Patient in Hospital at Home Program.

Tuberculosis (TB) patients in Pavlodar--a city in northeastern Kazakhstan--now have access to a new model of care.

With guidance from PIH-Kazakhstan (PIH-KZ), the Pavlodar TB Dispensary successfully launched a “Hospital at Home” program this fall, providing patients with treatment and social support in their homes. Obstacles such as distance, transportation costs, and physically inaccessible treatment facilities limit many patients’ ability to regularly attend clinics and receive medication. This program thus specifically targets TB patients who face barriers to accessing care: the elderly, pregnant women, geographically isolated patients, and patients who suffer from socio-economic problems such as poverty and alcoholism. By bringing medication and support directly to patients, this program aims to bolster adherence rates and consequently increase patients’ chances for complete recovery.

Each day, nurses and drivers deliver medication and food packages to patients, monitor side effects, and provide additional social support. Once a week, a TB doctor joins the “Hospital at Home” staff to provide check-ups. All of which is made possible from the support of the regional government and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. 

The program enrolls approximately 25 patients at a time.

The “Hospital at Home” program is based on PIH’s existing Sputnik project in Tomsk, Russia. Earlier this year, the Kazakh staff observed the Tomsk system of ambulatory care, patient accompaniment, and psychosocial support. Pavlodar TB doctors customized the program to fit their region’s needs.

In Tomsk, the Sputnik project has raised adherence rates from 40 percent to 94 percent. PIH-KZ is hoping to see similar positive results as the Pavlodar program matures. Plans are already underway to launch a similar program in Karaganda, KZ.

PIH began the Kazakhstan program about a year ago to work with the Kazakh government to help address an epidemic of multidrug-resistant tuberculosis.

Zanmi Lasante, PIH’s sister organization in Haiti, recently launched a program that addresses two top priorities – training the next generation of Haitian health professionals and fighting a cholera epidemic that has killed more than 2,300 patients since it first broke out in mid-October.

Beginning in late November, six Haitian medical students were deployed to assist PIH/Zanmi Lasante (ZL) medical staff dealing with the cholera outbreak in the country’s Central Plateau and Lower Artibonite departments. They are now helping manage the daily influx of new cholera patients--about 300 each day--across the organization’s medical clinics and cholera treatment centers.

The students significantly increase the number of site physicians working to control an epidemic that is expected to grow in coming months. The World Health Organization estimates that approximately 650,000 Haitians will be infected within the next six months.

The students have been divided into teams and sent on clinical rotations to three PIH/ZL sites – St. Marc, Cange, and Mirebalais – where they are participating in community health education and training activities used to slow the spread of a disease that had not been seen in Haiti since the 1960s.

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

“[During the rotations] PIH/ZL instructors discuss public health issues related to resource-poor countries,” says Dr. Charles-Patrick Almazor, the physician running this clinical rotation, which was established in partnership with the medical school at l’Université d’Etat d’Haïti, Haiti’s national university. “Topics range from the broad, such as health system strengthening, to the specific, like operating a cholera treatment center,” he added.

“We decided to start this program a few months after the earthquake,” says Dr. Almazor. “All the senior medical leaders involved felt it was important to help and to give back what we have learned, not only because we were once students from l’Université d’Etat d’Haïti ourselves but also because we thought it is part of our job to share our model with future generations.”

Though relatively small in size, initiatives like this are a crucial piece in the rebuilding of Haiti’s medical system – much of which was damaged as a result of the earthquake. As crucially, the students are providing much-needed relief for staff who have been working tirelessly these past few months.

The number of medical students working in the clinics will increase to eight when the next group of students moves into the month-long rotation in January. “The students learn by doing,” Dr. Almazor reports. “And when they have questions, we listen and teach.”

This is “not your grandmother’s cholera,” writes Paul Farmer and Zanmi Lasante’s codirector of women’s health, Jean-Renold Rejouit, in “How We Can Stop Cholera,” an essay appearing in the December 13 issue of Newsweek.

Many epidemiologists and other experts have observed that the strain that has surfaced throughout Haiti (“an El Tor biotype of Vibrio cholerae serogroup 01”) seems especially virulent and hard to slow down.

Meanwhile, since late October, more than two thousand people have died from cholera, and more than 36,000 have been hospitalized with the disease. “This makes it all the more urgent for the world to renew its relief efforts in Haiti,” writes Farmer and Dr. Rejouit, “and to resist the temptation to write off the country’s 10 million people as beyond hope.”

Farmer and Rejouit advocate delivering quality care to the sick, including two measures that have been deemed too costly by others in global health – aggressive use of antibiotics, and a massive oral cholera vaccination campaign.

More importantly, they emphasize the need to strengthen Haiti’s almost nonexistent water supply and sanitation infrastructure – this too, is an element of “fully integrated prevention and care.”

Read the full Newsweek article.

On Friday, December 10, Catherine Porter wrote an excellent in-depth article about health care in Haiti for the Toronto Star, "Death and Decay in Haiti's Hospitals."

The piece is framed with the story of Lovely, a 25-year-old Haitian who recently lost her baby because her family lacks access to medical treatment. Like most Haitians, Lovely can’t afford the $1.50 USD fee required for admission to her local hospital.

Porter explains the ways poverty underlies the high rates of maternal and child mortality in Haiti. More than that, she argues that Haiti’s health care system has been hampered by failure to strengthen the public sector. Instead, a vast number of NGOs work by themselves, while Haiti’s Ministry of Health (MOH) attempts to offer health care to nearly 10 million people on roughly $30 million (US) a year.

Of course, things should be different. And in some instances, they are.

Porter highlights Partners In Health’s work at de Lacolline clinic in Lascahobas as an example of a medical facility that works “for the rich and poor alike.” In Hospital de Lacolline and its 14 other facilities, PIH partners with the MOH to rehabilitate and adequately staff rural medical centers, and in turn offers free health care to everyone living in the facilities catchment area.

Read the story in its entirety.

“Haiti is one of the easiest places on Earth to die — not from violence, although last week more than a dozen people were shot in post-election protests, but from easily treated illnesses,” Porter notes. “Cholera, a disease cured with sugar, salt and clean water…has killed more than 2,100 Haitians since October.”

“Almost six babies of every 100 die soon after birth. One in 12 won’t make it to age 5 — most succumbing to diarrhea and the flu,” she continues. “More women die during childbirth here than in any other country in the western hemisphere. A lot more. For every 100,000 live births, 630 Haitian mothers perish — more than triple the number of mothers in Bolivia, which has the next-worst chance of survival (200 per 100,000). In Canada, only 7 die.”

The problem:

“The country’s primary hospital (HUEH) was funded like a university dorm, hence its pathetic legacy. While Toronto’s Mount Sinai spends $445 million a year, HUEH’s budget is $5 million — 90 per cent sapped by salaries, which were both low and irregular. Top doctors here make $590 a month, when they are paid, so everyone — including Lassegue — has a private clinic, where they work two to three days a week,” writes Porter. “In principle, treatment here was free. In practice, patients were sent across the street to private pharmacies to buy everything from surgical gloves to needles.”

The solution: 

“In April, the health ministry proposed rebuilding the many damaged hospitals, and adding others throughout the country so that every Haitian will be within 30 minutes of a health facility.”

An example of a solution that works - the PIH/Ministry Hospital de Lacoline in Lascahobas: 

Head north to “the dusty town of Lascahobas. At the end of the main road, lined with saloon-like stores, sits what could pass for an Oakville golf clubhouse: low-slung white buildings surrounded by manicured lawns and birds of paradise. People sit on benches under a trellis of white flowers awaiting prescriptions. No garbage, no pulsing gutter, no smell of urine. Yes, the hospital is basic, but it is clean and welcoming. Most importantly, it is free.”

“Officially, patients pay 25 gourdes (62 cents) as an admission fee, which covers all their treatments and medication. Most don’t pay even that.”

Read “Death and decay in Haiti’s hospitals” in its entirety.

“Haitians know that the earthquake has not, thus far at least, revealed a hoped-for silver lining; reconstruction remains stalled,” writes Dr. Louise Ivers and her colleagues in Haiti. “But there are hundreds of humanitarian groups that could be enjoined to participate in regional efforts to integrate cholera prevention and care. We can all do more to strengthen Haiti’s public health system.”

On December 10, Partners In Health and Zanmi Lasante, our sister organization in Haiti, published articles in two prominent medical journals on the ongoing cholera crisis.

In “Responding to Cholera in Post-Earthquake Haiti,” in The New England Journal of Medicine, the conditions and circumstances that precipitated the current epidemic are outlined. The authors of “Five complementary interventions to slow cholera: Haiti” in The Lancet, summarize the actions that NGOs and governmental organizations can still take to limit the spread of the disease, and save thousands of lives.

Since its inception, Partners In Health – in partnership with Harvard Medical School, Brigham and Women’s Hospital, and the Harvard School of Public Health – has broadly disseminated our experiences in the field, in the hope of better informing future medical research and improving our own work within resource-poor communities. Because it appears that hundreds of thousands of Haitians will become ill from cholera in 2011, we must refine and strengthen what we know about treatment and prevention as quickly as possible.

In The New England Journal of Medicine article, Dr. David Walton, PIH’s Deputy Chief of Mission in Haiti, and Louise Ivers, PIH’s Chief of Mission in Haiti trace some of the events that led to the outbreak. They focus on why the outbreak began in the Central Plateau, and how the disease – not found in Haiti for roughly five decades – was reintroduced into the country.

Walton and Ivers also correctly argue that the origins of this crisis took root well before the January earthquake. “The cholera outbreak took most people by surprise. Unexpectedly, it was centered in rural Haiti not in the displaced-person camps that are situated mainly in the greater Port-au-Prince area,” they write. “But history would suggest that an epidemic outbreak of waterborne disease was just waiting to strike rural Haiti.” For example, Walton and Ivers assert, it is “well known that Haiti has the worst water security in the hemisphere. In 2002, it ranked 147 out of 147 countries surveyed in the Water Poverty Index.”

Read The New England Journal of Medicine piece in its entirety.

In The Lancet article, Louise Ivers, PIH cofounder Paul Farmer, and PIH physicians Charles-Patrick Almazor and Fernet Léandre maintain that cholera efforts in Haiti “should be focused on improving access to clean drinking water through public works projects.”

Since late October, 80,860 cases of the illness have been recorded. 36,207 people have been hospitalized, and roughly 2,000 people have died from cholera. The World Health Organization estimates that up to 400,000 Haitians may become infected in the coming year.

“We must move swiftly, aggressively, and together: marshalling not only the tools needed to slow the epidemic in Haiti and its neighborhood, but also the political will of global health authorities and funders and large-scale implementers… [I]n this dire emergency, we can accept nothing less than complementary prevention and care,” they write.

Read the full article from The Lancet.

Partners In Health and our Haitian sister organization, Zanmi Lasante (ZL), continue to provide treatment around the clock for cholera victims and other patients, even as a wave of sometimes violent protests has shut down most businesses and services across the country.

In Port-au-Prince, Dr. Anany Prosper and other ZL staff have kept the Cholera Treatment Unit (CTU) at the settlement in Parc Jean-Marie Vincent (PJMV) up and running without any interruptions. The settlement is one of the largest in the capital city, with a population of more than 50,000 people. ZL has provided comprehensive primary health care services there since late January, and now operates a 50-bed CTU that regularly admits 35-50 patients a day. Earlier this week Dr. Prosper walked through PJMV, checking on residents recovering from cholera, and encouraging adherence to sanitation guidelines and use of the settlement's safe water supply.

PIH has also taken measures to ensure that essential supplies remain available at the clinic in PJMV, and at our hospitals and health centers across the Central Plateau and Lower Artibonite. In anticipation of possible unrest, supply trucks were dispatched to Mirebalais and Hinche just hours before the election results were announced.  ZL deliveries from the main warehouse in Port-au-Prince to facilities in the Central Plateau and Lower Artibonite may resume once the roads are determined to be safe for travel.

In a video from the PopTech Social Innovation Conference, Dr. Raj Panjabi presents on the story and model of Tiyatien Health, PIH's partner project in rural Liberia.

Dr. Panjabi was selected as one of 16 Social Innovation fellows for his work in pioneering new approaches to community-based health care in postwar Liberia.

A new community well is opening this week in the village of Mirebalais, bringing clean, drinkable water to thousands of people  living in a region affected by Haiti’s cholera epidemic. One of many PIH projects initiated in response to the now month-old outbreak, this new well is a small, but significant step towards curbing the spread of a disease which has infected at least 20,000 Haitians and taken at least 1,300 lives since mid-October.

Cholera is a devastating disease that causes intense vomiting and profuse watery diarrhea leading to dehydration, which can be fatal within 12 to 24 hours. The UN estimates that as the outbreak spreads, upwards of 200,000 Haitians could possibly become infected before the end of 2010, with a fatality rate of at least 2 percent.

Read more about PIH’s response to the cholera epidemic.

The well is located near the site of the Mirebalais National Teaching Hospital – a world-class hospital funded by PIH and Haiti’s Ministry of Health – which is set to begin serving patients by January 12, 2012. John Chew, PIH’s Mirebalais Hospital Coordinator, reports that on November 21, the cement surrounding the new well was poured, and the following day drilling was completed. On the 23^rd the cement cap was put in place.

Now for sale: Poets for Haiti: An Anthology of Poetry and Art. This incredible anthology of works about Haiti – including pieces by Robert Pinsky, Rosanna Warren, and Marilene Phipps-Kettlewell – grew out of a benefit reading at Harvard University in February, 2010. The collection includes a preface by PIH co-founders Paul Farmer and Ophelia Dahl, and reproductions of art by produced by Haitians. All proceeds from the sale of this book will go to Partners In Health to support the people in Haiti. 

Order your copy online from Yileen Press. 

People in the Boston area will be able to hear Ophelia, the book's editor, Kim Triedman, and a number of the contributing poets speak on Wednesday, December 8, at the Porter Square Bookstore in Cambridge, MA.

Event Information:

Book: Poets for Haiti: An Anthology of Poetry and Art, edited by Kim Triedman, preface by Paul Farmer and Ophelia Dahl

What: Book launch reading and reception

Where: Porter Square Bookstore, Porter Square, Cambridge, MA

When: Wednesday, Dec. 8, 7:00 - 9:00 pm

Readers: Robert Pinsky, Fred Marchant, Patrick Sylvain, Marilene Phipps-Kettlewell, Tom Daley, and Afaa Michael Weaver, with introductory remarks by Kim Triedman and Ophelia Dahl.

On January 24-30, 2011, PIH Lesotho will be holding a course on care delivery for multidrug resistant tuberculosis in Maseru, Lesotho. This course is intended for physicians, residents, fellows, epidemiologists, nurses, and other health care professionals with an interest in MDR- and XDR-TB. 

Course participants will leave with an in-depth understanding of MDR-TB, treatment regimens, and providing top-of-the-line medical care in a geographically challenging region, where much of the population lives in highland villages accessible only by foot or horseback.

Lesotho – a small, mountainous nation of 2 million people located entirely within the borders of South Africa – suffers from the third highest rate of HIV infection in the world, with an adult prevalence of 23.3%, and the fourth highest rate of tuberculosis infection. Over two thirds of all TB patients are co-infected with HIV. 

In response to an outbreak of XDR-TB in neighboring South Africa, Partners In Health Lesotho (PIHL) began working with the Lesotho National TB Program in 2007, supporting the creation of the first community-based MDR-TB treatment program in Africa. This program has since become a model for hospital- and community-based care of MDR/XDR-TB in Africa. 

As a result, clinical teams from throughout Africa (including Kenya, Malawi, Nigeria, Ethiopia, South Africa, Swaziland, Tanzania, and Zambia) have sought instruction from Dr. Hind Satti and Dr. Kwonjune (KJ) Justin Seung on MDR-TB prevention and treatment. For the first time, PIHL opens this MDR-TB course to physicians and health care workers from countries outside Africa.

So far, course participants have registered from South Africa, Medecin San Frontieres in Zimbabwe, Harvard Medical School in Boston, and Indus Hospital in Karachi, Pakistan.

Find out more about the program and register now.  Only a few seats remain!

In the December 2 edition of The New York Times, columnist Nicholas Kristof reports on Haiti’s cholera outbreak from a medical facility supported by PIH and the Haitian Ministry of Health in Mirebalais, Haiti. Noting the grimness of the situation, Kristof reflects on the larger institutional and structural problems facing the country. 

--

An emergency cholera hospital is the grimmest kind of medical center, and it’s a symbol of the succession of horrors that have battered Haiti over the last year.

Here in Haiti’s central plateau, I visited a cholera treatment center run by an excellent aid group, Partners in Health, in collaboration with the Ministry of Health. Nobody goes in or out without being thoroughly disinfected; to try to control the epidemic, bodies are buried rather than released to families…

Part of the problem is that the government, crippled by the quake, has done little. Another is that aid groups created a parallel state that further diminishes the government — and a country needs a central authority to make decisions. The limitations of aid are very much on display in Haiti.

Read Kristof’s full article.

Mark has been living with HIV since 1992. Over the past two decades he has experienced setbacks – depression, alcohol abuse – which ultimately prevented him from adhering to his treatment regimen. PIH's Prevention and Access to Care and Treatment (PACT) project focuses on helping people who, like Mark, are living with complex medical issues, and paired him with a community health worker.

Since last year, Mark’s health has improved dramatically. To commemorate this year’s World AIDS Day – held each year on December 1 – Mark asked to tell his story in an effort to let others know that living with HIV needn’t be a death sentence.

Since 1995, PIH’s Prevention and Access to Care and Treatment (PACT) project has worked some of Boston’s sickest and most marginalized HIV-positive and chronically ill patients. Learn more about PACT.

Read more about what you can do on World AIDS Day.

One month after the devastating earthquake, Partners In Health (PIH) launched the STAND WITH HAITI Fund, a $125 million plan both to provide emergency relief to earthquake victims and to help Haitians rebuild their public health system.

Tens of thousands of our supporters, including individuals as well as organizations and institutions, have already generously contributed $86 million to the fund.  

About $30 million went immediately to emergency relief—including emergency surgical services and supplies —as allocated by the plan set in February.

However, PIH has never been a disaster relief organization.  The bulk of the remaining STAND WITH HAITI Fund budget is designated for the type of work PIH is best known for--working with the local government and communities to build and strengthen public health systems -- with an emphasis on rebuilding and strengthening facilities and services that were badly damaged in the earthquake and desperately needed after it. 

A flagship project to strengthening Haiti’s health system is the construction of the new state-of-the-art national teaching hospital in Mirebalais, Haiti. Construction has already begun on the $15 million facility and it is scheduled to open before the second anniversary of the earthquake on January 12, 2012. In addition to bringing high-quality medical services to an estimated 140,000 people in central Haiti, the 320-bed hospital will help train the country’s next generation of doctors, nurses, and health workers.

The team has also begun constructing and renovating existing facilities to handle a growing volume of patients following the earthquake.  The STAND WITH HAITI Fund has designated roughly $5.7 million for these infrastructure improvements.

In addition to constructing and improving the facilities themselves, bolstering clinical services and community development programs at these centers is a top priority. The fund has allocated $57 million over the next two years to bring comprehensive services to poor communities, especially specialized services for which the need was greatly expanded by the earthquake, such as mental health, rehabilitation, and surgical care. The team is also in the process of hiring and training hundreds of community health workers to work in their villages, connecting their neighbors with health centers and helping to bring services to even the most remote areas. 

Learn more about the STAND WITH HAITI Fund and three-year plan.

A video from the Jubilee Project for World AIDS Day:

 
Reduced stigma and access to antiretrovirals and social support have changed the landscape around HIV/AIDS significantly in the past decade. A UNAIDS report released in mid-November notes that new HIV infections globally have decreased by almost 20 percent since 2000, and AIDS-related deaths have decreased by about 17 percent. Yet, more people than ever live with the disease, and an estimated 2 million people will die as a result of HIV/AIDS this year – roughly 4 people each minute, every day.

As part of the effort to fight these dire numbers, organizations, supporters, and persons affected by HIV around the globe have recognized World AIDS Day each December 1 since 1987. The day offers a chance to reflect, grieve, and most importantly renew the commitment to eradicating a horrific disease.
 
For over two decades Partners In Health (PIH) has offered medical care, education, and psychosocial support to communities afflicted by HIV/AIDS. This past year, more than 16,000 Haitians living with HIV/AIDS received regular care at a PIH clinic. In Rwanda, nearly 75,000 patients were tested for HIV, and roughly 5,500 people living with HIV received antiretroviral treatment. In Lesotho, PIH ensured that over 200 HIV-positive women were able to deliver and feed their newborns without transmitting the virus, breaking a cycle of disease in an impoverished country. In addition to increasing access to HIV/AIDS services, PIH is committed expanding access to comprehensive health care in resource-poor countries like Haiti and Rwanda, as well as for HIV patients in the U.S.
 
Yet, while much has been accomplished in the last 25 years, too many people living with HIV still lack access to life-saving medicines, health care, and other basic services. UNAIDS estimates that about 5.5 million people are in immediate need of life-saving HIV/AIDS drugs. In addition, approximately 33.4 million people are living with HIV/AIDS worldwide, and that an estimated 2.6 million more people will be infected before we recognize World AIDS Day again next year.
 
This needn’t be the case. We can demand funding increases for prevention and treatment of HIV/AIDS and other global health issues and ensure the rights of those already living with the disease are met.
 
Join people around the globe in commemorating the World AIDS Day by visiting the website of the World AIDS Campaign for a list of activities and ideas.
 
Learn more about PIH’s work in HIV/AIDS prevention and care.

On November 29, Foreign Policy published its second annual list of the Top 100 Global Thinkers. PIH cofounder Dr. Paul Farmer, listed at number 35, finds himself between Senators John Kerry and Dick Lugar (tied for 34) and UN Undersecretary-General Michelle Bachelet (36). From Warren Buffet (1) and President Obama (3) to Mo Ibrahim (52) and Tarja Halonen (99), FP’s list highlights the work of some of most influential figures in public policy in 2010. Foreign Policy commends Paul’s work in post-earthquake Haiti, noting that though simple, his belief that “the most successful aid efforts are driven by people on the ground, rather than dictates from Washington,” flies in the face of conventional aid relief.

Read FP’s entry on Paul.

In addition to listing Paul among the world’s top 100 global thinkers, FP also published a short piece by Dr. Farmer, in which he highlights what he believes are the largest challenges still facing Haiti. Below are some excerpts from 5 Lessons From Haiti’s Disaster:

Jobs are everything.

More Haitian’s must have access to employment if the country is to rebuild itself. As Paul notes, “Haiti has 9.8 million people, and at least half were unemployed even before the earthquake.”

Don’t starve the government.

Local people know best – we need to empower and trust Haiti’s government, and the public sector generally.

Give them something to go home to.

At least 1.3 million people were made homeless by the earthquake and are now living in spontaneous settlements in and around Port-au-Prince. Neither the capital nor the country can build back better if its people do not have access to housing, water, food, and sanitation.

Waste not, want not.

The international community must keep its promises to Haiti. To date, the country has only received 38 percent of the money promised by foreign governments and NGOs for 2010. 

Relief is the easy part.

Disaster relief is not reconstruction. ‘Building Haiti back better’ means sustaining those temporary gains and adding education, health care, services, and good governance.

Read Paul’s full article.

In a video produced by Midwives for Haiti, PIH physician Phuoc Le and medical staff at the St. Therese Hospital in Hinche, Haiti, show what it's like fighting the cholera epidemic on the ground.

NPR’s Jessica Harris recently interviewed PIH co-founder Paul Farmer on From Scratch. The focus: how did a college student with $1000 build an international organization that has helped reshape the public health landscape first in Haiti, and then a dozen other countries?

From Scratch focuses on the origins of successful entrepreneurial projects, this interview examines the ways Paul and fellow PIH co-founder Jim Yong Kim financed their first large-scale projects. Beginning with a grant from a Boston business man who was interested in helping the people Haiti, Paul and Jim expanded their work into Peru and Russia with the help of the then newly formed Gates Foundation, and eventually became a driving authority in conversations about health care and philanthropic work in resource-poor settings.

Listen to Paul's interview on the player below.

From Scratch is a weekly radio show about the entrepreneurial life that seeks to personalize the lives of entrepreneurs by providing listeners with a candid, first-hand view of the launching process. Guests speak openly about their sources of inspiration, set backs, helpful allies, and break though moments.

	Damaino Kandodo

Little Damaino Kandodo grinned broadly upon arriving at school. Like many first graders, he was excited for his first day of class. But Damaino is not a typical student. In addition to the obstacles to obtaining an education faced by many of the other children in his poor community in rural Malawi, he has an additional major hurdle—he is blind.

Because disabled children like Damaino face so many barriers to the classroom, PIH’s Malawian sister organization Abwenzi Pa Za Umoyo (APZU) has made removing these obstacles a priority in its work. The team knows that access to education is one proven way to break the cycle of poverty and poor health.

So last month, Damaino and four other young students with special needs piled into APZU vehicles.  Along with family members and APZU staff, they left their homes in the impoverished Neno district to begin their scholastic careers at a set of special boarding schools located about 70 miles away, just east of the city of Blantyre in southern Malawi.

Damaino, along with Maliko Kandodo and Lucy Kaudzu were all offered places at the Nguludi School for the Blind. The school is actually a special section within a regular primary school, so they will have the opportunity for an inclusive education, explained Emmie Kumbikano, a rehabilitation technician employed by Malawi Against Physical Disabilities (MAP), which works in partnership with the Ministry of Health and APZU in Neno.

	A classroom at the Nguludi School for the Deaf

Unlike the School for the Blind, the Nguludi School for the Deaf has a firm enrollment cap, with only 12 to 16 students per class. “This is because all students have to see the teacher and be within a ‘lip reading’ distance,” said Emmie.  A specialized classroom helps facilitate lip reading, as all the children sit at a u-shaped desk around the teacher. Out of the 72 children who had applied for this fall, Moreen Maguba and Henry Chikaoneka from Neno scored among the highest on the entrance exam and were among the few admitted.  The APZU team had originally hoped to enroll seven hearing-impaired children. Despite her best efforts to negotiate the admittance of the other five children, Emmie and her team are now looking for alternative options.

Damaino, Maliko, Lucy, Henry, and Moreen will live at Nguludi until the semester break in December. The PIH team is already making plans to bring them back to Neno for the holidays and bring them back when classes resume, reported Emmie.

In addition to transportation, APZU will help pay for the children’s boarding and medical fees (tuition for primary school in Malawi is free).  Each student also proudly toted a new plaid suitcase stuffed with a blanket, bed sheets, and a mosquito net (to ward off the malaria-carrying mosquitoes that are endemic throughout the country), courtesy of APZU’s Program on Social and Economic Rights.

This year’s top medical students in Rwanda all recently chose to train at hospitals supported by PIH’s Rwandan sister organization, Inshuti Mu Buzima (IMB).

The Medical School of the National University of Rwanda will soon graduate 90 new doctors. Each has committed to working two years in a rural district hospital to repay their education. The students get to choose the hospitals where they will work as interns by class rank, with the first choice going to the top ranked student, and down the line. Each of the country’s hospitals has slots for three interns.

“Where did the country's best young physicians choose to work? The first, second and third-ranked students chose Rwinkwavu Hospital,” reported PIH Rwanda Country Director Peter Drobac. “The fourth, fifth and sixth selected Kirehe. And students 7 through 9 chose Butaro Hospital.” All three of these hospitals are supported by IMB, in partnership with the Rwandan Ministry of Health. “In other words, Rwanda's top medical graduates all chose to work at PIH-supported hospitals. Nine-for-nine,” concluded Peter.

Why are young doctors so eager to work with PIH/IMB? "First of all, it's not the money," said Peter.  Indeed, higher salaries are available at other hospitals.

“Interns chose IMB partly because of its reputation,” said IMB physician Gilbert Biraro, who was himself an intern at Rwinkwavu Hospital. “IMB’s hospitals and clinics are places where young doctors flourish because of the robust working environment that allows them to round with both local and foreign specialists, from whom they acquire expert knowledge and skills.”

The rich learning environment is largely thanks to strong ties with Brigham and Women's Hospital, Children's Hospital Boston and Harvard Medical School, which provide stellar clinical faculty, research opportunities and transnational educational exchanges.

Gilbert also noted that many young Rwandan doctors pursue a career in medicine because they want to serve the poor and the sick—a mission that mirrors IMB/PIH’s. “Patients are treated holistically and comprehensively [at IMB/PIH supported facilities] including the most poorest and vulnerable who would have otherwise not have accessed health care due to lack of treatment fees,” said Gilbert.  IMB/PIH ensures that even the poorest patients have access to high-quality care, including ultrasound machines, operating facilities, and a well stocked pharmacy offering treatments from HIV to cancer chemotherapy, regardless, of their ability to pay.

“On top of all of this, [and despite living in a rural area] IMB staff has access to housing, transport, and food,” added Gilbert. “I believe all [of these factors] motivate young professionals want work here.”

IMB’s newest interns will begin their two-year terms at the end of the current academic school year.

By Kanupriya Tewari

	A Diabetes patient receives a visit from her community health worker at her home in Boston.

Partners In Health’s US-based PACT project (Prevention and Access to Care and Treatment) is expanding to serve thousands of Boston’s sickest and poorest residents.

In January, PACT began partnering with Network Health (a MassHealth insurance provider that supports low-income Massachusetts residents) and the nonprofit Commonwealth Care Alliance to provide specialized, individualized care to patients with particularly complex chronic needs. These patients are living with two or more chronic diseases, such as HIV/AIDS, diabetes, hypertension, heart disease, addiction, and mental illness. Using community health workers (CHWs), the goal is to improve health outcomes of the patients, while reducing the cost of care.

Since 1995, PACT has employed CHWs to provide home-based services to Boston’s most marginalized HIV/AIDS patients. Because CHWs come from the same communities and share many of the same experiences as their patients, they are uniquely qualified to provide effective treatment and support. They deliver individualized care within the real-world contexts, cultures, and belief systems of their patients. With training and support from PACT, CHWs aim to empower, not simply assist, their clients.

The new collaboration, known as Network Health Alliance (NHA) utilizes the approach PACT has used for HIV/AIDS patients to provide services to patients with other chronic conditions. NHA features a unique home-based and over-the-phone care management program that deploys teams of nurse practitioners, social workers, resource specialists, and CHWs to complement clinic-based provider care. The NHA teams educate and counsel individuals to avoid preventable emergencies, hospitalizations, and help them achieve better health and quality of life.

“We are hoping that our program evaluation will show that emergencies and hospitalization numbers have decreased and health outcomes improved because more patients are adhering to their treatment and going to their appointments,” says Dr. Heidi Behforouz, PACT’s founder and executive director.

The NHA teams are already working with about 400 children and 1,700 adults in the Cambridge Health Alliance system, a collaborative group of hospitals and health care centers in Cambridge, MA. Next up, the NHA plans to begin serving about 400 high-risk patients receiving care through the South Cove Health Centers, in Boston and Quincy.

This project is the first time PACT has served child patients. Of the 400 initially enrolled children, staff determined that approximately 60-65 percent could be aided by minimal but meaningful interventions. For example, often a child and his or her family just need someone to call and remind them to schedule a doctor’s appointment, or to renew a medication. The remaining 35-40 percent of children require more direct care. Many of these children live in challenging home environments, have significant mental and behavioral health needs, or struggle with asthma and obesity. An outreach team – a nurse, two community health workers, and one mental and behavioral health expert – will work together to address the specific needs of each of these children.

“The key to the model is the constant monitoring of patients to determine what kind of intervention they need most at what time,” emphasizes Dr. Behforouz.

While the outreach team monitors the patient’s and family’s health, CHWs also educate families on topics like parenting children with behavioral challenges; buying and preparing nutritious foods; and using HEPA-filter vacuum cleaners to minimize dust and mold in the home. To make this initiative a success, the NHA teams will work closely with each child’s support system to ensure that patients with complicated issues, like mental and behavioral health disorders, are provided adequate support at home and at school. 

PACT and its collaborators believe that better care coordination will improve health outcomes for adults and children, while and bringing new cost-saving efficiencies to Massachusetts’s public health care system. 

Our heartfelt thanks to the many of you who donated in response to the cholera outbreak and Hurricane Tomas. 

The situation in Haiti continues to worsen. The rains from Hurricane Tomas have flooded communities that were already heavily damaged by the January earthquake. The floods have exacerbated the cholera outbreak. Our clinicians have reported an increase in the number of cholera patients arriving at the the hospital in St Marc that we operated in partnership with Haiti's Ministry of Public Health and Population (MSPP)--from 125 cases a day to over 200.

However, your support is enabling PIH to mount an all-out response to the damage caused by these crises. Our community health workers continue to reach out to remote villages, spreading an awareness and prevention campaign and distributing water purification tablets and oral rehydration solution. 

Our logistical team is working overtime to provide medical supplies to the medical facilities we support in partnership with the MSPP, in addition to 16 other medical centers throughout the Artibonite Valley. To date, no PIH-supported facility has run short of the supplies required for cholera treatment. 

Please take a moment to watch a slideshow of this work, which your support has enabled. 

PIH co-founder Dr. Paul Farmer shares his views on Haitian leadership and how Haiti can recover with Byron Pitts of CBS's 60 Minutes. Watch the segments on the players below.

(If player does not start in your browser, watch this segment on the CBS website.)

(If player does not start in your browser, watch this segment on the CBS website.)

Paul's interview accompanied a recent episode of 60 Minutes that focused on the recent cholera outbreak in Haiti, and the devastation it has caused following so closely on the heels of the massive earthquake in January. 

In this episode, CBS correspondent Byron Pitts interviews PIH Deputy Chief of Mission in Haiti Dr. David Walton, who has been working on the ground to treat cholera patients and help stop the spread of the outbreak. "It's gonna be slow. It's gonna be tough. It's gonna be agonizing," said Walton. "But we will make it through."

Watch this segment on the player below:

(If player does not start in your browser, watch this segment on the CBS website.)

By Kate Thanel, PIH Haiti Curriculum and Training Specialist

	Johnny Bernard
	Johnny and his team.

"Working in health is like being in the army, there are situations to which we are automatically consigned," says Johnny Bernard, a pharmacist at the Hopital St. Nicolas (HSN) in St. Marc. "The first day of the cholera outbreak, my entire team spent the night at the hospital, making deliveries between the warehouse and the wards."

HSN, which is operated jointly by PIH's Haitian sister organization Zanmi Lasante (ZL) and Haiti's Ministry of Public Health and Population, is located in the region that has been hit hardest by the cholera epidemic. In the first days of the outbreak, hundreds of cholera patients flooded the facility. The emergency situation called on all of Johnny's experience and expertise to coordinate the work of ZL's pharmacy and warehouse staff to keep ZL's facilities stocked and supplied.

This isn't the first time Johnny has faced an emergency. In the aftermath of the January earthquake, he gained experience responding to the staggering needs of the immediate relief efforts. He trained his team to anticipate the needs of medical staff and they learned to respond to the crisis efficiently because they could not afford to lose time.

The strength and efficiency of Johnny's team was called on again on October 18. Days before test results confirming the cholera outbreak, doctors started calling the warehouse requesting large quantities of materials to respond to severe diarrhea and vomiting. "The emergency room was a crazy place, as everyone rushed around trying to meet the patients' needs," recalls Johnny. His team quickly figured out the materials they would need. However, predicting the quantities they would need was a challenge. They
soon realized that their usual system of delivering supplies on request by the nurses was not going to keep up with the increased demand. So they created a new system- each ward had its own stock to pull from and enough to last for an entire day. This way the warehouse team could take on the increased workload and the medical staff always had what they needed and wasted no time making orders.

On the second night after the outbreak was detected, Johnny's team again worked through the night. Johnny describes how one of his pharmacist colleagues spent two days sleeping in his car so as to stay at the pharmacy, because he knew his experience as a pharmacist would be in desperate need at the hospital. "Crisis brings out the human side of each of us," said Johnny.

The team fortunately was able to recruit volunteers to help take on some of the workload, but only after they had carefully trained the volunteers on how to make deliveries as well as perform needs assessments, as the clinicians were spending all their efforts treating patients, leaving them unable to track when supplies were running low. Johnny also wanted to make sure that the volunteers, who were not trained health workers, were knowledgeable about cholera transmission. "We needed to train them so that they would understand the dangers and respect security and contamination control measures," he said.

Although he describes his team as "consigned" to working around the clock in situations like these, it is a self-imposed dedication to their work and mission that drives them. "The institutional philosophy [at ZL] is you do whatever it takes to provide patients with the best possible care," says Johnny. "ZL chooses their employees and employees choose to work for ZL on this basis. Everyone was afraid but this was no excuse to turn our backs."

“The situation of women in Haiti has always been precarious, but this last trip, I found thousands of women in the camps on the brink of survival. Access to the most basic human needs of food, water, proper shelter, and school is severely limited for everyone,” explains Didi Bertrand Farmer in a World Pulse magazine article published on November 4. “Women face, however, a double dilemma: satisfying these needs often places them and young girls at high risk of sexual violence and exploitation.”

Bertrand Farmer, Director of the Community Health Program for Inshuti Mu Buzima, Partners In Health's sister organization in Rwanda, recently returned to her homeland of Haiti, but found herself unprepared for what she saw in the tent cities: an increase in sexual violence; mothers forced to leave their vulnerable daughters; young girls, pregnant as a result of rape.

“Leaving the camp, I felt compelled to increase awareness of the day-to-day atrocities that women and girls are facing there. Right now food, water, and shelter are critically needed and in short supply. But if we address these basic needs while neglecting the education and empowerment of women, we will continue to leave them and their daughters vulnerable to rape and the prospect of bearing children of rape for years to come.”

Read the full article.

http://worldpulse.com/magazine/columns/visionary-leaders/bearing-witness-girls-and-women-in-haiti-s-camps

In an accompanying photo essay, photographer Nadia Todres documents the lives of young girls coming of age in the settlement camps of Port-au-Prince.

http://www.worldpulse.com/magazine/articles/photo-essay-documenting-the-lives-of-girls-in-haiti

By Kate Thanel, PIH Haiti Curriculum and Training Specialist

Mikwob pa ka touye ayisyen. Sak pou ta touye ayisyen fok li ta  gwose yon kay.  Se yon kamyon ki pou ta pote l’.
Germs can’t kill a Hatian. To kill a Haitian, a germ would have to be as big as a house. You would need a semi-truck to transport such a germ.
          -Haitian Proverb

	Community health workers at a special training on treating and preventing cholera in their villages.
	Training participants practice using readily available materials to measure ingredients for Oral Rehydration Solution.

“Can germs kill a Haitian?” asks a facilitator at a recent training for community health workers in Haiti. A wavering “No” comes from the participants. “But haven’t we seen cholera killing Haitians?” the facilitator persists. “Yes,” comes the answer. “Cholera is color blind,” he continues. “Epidemics across the world have affected people regardless of their nationality or strong stomachs. That is why it is so important for us to learn about prevention.”
 
The session is one of many trainings that are being carried out by PIH’s Haitian sister organization, Zanmi Lasante (ZL) at sites across the Artibonite and Central Plateau regions of Haiti. The trainings are part of ZL’s efforts to slow the spread of the cholera epidemic through widespread community education on basic sanitation measures. The trainings are providing hundreds of community health workers (CHWs) with techniques for health promotion and community education, specifically focusing on sharing vital cholera prevention messages with their communities. Following the training, CHWS will have the tools they need to organize educational demonstrations in their neighborhoods on topics such as hand washing.
 
In addition to community outreach, the training participants learn to identify cases and to refer them to the Cholera Treatment Centers (CTCs), which are being set up near ZL facilities at many of our sites.  The training also lets CHWs practice preparing Oral Rehydration Solution (ORS). Because many cholera victims live in remote areas, receiving ORS from their local CHWs will help keep them hydrated as they seek medical care, which may mean traveling hours to reach a health center by foot, or by boat where the roads have been washed out. Without this support, many of these patients would not make it to a CTC.  In addition to ORS, the CHWs will also distribute water purification materials to those most in need. The training also stresses preventive measures such as hand washing and water purification, and provides techniques for sharing these at a community level.  Participants also learn basic guidelines for managing human waste and disposing of contaminated materials in areas that lack basic resources such as latrines.
 
ZL teams have been working diligently to respond to the sudden crisis, and to ensure that CHWs are well equipped to address outbreaks in their communities. Working through the night on Monday a week ago, the psychosocial team compiled relevant information on the epidemic into a comprehensive presentation, as the training team worked on a trainers guide to address specific health promotion needs.  ZL’s history of investing in a comprehensive training program facilitated these teams’ ability to hit the ground running in the rapid development and implementation of trainings that commenced the very next day.  ZL staff is working double time coordinating efforts and providing training support for our partners, doing whatever it takes to ensure that the needs of the most vulnerable communities are met.

To the great relief of all, Hurricane Tomas passed with less destructive force than had been feared. However, heavy rains greatly exacerbated miserable conditions and heightened cholera risks throughout Haiti.

Partners In Health / Zanmi Lasante (PIH/ZL) staff remained at their posts despite the storm and continued activities in THE Artibonite, THE Central Plateau and Port-au-Prince. This included staffing and support of cholera treatment centers, as well as crucial primary health care, nutrition programs and HIV/TB programs. On November 4 and 5, PIH/ZL community health agents in Port-au-Prince were mobilized to perform education activities regarding the incoming storm.

In Port-au-Prince, living conditions at the camps of Internally Displaced Persons (IDP) served by PIH/ZL have deteriorated as a result of the storm. Standing water, mud, lack of garbage collection - in combination with limited sanitation availability and limited uptake of hygiene messaging so far--make the camps a potential flashpoint for cholera outbreak. There is growing concern around 7 suspected cases in Parc Jean-Marie Vincent (PJMV) - where PIH/ZL provides health services—and additional suspected cases in the Cite Soleil section of the city.

In response, PIH/ZL continues to mount preventative outreach efforts while preparing for an outbreak in collaboration with Haiti's Ministry of Health and other partners. These preparations include establishing a cholera stabilization center at PJMV.

Over the weekend, reported cases of cholera continued to expand geographically. More cholera cases continue to appear in Haiti's Central Plateau, with PIH/ZL-supported facilities there reporting 111 cholera cases hospitalized. To address and restrain the spread, training of community agents on cholera continues and a further 153 community health agents were training in Hinche on November 6. We also pleased to report that, with PIH/ZL assistance, a fully functional cholera treatment center opened in Mirebalais today, November 8.

In the Artibonite Valley, the epicenter of the cholera outbreak, PIH/ZL continues to support facilities in St. Marc, Petite Riviere, and Verrettes. Before the storm's arrival, Haiti’s Ministry of Health reported 442 deaths and 6,742 cholera patients hospitalized throughout Haiti’s Lower Artibonite and Central Plateau regions. Hurricane Tomas complicated treatment efforts at these facilities by forcing the evacuation of patients from tents into solid structures. Cholera patients are now being returned to restricted treatment areas and off-site locations for cholera.

The PIH/ZL logistical team is also providing a large volume of support in the form of medical supplies to 16 additional medical centers throughout the Artibonite Valley. As a result of their tremendous efforts, no PIH/ZL supported facility has experienced stock out of the supplies required for cholera treatment.

Amidst this progress the PIH/ZL team remains alert. Reports indicate that rain waters have forced a key hydroelectric dam on the Artibonite River to release pressure, thus sending down a large volume of water. This release will affect communities all along the river in the Central Plateau and Artibonite - namely the areas in the Artibonite that were hit hard by the 2008 storms.

PIH staff in Port-au-Prince and the Artibonite region of Haiti document the flooding and damage left in Hurricane Tomas' wake.

PIH’s sister organization in Rwanda, Inshuti Mu Buzima (IMB), is constructing a state-of-the-art, 150-bed hospital in Burera, the only remaining district in the country without a district hospital. Built in partnership with the Rwandan Ministry of Health, the Clinton Foundation, and the local community, the new facility will be an example of how to create a modern hospital in rural Africa capable of delivering world-class medical care and training Africa's next generation of medical professionals. 

PIH co-founder Paul Farmer shares his thoughts on the hospital in the video below.

The hospital features innovative design to improve infection control, an expanded range of services that includes neonatal intensive care and three operating rooms, and brand new, high-quality medical equipment. It is also a stunning facility and public space, whose mountaintop setting affirms PIH's belief in "dignification."

Before PIH began working in Burera, people living in the district had to travel for many hours on foot – a nearly impossible task when carrying a family member or friend on a stretcher. The Butaro Hospital will change all of this, and save lives in doing so. “This sends a very clear message that high quality medical care can and must be delivered in good institutions that fit into a broader network of institutions,” says PIH cofounder Paul Farmer.

The vision for the hospital is to create a center of excellence and innovation by establishing a scientific community of clinical and non-clinical staff with the hope that people will come not only to seek care, but also to deliver care, teach and learn.

Butaro Hospital will open in late 2010.

Read more about the new hospital. 

Help PIH’s US-based PACT Project win $250,000 from the Pepsi Refresh Project! With just a few seconds of your time, your vote can help some of the poorest, most marginalized HIV/AIDS patients in the greater Boston area.

The PACT (Prevention and Access to Care and Treatment) project uses Community Health Workers to deliver home-based care and support in the most impoverished and disease-stricken neighborhoods in the Boston area. They help patients take their medications on time, navigate complex health care systems and communicate more effectively with their doctors and care providers. PACT is now expanding this model of care to complex patients of other chronic diseases such as Diabetes, Hypertension and mental illness.  Ultimately, PACT seeks to aid in the transformation of primary care and the quality and efficiency of the medical system in this country.

Please visit http://pih.org/refresh and vote for Partners In Health’s PACT Project. You can also vote on your cell phone by texting 104061 to 73774.  In doing so, you’re sending Community Health Workers into the homes of the sickest HIV/AIDS patients in Boston.

You can vote once every day. If you use Facebook and Twitter, join the PIH groups to receive daily reminders about voting. And please spread the word to all of your friends!  

Thanks for helping support some of the most marginalized patients in our community.

	Mother and child in a settlement camp as the rains fall.

The worst of the heavy rains and strong, gusting winds of Hurricane Tomas blew past Haiti by early this morning (Saturday, November 6). The eye of the storm fortunately skirted the beleaguered country. But PIH staff in the Lower Artibonite, Central Plateau, and Port-au-Prince regions reported that the rains are making already miserable living conditions even worse and that flooding heightens the threat that the deadly cholera epidemic that broke out late last month may spread more rapidly and widely.

In the capital city of Port-au-Prince, heavy rains pounded settlement camps where millions of displaced Haitians have been living since the January earthquake. PIH operates health clinics that serve four of these settlements, including the large camp Parc Jean-Marie Vincent.

	PIH mobile clinic pharmacy dispenses medicines.

"The living conditions are inhumane at the camp in Parc Jean-Marie Vincent," reported PIH Chief of Mission in Haiti Louise Ivers. "Displaced persons, having no other option but to stay out the storm in their flimsy shelters are today struggling with the persistent steady rain and the mud and flooding in the bottom of their dwellings." The clinical team continued to provide services at Parc Jean-Marie Vincent throughout Friday at a mobile clinic and pharmacy.

In the Artibonite Region, which has been battling a deadly cholera outbreak since October, the PIH team reports high winds and heavy rains, including flooding in Gonaives and the coastal town of Grande Saline, where PIH provided cholera relief by helicopter last week in collaboration with UN Humanitarian Air Support. Teams of community health workers continue to carry out outreach activities to educate local communities about cholera and distribute oral rehydration salts and water purification tablets, where possible. 

In the Central Plateau, PIH staff report heavy rain, but little flooding or serious damage. A team has been dispatched to check on the areas that were flooded during the hurricanes of 2008 and are now suffering from the cholera outbreak. A steady stream of cholera patients continues to arrive at hospitals that PIH operates in partnership with the Ministry of Public Health and Population (MSPP) in Hinche and Lacolline in the Central Plateau, as well as in St. Marc and Petite Rivière in the Artibonite. 

PIH Chief of Mission Dr. Louise Ivers is on the ground in Haiti. She sent the following update on Friday afternoon:

We continue to cautiously monitor the situation at all sites where we have activities including in the Artibonite, Central Plateau and in Port-au-Prince. What we see so far throughout the regions where we work is not a physical destruction caused by wind, but a serious compounding of the destitute misery that we have seen since the earthquake.

The living conditions are inhumane at the camp in Parc Jean Marie Vincent, and they are not much better at Dadadou. Displaced persons, having no other option but to stay out the storm in their flimsy shelters are today struggling with the persistent steady rain and the mud and flooding in the bottom of their dwellings. The Zanmi Lasante team has been out since this morning doing mobile clinics in the camps in Port-au-Prince. In the Artibonite, teams continue to care for patients with cholera and pursue their outreach activities as safely as they can .

At the hospital in St. Marc, Dr. Almazor and the rest of the ZL team are coordinating the flow of patients who come for emergency care. The storm's epicenter continues to move in a northerly direction and as it thankfully moved to the west we should be spared high winds. However, as steady, heavy rain continues for the next number of hours, we remain alert to the possibility of flash flooding.

Thanks for standing with us. More info to come.

Kenbe Fem,

Louise Ivers
PIH Chief of Mission, Haiti

Dear Friends,

In the last 10 months Haiti has suffered an earthquake leaving over 1 million homeless and 300,000 dead, and a cholera outbreak with more than 6,742 hospitalized sick and 442 dead.

And now, as Hurricane Tomas approaches Haiti's shores, I fear that numbers like these will only continue to rise.

As Deputy Chief of Mission in Haiti for Partners In Health, I have spent the last 13 years working alongside our colleagues at Zanmi Lasante, Partners In Health's sister organization. Our mission to break the cycle of poverty and disease in the Western Hemisphere's poorest nation has always been challenging—but 2010 has been by far the most difficult year we have faced.

Zanmi Lasante's hurricane preparedness plans are already underway. In anticipation of washed out bridges and roads, the team has rushed additional medical supplies to endangered facilities to ensure that patient care—including cholera treatment as well as primary care—continues. ZL staff members are being pre-positioned in key locations to ride out the storm, rapidly assess the damage, and effectively mobilize resources in its wake.

In the coming days, we'll be working to keep you updated about events on the ground. But today we're asking you to help us prepare by staying tuned and by spreading the word to friends and family.

We also want you to know that "60 Minutes" on CBS has recorded a major piece on earthquake recovery and cholera response efforts, focusing in large part on Zanmi Lasante's work. The air date is uncertain, but when confirmed it will be an opportunity for you to help us educate hundreds of thousands of people about the work that you have helped accomplish and all that remains to be done.

It would be easy to reflect on how "unlucky" Haiti has been to be struck by so many disasters in such a short sequence, but that line of thought masks responsibility and leaves us treating only symptoms, not the disease. There are clear root causes behind Haiti's vulnerability to these disasters—and there are equally clear solutions.

Seventy percent of Haitians lack continuous direct access to clean water, leaving them vulnerable to cholera and other water-borne diseases. Haiti's deforested hills are prone to mudslides making storms far more deadly.

We are fortunate to have a growing base of supporters, like you, to accompany us as we face this challenge. But our task remains daunting, and creating more awareness and a truly global movement of supporters will be needed if we hope to succeed.

Please stay tuned and help raise awareness by spreading the word to friends and family.

Thank you,

Dr. David Walton
Deputy Chief of Mission, Haiti

By Jon Lascher, PIH Haiti Procurement Manager

	Grand Saline is currently only accessible by boat or by air.

At PIH we do whatever it takes to provide access to treatment for the poorest of the poor. We use all of the resources at our disposal to reach as many people as we can, and when we do not have the resources, we ask our strong network of partners to help us carry out our mission.  

Last week, we were alerted to the plight of Grande Saline, a large town occupying a small strip of land surrounded by salt farms to the north, the sea to the west, and the mouth of the Artibonite River to the south and east.  The only water source in the community is the river, which likely carries cholera. 

Currently, the one road leading to the community is flooded, preventing us from delivering supplies over land. So our team tried to secure a helicopter--we asked for the largest humanitarian helicopter available in order to load as much cargo as possible. With the support of the UN Humanitarian Air Service, and the World Food Program, we were able to secure one within hours.

Our partners at Operation Blessing donated a water filter capable of filtering 10,000 gallons of river water each day.  We loaded medical supplies, oral rehydration salt, chlorox to help disinfect houses, hygiene kits, and hand sanitizer.  We didn't just bring supplies; we brought the director of all Zanmi Lasante (PIH's Haitian sister organization) health initiatives for the Artibonite Region, Dr. Patrick Almazor as well as Erline Andre, a local community health educator. With the helicopter filled, we took off.

	PIH staff load supplies onto a UN helicopter for delivery Grande Saline.
	Dr. Patrick Alamazor and Erline Andre, a community health educator, addressing the community at Grande Saline.

Community members from Grande Saline began gathering to meet with us as soon as they saw the helicopter circling, looking for a safe place to land. We spoke to the community about the cholera situation and found out that many had died and others were trying to reach the closest health centers in Drouin and St. Marc by boat. The community had received water from two humanitarian ships, but the stocks were all used by the time we arrived. They had no choice but to fill empty water bottles with yellow river water.

Using a megaphone, Dr. Almazor and Erline then addressed the community, providing information about how to avoid falling ill with cholera as well as how to avoid the spreading the disease.  They asked the community where the water filter should be set up. The next morning, Operation Blessing returned to Grande Saline to install and train the community to use the filter. 

The United Nations Stabilization Mission in Haiti (MINUSTAH) plans to begin repairs to the road today, with supplies from PIH and the local mayor. With the road repaired, the community will have greater access to both supplies and medical care.

Yesterday, we learned of another isolated community named Celio on the side of a mountain that had reported 18 deaths from cholera. The village has a small health center with medical staff but no supplies. Yesterday, we sent a car to deliver supplies to the nearest town. Where the car can no longer pass, community health workers will carry the supplies. We have a helicopter on stand-by, in case the community health workers can't reach the site. For PIH and Zanmi Lasante, Gen Pwoblem Gen Solisyon--where there is a problem, there is always a solution.

	PIH staff load supplies onto a UN helicopter for delivery to an isolated community.

With Hurricane Tomas looming in the Caribbean, Partners In Health is focusing its efforts on storm preparations in conjunction with its work to treat and control the outbreak of cholera.

Experts are predicting that Tomas will hit the southern coast of Haiti as a Category 2 hurricane on late Friday or early Saturday morning, bringing strong winds, flooding, and mudslides. PIH expects that the storm may exacerbate transportation issues into and within the Artibonite region—the area hit hardest by the cholera epidemic. Our procurement team is preparing to move extra supplies from PIH’s warehouses in the Central Plateau and Port-au-Prince to ensure that the 16 health centers supported by PIH remain stocked in the event that the roads become impassable.

Even now, road access is already one of the main challenges to addressing the cholera outbreak, both for patients trying to access health facilities, and for PIH teams trying to bring supplies and community outreach campaigns to remote communities. Over the weekend, PIH and the UN spent hours attempting to reach a health center in the mountainous Poste Pierrot district, where 18 deaths from cholera have been reported. After the off-road vehicles failed, medical supplies had to be delivered on foot and by donkey, reported PIH Chief of Mission Dr. Louise Ivers. A UN helicopter is scheduled to bring additional supplies and staff to evaluate the community tomorrow. 

As of Sunday night, the cholera outbreak has hospitalized 4,764 people in the Artibonite and Central Plateau regions, with 337 reported deaths, according to Haiti's Ministry of Public Health and Population (MSPP). PIH clinicians report fewer cholera patients arriving at the three PIH hospitals operated in partnership with MSPP. Hôpital St Nicolas in St Marc is now triaging 200-300 patients daily, compared with the 600 patients each day in the early days of the outbreak.

	Cholera patient being treated at the hospital in Lacolline.

However, despite shrinking numbers of cholera cases at hospitals in the Artibonite, the disease is still expanding geographically, reports Dr. Ivers. On Sunday, 30 cases of acute diarrhea (possibly cholera) were reported at PIH/MSPP’s Hôpital St Thérèse in Hinche. This is the first possible report of cholera this far north in the Central Plateau of Haiti. And new cases are still arriving at the PIH/MSPP medical facility in Lacolline in the southern Central Plateau—some from communities that previously did not have any reported cholera cases.

As of Monday morning, there have been no reported cases of cholera at the four Port-au-Prince settlement camps served by PIH health clinics, where 100,000 displaced earthquake survivors are currently living. The clinic teams are working in collaboration with the MSPP and other non-governmental organizations to prepare emergency responses for both a potential cholera outbreak and potential hurricane-related damage and flooding.

	Community health workers distributing clean water to communities in the regions most affected by the cholera outbreak.
	Community health educators demonstrating how to use water purification tablets to a community near St. Marc.

Of PIH’s 3,000 HIV patients in St Marc, a community at the center of Haiti’s current outbreak, none have fallen ill from cholera as of today, reported Dr. Suffrin Dimitri, the head of the HIV program at Hopital St Nicholas in St Marc. In addition, so far only one child has been hospitalized out of the 2,000 children enrolled in a pediatric malnutrition program operated by PIH and the non-profit organization ACTED. 

PIH’s network of community health workers (CHWs) played a major role in this bit of good news among reports that the epidemic has infected over 4,000 and killed about 300 since it first broke out last week.

For over two decades, CHWs—including social workers and community health educators—have made up the backbone of PIH’s approach to providing high-quality health care to poor communities in Haiti. Trained and employed by PIH, they serve as a vital link between health centers and villages by regularly monitoring patients, delivering medicine, providing social and emotional support, finding sick neighbors and accompanying them to the hospital, and educating their communities.

So well before the outbreak, PIH’s HIV and malnutrition patients (and their families) were linked to health services through their CHWs. They had already received hygiene education and water filters from their CHWs, which helped to protect them from the disease, reported PIH’s Cate Oswald.

PIH Chief Medical Officer Joia Mukherjee also credits CHWs for helping to keep the epidemic mostly contained in the Lower Artibonite region. Thousands were already on the ground across the Artibonite and Central Plateau regions. They quickly mobilized and initiated an outreach campaign as soon as the outbreak was detected. Key activities included finding sick patients, educating remote villages on the importance of washing hands and drinking purified water, and distributing the soap and water purification tablets needed to do this.

 “The community health worker network acts as a safety net against outbreaks like this,” said Dr. Mukherjee.

CHWs will continue to play a major role in PIH’s on-going efforts to treat and contain the epidemic. The organization recently drafted a $3 million cholera response budget, which includes substantial support for hiring and training additional CHWs and continued outreach and prevention activities.

"To describe [the cholera outbreak in Haiti] is pretty difficult," said PIH Physician Evan Lyon on a recent interview on Democracy Now! "It’s a terrifying—it’s a terrifying situation. The economic and social conditions in Haiti have left Haitians vulnerable to any manner of infectious diseases that are endemic there—typhoid, TB, malaria, HIV. But this is new."

"There hasn’t been cholera in Haiti for more than fifty years, so the population has little experience with it," Evan told host Amy Goodman. "Their immune systems have no exposure, which will help the disease spread more rapidly. And then, of course, nurses and doctors also have not seen this disease in several generations. So it’s a terrifying situation, rooted... in the lack of infrastructure, lack of sanitation and clean water, which has been very clearly—very clearly slowed down and diminished by manipulation from the outside."

Watch Evan's full interview on the player below.

Dear Friends,

The Partners In Health team in Haiti, Zanmi Lasante, continues to respond to the cholera outbreak, as hundreds of critically ill patients arrive every day at the Ministry of Health facilities we support.

To treat the large volume of patients ill with cholera who continue streaming into the clinics, and to ensure high-quality care 24 hours a day, we are rapidly hiring additional Haitian doctors and nurses. Prevention through community outreach remains key to containing the epidemic. PIH/ZL is bolstering its force of more than 2,000 community health workers - including those in the camps we serve in Port-au-Prince - with training in hygiene and infection control. Community health workers are also being supplied with the tools to prevent infection, such as soap and water purification tablets, as well as oral rehydration salts for treatment of early symptoms.

And despite focused efforts, Zanmi Lasante and other organizations remain concerned about access to clean water, both in Port-au-Prince where conditions of overcrowding and squalor continue, and in rural communities where rivers and rain runoff are the only available water sources.

This cholera outbreak is a tragic example of how disease takes root in poor communities, an example that reinforces PIH's deep commitment to treating the sick while simultaneously working to address basic rights such as water, housing and sanitation. It is work carried out and constantly improved by engaging people who themselves are suffering these indignities, and by forging a bond of solidarity and support between them and others who understand this grass roots approach to addressing health and its social determinants.

Our mission is not simply to respond to these crises but to work toward averting them through an approach rooted in solidarity and assuring human dignity. That's why PIH exists, and why I work here. It's why you support this organization.

Please donate now to help PIH respond to this cholera outbreak in Haiti and to support our efforts around the world.

In the short term, our goal is to treat the victims of the outbreak in Haiti and halt its rapid spread.

Over the long term, however, our vision is that a cholera outbreak will be just as unheard of anywhere around the world as it is in the United States today, that high-quality health care and water security will not be considered luxuries but rather basic rights.

Help us achieve this vision, make a donation now.

In solidarity,

Joia Mukherjee
Chief Medical Officer
Partners In Health

	Purified water provided by our partners at Operation Blessing. Photo courtesy of David Darg, Operation Blessing International.

As of Monday night, a total of 4,519 cholera patients have been hospitalized throughout Haiti’s Lower Artibonite and Central Plateau regions, and 292 reported deaths.

Most of the hospitalizations and deaths have been concentrated in the Lower Artibonite where PIH operates three hospitals in partnership with Haiti's Ministry of Public Health and Population (MSPP).

PIH’s procurement team has been working around the clock to supply these facilities with what they need to treat the hundreds of patients streaming in each day. PIH Procurement Manager Jon Lascher reported that PIH is also providing supplies to eight additional community centers surrounding St Marc. The supply situation at PIH’s hospital in St Marc is currently stable, he added.

PIH’s efficiency at procuring supplies is aided by over two decades experience on the ground in Haiti, as well as protocol and infrastructure established following the January 12 earthquake.  “Compared to the earthquake the diversity of products [needed] is much smaller, but the quantity of products needed is staggering,” Lascher said.

Access to both medical facilities and clean water continues to be a major challenge to treating and controlling the cholera outbreak. In remote areas, oral rehydration posts are being set up to supply patients with clean water and oral rehydration. For patients with more serious cases, who may be unable to be treated orally, stabilization posts are also being established. These posts will be staffed with a nurse who will be able to administer IV fluids.

Over the past few days, 42 water trucks, each holding 1,200 gallons of potable water, have reached 15 communities in the region most affected by the outbreak, thanks to our partners at the nonprofit Yele Haiti. Permanent water filters have been installed at three communities, in partnership with Operation Blessing.

Although the outbreak has so far remained concentrated in the Lower Artibonite, PIH medical facilities in the Central Plateau have also reported cholera cases. The public medical facility operated by PIH in Lacolline has seen 90 cholera cases since the epidemic began, and currently has only 15 cholera in-patients. Many of those infected were inmates at the prison in Mirebalais. However, situation has improved dramatically, reported PIH Deputy Chief of Mission for Haiti David Walton. There have been no patients admitted from the prison in the last 48 hours. Prisoners have potable water, their cells have been cleaned, and infection control has been instituted, he added. 

Community outreach continues to be a priority for the PIH team, as access to both medical facilities and clean water continues to be a major challenge to treating and controlling the cholera outbreak. Community health workers, social workers, and community volunteers have been mobilized in affected areas. By driving trucks with loudspeakers playing community education campaigns about cholera, and tireless outreach to individual homes, schools, churches, and community gathering places, the team continues to spread the word of how to prevent cholera, and bring access to clean water to isolated communities.

View images of PIH's community outreach efforts below:

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By Michelle Morse

Dr. Michelle Morse is a Global Health Equity resident at Brigham and Women's Hospital who is currently working with PIH in Haiti. Last week, she traveled to St. Marc to help with PIH's efforts to treat and control the cholera outbreak. She wrote the following piece about her experience.

	Patients receiving treatment at the hospital in St. Marc. Photo courtesy of David Darg, Operation Blessing International.

The trip from Cange to St. Marc on Thursday, October 21st was filled with uncertainty about the magnitude of the diarrhea outbreak, the potential number of people affected, and speculation about the causative agent. I traveled with Cate Oswald (PIH's Program Manager for Psychosocial Support and Mental Health in Haiti) who would be managing the community response to the epidemic, and Dr. Merly Robert, an internal medicine resident from the General Hospital in Port-au-Prince (HUEH) who was doing a rotation at Cange when the outbreak began. We all had our theories, but cholera certainly was not at the top of the list.

We pulled into Hopital St. Nicholas in St. Marc just as rain began to fall. The courtyard was filled with people and there were rows of tents with patients crammed into every inch of space, mostly on the ground lying on blankets and plastic. There were few obvious medical personnel, and many empty bags of IV fluids attached to clearly dehydrated patients.

We walked upstairs to the Zanmi Lasante office to get updates from PIH's Dr. Koji Nakashima who had been at the hospital since the outbreak started. The CDC had several samples for testing, but we still didn’t have a diagnosis.  The clinical teams already at work were stretched thin, and they really needed extra hands. We made our way to the wards, and it was clear that the influx of over 500 patients within 24 hours had overwhelmed the hospital’s capacity. Nurses were hard at work changing IV fluids and putting in IVs, but everyone had a certain shell-shocked frown upon their faces, perhaps most apparent on the faces of family members of patients.

The first patient I cared for was a young man in his 20s. I could not measure a blood pressure.  We started two IVs and asked the patient’s mom to squeeze the bag of fluids since we had no pressure bags or IV pumps. We got a stool sample from the patient, and it was clearly “rice water” diarrhea, a characteristic unique to cholera.

A few hours later, the CDC confirmed that cholera was the cause of the outbreak. The large majority of patients I saw for the rest of the night were also in shock with no blood pressure, no pulse, and severe vomiting and diarrhea, the likes of which I have never seen. Luckily, with IV fluids almost every patient survived the night and I only saw one death.

What I could not forget that night was a 2-year-old boy who I found alone with an empty bag of IV fluids, lying in a puddle. I was told that his parents had died of cholera the night before, and there was nobody there with him. He was doing well and had responded quickly to rehydration. After changing his diaper and having him drink two big cups of Pedialyte, he was off to sleep. The next morning, a family member showed up to take care of him, and I couldn’t have been more relieved.

The second night, I was overjoyed to see that most patients had stabilized. There were still several cases of patients in shock, but many fewer than the night before. There were still not enough hands to do the work, but there were more hands than that first, very difficult night. Nurses from the Port-au-Prince nursing school and from HUEH came to offer their help, and it was beyond inspiring to see their compassion, diligence, and commitment to taking care of the patients despite the obvious risks to their own health. Somehow, we still found time to smile and tell a few jokes. I was honored to be a part of the team.

Bearing witness to this outbreak has been transformative. Every patient that recovers within hours from shock gives me strength. Every nurse that succeeds in placing an impossible IV gives me hope. Every new set of hands that shows up, every kind-hearted, humble volunteer, every health worker that knows the risks and comes anyway, seems like a miracle.

It is the injustice of the circumstances of this outbreak that hurts. The injustice of the ongoing poverty, lack of potable water, lack of access to health care, and weakened public health infrastructure that produces the perfect storm of opportunity for cholera to be this week’s cause of preventable death in Haiti. For this reason, our commitment to improving health in Haiti must be revived and reinvigorated. We are now more than 9 months post-earthquake, and there is no better time than the present to renew our vows.