Six days can seem like an eternity. It's hard to believe that so little time has passed since the earthquake shook Port-au-Prince. In the days since, we've worked around the clock to bring urgently needed surgical teams, medical supplies, water, and food into a devastated city.

Thanks to a true team effort, at the general hospital in Port-au-Prince alone, we helped get seven operating rooms up and running, performing surgeries around the clock. By tomorrow night, we should have 10 or 12. At our sites in the Central Plateau and Artibonite regions, we have eight more functional operating rooms that are already supplying surgical and medical care to hundreds of earthquake victims fleeing the destruction of Port-au-Prince. And thanks to a partnership with many people and organizations here in the U.S., we've filled 10 planes with surgical teams and supplies, and have many more scheduled flights throughout this coming week.

However, the logistical challenges of our immediate response are only the beginning of our effort to bring relief to the people of Haiti. While our progress has been impressive and rapid, it is dwarfed by the immense need. At this stage, we are working on streamlining bulk deliveries of supplies, medicines, and human resources to help handle the thousands more patients that still await care. And we know that to truly help Haiti "build back better," as President Bill Clinton has said, we need to ensure that the aid doesn't stop when the final emergency surgical team returns home.

After having their lives saved, many of our patients' worlds are changed forever. Many will require months or even years of physical and emotional therapy. Many have lost their homes and jobs. Some are orphans. On a larger scale, the earthquake will shake Haiti for generations--government buildings lie in shambles, as do schools, hospitals, and roads. Before the earthquake, Haiti was already the poorest country in the western hemisphere. Just getting the country back to square one requires more work than what can be delivered in a single news cycle. But with your support, we remain steadfast in our commitment to build back better. After all, we've been working in partnership with poor communities and the government in Haiti for 25 years, and we don't plan to leave any time soon.

Watch PIH Executive Director Ophelia Dahl discuss the importance of long term rebuilding efforts with CBS's Katie Couric.

Read an op-ed by PIH co-founder Paul Farmer focusing on the importance of building back better.

In solidarity,

Ted Constan
Chief Program Officer

As people flee the devastation of Port-au-Prince, many are arriving at PIH's hospital in Cange, where PIH/Zanmi Lasante staff and volunteers are working around the clock to bring medical care and comfort both patients and family members.

The Sociomedical Complex in Cange was PIH/ZL's first site in Haiti. Over the past 25 years, the facility has grown to include a full-service hospital with two operating rooms, adult and pediatric inpatient wards, an infectious disease center (the Thomas J. White Center), an outpatient clinic, a women’s health clinic (Proje Sante Fanm), ophthalmology and general medicine clinics, a laboratory, a pharmaceutical warehouse, a Red Cross blood bank, radiographic services, and a dozen local schools.

Watch a video of Katie Couric's interview with PIH Executive Director Ophelia Dahl on CBS.

Watch CBS News Videos Online

We've been incredibly touched and inspired by the outpouring of support we've received over the past 6 days. From to celebrities to sports teams to activists--we are so thankful to all our partners in health. Below is a message from one of the thousands of supporters standing in solidarity with PIH, and with the people of Haiti.

Leah Bogen and her fiance Will.

Today I donated the food budget for my wedding to relief efforts in Haiti. Getting married and planning the perfect wedding is something most women, including me, dream about for a very long time. The perfect dress, decorations, catering, flowers, cakes, the list goes on and on. It is my chance to be "queen for a day" and it feels great. My fiancé and I have been planning our wedding for a few months now, meeting with vendors, setting our budget and having many long conversations about creating the perfect wedding.

Running in tandem with our wedding planning conversations over the past few days has been the horror and human tragedy in Haiti. I woke up Sunday morning and sat down with a cup of coffee and the newspaper and read about people with no food or water, having limbs amputated in makeshift hospitals in a last chance effort to save their lives. I suggested to my fiancé right then that we should donate part of our wedding budget to disaster relief in Haiti. Anyone who has planned a wedding knows how tight the budget can get, but without a moment's pause he said "YES! I love you SO much!"

We have decided to donate our food budget - 25% of our wedding funds - to aid victims of the Haiti earthquake. Our friends and family can go without a fancy wedding dinner, especially if it means helping provide food, medical care and shelter for those desperately in need.

The tragedy in Haiti is so huge I hope that other brides- to-be will take this message to heart and find a way to donate to a relief organization. Find something in your wedding budget that you don't need and just cut it out. Assess what is most important to you on your wedding day, harness your bride-power, and take action to do something that will make your wedding unbelievably meaningful! Your wedding will be spectacular, and the money you donate will make a huge difference to someone in dire need.

Sincerely,
Leah Bogen
Duluth, MN

P.S. My fiance suggested your organization as the group we should donate too, you have done amazing work already and we know you will still be in Haiti long after the hype dies down and other groups leave. We hope others will do the same, and find money in their budget that they can do without.

The Resurrection of the Dead by Frantz Zephirin

The cover of this week’s The New Yorker pays a special tribute those who died in the earthquake, as well as those who survived. Entitled “The Resurrection of the Dead,” and painted by Haitian artist Frantz Zephirin, the artwork depicts a family of spirits guarding the frontier between life and death, as well as the spirits of the recently dead, according to one interpretation. Read more about the artist and "The Resurrection of the Dead" on The New Yorker website.

The New Yorker is also selling prints of this cover, with all profits donated to Partners In Health. Visit their online store to purchase your copy.

Partners In Health sends thanks to Meryl Streep tonight on behalf of the people of Haiti. In her Golden Globe acceptance speech, by paying homage to her mother’s intolerance of “gloom and doom,” and by channeling her mother’s voice, Meryl gave hope to many—to our staff in Haiti, to our patients, to all those pained by the footage of a country in ruins.

For five days, we have been mourning for Haiti. Our hearts are broken, and yet, we know that we must not languish in our grief. We must persevere in our efforts to provide relief in Haiti; to increase our support with supplies, medicines, and trained medical staff; to continue to spread, expand, and disseminate our services throughout Port-au-Prince; and to ensure that our 12 facilities in Haiti’s Central Plateau and Artibonite Valley can absorb the increased medical and health needs of thousands of people for months—years—to come.

And like Meryl, we at PIH are grateful, extremely grateful, that we are in a position to help.

Since our founding, we have often had to explain that our mission is not simply one of charity—we do not limit ourselves to giving away medicines, but rather we live and work within communities to help build and strengthen health systems; to deliver and sustain medical, social, and economic services; and to promote solidarity.

Our goal has always been to serve as an antidote to despair by persevering in the face of even the greatest challenges. We have learned this from our Haitian friends, colleagues, and partners. As Dr. Paul Farmer articulated clearly on 60 Minutes  tonight, “Haiti’s got a lot to teach the rest of us about how to climb out of hell and they need it now more than ever… I’m not trying to romanticize anything about this resistance, or not giving up, that I see here in Haiti, but I think it’s palpable. Even at a dreadful time like this, it’s palpable to me.”

Meryl, you are much more than “a vessel for other people’s stories,” but we thank you tonight for launching Partners In Health’s story, and, therefore, Haiti’s story. Partners In Health is proud to be an organization that inspires hope and gratitude in you and many others. But we cannot take credit—all of our lessons in hope have come from Haiti.

60 Minutes on CBS aired a segment on the earthquake in Haiti, which included a short interview with PIH co-founder Paul Farmer, and focused on the difficulties of delivering medical care in the first days following the earthquake.

Watch CBS News Videos Online

PIH co-founder Paul Farmer penned this op-ed in Sunday's Miami Herald. 

A few months ago, I joined President Clinton as a volunteer to, in his words, help Haiti ``build back better'' after a series of storms in 2008 destroyed an estimated 15 percent of already beleaguered Haiti's GDP. We had just been meeting about these efforts and a series of upcoming forums to be held in Port-au-Prince, and I was then going to join colleagues from Partners In Health in central Haiti, where I have had the good fortune to work with remarkable Haitian medical colleagues for many years. The day before our New York meeting, Port-au-Prince was flattened by an earthquake. There is not a lot left to be said, but having just returned from Port-au-Prince, there are some points worth underlining.

If Haiti is to ``build back better,'' as President Clinton has been saying, there are lessons to be learned from our efforts, not always honorable or effective, to help Haiti over the past two centuries. This can change and must do so, if we are to be real partners in responding to this latest misfortune.

The scale of the disaster is coming into view. All of the clichés born of extremity came to mind as I saw the city of Port-au-Prince in the dark after this huge earthquake. Symbols of authority and some sort of civility were flattened or tottering. The National Palace looked like a meringue pie that had been sat on. A foul smell hung over the General Hospital, which had just run out of diesel fuel and was surrounded by the injured, the sick, and, of course, piles of those who did not make it. But contrary to rumors of looting and mayhem, the city of two million was quiet, which in itself was unusual. I had never experienced Port-au-Prince without the blaring of radios and car horns. And I expect it will remain this way -- calm, as long as people are offered dignity and respect and the necessities of daily survival: food, water, sanitation and shelter.

The public open spaces of the city (there are few of these) and many streets have been closed off by the citizenry seeking protection from both aftershocks and troublemakers (there have been more of the former than of the latter). What strikes me from Port-au-Prince, apart from the enormity of the disaster, has been the magnitude of the response among those unaffected, whether within Haiti or without -- the simple desire to help -- and the difficulty we will face in seeking to match that goodness with the surpassingly enormous need. So far the desire to help has not been matched to the need, and there are several things to keep in mind as the situation on the ground changes rapidly.

First, rescue and relief efforts are far from over. Although for some they are too late, for others they are just beginning. The head of the United Nations here, who stepped in to replace a fallen comrade, just told me that by digging through rubble they have found someone alive under the ruins of their headquarters. Throughout the city and in the debris of a number of public buildings, people can be heard calling for help. Some are texting on phones that they are alive. It must be no different in other devastated cities, such as Jacmel in the south.

Rescuing survivors will take heavy equipment and experts. These are being brought in now from around the world. But this enormous outpouring of concern and support will be hard to receive. The airport in Port-au-Prince is clogged with aircraft. Some are turned away. All day yesterday, I was with a group of surgeons and anesthesiologists who had brought their skills and supplies. They had to wait many hours before being cleared to land, not because the control tower was destroyed (it was), but because there simply were so many aircraft requesting clearance. A plane full of requested personnel and supplies circling overhead while people die is the right metaphor for the challenges facing us in the short term. Making sure this concern is translated into meaningful rescue and relief efforts is a significant challenge, and here are some basic points that experts in disaster relief make all the time.

Second, in-kind donations are not really what is needed now. I attended a meeting at the U.N. in which this was underlined to assembled ambassadors and donors. Send money, not in-kind donations. To my surprise, the only exception noted that day was Meals Ready to Eat, as there is no way to cook safely in Port-au-Prince at present.

To this I would add that some people do have in-kind services to offer. Trauma specialists are a good example, but in addition to the obvious supplies, surgeons need blood banks, water, and space in which to work. Fuel is needed for generators. All of these are in short supply. So even when a response is highly specific and of obvious utility, like the call for trauma specialists, anesthesiologists, orthopedists, and hospital supplies, coordination is king. But coordination also requires resources -- telecommunications equipment, vehicles, fuel, and cash, to say nothing of feeding and housing of staff. And so coordination can exist in principle and be visible on the ground, yet still be a key goal.

In other words, we cannot give up on improving coordination by dismissing important actors as unable to perform their function. The Haitian people, victims of yet another series of blows, are already helping one another, and many have built up informal networks to help their neighbors in need of food, water, or first aid. The Haitian attitude expressed in the saying, ``If there's enough for two, there's enough for three'' has no doubt saved many lives over the past 72 hours. Coordinating with the people of Haiti means getting messages out on the radio and cellphone, when these services have been restored, to direct people to places where basic needs can be met.

Third, the Haitian government has been dealt a severe blow and not just to its buildings. If at a quarter to five in the afternoon an earthquake takes down not only the National Palace but also the Ministry of the Interior, the State Department, the Tax Bureau, and the Ministries of Finance, Planning, Public Works and Public Health, as well as the parliament building, you can well imagine the gaps created in an already weak public sector. The situation at the United Nations mission is similar. Although the U.N. headquarters collapsed and most of its leadership remains unaccounted-for, the U.N. is rebuilding. Central to this effort is the U.N. arm responsible for bringing together humanitarian groups including nongovernmental organizations to ensure a coherent response to emergencies. The World Food Program, too, has expertise in responding to such disasters; it is already present in Haiti.

Fourth, aid should be coordinated and conceived in a way that shores up Haitian capacity to respond. The planeload of surgeons mentioned above were responding to a call from the Haitian National University hospital. It should be noted that the leadership of that hospital (also surgeons) and the director of nursing have been at their posts for days. They are showing up to work even without the coordination and cash and supplies they need. Identifying such priceless local partners is important for many reasons related to relief and rescue, but it is most important for reasons related to recovery.

Some of this emergency response can be done with longer-range views in mind. Schools must be rebuilt, but in the interim, children must be back in school soon, and rebuilding the city's housing stock will require a different kind of urban planning and a long-term commitment to respect for the Haitian people's wishes.

Finally, I was reminded last night that rescuers will get tired. I went to see my hardy colleagues -- Haitian, Americans from Boston and Miami, Irish, and Cuban. A couple of them had been in Port-au-Prince before the quake -- attending, ironically, a meeting on disaster preparedness -- and had spent every waking moment attempting to assuage suffering the scale of which most of us have never seen. Here again, coordination and cash are king. Just like everyone else, they will need food and a safe place to sleep. Two of my medical colleagues have been sleeping in a jeep. Another two have spent the past two nights without any sleep at all. One of my Haitian colleagues had a dressing on her hand but did not comment on it. She was looking for water and food for the rescuers and, of course, worrying about her own family, some of whom were still unaccounted for.

Like so many of my Haitian colleagues, she represents what is best about that country: an inextinguishable spirit of resistance that represents hope even in the darkest of times.

Paul Farmer is the Presley Professor of Social Medicine at the Harvard Medical School, the co-founder of Partners In Health, and the deputy to Bill Clinton, United Nations Special Envoy for Haiti.

In today’s earliest hours, Dr. Evan Lyon recounted his reactions to PIH staff in Boston. He spent his first twelve hours in Port-au-Prince driving around the city identifying places in need so that PIH could pursue a more decentralized approach to emergency medical care delivery today. He and other PIH leadership forged important relationships with the hospital administration at the University Hospital (HUEH) where PIH has partnered with the Ministry of Health to pursue a fully coordinated approach to restoring of services for the thousands of patients awaiting care there. And together with the PIH logistics team and Dr. Joia Mukherjee, he helped evacuate four of the most in need patients and a guardian from Port-au-Prince to Philadelphia for urgent care. We hope his words will give you all who are supporting this relief effort a small window into what it is like to be in Port-au-Prince now.

Sent on January 17, 2010, 3:34AM by Dr. Evan Lyon of PIH

can't get through much now but beyond the horror, one very striking reality is that things are totally peaceful.  we circulated in PAP in the middle of everything until just now.  everywhere.  no UN.  no police.  no US marines and no violence or chaos or anything.  just people helping each other.  drove past the main central park in PAP where at least 50K people must be sleeping and it was almost silent. 

people cooking, talking, some singing and crying.  people are kind, calm, generous to us and others.  even with hundreds lying on the ground, open fractures, massive injuries of all kinds.

there are few dead bodies on the street.  stench is everywhere.  the city is changed forever.

we had a late day opportunity to evacuate 4 patients to the US.  these may be the first haitian nationals allowed to leave for the US. but martinique has taken over 200.  the DR has taken many many more.  so we circulated in PAP looking for urgent cases.  found hundreds but picked up the 4 to get out, hopefully to philadelphia.  open fractures, gangrene, one 4 year old boy with a leg broken in 3 places, a minor head wound, and now 4 days of sleeping outside with IV fluid and maybe some pain meds.  probably none.

at the airport, we drove onto the tarmac to meet the air ambulance.  surrounded by marines and UN, massive weapons.  a humvee with a gunner turret at the top drove by.  the noise from the large transport planes was deafening.  us citizens and haitian american citizens leaving by the hundreds on US planes.   and our small team of haitian and american docs evacuating a drop in the bucket.  my ears are still ringing from the noise of it all.

in contrast, port au prince is silent.  no current.  no car traffic. people sleeping in the streets but little else.  beside the impossible weight and tragedy of this city completely devastated, one lasting impression was the stillness of the city.  in shock, tragically sad, but quiet.  so good to get away from the airport.

sleeping tonight in the house of a dear PIH friend and doctor. attending to neighbors here and able to rest. safety and the work is with our sisters and brothers in this beautiful, proud, and strong nation.

the safest and best way to be here and help is with our colleagues and friends.  wonderful to be in the city, away from the airplanes, and working shoulder to shoulder with people we know and love and will continue work with to mourn, assist, and rebuild this special country.

in the photo you see the first time operating of any kind possible at the main general and academic center.

for press / outreach strategy, we might highlight the generosity and getting it done kindness of the air ambulance team.  they also left us all the supplies they had on board - water, meds, IV material, blankets, food.

goodnight everyone.  love.  evan.

Dr. David Walton landed on the ground in Port-au-Prince just 48 hours after the earthquake devastated the city. In addition to providing medical care and helping to arrange logistics for relief efforts, he was able to document the scene with his camera.

Dear Friends,

Since Tuesday evening, PIH staff has been working around the clock to bring relief to the people of Haiti who are suffering immensely in the aftermath of the catastrophic earthquake. You have seen the images on the news, read the updates on the web, and responded in a profoundly generous way to our calls for help - we are indebted to you for your quick mobilization and generous contributions.

Clinicians at the PIH site in Hinche examine x-rays from a patient injured in the earthquake.
PIH helps as Director of HUEH coordinates with US military.

Our team, because of our deep roots in Haiti, was able to be among the first to respond with emergency medical services. Since the first days, our staff has stepped up to take on the challenge of serving the most vulnerable in Port-au-Prince and of providing comprehensive care ranging from basic primary care to complicated surgical services at our sites in the Central Plateau and Artibonite Valley. Co-founder Dr. Paul Farmer wrote yesterday, "We find that years of investment in building a strong local partner organization mean that we are again in the position of responding effectively to a natural disaster. We are very proud of our team."

All of this work-our years of investment and our ability to respond is made possible because of people like you who do not become paralyzed in the face of suffering but rather stand up and help serve.

Yesterday, Dr. Farmer arrived in Port-au-Prince to check in with our team and to meet with Government and UN officials. Since his visit, we have already seen the tide begin to change - this morning, the PIH/Zanmi Lasante team was designated by the World Health Organization to serve as the coordinators of the public hospital, Hopital de l' Universite d'Etat d'Haiti (HUEH), where thousands are suffering in need of medicines and surgeries. In this new role, we will be supporting the administration and staff and recruiting other NGOs to help restore services, particularly triage, nursing, and surgical, at the city's central hospital. Our priority is to increase stock of medicines and supplies, ensure steadily functioning operating rooms, and guarantee sufficient medical staff is available, particularly for nursing care to help with post-op recovery, iv management, and other care that has had to be self managed over the past three days.

With supply chains in place and flights arriving more consistently in Port-au-Prince since the air traffic control has been reinstated, today has already been a turning point in our ability to respond to the enormity of the devastation and really get the field hospitals and public hospitals up and running. We have two planes of surgeons and surgical supplies arriving within hours, we have fuel on its way to Haiti through the DR, and we are reallocating supplies from our ten sites to where they are needed most on a regular basis.

It is clear to us all that relief for Haiti must rely on our collective immediate response and our sustained long-term commitment to building back better. Our approach to health care delivery in resource-poor settings-partnering with the public sector, employing locally, and investing for the long-term-is a key part of the solution for Haiti now and in the future. We hope that you will continue to stand with Haiti now and in the months and years to come.  

Thank you for your solidarity during this crisis,

-Ophelia Dahl

What's been on the minds of Partners In Health/Zanmi Lasante staff over the past 24 hours? Below are just a few thoughts selected from the torrent of emails that circulated through our servers:

• From Port-au-Prince: Our team has been designated by the WHO to serve as the coordinators of the public University Hospital (HUEH) alongside Haitian Ministry of Health. In that role, PIH is supporting the administration and staff in restoring services at the city's central hospital, which will also serve as the base of operations for our emergency triage and surgical teams in Port-au-Prince and for referring patients who need more advanced care for transport to our facilities in the Central Plateau and Lower Artibonite.

• 	A plane of volunteer surgical teams prepares to depart to Port-au-Prince.

  From the Port-au-Prince airport: Planes arrived from Florida, New York, and Montreal, carrying volunteers surgical teams and surgical supplies, blankets, and water. Pulling out the stops to quickly unload and route people and supplies to where they’re needed most.
• From HUEH/Port-au-Prince: Surgical teams slept at the hospital with all their supplies so they could begin surgeries at 6am this morning.
• From St. Marc: Hundreds of patients are in need of surgery. Eagerly awaiting a surgical team—which is now on its way from Port-au-Prince. 
• From Cange doctor: Planning to host the other surgical teams, and organizing where to station them throughout the Central Plateau.
• From on road from Belladère: Racing from the Dominican Republic—a medical team from Dartmouth flew into Santo Domingo yesterday and are en route to Cange now. 
• From Cange hospital: We've had a number of severely injured patients trickle in today saying that they've been trying for days to get here but transportation/gas prices were too high. 
• From Belladère: The mayor asked us for our help to find housing for all the newly homeless people arriving from Port-au-Prince.

PIH Executive Director Ophelia Dahl posts from Boston:

Over the past 24 hours, with communication partially restored in Port-au-Prince, we have been able to coordinate strategy, challenges, and needs efficiently and effectively with our medical and logistics teams on the ground in Haiti. With supplies delivered and initial surgical teams deployed there have been numerous successes at PIH's sites of medical operations in Port-au-Prince and outside of the city. Today, we initiated a more decentralized approach, identifying four communities and a medical complex in Croix-des-Boquets into which we will expand our efforts tomorrow. We also began a MedEvac program for the most critical patients - four patients arrived in Philadelphia this morning where they all had surgery today and five additional patients were flown to the Dominican Republic this afternoon.

In addition to these details, we have received painful emails, commentaries, and images about the state of Port-au-Prince. We hope that the following two pieces will provide you-our supporters who now stand in solidarity with Haiti-a glimpse of Port-au-Prince. You'll note, as we have, the profound need for a sustained, long-term international response to this crisis.

An email from Dr. Evan Lyon:
In an email sent very early this morning, Dr. Evan Lyon documented his reaction to the catastrophe in Port-au-Prince.

Read more about his first twelve hours in the city

Dr. David Walton documents the tragedy and PIH's response in images:

Arriving in Port-au-Prince within 48 hours of the tragedy, Dr. David Walton met up with Partners In Health and Zanmi Lasante (Partners In Health's Haitian sister organization) leadership to care for patients and pursue a coordinated strategy for medical relief.

On behalf of all of our patients and the hundreds of thousands suffering, we thank you for your efforts to spread the word of our work. Please share these accounts with others.

http://act.pih.org/sharewithafriend

In solidarity,

Ophelia Dahl
Executive Director

PIH Executive Director Ophelia Dahl writes from Boston:

Since Tuesday evening, PIH staff has been working around the clock to bring relief to the people of Haiti who are suffering immensely in the aftermath of the catastrophic earthquake. You have seen the images on the news, read the updates on the web, and responded in a profoundly generous way to our calls for help - we are indebted to you for your quick mobilization and generous contributions.

Our team, because of our deep roots in Haiti, was able to be among the first to respond with emergency medical services. Since the first days, our staff has stepped up to take on the challenge of serving the most vulnerable in Port-au-Prince and of providing comprehensive care ranging from basic primary care to complicated surgical services at our sites in the Central Plateau and Artibonite Valley. Co-founder Dr. Paul Farmer wrote yesterday, "We find that years of investment in building a strong local partner organization mean that we are again in the position of responding effectively to a natural disaster. We are very proud of our team."

All of this work-our years of investment and our ability to respond is made possible because of people like you who do not become paralyzed in the face of suffering but rather stand up and help serve.

Yesterday, Dr. Farmer arrived in Port-au-Prince to check in with our team and to meet with Government and UN officials. Since his visit, we have already seen the tide begin to change - this morning, the PIH/Zanmi Lasante team was designated by the World Health Organization to serve as the coordinators of the public hospital, Hopital de l' Universite d'Etat d'Haiti (HUEH), where thousands are suffering in need of medicines and surgeries. In this new role, we will be supporting the administration and staff and recruiting other NGOs to help restore services, particularly triage, nursing, and surgical, at the city's central hospital. Our priority is to increase stock of medicines and supplies, ensure steadily functioning operating rooms, and guarantee sufficient medical staff is available, particularly for nursing care to help with post-op recovery, iv management, and other care that has had to be self managed over the past three days.

With supply chains in place and flights arriving more consistently in Port-au-Prince since the air traffic control has been reinstated, today has already been a turning point in our ability to respond to the enormity of the devastation and really get the field hospitals and public hospitals up and running. We have two planes of surgeons and surgical supplies arriving within hours, we have fuel on its way to Haiti through the DR, and we are reallocating supplies from our ten sites to where they are needed most on a regular basis.

It is clear to us all that relief for Haiti must rely on our collective immediate response and our sustained long-term commitment to building back better. Our approach to health care delivery in resource-poor settings-partnering with the public sector, employing locally, and investing for the long-term-is a key part of the solution for Haiti now and in the future. We hope that you will continue to stand with Haiti now and in the months and years to come.  

Thank you for your solidarity during this crisis,

Ophelia Dahl
Executive Director

PIH is one of six prominent rights groups that issued a statement calling for relief efforts to be grounded in human rights principles, transparency, and respect for the human dignity of all Haitians. The groups warned that failure to do so could aggravate the already disastrous impacts of the earthquake.

“There is no doubt that Haiti’s hungry, thirsty, injured, and sick urgently need all the assistance the international community can provide, but it is critical that the underlying goal of improving human rights drives the distribution of every dollar of aid given to Haiti,” said Loune Viaud, Director of Strategic Planning and Operations at Zanmi Lasante (PIH’s sister organization in Haiti) “The only way to avoid escalation of this crisis is for international aid to take a long-term view and strive to rebuild a stronger Haiti—one that includes a government that can ensure the basic human rights of all Haitians and a nation that is empowered to demand those rights.”

The groups cited past relief efforts in Haiti that were uncoordinated, unpredictable, and lacked community participation, often leading to increased suffering. They called on the international community to seize on this opportunity to advance human rights and sustainability in the ravaged country.

In their statement, the groups call on the international community to employ a rights based approach at all stages of the relief effort, from planning to implementation and monitoring by:

• Following the UN’s Guiding Principles on Internal Displacement, which include the right to assistance from the government and the right to return;
• Complying with the Paris Principles on Aid Effectiveness, which aim to ensure aid harmonization, alignment, and management for results with monitorable indicators;
• Recognizing the human rights context that existed prior to the earthquakes and take steps to ensure that humanitarian and development efforts do not exacerbate or reinforce the marginalization of vulnerable groups such as women, children, and the landless;
• Ensuring that relief is coordinated and provided in a transparent process including through shared needs assessments and a high level of coordination with the government of Haiti itself; and,
• Empowering all strata of the Haitian population to participate in decision making at each level of the aid and development process, from the initial needs assessment to project planning, implementation, and evaluation.

In addition to Partners In Health, the six groups include the Center for Constitutional Rights (CCR), the Center for Human Rights and Global Justice (CHRGJ), the Institute for Justice & Democracy in Haiti (IJDH), the Robert F. Kennedy Center for Justice and Human Rights (RFK Center), and TransAfrica Forum.

Read the full statement issued by the groups.

Dr. Patrick Almazor of PIH/ZL reported from the field last night that people seem to be fleeing Port-au-Prince as the situation in the city becomes more and more dire. In a note expressing the need to keep some resources at our facilities in the Central Plateau and Lower Artibonite Valley, he wrote, “People are fleeing PAP whether they are sick or not.”

	Patients arrive at the PIH/ZL hospital in Hinche from Port-au-Prince.

As patients and their families leave Port-au-Prince in buses, trucks, and cars to seek medical care away from the disaster, PIH is grateful to have two planes full of surgical teams arriving today, some of which will staff our four safe and stocked operating rooms in Cange, Hinche, and St. Marc. The PIH facility in St. Marc is particularly inundated with orthopedic surgery cases – 200 waiting at the last count.

The acute need is certainly still greatest in Port-au-Prince, and we’re lucky that a surgical team already arrived on a plane with Dr. Paul Farmer to Port-au-Prince yesterday. With PIH/Zanmi Lasante leadership, they worked overnight with local officials and other NGOs to develop a plan for strengthening services at the public hospital, Hopital de l' Universite d'Etat d'Haiti (HUEH), where thousands are suffering in need of medicines and surgeries.

This morning, the PIH team in Port-au-Prince reports that PIH/Zanmi Lasante has been designated by the World Health Organization to serve as coordinators at the hospital. In this role, we will be supporting the administration and staff and recruiting additional NGO support to restore services, particularly triage, nursing, and surgical, at the city’s main hospital. Additionally, the team has identified a secondary site at the Aristide Medical School at Tabarre for additional emergency triage and surgery and for referring patients who need more advanced care for transport to our facilities in the Central Plateau and Lower Artibonite Valley.

Cross-site collaboration makes the expansion and dissemination of our work possible. In particular, our almost 25 years of experience in Haiti has helped our projects in Africa to flourish. Such an exchange of resources, technology, and knowledge between developing countries is often referred to as a south-south collaboration.

Since 2004, Haitian doctors, nurses, and administrators have traveled to our sites in Rwanda, Malawi, and Lesotho to help train staff and launch programs. And beginning last year, leaders from our Rwandan projects have traveled to Haiti to work with Zanmi Lasante there. 

Yesterday, the power of this south-south collaboration took on new significance to all of us at Partners In Health in Boston and around the world when we received the following message from the Government of Rwanda:

President Kagame has been following the news [about the earthquake in Haiti] closely: "The Rwandan people are saddened by this tragedy. Yesterday, my government sent a message of solidarity to the government and people of Haiti and bereaved families, and we will be wiring our contribution this weekend."

We are extremely grateful to the government and people of Rwanda for their generosity and solidarity. Murakoze cyane!

Watch a video of PIH Executive Director Ophelia Dahl speaking about the situation in Haiti and PIH's work to support the earthquake relief efforts.

What's been on the minds of Partners In Health/Zanmi Lasante staff over the past 24 hours? Below are just a few thoughts plucked from the torrent of emails that circulated through our servers:

• From ER in Hinche: “Patients trickling in throughout the night. Doing all the surgeries we can around the clock."
• From St. Marc Hospital: “We are receiving a lot of people. Most of them are surgery cases. We have operating rooms, anesthesiologist, nurses, equipment but no surgeons.”
• From a PIH doctor helping out at Diquini Hospital: “There are about hundred people lying on the floor and suffering. The pharmacy there ran out… Now I worry about infections of wounds and septicemia.”
• From Belledere: CHAI truck from Santo Domingo in the Dominican Republic arrives with surgical supplies and "First Things First" kits.
• From Florida: Planes with surgical teams (30 people) arriving in Port-au-Prince later today!
• In Cange: Getting desperate for diesel. Fuel costs are soaring to $25/gallon in-country.

Dr. Joia Mukherjee, Dr. Louise Ivers, and Dr. David Walton reported from Port-au-Prince this morning to PIH staff in Boston, and we in Boston laid out our plan for getting additional medicines and supplies into the country.

We were lucky enough to be in a position to respond quickly with supplies as our facilities in the Central Plateau and Artibonite Valley had fully stocked pharmacies and staffed wards and operating rooms. Dr. Paul Farmer wrote earlier today, “We find that years of investment in building a strong local partner organization mean that we are again in the position of responding effectively to a natural disaster. We are very proud of our team.”

That said, our supplies are depleting quickly as we treat and care for thousands of patients at our sites and also send trucks into Port-au-Prince multiple times a day to serve many more in need there. Our procurement and logistics team are forging partnerships with organizations in the Dominican Republic with the CHAI team to develop a supply chain that will ensure we can get shipments, containers, and other supplies into Haiti. Our site in Belladare, on the Dominican border, has staff standing by to help deliveries get though customs and into Haiti. We are vetting various shipping methods for efficiency and still trying to get plans into Port-au-Prince, but fortunately, we have already successfully delivered trucks of supplies to Belladare, which are making their way to Port-au-Prince now.

Another big need in the coming days will be fuel, as the whole country is running on generators and both air and ground transportation are of utmost importance to sustaining relief efforts. Finding ways of getting fuel into the country is a huge and looming priority – Dr. Walton suggested this morning that fuel prices in Haiti have soared to $25 per gallon.

PIH co-founder Dr. Paul Farmer is on his way to Haiti. He is expected to fly into Port-au-Prince later today.

Read the transcript from Paul's interview with Campbell Brown on CNN last night.

In addition to co-founding Partners In Health, Paul is also Deputy United Nations Special Envoy to Haiti, appointed by President Bill Clinton; as well as the Presley Professor and Chair at Harvard Medical School's Department of Global Health and Social Medicine. 

Tracy Kidder, author of Mountains Beyond Mountains, pens a blog post for www.standwithhaiti.org:

The catastrophe in Haiti spared the country’s largest – and, I believe, most effective – rural health care provider, Partners In Health. The organization’s principal founder, Dr. Paul Farmer, is on his way to Haiti now with a surgical team. The staff already in Haiti will welcome his arrival, but they have been at work for days now. Indeed, they were some of the first medical personnel to respond to the crisis. This is a large, highly skilled group of about 2000 community health workers, 500 nurses, and 120 doctors. All but a few of them are Haitian. They are spread out now. Thousands of injured people have been traveling from the capital to the hospitals that PIH operates, along with the Ministry of Health, in the Central Plateau – 10 hospitals, all well-equipped and fully functional. Others of the PIH-Haiti team are in the capital Port-au-Prince, where they have set up mobile clinics and where they are now establishing a central base of operations. The plan is to provide emergency care to all comers and to stabilize patients who need higher levels of care and arrange to get them to the PIH hospitals.

Personally, I take hope from the example that PIH has set and is setting again. I think it is one excellent model for the reconstruction of Haiti to come: an endeavor that employs and trains Haitians every step of the way, that builds infrastructure while attending to the basic needs of the poor, that does all it can to strengthen the public sector.

Many people have been writing to ask what they can do. Paul reports, “I just talked to some of my Haitian coworkers who are in Port-au-Prince in the general hospital, and they’ve reported to work. [But] they don't have electricity yet. They don't have the supplies that they need. But there's a lot of Haitian health professionals, doctors, nurses, aides who would like to [do their job], but to do that you need the supplies. You have to have the basics. Gauze, plaster, or other casts. You have to have the equipment that you need. Anesthesia, pain medications, antibiotics. And that's what some of my medical colleagues are asking us for, supplies."

PIH is purchasing and procuring donated supplies around the clock. To aid in these efforts, please consider making a donation to their efforts today.

- Tracy Kidder

Tremors from Tuesday’s massive earthquake were still being felt in Port-au-Prince this morning. “Little earthquake passed this morning, it’s not done yet,” wrote Dr. Fernet Leandre, a physician at PIH’s sister organization Zanmi Lasante. “[People are] crying, yelling… some are still alive under houses’ debris or ruins.”

Like our facilities in Hinche and Cange, the St. Marc Hospital where Fernet sent his message from, is handling many cases from Port-au-Prince. "The crowd of injured continues to arrive at St. Marc, and there's no surgeon," he said. He and Zanmi Lasante staff are working to bring in a surgeon to handle the many orthopedic cases facing the facility.

Cars and buses of injured patients from Port-au-Prince have been arriving at the PIH/Zanmi Lasante hospital in Hinche.
UN and Red Cross workers helped facilitate the patient arrivals as well as handle family members arriving to search for injured loved ones.
The hospital is seeing many cases needing orthopedic surgery.
Clinician caring for the injured.
A shipment of mattresses to help accomodate more patients.

Photos taken at the Hinche Hospital, which is run by PIH/Zanmi Lasante. Hinche is about 3 hours by car from the capital city of Port-au-Prince. As the facility was structurally unharmed by the earthquake, many patients are being sent here for medical care.

Tracy Kidder and Rachel Maddow discuss Partners In Health and its work in Haiti. Watch the video now!

Visit msnbc.com for breaking news, world news, and news about the economy

	The Cange hospital converted a nearby church into a makeshift triage center.
	Patients from Port-au-Prince have already filled every bed in the hospital and church.

After losing its internet connection yesterday, the PIH/Zanmi Lasante hospital in Cange finally regained connectivity this afternoon. As phone lines are still down, all our sites are relying heavily on satellite internet connections to stay in touch.

In an email sent shortly after the Cange site came back online, PIH Women's Health Coordinator in Haiti Sarah Marsh sent a short update focusing on the number of patients the Cange hospital has been receiving from Port-au-Prince, which is located about 2 hours away by car. "We’ve admitted about 70 patients with earthquake related injuries – primarily fractures and abrasions," she wrote. "We have 20ish patients who require orthopedic surgery."

"All beds are full tonight," she wrote, including those in a nearby church the hospital has been using as a makeshift triage center; and the staff is now using a local school for overflow.

PIH has been working very closely with the UN, Government of Haiti, United States Government, other non-profit organizations and relief agencies to determine the immediate needs for Port au Prince and the surrounding areas. An initial needs assessment identifies the following immediate needs, which will be addressed through a coordinated effort of public, private, and civilian sector organizations:

1. Reopen the airport
2. Repair cell phone communication systems
3. Clear main roads from debris
4. Send in search and rescue teams
5. Set-up protected shelters throughout the city in strategic public places all over the city that have food, water, and basic medical and surgical services. These shelter sites should be close to large slums.
6. Procure and distribute clean water
7. Procure, distribute, and stock food
8. Procure, distribute, and stock basic medical and surgical kits and IV fluids at mobile clinic points throughout the city
9. Increase medical and surgical capacity at all large medical institutions with three centers focused on specialized surgical interventions.
10. Ensure rapid disposal of all bodies
11. Conduct a rapid assessment of places to build new homes for homeless

In the immediate term, PIH is paying particular attention to the immediate medical and surgical needs.

In the Delmas section of Port-au-Prince, Dr. Patrick Almazor of PIH/Zanmi Lasante reports that he and several other doctors have set up mobile clinics. “We have a lot of fractures,” he wrote in an email. “We are running out of meds, I’m on my way to St Marc [a facility operated by PIH's partner organization Zanmi Lasante] for supplies.”

Tune into MSNBC tonight at 9:20 EST to watch Pulitzer prize-winning journalist Tracy Kidder discuss the situation in Haiti with Rachel Maddow. Tracy is the author of the best-selling book Mountains Beyond Mountains.

A report from Cate Oswald, one of our staff in Haiti, reveals a tragedy more dire than we could have ever expected. Yesterday, she traveled through the Central Plateau to Port-au-Prince and back with our two trucks of meds and supplies. She described the scene:

We started seeing destruction from Mt. Cabrit (where big rocks lie in the middle of the road) through Croix de Bouquets where it doesn't seem as bad but lots of walls down. Then the scene gets much, much worse. Tonight, everywhere throughout the city, as we drove by the national plaza, there are thousands of people sleeping outside. While I was in Port-au-Prince, there were still aftershocks being felt. I didn't venture into other parts of the city, but as you all know, koze sa pa jwet menm [Haitian saying literally translated as “this is not a game”].

The trucks met up with PIH staff, including Dr. Louise Ivers in Port-au-Prince, at the UN’s Log Base in Port-au-Prince. Louise was one of two doctors attending at the time, and they had nothing but aspirin until our trucks showed up. The conditions are horrific and people are dying, but in Cate’s report she was hopeful that the supplies will help those at Log Base for the time being.

Importantly, given the patients already flowing out of Port-au-Prince to St. Marc and our other facilities outside the city, we cannot leave our hospitals understaffed. So we are recruiting surgeons, anesthetists, nurses, and other medical professionals to go down in the next couple of days to help with staffing, particularly as many of our staff have lost family members and friends.

There are still a handful of our colleagues unaccounted for – we continue to have every hope that it is due to lack of ability to communicate via telephone and the lack of electricity for computers, but we do not know.

We are working on the logistics of transporting trained medical volunteers to Haiti, and will contact you when we have assessed both our needs and the situation on the ground.

Once again – thank you for your support.  Kenbe fèm.

PIH Executive Director Ophelia Dahl posts from Boston:

Over the past 18 hours, Partners In Health staff in Boston and Haiti have been working to collect as much information as possible about the conditions on the ground, the relief efforts taking shape, and all relevant logistics issues in order to respond efficiently and effectively to the most urgent needs in the field. At the moment, PIH's Chief Medical Officer is on her way to Haiti, where she will meet with Zanmi Lasante leadership and head physicians, who are already working to ensure PIH's coordinated relief efforts leveraging the skills of more than 120 doctors and nearly 500 nurses and nursing assistants who work at Zanmi Lasante's sites.

We have already begun to implement a two-part strategy to address the immediate need for emergency medical care in Port-au-Prince. First, we are organizing the logistics to get the medical staff and supplies needed for setting up field hospital sites in Port-au-Prince where we can triage patients, provide emergency care, and send those who need surgery or more complex treatment to our functioning hospitals and surgical facilities. To do this, we are creating a supply chain through the Dominican Republic. Second, we are ensuring that our facilities in the Central Plateau are ready to serve the flow of patients from Port-au-Prince. Operating and procedure rooms are staffed, supplied, and equipped for surgeries and we have converted a church in Cange into a large triage area. Already our sites in Cange and Hinche are reporting a steady flow of people coming with medical needs from the capital city. In the days that come we will need to make sure our pharmacies and supplies stay stocked and our staff continue to be able to respond.

Currently, our greatest need is financial support. Haiti is facing a crisis worse than it has seen in years, and it is a country that has faced years of crisis, both natural disaster and otherwise. The country is in need of millions of dollars right now to meet the needs of the communities hardest hit by the earthquake. Our facilities are strategically placed just two hours outside of Port-au-Prince and will inevitably absorb the flow of patients out of the city. In addition, we need cash on-hand to quickly procure emergency medical supplies, basic living necessities, as well as transportation and logistics support for the tens of thousands of people that will be seeking care at mobile field hospitals in the capital city. Any and all support that will help us respond to the immediate needs and continue our mission of strengthening the public health system in Haiti is greatly appreciated. Help us stand up for Haiti now.

If you are not in a position to make a financial contribution, you can help us raise awareness of the earthquake tragedy. Please alert your friends to the situation and direct them to www.pih.org for updates and ways to help.

Thank you for your solidarity during this crisis,

Ophelia Dahl
Executive Director

We are deeply grateful for the multitude of people who have contacted us wanting to provide medical assistance. As patients flood to our sites from Port-au-Prince, we're finding ourselves in need of both medical personnel and supplies. In particular, we need surgeons (especially trauma/orthopedic surgeons), ER doctors and nurses, and full surgical teams (including anesthesiologists, scrub and post-op nurses, and nurse anesthetists).

If you are a health professional interested in volunteering, please send an email to volunteer@pih.org with information on:

• Your credentials
• Language capabilities (Haitian Creole or French desired)
• Overseas experience (if any)
• Any prior experience in emergency/post-disaster relief efforts
• Availability
• Contact information

As phone lines in Haiti remain down and transportation and communication are difficult, PIH is still in the process of determining where we can set up operations in Port-au-Prince, and how we can transport patients and volunteers to our sites. We will be able to offer more concrete information after these logistical matters are resolved.

Once again – thank you for your support.  Kenbe fèm.

Over the past 18 hours, Partners In Health staff in Boston and Haiti have been working to collect as much information as possible about the conditions on the ground, the relief efforts taking shape, and all relevant logistics issues in order to respond efficiently and effectively to the most urgent needs in the field.  At the moment, PIH’s Chief Medical Officer is on her way to Haiti, where she will meet with Zanmi Lasante leadership and head physicians, who are already working to ensure PIH’s coordinated relief efforts leveraging the skills of more than 120 doctors and nearly 500 nurses and nursing assistants who work at Zanmi Lasante’s sites. 

We have already begun to implement a two-part strategy to address the immediate need for emergency medical care in Port-au-Prince. First, we are organizing the logistics to get the medical staff and supplies needed for setting up field hospital sites in Port-au-Prince where we can triage patients, provide emergency care, and send those who need surgery or more complex treatment to our functioning hospitals and surgical facilities. To do this, we are creating a supply chain through the Dominican Republic. Second, we are ensuring that our facilities in the Central Plateau are ready to serve the flow of patients from Port-au-Prince. Operating and procedure rooms are staffed, supplied, and equipped for surgeries and we have converted a church in Cange into a large triage area. Already our sites in Cange and Hinche are reporting a steady flow of people coming with medical needs from the capital city. In the days that come we will need to make sure our pharmacies and supplies stay stocked and our staff continue to be able to respond.

Currently, our greatest need is financial support. Haiti is facing a crisis worse than it has seen in years, and it is a country that has faced years of crisis, both natural disaster and otherwise. The country is in need of millions of dollars right now to meet the needs of the communities hardest hit by the earthquake. Our facilities are strategically placed just two hours outside of Port-au-Prince and will inevitably absorb the flow of patients out of the city. In addition, we need cash on-hand to quickly procure emergency medical supplies, basic living necessities, as well as transportation and logistics support for the tens of thousands of people that will be seeking care at mobile field hospitals in the capital city.  Any and all support that will help us respond to the immediate needs and continue our mission of strengthening the public health system in Haiti is greatly appreciated. Help us stand up for Haiti now.

If you are not in a position to make a financial contribution, you can help us raise awareness of the earthquake tragedy. Please alert your friends to the situation and direct them to this webpage for updates and ways to help.

PIH Executive Director Ophelia Dahl posts from Boston:

A major earthquake centered just 10 miles from Port-au-Prince has devastated sections of the city and knocked out telephone communications throughout the country. Reached via email, Partners In Health staff at our facilities in the Central Plateau report that they experienced a strong shock but no major damage or injuries. We are still attempting to establish contact with other PIH facilities and to locate several staff members who were traveling in and around Port-au-Prince.

The earthquake has destroyed much of the already fragile and overburdened infrastructure in the most densely populated part of the country. A massive and immediate international response is needed to provide food, water, shelter, and medical supplies for tens of thousands of people.

In an urgent email from Port-au-Prince, Louise Ivers, our clinical director in Haiti, appealed for assistance from her colleagues in the Central Plateau: "Port-au-Prince is devastated, lot of deaths. SOS. SOS... Temporary field hospital by us at UNDP needs supplies, pain meds, bandages. Please help us."

With our hospitals and our highly trained medical staff in place in Haiti, Partners In Health is already mobilizing resources and preparing plans to bring medical assistance and supplies to areas that have been hardest hit. In Boston, our procurement and development teams are already fielding numerous offers of support and making arrangements to deliver resources as quickly as possible to the places where they are needed most.

Thank you for your solidarity during this crisis,

Ophelia Dahl
Executive Director

By Ivy Kuperberg

	Ivy Kuperberg

Ivy Kuperberg worked for a year for PIH's partner organization in Malawi, Abwenzi Pa Za Umoyo, as the assistant to the project's Country Director. The following is excerpted from an article in which Ivy describes an event that revealed both how much she shares with her closest Malawian friend and colleague (her "twin") and how wide a gulf separates the experiences of those born in the United States from their peers in poor countries like Malawi.

That snake does not look friendly.

It’s 6:00am and I’m doing my daily run through the African bush. Jay-Z pulsing through my iPod, I round the corner of the maize fields and come upon something distinctly green and succinctly unhappy. I take half a second to let my life flash before my eyes and then whip around and sprint back into the village. The staff houses fade into the distance and I bang on the door of the mud and thatched roof dwelling of Magdalene Johnson.

There’s no answer. Where in the world is Maggie? Maybe she ran to fetch water?

I look around wildly for a Plan B. The sun is just starting to rise over the mountains, a beautiful sight if I wasn’t so terrified. It’s morning in Neno, Malawi, one of the poorest districts in one of the poorest countries in the world, and instead of celebrating my one year anniversary at Partners in Health (PIH), a global health non-profit, I’m becoming the poster child for Ophidiophia.

	Dirt roads in Neno, Malawi (Photographer: Jamil Simon)

I take up a slow jog towards my house, keeping my eyes peeled for any more ferocious fauna. At home, I dart through the screen door and make a beeline for the bathroom. Too lazy to heat up the water, I submerge myself into an icy morning shower.

I’m almost finished toweling off when there’s a frenetic banging on my door. Slipping into my culturally appropriate outfit of a long skirt and t-shirt, I hop to the door while attempting to strap on my sandals. The screen opens to reveal the Hospital Maintenance Head.

 “Modi Bwanji? (Good morning how are you?)” I ask him.

“Ndi Bwino (I’m good),” He responds automatically. “Where is your twin?” he demands.

“Where is my what?”

“Your twin?” The Head looks at me expectantly.

“Oh. You mean Maggie. You mean she’s not at work?”

* * *

	Road leading from Ivy's house to the hospital (Photographer: Ellie Feinglass)

My house is right across the street from the Neno District Hospital, and I quickly skip across the dusty road to the main entrance. I pass the Emergency Room and peak into the Rehab Clinic my Malawian roommate, Claire, is running.

“Bo bo (what’s up)?” I shout into the room.  

Claire looks up. “Bo bo.” She grins.

“Hey, have you seen Maggie? The Head came to my house looking for her. And she wasn’t at home this morning.”

“Your twin?” Claire asks, shaking her head. “Haven’t seen her.”

Maggie is not really my twin; my birth in Beverly Hills and her concurrent birth here in Malawi makes that physically impossible. But it’s not the birthdays that earn us the nickname-rather, it’s our affinity for high heeled boots in the middle of rural Africa, and our penchant for watching music videos of Rihanna and Chris Brown together at sunset. Both of us hail from the city (Maggie’s originally from Blantyre, Malawi’s financial capital) and have both found out that while you can take the girl out of the city you can’t take the… well you know the rest.

	Pediatric clinic at Neno District Hospital (Photographer: Craig Bender)

I step outside again, and am met with a throng of people at the pediatric clinic. The crowds are especially thick today, the veranda flooded by mothers with babies and toddlers tied to their backs. I peak into the throng to see if I can spot Maggie. Her youngest brother, Thomas, wasn’t feeling well last night.  Between eating French fries and watching Disturbia, Maggie had mentioned taking Thomas to the clinic. Maybe she’s in line? I stand on my tip toes to get a better view and almost crash into a 3 year old. Lost in my thought, I then run smack into Dr. Jay, who’s about to climb into a car. “Sorry!” I say and then remember that he was the doctor on call last night. “Hey,” I say to him as he sticks one foot into the car. “Have you seen Maggie at all?”

Dr. Jay turns his head around and I prepare for more twin talk. But instead he nods. “Yeah, she came in last night with her brother-we referred him to the main hospital.”

That being said, I decide to call the city hospital just to see how Maggie’s doing. The nighttime rides can be pretty long, and bumpy. I hear a click on my phone and the patient registrar comes on the phone. I ask whether they have an 8 year old named Thomas Johnson in the wards. The registrar tells me to wait a second while she checks the rooms, and five minutes later she comes back on the line. “There’s no one here by that name,” she informs me.

 I’m very confused.

* * *

That evening, I feel a buzz and take out my phone. A text message appears on my screen. I open it up, and the words flash across the screen. On shaky legs, I rush towards the hospital, nearly bowling over three boys playing a makeshift soccer game in the road.

	Ambulance unloading passengers outside the hospital (Photographer: Jamil Simon)

The ambulance pulls in, bringing patients back from the city hospital. As the lowering sun’s rays bouncing off of the vehicle, I watch as the patients disembark, clutching their cloth bundles of food and medicine. Their chitinges are bundled tightly around them as they walk off in various directions, towards the market, towards home.

There’s a long, slow moment. And then--
           
Maggie appears, gingerly climbing out from the torn leather seats. She blinks into the setting sun and slowly removes a bundle of belongings from the ambulance. Nobody follows after.

Her gaze settles on me, and five feet away I feel the millions of miles between us, the ones that can be invisible when you’re sitting two feet apart from one another, but are nevertheless always there. There’s 10334 miles between Beverly Hills and Neno, and those miles, what they mean, never goes away.

We look at each other in silence.

And then I break it.

“Thomas died.”

She nods.

I think back to this morning, and remember the Head calling Maggie my twin as if it was the most natural thing in the world.

A joke. A lie.

And there’s the rub. Because for whatever does make us similar- the superficial hair and clothes, the not so superficial fitting in-there are things that Maggie will experience that I never will. My brother won’t die of cerebral malaria. And my parents won’t die of AIDS.

Maggie is an orphan. She’s raising her brothers, and lives without a safety net. Even when things are going well, it only takes one thing—a paycheck delayed too long, someone getting sick—to make it come crashing down around them.

We’re both still standing there, and it’s starting to get dark.

“You want to start heading home?” I ask quietly.

She takes a deep breath and watches as the sun disappears for the day. Then she turns back to me. “Yes.”

We start back down the path, each holding our own bundles, and our own burdens. For what else can you do in times like these but walk silently beside each other?

[posted November 2009]

At 1 p.m. on November 12, Dr. Eddy Jonas and his team performed the first surgery in a brand-new operating room at the hospital at Petite Rivière de l'Artibonite in Haiti. The operating suite, funded by Deerfield Partners, is the latest achievement for Zanmi Lasante (PIH's partner organization in Haiti) and its program to bring lifesaving surgical services to the poorest communities in Haiti.

The first surgery was to remove a fibroid in a patient's breast (see photo above). In the first few weeks of operation, they've also performed several gynecological surgeries, including a cesarean section.

The opening of the operating room at Petite Rivière continues the work of Dr. Josue Augustin, director of surgery for Zamni Lasante, whose tragic death we continue to mourn.

By Geoff Gusoff

	Geoff Gusoff hiking to visit patients in Lima.

After almost a full year in Lima, I arrived in a quite different “bean town,” Boston. It’s been nice for a change to take public transportation that doesn’t feel like an hour-long game of Twister, but I still sometimes have no idea what people are saying (I spent an hour last Sunday praying to someone named “Lawd Gawd”). Being in Boston these past few months has allowed me to get some perspective on my time in Peru.

What initially struck me most about Lima was its geographic and economic landscape. Class was largely divided by altitude, with the poorer residents occupying increasingly higher segments of the city’s many hills or cerros. The vast majority of the people I worked with lived in these cerros, including two who lived in the very last houses on a massive hill affectionately referred to as Machu Picchu. When I would trek to their homes two or three times a month to check on their micro-businesses, I’d always wonder, between panting breaths, how seriously ill patients made this trek everyday.

	Houses on the outskirts of Lima. ©SES

My main job in Lima was to help run a micro-enterprise program, which provides small loans to former patients so they can establish small businesses and have a sustainable income after their treatment ends. The program was something of a radical experiment: to create a micro-enterprise program with a preferential option for the poor. Unlike other micro-finance organizations, we took on many clients considered high-risk because of their history of illness and we committed resources to intensively train each participant. We also provided no-interest loans because we found that for many patients paying interest would mean drawing from the food budget or other necessities, raising their risk of becoming re-infected with TB.

I was responsible for making regular visits to mentor and collect loans from thirty-five (roughly half) of the businesses. Through these visits, I gained a deeper appreciation for Lima’s economic landscape. I learned how precarious it was to live in the hills, with many residents suffering injuries from terrible falls or from carrying heavy items. I also learned that the landscape was not completely static. People occasionally moved downhill to higher economic ground, and employment was a key factor in making that transition. Through the success of their businesses, the two residents of Machu Picchu were both able to move lower down on the cerros. Others were able to make improvements on their homes, adding a bathroom or a roof. Perhaps most importantly, many used their business revenues to pay their children’s educational fees to help break the cycle of poverty.

As I left Lima in August, I looked down at the same city I had seen from the plane a year before, with its mountains of poverty. I felt the same sinking feeling in my stomach, but this time there was another image to accompany it. I thought of my co-workers, the community health workers, the patients, and their family members, traveling through that massive city, each armed with little spoons for leveling those mountains. It was a painstakingly slow process, and yet, you could see progress if you looked close enough. Kids graduated high school, houses were built, people were cured for good. I thought of how much that army of spoon-holders had grown even during my brief time there, and I couldn’t help but feel some hope. Hope, and gratitude, for having been able to share a small part in that process.

Read Geoff's blog post from last year.

[posted November 2009]

My name is Heidi Behforouz. I am the Director of the Prevention and Access to Care and Treatment or PACT Project, PIH’s domestic project, where we employ community health workers—inspired by those in Haiti, Peru, and Malawi—to provide home-based services to the most marginalized HIV/AIDS patients in the city of Boston.

We hear a lot of talk these days about health care reform. The new lingo includes phrases like “public option”, “single payer”, and “global fees.” Perhaps the most interesting phrase is that of a “patient-centered medical home”: the concept that all medical care should be patient-centered and that all clinics and hospitals should be revamped to create a home-like atmosphere for patients and provide wrap-around services that address patients’ most complex needs.

I find the term “interesting” because the community health workers of PIH, including those of the PACT Project here in Boston, have been creating patient-centered medical homes all along. And in some ways, they do it better than we, as doctors and nurses, ever will. Because they come from the same communities and share many of the same experiences as their patients, they are uniquely qualified to bring sophisticated medicine to patient homes and deliver individualized care within the real contexts and belief systems of their patients.

A patient-centered medical home is not a new concept, and although I laud every attempt to improve our health care delivery system, I fear that we’ll forget that “best practice” for this kind of care already exists. We don’t need to start fresh; we just need to look around and acknowledge community-based models of care that are highly effective but largely unrecognized, perhaps because much of the care is being delivered by “paraprofessionals” who have not been extensively schooled in the biomedical model and don’t prescribe to hierarchical or office-based care. Their schooling and expertise is in the art and science of what we call accompaniment.

Accompaniment in one sense is an easy term. You walk with the patient—not behind or in front of the patient—lending solidarity, a shoulder, a sounding board, a word of counsel or caution. Empowering not enabling.

But in another sense, accompaniment is incredibly difficult, because you must walk with patients as they suffer from the violence of poverty, racism, illiteracy, social isolation, and fatalism. These are things that neither you nor your patients can fix; and yet you have to manage them somehow in order to help your patients swallow their pills every day, get to their appointments on time, and renew their Medicaid applications.

Community Health Workers offer tales of accompaniment

I asked my PACT community health workers this week to talk to me about what accompaniment means to them. Most of them launched into patient stories.

	Sori Santana of PACT on her rounds

Sori told the story of Maria, a young woman with significant mental illness, a cocaine user, who was referred to PACT with a CD4 count of 4. (It should be around 1000; a count of 4 signifies a very weak immune system ravaged by uncontrolled HIV.) For four years, Sori visited Maria off and on in her home, riding life’s up and downs with her, always encouraging, supporting, never forcing. Yet she was never able to help Maria consistently take her medications. Then one day, something clicked. And Sori was there. Maria began taking her pills. She’s now getting stronger and has become a directly observed therapy specialist in her own right… showing up in her boyfriend’s bedroom with a cup of coffee in one hand and his psych pills in another- telling him that if he doesn’t get up and take his meds, she is going to “pull a Sori on him.”

Magalie recounted the story of Barbara, a 35-year-old Black woman with AIDS, diabetes, below the knee amputation, end-stage kidney disease on dialysis, stroke, and depression—living in an emotionally abusive home—who just couldn’t take it anymore. Barbara didn’t want to take her pills. More than anything, she just wanted to have her teeth fixed so that she could enjoy a piece of corn on the cob and to get the callous on her remaining foot shaved off so she could walk without pain. Magalie took her to the dentist and accompanied her to the podiatrist. She just sat with her, as Barbara breathed a sigh of relief for the first time in months. And maybe just maybe, at the next home visit, she might be able to talk about taking her Norvir again.

The PACT community health workers have demonstrated the power of accompaniment just as their cousin CHWs in Haiti, Lesotho, and Rwanda have. Although they share this common methodology, CHWs in different countries take on different challenges. In Haiti, CHWs help build tin roofs as well as hand out medications. In Lesotho, CHWs hand out shoes and blankets for warmth. In Boston, CHWs counsel on safe injection techniques for heroin users, manage homeless patients with psychotic illness, and contend with the patient’s conundrum of being poor and Black or Latino in a wealthy city that is a mecca of health care.

Accompaniment improves outcomes, reduces costs

With the proper training and support, these accompagnateurs effect results. Here in Boston, not only have we demonstrated significant clinical improvements in the majority of our patients, we have reduced preventable hospitalizations by 40 percent and cut overall medical expenditures of our Medicaid patients. Clinic-based practitioners have also come to value the role of the CHWs—seeking their services for more of their patients and welcoming their input in case conferences and during office visits. We have been creating, in essence, patient-centered medical homes that offer quality care at lower cost.

Over the next five years, PACT is expanding its scope of work to utilize CHWs for the care of patients with other chronic diseases, including diabetes, heart disease, pulmonary disease, and mental illness. A managed care organization that is a Medicaid vendor here in Massachusetts will subcontract with PACT to provide CHW services to its highest risk patients: those with the poorest outcomes, the worst health care utilization patterns, and the highest costs. Our hope is that our CHWs can complement the work of office-based practitioners, improve the health of these patients, and reduce preventable emergency room visits and hospitalizations.

If successful, we will have laid the groundwork for CHWs being recognized as legitimate health care professionals who deserve payer reimbursement and a place in the medical home … just as doctors, social workers, and nurses do.

Accompaniment is a beautiful thing. As practiced in the central plateau of Haiti, the foothills of Rwanda, or Boston’s inner city, it just may be the right phrase around which to reform health care, both here and abroad.

Dr. Heidi Behforouz is a staff physician at Brigham & Women's Hospital, an assistant professor at Harvard Medical School, and Medical and Executive Director of the Prevention and Access to Care and Treatment (PACT) project.

[published October 2009]

At the end of the internship program every summer, participants are asked to evaluate the experience. We encourage them to be candid, in the hope that their comments will help us iron out problems and keep improving the experience every year. The overwhelming majority of responses are extremely positive, as the examples quoted here confirm.

“I really liked having various PIH members talk with us in an informal, more personal setting. Hearing about their work, philosophy, and how they got where they were provided some of the most valuable experiences I had over the summer.”

“I came with the expectations of learning more about PIH as an organization and how it works, as well as how medical science might be applied outside of the laboratory to real people in need. My first expectation was certainly realized, especially since we were invited to all the staff meetings and many of the program or site-specific ones as well – it was really an invaluable experience.”

“I think I have gained a much more informed perspective on global health challenges, as well as the myriad of details/issues/problems that need to be addressed in order to meet those challenges.”

“In terms of science, instead of learning about its applications, I learned how it is often misused when it comes to global health policies, and that a purely “scientific” approach is often not applicable to some of the problems that need to be dealt with.”

 “It was really great for me to be able to work with different people at PIH on their various projects rather than focusing entirely on my own research project.”

“I have learned that although science can be a powerful tool, it is not (or should not) always be the final word.”

“The internship as a whole has made me more excited about the training I hope to receive in medical school, and I think that motivation will definitely help carry me through some of the perhaps less enjoyable years of my life.”

“I expected to get an inside look at how PIH manages to do what I perceive to be some of the most outstanding work in resource-poor settings, particularly in Haiti.  Having unfettered access to meetings and personal interactions with staff of all levels was instrumental in helping me meet this expectation.”

“This was one of the most amazing summers I have ever had – thanks so much for the opportunity!!”

“Having a heterogeneous group is conducive to learning from each other, and brings more skills and experiences to the table.”

“Talk to people.  PIH is full of fascinating stories, and everyone seems willing to share.” 

“The research I did will contribute to my base knowledge that will support me in my career and studies.”

“The work I did around the office, outside of my specific project, provided valuable experience that will help with my career.” 

“Making connections and meeting people with whom I can collaborate and work in the future is of much value.”

“I liked the group meetings and the chance to hear about what everyone else was doing.  I also really enjoyed the lunches with PIH staff.”

“My project was very interesting and seemed to come into a life of its own. 

 “Helping with the AIDS manual and the Global Fund proposal really drew on my studies.  It was nice to see how the nuts and bolts of my studies are integrated into the everyday workings of an organization.”

“I really like the research model; it capitalized on the strengths of everyone.  And it was nice to have a variety of people around to bounce ideas off of.”

“The structure allowed for a very diverse experience—not only could we work on our own projects, but the opportunity was available to work on office-oriented projects as well.”

“The heterogeneity was great.  It made the summer interesting to interact with a varied group of people. Overall though, I liked the different individual projects in the research model, with the opportunity to work on a group project.”

“I liked the group meetings and the chance to hear about what everyone else was doing.  I also really enjoyed the lunches with PIH staff.”

“Take advantage of every opportunity!”

“The program seemed to be very well organized and engaging on many levels.”