a story about strong and mutually benefiting partnerships and the fact that when we come together and join forces, commendable results can be achieved.”

Read more about the flagship Butaro Hospital and PIH’s collaboration with the Rwandan government to rebuild Burera’s health system.

By Kathryn Mahoney, PIH Haiti Communications Coordinator

	Construction site of the new Mirebalais Hospital at sunset.

At dusk on March 19th, just as the “supermoon” was rising, PIH doctor David Walton took me on tour of the site of the future Mirebalais Hospital. Normally, it’s bustling with more than 100 Haitian construction workers who work around the clock, even over the weekend. But on the eve of the second round of presidential elections, they had all returned to their homes to vote on Sunday, offering us a rare and quiet opportunity to explore the site.

A few weeks prior, I found myself standing on the roof of the hospital, overlooking the future location of the OB-GYN and inpatient women’s ward. At the time, I contemplated the footprint of the buildings and grew lost in a forest of steel rebar. I tried, and failed, to imagine what the building would look like when the walls are raised.

Standing once again on the roof weeks later, I see that walls have been erected for these two wards, and also for the neonatal intensive care unit; the radiology department; the main laboratory; and the pharmacy. For someone as challenged with blueprints as I am, I could finally visualize not only what this part of the hospital will resemble, but also how it will functionally serve up to 500 patients a day.

We climb down from the roof precariously, almost in total darkness. We arrive in front of a recently constructed wall, which Dr. Walton tells me we will have to knock down. Days prior, the team made a decision to alter the blueprint in a way that will fundamentally transform the provision of care at the hospital. PIH has decided to add a room to house the first CT scanner in Haiti’s public health sector. With only three functional CT scanners in the country—all of them in costly private practices—Mirebalais will be the first public hospital equipped with this important tool for disease detection and diagnosis. Short for computed tomography, CT Scans combine computer technology with x-ray imagery to generate a clear and detailed 3D image for doctors to examine. Such scans of internal organs, soft tissue, and bones help doctors to more easily diagnose a myriad of conditions such as cancer, infectious disease, trauma and cardiovascular disease. For the increased safety of patients and medical personnel, PIH will procure a new energy-efficient model that releases significantly less radiation.

Bringing innovative technology from developed countries into a resource-poor setting is not just about purchasing a machine—it’s about building human capacity through educational training to operate, maintain and repair the equipment to effect improved care.  A CT scanner in Mirebalais is much more than a tool that will strengthen public sector care and avert preventable deaths—it’s an important investment in human capital to equip Haitian medical professionals with a new skill set in disease detection and management.

With the rainy season only a few weeks away, Dr. Walton informs me that the team has been working quickly on a drainage system to ensure that the incoming torrential rains will not stop the construction’s momentum. In the future, functional drainage will not only help prevent flooding during the long rainy season, but will have a huge impact on public health. Blocked drains and stagnant water are breeding grounds for harmful bacteria, mosquitoes carrying malaria and dengue fever, and have been a contributing factor to the ongoing cholera crisis in Haiti.

Behind the scenes of the chaotic construction site, Partners In Health has been holding ongoing discussions with a number of American and Canadian universities to enhance academic involvement at Mirebalais in the future. Many schools have indicated a willingness to participate in institutional partnerships on specialized care, such as emergency medicine and intensive care. Academic partnerships allow for a sharing of experiences whereby US experts in specialty care can train Haitian doctors, who in return, expose Americans to cases and challenges they wouldn’t normally see outside of the US. It is exactly this type of cross-site fertilization that PIH is looking to foster at the teaching hospital.

Seeing rapid construction in Mirebalais is realizing that each wall that rises is one of many that will support Haiti’s largest public sector hospital. In less than a year, these are the walls that will provide thousands of Haitians quality care in dignity. And by the time all phases of construction are complete, Mirebalais Hospital will be a beacon of specialized care for the region.

As we leave, I ask Dr. Walton if the blueprint might have to be altered again. “If these walls keep going up, and I know they will, I think, perhaps, we might need a landing strip to accommodate all those who will flock here.”

Find out more about Mirebalais Hospital.

By KJ Seung, PIH Lesotho MDR-TB Program Officer

	Maliketso Lati with her daughter.

When I first met Maliketso Lati she was 22 years old. She had multidrug resistant tuberculosis (MDR-TB) and a young baby girl named Tsoanelo Pheko.

A single mother, Maliketso contracted MDR-TB--a virulent strain of tuberculosis--from her father with whom she lived. At the time of her diagnosis, Partners In Health in Lesotho had just started Maliketso's father on treatment for MDR-TB. He experienced painful, life-threatening side effects and extended stays in the hospital.

Understandably, his experience left Maliketso reluctant to begin treatment. In the end, only her fear of leaving Tsoanelo Pheko an orphan or passing the disease to her child convinced Maliketso to undergo treatment. The treatment worked and both she and her father survived.

Today is World TB Day.  Please take a moment to see photos of Maliketso and the many other MDR-TB patients whom Partners In Health strives to save every day.

As recently as the mid-1990s, public health doctrine would have consigned Maliketso and her father to death. MDR-TB treatment is expensive. Experts encouraged poor countries like the African nation of Lesotho--Maliketso's home--to sacrifice patients like her so that others less costly to treat could live.

For Partners In Health, this was morally and medically unacceptable. So we set about gathering evidence and creating new systems for MDR-TB care - first in Haiti, then Peru, then Russia, then Rwanda, and starting in 2006 in Lesotho. Today, the World Health Organization calls for treating all MDR-TB patients using an approach based on the PIH model.

But much remains to be done.

Since 2006, PIH Lesotho has treated more than 500 MDR-TB patients. Maliketso Lati and her father were among the first. Yet, estimates show there will be 500 new MDR-TB and 11,000 to 12,000 new TB infections every year in Lesotho.

Learn more about PIH's fight against TB and multidrug resistant TB.

Find fact sheets and resources about tuberculosis.

	A patient receives a Visual Inspection with Acetic Acid as part of PIH/ETSEC's weeklong training session.

Women living near Santa Ana Huista, Guatemala, now have unprecedented access to cervical cancer screening and treatment at two local clinics. During the program’s launch week in March, 160 women from this rural department were screened for the disease. Cervical lesions were removed from nine women who tested positive for abnormal cervical cells using cryotherapy--a simple procedure that removes those cells by freezing them with nitrous oxide. 

The screenings were performed by three nurses and one doctor--two from the local public clinic and two from a private NGO clinic in the region--working under the supervision of two gynecologists from Basic Health International in El Salvador. Both the screenings and the trainings were organized by PIH and the local nonprofit Equipo Técnico de Educación en Salud Comunitaria (ETESC), longtime partners in the region.

The visiting clinicians taught the local staff how to screen for cervical cancer employing visual inspections with acetic acid (VIA). In the relatively simple procedure, a health care worker swabs a small amount of acetic acid--common vinegar--across the cervix. Normal cervical tissue remains unaffected by the acetic acid, but damaged tissue found in pre-cancerous or cancerous lesions turns white.

This team of local nurses and physicians were taught VIA, but they also learned how to remove abnormal cells using cryotheraphy.

Both procedures will now be added to the range of permanent services offered at two of the region's local medical centers.

“The main advantage of VIA is that it gives immediate results,” says PIH’s project coordinator in Guatemala, Lindsay Palazuelos. “When you add cryotherapy, most women can be treated for pre-cancerous lesions during the same visit. This pairing is often called the ‘single visit approach.’”

“This is in contrast to pap smears, which may take months to return results, and require the woman to make a chain of several visits: to get the pap, to get results, and typically a third time to get treatment,” continues Lindsay. “In rural areas where a trip to the clinic is a huge investment of time and money, this chain often breaks.”  

“We are working to make this clinic a holistic center for women of the region, a place where a woman can come for all of her care,” says Dr. Humberto Hernandez, director of Santa Ana Huista's public clinic.

“We are the first health center to be able to provide this service of cryotherapy. Guatemalan public health protocols call for VIA, but this is the first time we’ll be able to include treatment with cryotherapy as well.”

“This training was a beautiful and valuable experience to better help and serve our local women,” recalls Rosalva Hernandez Lemus, the nurse who runs the region's private clinic. “After the first day or so we joked to the trainers, ‘You go rest at home and we’ll take it from here.’ They helped us refine our skills a great deal.”

	A patient receives her test results (top); the team of physicians and nurses who received training, along with the trainers from El Salvador (bottom).

In Guatemala, cervical cancer is the leading cause of cancer-related deaths among women of reproductive age, with 3.77 million Guatemalan women currently at risk for this potentially fatal cancer. The disease accounts for nearly 60 percent of female cancer cases seen at Guatemala’s National Cancer Institute--far more than breast, skin, ovarian, and stomach cancers combined.

Because cervical cancer grows slowly, regular screening and accessible treatment save women’s lives by significantly reducing incidence and mortality rates. Too often screening and treatment programs in resource-poor countries like Guatemala are unable to reach many rural women; as a result hundreds of Guatemalan women continue to die unnecessarily each year.

“This has been a lovely experience,” says Dr. Dalia Saravia, one of two El Salvadorian gynecologists from Basic Health International (BHI) who facilitated the training. “I didn’t think the patients would agree to come to the exams so easily, but they chose to come, even with some male providers. In fact the number of women that came increased [as the week went on]. So that tells me the people want this care.”

“I am filled with satisfaction that the women felt empowered, they asked questions, and had the capacity to do so,” says Dr. Gerardo Zelaya, also from BHI. “I’m very satisfied and happy that the reach of this work has been extended.” 

The National Cancer Institute estimates that at least 75 percent of the women living in Guatemala’s rural areas and poor urban communities have never been screened for cervical cancer.

VIA has been proven to be as sensitive as pap smears. Cryotherapy has almost no risk, goes about 1mm deep (sufficient to get the lesions, but in no way damaging the integrity of the cervix), and healthy cells regenerate within about 3 months.  

ETESC is also conducting educational outreach to rural communities to educate men and women about cervical cancer risks, and the benefits of VIA.

Learn more about PIH’s work in Guatemala.

Read about PIH’s cervical cancer work in Haiti.

PIH’s Guatemala project is run in collaboration with the nonprofit Equipo Técnico de Educación en Salud Comunitaria, Spanish for Technical Team for Education in Community Health. Refugees of the Guatemalan civil war, a conflict that ran from 1960-1996 and resulted in 200,000 deaths, founded the project in the 1990s. PIH/ETESC seek to revitalize and repair the social fabric in rural communities of Huehuetenango, Guatemala, through legal accompaniment, health promotion, and HIV/AIDS education.

	Students at Carrboro High School teleconference with PIH co-founders Paul Farmer and Ophelia Dahl.

“Personally, this talk has given me inspiration to do something,” says Ben Aronson, speaking of his class’s hour-long conversation with PIH cofounders Paul Farmer and Ophelia Dahl. “Prior to taking this Global Issues class, this line of work never really interested me. It wasn’t like I knew about the problems and I just didn’t care, but I really was blind to this work.”

“When I started to learn the epic history of Haiti and read Mountains Beyond Mountains, an entire new door opened for me,” says Ben, who hopes to be a physician one day. “This concept of applying human behavior to medicine is necessary to understand world medicine. One cannot simply apply medicine in developed countries to the entire world.”

On March 8 a classroom full of high school students enrolled in Matt Cone’s Global Issues class at Carrboro High teleconferenced with Paul and Ophelia. For a group of young people devoted to changing the world, the pair was a natural fit. To prepare for the talk, Mr. Cone’s class read Tracy Kidder’s award-winning book, Mountains Beyond Mountains.

“Talking with Paul Farmer was an inspiration,” says Scott Weathers. 

The conversation pushed a number of students to ask both critical and oftentimes difficult questions of Paul and Ophelia. 

“Seeing the tools Paul used, I have to say, I didn’t always agree with the work that he did,” argues Scott. “[Paul and Ophelia] occasionally gave certain patients treatment which could be deemed cost-ineffective, given that PIH was dealing with limited resources and abundant needs.”

After some reflection, Scott continues: “Hearing Paul say that addressing a variety of a community’s needs rather than just a few can provide a much greater impact gave me something to consider… It’s much easier to realize the great work that we as individuals can accomplish if we only use our capacity to care for others.”

“The talk widened my perspective of the world,” says a contemplative Kholiswa Tsotets. “I always thought that it was so hard to [grasp] complex world issues.”

“I feel like many people see it this way therefore, they don’t want anything to do with it [complex world issues],” speculates Kholiswa. Despite that, she notes: “The poor have been suffering for too long.”

“I keep returning what Ophelia told me,” says Kholiswa. “Always remember the small victories.”

At various points the conversation moved away from Mountains and to the topic of post-earthquake Haiti.

“We asked them about the troubles in Haiti and they responded with the harsh realities of everyday life, they didn’t sugarcoat their answers,” says Elliot Pahel-Short. “Paul spoke of the equality of the human race and Ophelia backed him up with the logistics of sustainability.”

Thinking globally, acting locally

“Our club has a goal to raise $20,000 to support PIH projects in Rwanda,” says an enthusiastic Vivian McElroy. “Dr. Farmer and Ms. Dahl’s genuine enthusiasm about our fundraiser excited the students in the room to take part in the movement…they applauded our fundraising.”

“The students are collecting money from now until April 17 for a fundraising walk for FACE AIDS,” says Mr. Cone. “The day after the talk they collected a shade over $2,400.”

“It was really cool that they were inspired by what we're doing with our FACE AIDS club, even though they've done so much more and have spent so much time on it when we've just started working to help the cause,” says Emily McDaniels. “They talked to us as equals, and acted like what we did is really important to them.”

“A morning fundraiser on March 21 raised another $4,023, which means that we are over $7,000 with just about a month to go until our big walk,” says Mr. Cone.

A lasting influence

“Most of the people in my class never wouldn’t have known how to take an initiative and help the world in their own, unique way,” says an insightful Lewis Randall. “After hearing Paul and Ophelia speak, we realized we were in full possession of our own limitations and flaws, but also our own ability to change the world.”

“What I came out of it realizing was that I have a place in the global community, no matter my profession,” says Elliot. “As a future computer scientist of the world, I can do my part to alleviate world suffering. It simply requires having a passion for work and a dedication to being realistic.”

At the Rwinkwavu Hospital in eastern Rwanda, PIH and the Rwandan Government have launched an ambitious project to strengthen health care services throughout the district. In addition to supplying the needed equipment and facilities, the success of this project lies in having a well-trained medical staff and trained community health workers to deliver health care.

"The training of clinical providers and community health workers are critical to building local capacity to provide quality health care services in the most underserved areas," says PIH Director of Training Jill Hackett. "High quality training programs are the cornerstone of community health and maximize the impact of PIH's programs around the world."

PIH's training team utilizes lessons learned from the organization's projects around the world. From organizing workshops, to bringing in experts from institutions like Harvard Medical School, to producing culturally-appropriate manuals, the team strives to share information and innovations with local staff.

"Our training programs are designed for physicians, nurses, and community health workers," says Jill. "We invest in educational activities for patients, their families, and for the wider community to equip them with tools for improving their own health. Both staff and the community benefit when training becomes everyone's responsibility."

"Training is like a light; we can't do our work without it," adds one community health worker attending a training. Learn more about PIH's focus on training activities in Rwanda and around the world in the video above.

Check out some of PIH's training manuals, available for free download. The training team plans to finalize and make available even more manuals and resources in the coming months--stay tuned! 

In rural Rwanda, the first point of contact for patient care is the community health center. Thanks to a grant made possible by the Doris Duke Foundation, nearly two-dozen centers are being upgraded to offer the very best in basic health care at the community level.

Read more about PIH's work in Rwanda.

	Mercedes Becerra

Early in her public health career, when epidemiologist Mercedes Becerra was a graduate student and just beginning her work with Socios En Salud, PIH’s sister organization in Peru, one of her primary responsibilities was to serve as a translator.

“I would sit between Paul [Farmer] and each patient, listening to stories,” she said. “Because I was invisible, I heard these amazing and detailed exchanges about people’s home lives, how TB had affected them directly, how it had affected their families, how so many had lost loved ones to TB,” she said. “That experience was the seed that grew into this study.” Dr. Becerra, a senior TB specialist at PIH and Assistant Professor of Social Medicine at Harvard Medical School, is lead author of a report (“Tuberculosis burden in households of patients with multidrug-resistant and extensively drug-resistant tuberculosis: a retrospective cohort study”) published in the January 2011 issue of The Lancet. 

Between September 1996 and September 2003, a PIH team of local Peruvian staff visited nearly 700 households in Lima to complete interviews. Each of these households was home to at least one patient who had been treated by the PIH program because the patient was sick with a strain of multidrug-resistant tuberculosis (MDR-TB) or extensively drug-resistant tuberculosis (XDR-TB). The study had two principal findings. First, persons living with these patients--their “household contacts”--had significant rates of tuberculosis disease themselves. Similar rates have been recorded in prisons and holding centers in Siberia. Second, when these household contacts had their TB strains tested for susceptibility to TB drugs, 90% also had MDR-TB strains themselves.

While the comparison to Siberian prisons may startle, the conclusion may not be as surprising: TB is transmitted through the air, and many of the families interviewed were living in small spaces, sometimes with poor ventilation. However, treating patients in their homes is still preferable to secluding them away from their families in medical facilities, said Dr. Carole Mitnick, a co-author of The Lancet study. "In most places in the world, hospitals are not equipped to protect other patients and health care workers from active TB or other airborne diseases," said Dr. Mitnick. "So even if people were hospitalized, this would put the most vulnerable people at risk--those who already have compromised immune systems--as well as health care workers." In addition, most transmissions actually occur even before an initial TB diagnosis is made, she added. 

In the study, Dr. Becerra, Dr. Mitnick, and the other authors (all affiliated with PIH, the Department of Global Health and Social Medicine at Harvard Medical School, and the Division of Global Health Equity at Brigham and Women’s Hospital) make some new observations about the arc of this disease, and offer recommendations to counter the burden it places on family and community members.

For example, international guidelines recommend that TB programs screen patients’ households for others with TB, but Becerra says this is not always a priority. “It can be difficult for local health staff to systematically implement TB contact investigations, because of immediate limits on resources and time,” she said. “It is difficult to prioritize going into the community to look for sick people when there are sick people who require TB treatment already at the clinic.”

Nevertheless, Becerra says this is an essential step. “Contact investigations should be done for all TB patients. Patients with active TB require prompt treatment, but those with latent [sub-clinical] TB infection who are at high risk for developing active TB must also be identified so that they can receive preventive treatment. This is the standard of care in the U.S. and in other countries where TB elimination is the goal.”

Furthermore, said Becerra, “in some parts of the world, TB patients who live with patients who have drug-resistant TB are treated with first-line TB drugs, as if they did not have this known risk. This puts them at risk, in turn, for bad outcomes: either death or ‘treatment failure,’ which means they survived the incorrect treatment but may have an even more resistant strain of TB.” Becerra says the take-home message is that if a patient has active TB, and is a close contact of someone known to have drug-resistant TB, that patient “should be treated as if they have drug-resistant TB disease until there is microbiological evidence that they do not.”

	Community health worker visiting a patient at her home.

These PIH researchers also found that conventional wisdom about the length of time to monitor and follow these household contacts--two years--may not be enough. “We found that even after resistant TB patients were treated, the risk to others in their households remained high, even four years later,” said Becerra.

According to the authors, “more work is needed to establish for how long a contact should be monitored and the optimum frequency and methods with which to monitor [and]…more research is needed to identify the best strategies to monitor households after an initial visit.” The World Health Organization estimates that 440,000 people had MDR-TB worldwide in 2008, and that a third of them died. WHO also calculates that almost 50% of MDR-TB cases worldwide occur in China and India.

See the study in The Lancet.

“The call came into Dilidai, our ambulance driver,” writes Nyaya Health’s Duncan Maru. “A man from a village about six hours away from Nyaya’s hospital in Achham had been bitten by a bear while collecting wood.”

“His leg had a large gaping wound – he needed to be seen by a doctor as soon as possible.”

“Nyaya Health’s Dr. Bikash Gauchan drove down to the village to assess… [eventually] transporting him back to the hospital.” 

After nearly 5 weeks in the hospital, Ganesh Sunar left Nyaya’s Bayalpata Hospital and headed home. Though the hospital’s staff would like to follow up on Ganesh’s case, they have not seen him since he left the facility.

"We accomplished an extraordinary amount during the five weeks that we treated him, and indeed, if it were not for the persistent work of our staff, he might not have lived, and certainly would never have walked again,” says Dan Schwarz, Executive Director of Nyaya Health. “Nonetheless, he managed to walk home, with the help of his two friends, through six hours of mountain jungles, to his village. That alone is an incredible victory for us.”
 
“Unfortunately, since then, we have not seen him again,” continues Dan. “Given the distance through the mountains to his village, he is not likely to return any time soon, and sadly, he lives outside the catchment area of our community health workers (CHWs).”

“We are working to extend our CHW networks, but over 75 percent of our patients live outside these areas. Due to the near-complete lack of other health facilities in the region, many of our patients walk over two days each way just to reach our hospital. At least for the present, our ability to cover all that area with CHWs is very limited.”
 
“In the future, we will continue to expand our CHWs' catchment area, and also hope to start working directly with the government Health Posts very soon, in order to strengthen them and ensure a minimum package of services and proper staffing.”

“Over time, we will be able to slowly improve not only access to care, but quality of care,” says Dan. “For Mr. Sunar, that will mean not having to walk hours through the mountains to have his leg repaired, and also the assurance that when he does get to a facility (our hospital or the area health posts), he will get the high quality care that he deserves."

Read Duncan Maru’s article in it’s 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.

Twa families celebrating their new homes.

On March 10th, seven Twa (pygmy) families moved into new homes—modest but sturdy houses with metal roofs and solid walls, built conveniently close to schools, health care, and water facilities. Members of a minority group in Rwanda, these families had previously been living in Nyakatsi (grass-thatched housing) in the remote hills of Nyamicucu in northern Rwanda’s Burera District.

The new houses were constructed in a partnership between PIH’s Rwandan sister organization Inshuti Mu Buzima (IMB) and the local district government, and are part of a national campaign to help people move out of Nyakatsi. IMB has been working with the Burera District Leadership to build new houses for a total of 39 Twa families, each with an average of 6 people. IMB hopes to get the remaining 32 families into their new homes by May 2011. In addition to the houses, PIH/IMB gave each family basic furnishings, which included mattresses to sleep on, plates, caps, mats, lamps, and jerry cans, as well as additional furniture to be supplied later.

	Clockwise from right: Burera Mayor Samuel Sembagari, Twa community representative Fundi Munyarugarama, Executive Secretary of Butaro Sector Maximillien, IMB's Dr. Gilbert Biraro, and IMB/PIH Deputy Country Director Antoinette Habinshuti.
	The Twa families were living in grass-roofed houses like this one.
	Constructing a new house for a Twa family.
	On March 10th, seven Twa families receive jerry cans and other furnishings outside their new homes.

“We were living in ant hill holes, our wives used to cook and rain would pour into our food and then it would be difficult to eat it,” said Twa representative Fundi Munyarugarama, who spoke at a function to inaugurate the new houses. “Even when we started sending our children to school, their books would be torn and they couldn’t read because of the rain. Now everyone can see that we are in a better place,” he added.   

Watch a video about the Twa housing project.

Present at the function to inaugurate the new houses was the Mayor of Burera District, Samuel Sembagari, who was also the guest of honor. Other attendees included IMB Deputy Director Antoinette Habinshuti, IMB's Butaro management team and staff, the Army Colonel for the District, and local district authorities. Many of the Twa also attended, and danced and sang with great excitement.

In his opening remarks, Executive Secretary of Butaro Sector Maximillien quoted Martin Luther King, Jr.’s "I have a dream" speech. Just like Martin Luther King said that the he had a dream, the pygmies also had a dream of getting houses. This dream had now come true, he said. He added that PIH is a friend that Rwandan President Kagame got for his country, and that the houses PIH built for the Twa were a symbol or an act of love and friendship.

On behalf of IMB's Butaro team, Dr. Matthew Craven, Deputy District Manager for PIH in Burera, said that the housing project was due to a good partnership with the district of Burera and the government of Rwanda. IMB’s Deputy Country Director Antoinette Habinshuti added, “In the work we (PIH/IMB) do, we align with government of Rwanda’s philosophy and policies.”

In his speech, Mayor Sembagari said that he did not find any reason to write an official speech, since the newly constructed houses could simply speak for themselves. “Life is the only gift God gives us, a good friend gives you health for life, and that good friend is President Paul Kagame [and] PIH. [They] took these [the Twa] from the miserable housing and living conditions to where they are now,” he said. He added that since Twa children can now return from school and have a home where they can comfortably read and study, they are poised to become the mayors, colonels, directors, and leaders of tomorrow. He also announced district’s plan to allocate cultivation land to the historically marginalized people.

Mayor Sembagari added that on behalf of the people of Burera, he would like to let PIH know that the community continues to thank them for the good things like these houses, the hospital, and the partnership. “The hospital is a source of good health for the future, and when people sleep well, they think great.”

Moving the 39 pygmy families into houses and from their isolated Nyamicucu area is also a way of integrating them into the community in addition to providing shelter. They will be able to easily have access to health care, education, water, agricultural support and advice among others that are directed to the general public.

Learn more about IMB/PIH’s work to help the Twa community in the Burera District. 

PIH Monitoring & Evaluation Coordinator for Lesotho, Sophie Motsamai, sent this update earlier today:

	Bags of food donated by the World Food Program.

In Lesotho, we just completed the first phase of a new partnership with the World Food Program, where we did 3 months of food distribution to all pregnant women and children under 2 years old, who were seen at the Bobete and Methalaneng clinics. Food packages were distributed to a total of 71 pregnant women and 231 children.

This project addresses the chronic and acute malnutrition that this small southern African country frequently struggles with, particularly in the rural mountain communities served by clinics like Bobete and Methalaneng. Read more about PIH’s work to fight hunger and malnutrition in Lesotho. 

	The Manual of Ultrasound for Resource-Limited Settings

Unable to speak and essentially paralyzed, a 16-year-old girl arrived at a rural hospital in eastern Rwanda. Clinicians used an ultrasound machine to perform an echocardiogram—a sonogram of her heart—to diagnose that she had suffered a stroke.  At another hospital in northern Rwanda, 3-month-old baby boy arrived suffering from a painfully swollen leg. An ultrasound helped clinicians make the diagnosis—a hematoma, or mass of clotted blood—most likely caused by the needle from a recent vaccination. Knowing the cause, hospital staff were able to quickly begin providing treatment for both patients.

As ultrasound machines become more durable, portable, lightweight and affordable, they are fast becoming the vital diagnostic tools for even the most rural of PIH’s hospitals.

As the equipment becomes available, PIH and its partners have been working hard to train staff on the use of these machines. As part of this effort, PIH has recently published The Manual of Ultrasound for Resource-Limited Settings. This manual, developed by a team of PIH clinicians led by Dr. Sachita Shah, is a concise review of bedside, clinician-performed ultrasound, with focus on specific diagnostic questions and disease processes common in the developing world.

"We wanted to create a free resource that providers could use in places where access to formal sonography and radiologists is extremely limited,” says Dr. Shah. “The manual covers clinician-performed ultrasound as it is used for common diagnostic dilemmas such as: Does my patient with shortness of breath have heart failure or fluid around the heart? Is this trauma patient bleeding internally? and Is this fetus breech? As clinicians working in resource poor settings know, the right answers to these questions can save a patient's life, and ultrasound, in trained hands, is an invaluable tool for speedy and accurate diagnosis of life-threatening conditions."

In addition to diagrams and basic how-to information, it also includes case studies from PIH’s partners in Rwanda, Haiti, and Burundi.

Already in use by PIH’s team in Rwanda, the manual has been used for trainings at several of PIH’s sites in Haiti, as well as for trainings by other organizations in Uganda, Kenya, and Ghana.

The Manual of Ultrasound for Resource-Limited Settings is now available as a free download from PIH’s website.

By Betsy Dickey, Ready for Reading Founder and Executive Director 

	Breaking ground for the new Rwinkwavu Community Library and Learning Center.
	Dancers from the local community perform at the groundbreaking event.

The Rwinkwavu community in eastern Rwanda gathered on February 7th to celebrate the ground-breaking of the Rwinkwavu Community Library and Learning Center. The Ready for Reading Initiative (RfR) is building the 775-square-meter facility in collaboration with Partners In Health (PIH), the Ministry of Sports and Culture, the local government and the community of Rwinkwavu.

RfR believes that the Center represents the educational component of a holistic prototype for rural development: health care + education + economic opportunity. The nearby Rwinkwavu District Hospital began providing access to high-quality health care in 2005. In addition, the hospital has employed hundreds of local villagers as hospital staff and community health workers, spurring the growth of other industries around the hospital and beginning an economic transformation in the community. As these new businesses develop, the need for language and computer literacy is more important than ever. The attainment of these skills will offer individuals the ability to achieve sustainable economic development. The Rwinkwavu Community Library and Learning Center will work to increase literacy, provide access to information, and develop a culture of reading in Rwanda.

Scheduled to be completed in approximately one year, the new Center will house many books for children and adults in languages including: Kinyarwanda, Swahili, English and French. The facility will also offer classes in Kinyarwanda literacy, English as a foreign language, and basic computer skills. In addition, PIH will use the facility to conduct educational programming on community health issues. As the central gathering place for the community, the Center will provide ample space for cultural activities including dance, music, drama, and movie nights, and will afford patrons a comfortable place to relax and read.

At the ground-breaking event, Emmanuel Bugingo, Acting Director of the National Library and Public Reading for the Ministry of Sports and Culture, encouraged Rwinkwavu residents “to come to this Center and make use of it.” He went on to say that the Center is in line with the government’s plans to educate people, to increase their knowledge, and encourage them to read for pleasure.

Many Partners In Health staff were on hand to mark the day as well. Dr. Peter Drobac, Rwanda Country Director for PIH, spoke about the connection between health and education as the foundations of prosperity. “Once people are healthy they ask, ‘Now what? How am I going to have a brighter future?’ The answer is, education,” he said.

The Rwandan Government has implemented many countrywide positive changes in the education system in the past few years. The Center will expand on these efforts by offering all segments of the population in Rwinkwavu the opportunity to improve literacy and have access to global information. 

Learn more about the Ready for Reading Initiative.

	Evening lights at Butaro Hospital.

PIH's Country Director for Rwanda, Peter Drobac, emailed the following update last night:

[Tuesday morning] Butaro Hospital and all of the surrounding communities were connected to the electricity grid for the first time--ever. The government completed a major hydroelectric project that was catalyzed by the hospital construction. Small business development is poised to explode in Butaro town, and nearby communities will be transformed now that they've been brought out of the (literal) darkness. It's a great example of the ripple effects that follow our investments in health infrastructure. 

Read more about the new Butaro Hospital in northern Rwanda.

In response to reports showing that cholera will continue to spread in Haiti, and to evidence that even a limited vaccination campaign could save thousands of lives, Partners In Health continues to advocate that the international community must step up vaccination and efforts to provide clean potable water to all Haitians.

Drs. David Walton, Arjun Suri, and Paul Farmer write that the international community should not be arguing the “value of competing interventions when in fact complementary ones are needed.”

In “Cholera in Haiti: Fully Integrating Prevention and Care,” published in the March 7 edition of Annals of Internal Medicine, the team of PIH physicians contend that: “Because cholera is part of a vicious cycle of poverty, poor sanitation, water contamination, and a weak health system, we argue for an approach that combines prevention and care at every step.”

PIH’s Drs. Walton, Suri, and Farmer argue three points in their article: 

• Cholera will continue to spread, and it will continue to be deadly. 

Morbidity and mortality rates during the epidemic phase of cholera is likely to last well into 2011… [C]holera may become endemic in Haiti.

Since October, 2010, at least 215,936 cases of cholera have been reported across all 10 of Haiti's geographic departments, and among these, at least 4,131 patients (or 1.9 percent of those infected) have died. These numbers very likely underestimate the actual scope of infection and death.

• Even a limited vaccination campaign would significantly impact the number of new infections.

[Evidence supports our] initiating and expanding cholera vaccination in Haiti as soon as possible. Although vaccines can be effective even with limited use, broader and earlier intervention leads to greater risk reduction, highlighting the need for a global stockpile of cholera vaccine to respond rapidly to epidemics.

[W]idespread rapid vaccination in previous epidemics in the last decade may have averted 40 percent of cases and deaths… even a “reactive” cholera vaccination campaign with 50 percent coverage could have prevented more than 10,000 cases of the disease in Zimbabwe in 2008 and 2009.

• An impactful intervention must recognize the complexity of Haiti’s current situation.

The dual approach of vaccination and clean water illustrates the positive synergies of a comprehensive strategy that combines multiple interventions.

The challenge of cholera in Haiti reveals the biosocial complexity before us. A comprehensive strategy that ranges from oral and intravenous rehydration and antibiotic therapy to strengthening Haiti's public water and sanitation systems, while also including vaccination, is the best way to limit the spread of cholera in Haiti.

Read “Cholera in Haiti: Fully Integrating Prevention and Care” in its entirety.

Read more about PIH’s response to Haiti’s cholera outbreak.

	The new bridge to Ti Peligre.
	About to cut the ribbon to inaugurate the bridge.
	The community of Ti Peligre celebrates the new bridge.

On Sunday, March 6, hundreds of members of the Ti Peligre community flocked from a lively church service to the banks of the Thomonde River to celebrate the construction of a life-saving bridge.

Until yesterday, the river was more often than not a source of danger to the 5,000 members of Ti Peligre, located approximately 30 miles northeast of the Central Plateau’s largest city, Mirebalais. The remote mountain village is right off of a rough road, and squeezed between the Thomonde and Feliciane Rivers. When the two rivers swell during the rainy season, between March and November, Ti Peligre transforms into a remote island.

Because the rivers are frequently too dangerous to cross, the inhabitants of Ti Peligre are isolated from the rest of the Central Plateau for almost eight months of the year, and cut off from access to health clinics, schools and markets. While the river provides fertile land to grow sugar cane and opportunity to wash, members of the community have been swept away trying to reach a doctor, and children have perished merely trying to get to school. Since the end of 2009 alone, three children have been lost to the river.

Alongside community members, Partners In Health/Zanmi Lasante staff joined the professors and students from Virginia Polytechnic Institute and State University (Virginia Tech) who designed, funded and helped community workers build the pedestrian bridge just shy of 200 feet. The occasion was marked with songs, sketches, and speeches in the shadow of the new infrastructure that now allows, people, motorbikes, horses and livestock to cross, thereby restoring year-round access to critical services.

In the aftermath of the 2010 earthquake, Virginia Tech teamed up with PIH/ZL to start an internship program for Haitian students at their university. While American civil engineering students from Virginia Tech began designing plans for the bridge in Ti Peligre, 14 Haitian students have been given the opportunity to pursue studies at Virginia Tech, and have become important members of the Blacksburg, VA community. PIH hopes to engage the Haitian interns upon return and to help them use their new technical and linguistic skills for future project management in Haiti. 

	HIV-positive mothers in PIH's PMTCT program receive formula in addition to jerry cans, a stove, fuel, oil, and bottles.

Chantal* is a hospital laundry woman with a five-year-old son living in rural Rwanda. She tested positive for HIV shortly before finding out that she was pregnant with her second child. Thankfully, her son tested negative for the disease, and Chantal felt deeply committed to doing everything within her power to ensure that her second child also tested negative. 

Chantal was immediately transferred from the Adult Infectious Disease Clinic to the Prevention of Mother-to-Child Transmission Clinic (PMTCT), where she began triple antiretroviral therapy (ART) and received nutritional support in the form of food packages of sosoma (a nutritious mixture of sorghum, soy, and corn) and sugar. 

As part of PIH’s HIV-Free Child Survival Program, Chantal followed-up regularly with the clinic and remained healthy throughout her prenatal care visits. In addition to the medical clinic, she also attended a counseling and education group for pregnant, HIV-positive women and their partners, which shared information about hygiene, nutrition, coping with stigma, prevention of transmission, family planning, child development, and parenting. 

Six months ago, Chantal gave birth to a daughter who received immediate prophylaxis in order to prevent transmission. Chantal was also educated about replacement feeding and was provided with the materials needed to safely formula feed her new daughter, including jerry cans, a stove, fuel, oil, bottles, and formula.  Chantal also receives a comprehensive package of services that includes community-based follow-up and regular education sessions as well as ART and food packages.

At six months, the baby has tested negative for HIV. Her thrilled mother remains committed to ensuring that the infant continues to test negative by adhering to replacement feeding and keeping herself healthy to be the mother her children need. 

*Name has been changed to protect the privacy of the patient.

	In Achham, new mothers hold their babies after delivering at Bayalpata Hospital.

Women in rural Nepal are not just being encouraged to seek neonatal health care, they are being rewarded for it.

The Government of Nepal recently invited Nyaya Health, a PIH-supported project in the rural district of Achham, to participate in its new Safe Motherhood Program. 

“This program provides a great incentive to encourage in-facility delivery in our region,” says Ranju Sharma, Bayalpata Hospital’s Director of Community Health. “Since initiating this program, we have seen an impressive increase in our delivery numbers; nonetheless, for a hospital serving over 250,000 people, we are still not seeing nearly as many as we would like.”

With less than one percent of the region’s women delivering their babies in health centers or hospitals, this program--initiated by the UK Department for International Development and the Nepali Ministry of Health and Population--financially reimburses expectant mothers who attend four antenatal care visits and deliver in a hospital with roughly $20USD. 

In a country where women are often confined to the home, and where the median family income is often less than $400USD, these incentives can have a very real impact for struggling families.

More importantly, the program helps save the lives of women and newborns.

Achham District suffers from one of the highest maternal mortality rates in South Asia with nearly one in one hundred deliveries resulting in the death of the mother. This program has already benefited the region’s women by reducing maternal and infant mortality rates. 

“By utilizing our [Nyaya’s] community health worker networks in the villages of our district, we are working on additional community awareness programs to further promote in-hospital deliveries and improve women’s healthcare situation here in Achham,” says Ms. Sharma.

Read Astha Ramaiya’s post about “Safe Motherhood”.

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.

March 8, 2011 marks the 100th anniversary of International Women's Day, a global day celebrating the economic, political, and social achievements of women past, present, and future. 

Commemorate the day by watching a slideshow featuring women from PIH projects around the world:

View in full screen.

	Psychologist Tatiana Therosme outside a patient's home in Cange, Haiti.

"Not all lives are saved in hospitals--some are saved at kitchen tables. That's where [Tatiana] Therosme, a psychologist, often does her work," states the Women Deliver website, which recently named Therosme as one of the 100 most inspiring people working to improve the lives of girls and women around the world. Therosme works with PIH’s sister organization in Haiti, Zanmi Lasante.

The list was compiled to commemorate the 100th anniversary of International Women's Day. Other honorees include Secretary of State Hillary Clinton, Grameen Bank founder and Nobel Laureate Muhammad Yunus, and celebrity philanthropist Oprah Winfrey.

"Even before the devastation of last year’s earthquake, she [Therosme] was one of very few mental health professionals in all of Haiti," writes Women Deliver. "She is working with women recovering from the trauma of the 2010 earthquake, and the epidemic of sexual assault, physical abuse, depression and anxiety that followed. Helping women to work through their experiences and look forward into the future, Therosme is more than just a listening ear--she is helping women to recover their lives."

"When I think of all those who constantly struggle to improve conditions for the Haitian woman and of all the parents who make sacrifices so that their girls can have better living conditions than their own, I will say that I am far from deserving this award," writes Therosme from Zanmi Lasante's Cange hospital in Haiti's Central Plateau. "However, this does not prevent me from feeling honored and I want to take this opportunity to acknowledge the courage of all Haitian women and to also share this rain of honor to all women in the world who deserve this award but remain in the shadows. THANK YOU!”

"Working with PIH gives me the opportunity to discover myself and to be useful where my services are needed," writes Therosme. "Thanks to PIH I find more reasons to attach myself to my country and to my brothers and sisters who live in the rural areas of Haiti."

Read about Tatiana Therosme’s work with one patient suffering from psychosis following the earthquake.

By Mary Kay Smith-Fawzi

In compiling a paper this morning, I came across some statistics I wanted to share.

In 2001, the World Bank estimated the number of children orphaned due to HIV/AIDS would be 35 million in 2010.

In 2010, UNICEF reported an estimate of 16.6 million children orphaned due to HIV/AIDS worldwide (less than half of the original projection prior to GFATM, PEPFAR, and WHO's 3 by 5 program).

Although many societal influences had driven the development of these programs in the past 10 years, PIH and our broader efforts have played a part in this sea change. 

Imagine, each of these 18.4 million children now have parents; without this sea change of increased ART access these children would have been orphaned.

However, there is a long way to go, and 16.6 million orphans is highly significant without doubt. 

Sometimes it's hard to see 'progress' in light of the continued suffering we see every day, so I wanted to share this.  Everyone receiving this email has played a part in this progress, and we shouldn't lose sight of this. At the same time, it's a reminder to keep up the good fight, since there is still a long way to go.

Dr. Smith-Fawzi recently emailed the above note to staff at PIH and institutional partners. She is an epidemiologist for Partners In Health and an Instructor for the Department of Global Health and Social Medicine at Harvard Medical School.

	Claudine Manizabayo, a Rwandan teenager and rheumatic heart disease patient.

Claudine Manizabayo was suffering from shortness of breath and a cough. At first, doctors mistook her symptoms for asthma. Then a clinical team specializing in non-communicable diseases examined her and came back with a different diagnosis--heart failure. In affluent countries like the United States, the symptoms and the diagnosis are feared and familiar among the elderly and people with coronary artery disease.  Claudine is only 18. In poor countries like Rwanda, where she grew up in a family of farm laborers, heart failure often afflicts the young and the destitute.

Non-communicable diseases (NCDs) like coronary disease, adult-onset diabetes, and some cancers have attracted a great deal of attention and resources in wealthy and middle-income countries, where they have emerged as leading causes of death and disability among populations who eat too much, exercise too little, and are heavy consumers of tobacco and alcohol. “The NCDs that afflict people living on less than a dollar a day in countries like Rwanda or Haiti, have received far less attention and have very different causes,” says PIH physician Gene Bukhman. “For this ‘bottom billion,’ NCDs--like rheumatic heart disease, type 1 diabetes, mental illnesses, epilepsy, and cervical cancer--are often the result of lack of access to food, shelter, education, and health care interventions readily available in developed countries.”

For example, Claudine’s condition--rheumatic heart disease most likely caused by a bacterial infection--required an operation to replace a damaged valve in her heart, said Dr. Bukhman, who is also Director of the Program in Global Non-communicable Disease and Social Change at Harvard Medical School. While such procedures are available to people living in places like the United States, they are rarely accessible to poor populations like Claudine’s community. Fortunately for Claudine,  the Rwandan Government has begun a focus on treating NCDs; and in partnership with a visiting surgical team from the US (Team Heart), Claudine was able to receive the treatment she needed.

“PIH has faced this issue of inequity before—for treating HIV and MDR-TB patients in poor populations,” says Dr. Bukhman. “Likewise, I see treating NCDs in poor populations as a social justice issue.” 

To call attention to the plight of these underserved populations, Partners In Health and its partners at Harvard Medical School and Brigham and Women’s Hospital have joined with numerous likeminded organizations to host a landmark conference, “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion,”  on March 2- 3, 2011.

This “long tail” refers to the curve of a graph plotting out the diseases that most affect a population. Communicable diseases like HIV and malaria at the top of the curve may cause more deaths and infect more people than NCDs like epilepsy or heart disease on the long end of the curve (see chart below).

However, NCDs still add up to a substantial burden of disease, says Dr. Bukhman. “In communities where PIH has been providing comprehensive, community-based care for many years, we no longer see large numbers of patients coming to the hospital suffering from HIV, tuberculosis, and other infectious diseases,” he adds. “Instead, our wards are increasingly filled with patients requiring treatment for NCDs.” 

Dr. Bukhman and other conference organizers intend to use the event to focus attention on NCDs among the world’s bottom billion in advance of a United Nations high-level assembly meeting on NCDs in September 2011.

“The single previous occasion on which the United Nations held a high level, disease-focused assembly meeting was in 2001. The assembly focused on HIV and played a crucial role in launching the incredibly effective Global Fund to Fight AIDS, Tuberculosis & Malaria,” said Dr. Bukhman.

“The UN assembly this September is a historic moment for the poor afflicted by non-communicable diseases,” Dr. Bukhman concluded. "We who advocate for their treatment must ensure their voice is heard."

	A patient in Rwanda uses an inhaler to treat asthma.

The March 2-3 Long Tail conference features 50 respected speakers and panelists, both experts treating these illnesses and those living with non-communicable diseases in developing nations, including Claudine from Rwanda, who is now healthy enough to attend school. In addition, several other speakers from Rwanda will also be featured, as the Government of Rwanda has been a leader in non-communicable disease control.

In addition, the conference will include presentations from Julio Frenk (Dean, Harvard School of Public Health) and Felicia Knaul (Director of the Harvard Global Equity Initiative), principal authors on a recent call to action to address cancer in developing countries. Other presenters will include: PIH co-founder and Harvard Kolokotrones University Professor Paul Farmer, Elizabeth G. Nabel  (President, Brigham and Women's Hospital), Dean Jamison (Professor of Global Health, University of Washington), Peter Hotez (Professor and Chair, Department of Microbiology, Immunology, and Tropical Medicine, George Washington University), Ann Keeling (Chair, NCD Alliance Steering Group), and K. Srinath Reddy (President, Public Health Foundation of India).

Registration is free for public health professionals and advocates. The conference will be webcast live.

For more information, visit http://www.pih.org/harvardncd.

A story by Pulitzer Prize-winning author Tina Rosenberg in Monday’s New York Times chronicles the efforts of a New York-based program modeled after PIH’s Prevention and Access to Care and Treatment (PACT) project in Boston.

“The Care Coordination program, a city-wide initiative now in 28 sites in different hospitals around New York, was inspired and trained by a Boston-based program called PACT, for Prevention, Access to Care and Treatment,” writes Rosenberg. “PACT is part of Partners In Health--a nongovernmental group famous for its work in Haiti, Rwanda and elsewhere.”

“Part of Partners’ strategy is to use people from the community who are paid a stipend to visit patients, watch them take their pills and support them. Since 1995, PACT has been using these ideas in tough neighborhoods of Boston, first with H.I.V. patients and now with people with chronic diseases such as diabetes. The PACT project trains people from the community, some of whom have the same diseases and similar problems as their patients, to be community health workers.”

Read Rosenberg’s story in its entirety.

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

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

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

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

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

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

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

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

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

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

	Carmen poses with her MAKI brand honey - named after her daughter, Makensy.
	Not only does Carmen make her own honey, but she's also branched out to making other flavored treats.
	Carmen adds honey flavoring to homemade popcorn.

Carmen was born with a knack for business. "I could even sell stones," she jokes. The key to her blossoming career is personalized attention and persistence – she once spent an entire day marketing honey to a single restaurant. Yet, before Carmen could focus on building her now thriving honey business she had to first overcome a dangerous and often deadly disease – multidrug-resistant tuberculosis (MDR-TB) – a challenge she won with the help of PIH’s sister organization in Peru, Socios En Salud (SES). 

“Even before I was sick I knew I wanted to go into business,” recounts Carmen. Born and raised in Vino de Oyococha, a small and very poor town in Peru’s Huancavelica region, she was keenly aware of the challenges her family and friends faced because of poverty. 

“Everywhere you looked there was malnutrition and tuberculosis,” Carmen recalls. “I worked all the time, for other people, for myself. But I could never make enough money to get ahead.”  

So in the late 1990s, while she still was still in her teens, Carmen travelled the six hours north from her hometown of Vino de Oyococha to Lima, Peru’s capital, to study at the Servicio Nacional de Adiestramiento en Trabajo Industrial, a large industrial training school that prepared students to work skilled factory and apprentice-type jobs. A quick study, Carmen was admitted to the school, and found a job in a local textile factory after graduation. She met her husband, and shortly thereafter their daughter Makensy was born. 

Yet their happiness was short-lived. Not long after giving birth, Carmen was diagnosed with tuberculosis. An already difficult situation was made worse when her husband left her, fearing that he too would become sick. Carmen suddenly found herself homeless, seeking TB treatment, and weighted down with debt. Overwhelmed, she was eventually let go from her job. 

Despite feeling isolated and stigmatized by her illness, Carmen was motivated to recover her health. But by the time she was able to access treatment, her disease was relatively advanced. "I weighed 29 kilos [64 pounds],” says Carmen. “I would walk half a block and be so out of breath that I could not advance." 

Because she was unable to take her medication every day during the required six-month treatment, Carmen underwent treatment three times before finally developing MDR-TB. While TB is curable, treatment requires that a consistent regimen of drugs be taken every day for six months. If a patient only partially overcomes the infection, he or she will develop MDR-TB – a dangerous strain of the disease considered incurable in resource-poor settings like Peru until relatively recently.

It was then, after seeking out care with SES in Lima, that Carmen began to heal. “The doctors told me, ‘This is your last chance to live – MDR-TB will kill you, you’ve been infected too many times.’” 

She agreed to be quarantined, and to take medicine every day for two years – the only cure for MDR-TB, one that often comes with painful side effects. SES offered Carmen medical and social support – a safe and stable home, food, water, and childcare – in order to offer her the best possible chances of overcoming the disease. “I felt sure it would heal me,” says Carmen. “I knew this was my last chance.” 

As Carmen regained her strength and health, SES staff asked if Carmen wanted to enroll in the program’s microloan program, which requires intensive training and mentoring. Carmen immediately agreed. After developing a business plan, she was given 1,200 Nuevo Sol ($432 US). Soon, she began bottling and distributing honey.

Initiated in 1994, SES’s program helps MDR-TB or HIV patients start their own small businesses, gain economic independence, and reintegrate into their communities. Recipients are required to attend trainings in formulating business plans. Staff accompany patients until they solidify their business and are able to return the loans. 

“The most important thing is to listen to customers and provide quality,” recounts Carmen. Driven by this conviction, she was soon running a thriving business. Yet, there was something important she still needed to do. “I also knew that I wanted to create jobs for rural people.” 

So Carmen – now healthy and independent – returned to Oyococha. “You cannot educate without nutrition, and cannot be an entrepreneur without education,” says Carmen. “My goal is to help people in the position I found myself.” 

Built on these relationships of trust, Socios En Salud’s income generation program has been quite successful. In 2008, 55 new businesses were started, and 15 patients reentered the labor market. In 2009, 64 interest-free loans were provided to patients, and an equal number of businesses were started. And in the first half of 2010, more than 30 new businesses were launched, and at least 17 patients reentered the labor market.

	Inshuti Mu Buzima, PIH's partner organization in Rwanda, holds support groups for children (pictured above), as well as for adults and adolescents.

When Angelique* tested positive for HIV three and a half years ago, she had already lost both her mother and stepmother to AIDS. Her younger brother also tested positive for HIV. The 19-year-old from the rural Rwinkwavu community in eastern Rwanda blamed her father for infecting her family.

After an initial grieving period, she came to terms with her status. She began antiretroviral therapy (ART) and started to attend the adolescent counseling group at Rwinkwavu Hospital in August 2007. 

When Angelique first joined the adolescent counseling and support group, she harbored a lot of insecurities. She was uncomfortable with the realities of her diagnosis and was afraid of facing stigma and having others find out about her status. But thanks in large part to the holistic bio-psycho-social curriculum and the support of an HIV-positive peer group, she overcame her fears and is now the leader of the adolescent girls’ Saturday counseling group. 

Angelique leads the group in song and drumming and assists the nurse and social worker in educating her peers as well as in directing field trips. Her confidence and willingness to share her experiences with the group has inspired other young women to talk about living with HIV and coping with stigma. She now presents herself as an example of how to take care of oneself and often shares her struggles with opportunistic infections with her peers to teach them how to stay healthy and manage their HIV. 

Angelique is currently in her second year of a secondary school at a boarding school in Kigali, where her teachers support both her health and her learning. 

She remains more comfortable with peers in her counseling group than others her age; she is anxious about relatives and members of her community at her school or elsewhere finding out her status. Even so, she has come a long way.

Once she completes secondary school, Angelique will transition into an Adult HIV support group, where the nurses are confident that she will flourish. She has already exhibited the capacity to manage her own health and has been a valuable resource to other HIV-positive adolescents learning to care for themselves. 

*Name has been changed to protect the privacy of the patient.

How a new world-class hospital serves as the hub for a district-wide network of care.

A three-mile walk through the streets of Cambridge, MA, on Saturday, April 2, will help provide food and jobs to hundreds of Haitians by supporting Partners In Health’s agricultural program, Zanmi Agrikol. More specifically, this year’s 8th annual Urban Walk for Haiti will raise money and focus attention on PIH’s efforts to combat pediatric malnutrition in central Haiti.

“PIH’s Zanmi Agrikol project is a critical effort to combat pediatric malnutrition by locally producing and then distributing two therapeutic ‘ready to use’ food supplements called Nourimanba and Nourimil,” say Walk cofounders in a recent press release.

	8th annual Urban Walk for Haiti 12 pm on Saturday, April 2 29 Mt Auburn Street, Cambridge (St. Paul's Church, near Harvard Sq) Music, Haitian food, crafts, and rally
	Supporters walk with the Haiti flag.
	Listening to Haitian music, rallying for a cause.
	Highlights from last year's Urban Walk for Haiti.

“It currently costs $150 to nourish a child for 6-8 weeks with special programs using these food supplements to recover a child from severe malnutrition. $3.06 per day to save a child!”

Read more about Zanmi Agrikol, including information about the pediatric malnutrition initiative.

Organized by a group of high school students, community activists, and now in partnership with the Cambridge Mayor’s office and the Councilors of the City, the Walk brings awareness of the desperate situation faced by millions of Haitians forced to live with homelessness, hunger pains, HIV/AIDS, malaria, unsanitary water supplies, and other dire circumstances caused by poverty.

The Walk begins Saturday, April 2, at noon at 29 Mt Auburn St. (St. Paul’s Church) in Cambridge.

“Zanmi Agrikol is rooted firmly in Haitian soil, nourished by local knowledge,” says local schoolteacher and Walk committee member Jen Schongalla. “It is restorative on many levels: from amending the soil and planting the seeds, to weeding, watering, tending, harvesting, processing, packaging…all the way to the child eating the yummy peanut butter that will restore his life.”

“Each of these steps requires an extensive network of people, all of whom are interdependent and play particular roles,” continues Jen. “This fosters vitality in the community in the form of jobs, education, pride in rural life, and a path toward food security. This network depends upon the inherent value and unique talents of each person, so that everyone can work together toward a thriving community.”

Watch a slideshow of PIH’s Nourimanba program.

The organizers are planning to have a strong presence from the Haitian community at the walk, as well as Haitian food, crafts, dancing, and music—including the all-female Afro-Caribbean music ensemble, ZiliMisik. PIH Medical Director Joia Mukherjee will also speak at the event.

Speaking of last year’s event, McElroy says: “Dr. Mukerjee's speech was energizing and a perfect way to start the Walk. Hearing her once again combine Haiti's history as a country of liberty for all and tying Haiti's lack of economic progress to the strictures set upon Haiti by outsiders, in particular, was inspiring to walkers.”

“Haitians already have hope—they've been hopeful and determined for centuries; we aspire to instill that same sense of hope in those who attend the Walk,” added McElroy.

Click here to see a full list of events.

Since its inception, the Walk has helped equip operating rooms, provide community health education and schooling—including scholarships for over 2,000 students, medicine, reliable shelter, water and food programs, all of which has raised the living standards for thousands of Haitians.

After last year’s devastating earthquake, well over 2,200 people came out on a brisk winter day to show their support for Haiti. Eating Haitian food, listening to live music, and purchasing crafts from the island nation, the Walk raised $71,000—a goal it hopes to match again this year.

Money raised during last year’s Walk allowed 203 high school students to complete classes for the year, with all of the school’s senior students graduating. Funds covered the students’ school fees, uniforms, books, and one meal a day. The donations also significantly augmented local teachers’ salaries.  

Over the course of the last seven years, the Walk has raised $283,414.

For more information, please visit walkforhaiti.org.

Get ideas for organizing your own event to support social justice, health care, and the work of PIH.

we're almost there!!! i am told construction will be done in the next couple of weeks. let's say in another month (april) we're also working on the bakery, kitchen/cafeteria/dining after that, we will start the renovation for the music and arts center....

Zanmi Lasante Director of Strategic Planning and Operations Loune Viaud just sent the above note from Haiti, reporting on construction on a new dorm for the children of Zanmi Beni. Located near Port-au-Prince, Zanmi Beni cares for abandoned and physically or mentally disabled children.

Check out some artist renderings for the new dorm below.

Learn more about Zanmi Beni

{"preview_thumbnail":"/sites/default/files/styles/video_embed_wysiwyg_preview/public/video_thumbnails/nMlPKkL4iC4.jpg?itok=K1PVnKVp","video_url":"https://www.youtube.com/watch?v=nMlPKkL4iC4&t=53s","settings":{"responsive":1,"width":"854","height":"480","autoplay":0},"settings_summary":["Embedded Video (Responsive)."]}

"I couldn't work in the garden. I couldn't clean. I couldn't care for my child. I couldn't really do anything for myself," says Anet Mukakibibi, a woman living with asthma in rural Rwanda. "I couldn't even manage to build a fire to cook food." 

PIH's partner organization in Rwanda, Inshuti Mu Buzima (IMB), is strengthening its services for treating patients with asthma and other chronic, non-communicable diseases, such as diabetes and epilepsy. These services are not only delivered at the hospital-level, but also in the homes and communities of the patients by trained community health workers.  

Learn more about treating non-communicable diseases in poor communities. 

To call attention to the plight of poor patients suffering from non-communicable diseases, Partners In Health and its partners at Harvard Medical School and the Brigham and Women’s Hospital have joined with numerous likeminded organizations to host a landmark conference, “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion,” on March 2-3, 2011.

Mirebalais Teaching Hospital is quickly rising in the Central Plateau of Haiti.

The walls have been erected for six of the buildings—the women’s outpatient clinic, the ambulatory clinic, the emergency room, the women’s triage, the labor and delivery unit, and the community health clinic.

Additionally, the workers’ camp is almost complete, so the non-local workers will soon have an on-site residence. After the hospital has been inaugurated, the workers’ camp will be turned into medical student dorms.

Every day, the construction employs over 100 workers, approximately 95 percent of whom are Haitians laborers, masons, and carpenters from Mirebalais and nearby towns.

This week, a 280’ well was drilled, and groundwork was laid for the third and final well that will converge into the hospital’s extensive water pipe system. This is in addition to the well created for community use by Mirebalais residents.

	Dr. Karla Sánchez

A new physician is now seeing patients in the rural Chiapas region in Mexico. In January, Dr. Karla Sánchez became the third physician--and the first female clinician--with PIH's partner project in Mexico, which works in collaboration with the nonprofit El Equipo de Apoyo en Salud y Educación Comunitaria (EAPSEC)--the Team for the Support of Community Health and Education.

Karla’s presence is not only welcomed by the busy EAPSEC/PIH Mexico clinical team, but could also have an immeasurable positive impact in a region where so many girls do not attend or drop out of school, says PIH-Mexico coordinator Lindsay Palazuelos. 

Karla recently sat down to discuss how and why she chose to work in Chiapas.

Having gone to medical school in Puebla--a large city in the center of Mexico--what made you come work in the Sierra Madre--a tropical, mountainous region in southern Chiapas?

	The mountainous tropical Chiapas region.

I’m driven by a desire to provide medical services to people who need them, and one of the most satisfying ways for me to do this is by working in a rural area. Being here actually strengthens my convictions and gives me a different--and very positive--perception of life.

Ultimately I firmly adhere to the idea that all human beings have the right to health, regardless of distance or social class. In the end, I identify with all the people that form our society--all the people of Mexico--and I see a real need for justice in underserved places like Chiapas. This is especially true when discussing access to health care.  

Benemérita Universidad Autónoma de Puebla--the medical school where you received your degree--is particularly interested in social justice. Is this what drew you to the Chiapas project?

I believe that things can change for the better, if each of us contributes, and if we as a society adhere to the idea of social justice. I want to be a part of positive change in places that need the noble art of medicine. 

Even as a medical student I knew this was something I wanted to do. Before coming to EAPSEC/PIH I worked for a year with an NGO in rural Oaxaca--a region west of Chiapas. The experiences gained during that time very much influence how I think now. I strive to provide the best service possible to patients, to earn their trust, and to give my best to each person seeking medical attention.

What do you see as the biggest challenges facing the people of Chiapas?

For a long time we’ve known that the biggest challenge facing these communities is the large coffee and corn companies who have purchased the region’s fertile land, pushing the people into the mountains.

Almost all the people in Chiapas control and work their own land and then sell their crops to large buyers—these corporations—and are often at the mercy of fluctuating commodity prices which rarely work in their favor... [These jobs] leave them as poor as they were before working for these companies.

	A washed out mountain road.

Many of these people come back from work and try to farm small plots of land on the side of a mountain. The lack of [financial] resources to have domestic animals such as chickens, pigs, and horses leaves people without--without food [and] animals to help plough.

[Another problem is the isolation of Chiapas villages] To say that the road into these villages is dangerous to travel would be an understatement. Because of the region’s geography and the high levels of deforestation, the journey in and out of Chiapas is a very dangerous one. Not just that, it’s arduous. It takes about six hours to get to the closest city by car. And of course most people don’t own cars. This is a long-standing problem, and one that has led to disproportionate levels of illness and chronic disease in the region.

What role do you see yourself playing in breaking the cycle of poverty and disease in the Sierra Madre in Chiapas?

The people of Sierra Madre feel like they are forgotten by Mexico’s state-run health system. This is obviously the largest health problem facing the region’s communities.

I see myself as needing to do a number of things. First, I need to understand the way of life here. Doing that will allow me to better understand the causes of certain infectious diseases. Then I can contribute to an effective solution to dangerous trends in the region, as well as help develop preventative interventions.

I’m excited to improve the health of the inhabitants of Chiapas. There is a lot of reward in helping people here, and it justifies why I became a doctor.

Since 1989, PIH has worked with EAPSEC to deliver health care, access to education, employment, and social support to tens of thousands of people living in the isolated mountain communities of Chiapas – Mexico’s southernmost state. 

Read more about PIH-Mexico.