"Solidarity can end structural violence"

By Loune Viaud and Joia Mukherjee

On September 6 and 7, Zanmi Lasante held its thirteenth forum on health and human rights, “Sante ak Dwa Moun,” a gathering of the whole Zanmi Lasante family—patients, their families, people from the communities of the Central Plateau and the neighboring Artibonite Department, accompagnateurs, teachers, archivists, cleaners, nurses, doctors and students.  

Also in attendance were government officials, members of other non-governmental organizations (NGOs), and two members of our Rwandan partner organization, Inshuti Mu Buzima—Jean René Shema and Manzi Anatole.

	A women's health class run by Zanmi Lasante. Women's health was the focus of this year's forum on health and human rights.

Women’s health was the focus of this year’s forum. Haiti’s Surgeon General, Dr. Gabriel Timothé, opened the first day, after prayers by the executive director of Zanmi Lasante (ZL), Fr. Fritz Lafontant. Dr. Timothé’s moving speech supported the human rights foundation of ZL’s work. He emphasized not only that ZL’s work is defined by our commitment to women’s rights and human rights as a whole but that it strengthens the Haitian government’s ability to respect, protect and fulfill the human rights of the Haitian people.  

Dr. Timothé remarked that when he visited the Rwinkwavu site of Inshuti Mu Buzima in Rwanda earlier this year, he felt the spirit of Cange, of ZL’s work and of Haiti there and was proud to be part of this global effort.  He ended by pledging the support of the government to expand the model of solidarity, human rights and health care throughout Haiti, encouraging other partners to take up the lessons of the successful NGO-MOH partnership.

Women’s issues were highlighted from the beginning of the day. A panel from the ZL project sites discussed the challenges of increasing family planning coverage in the region. Nurse-midwife Agnès Jacobs, representing the Ministry of Health and Médecins sans Frontière team from Petite Rivière, led an engaging discussion about the causes of maternal mortality and how they can be addressed through improving emergency obstetrical services.  Much discussion followed about the barriers to access to care for women—particularly in regard to user fees and transportation support.  

The topic of vulnerable populations followed.  A tragic case of domestic violence was presented by Jinette Georges, the program nurse in charge at Hôpital Sainte-Thérèse in Hinche, which highlighted the importance of the psychosocial approach in all aspects of patient care.

A team of community educators with Dr. Ralph Ternier from Hôpital Notre Dame de la Nativité in Belladère presented their amazing work to reach out to commercial sex workers. The presentation highlighted the lack of basic rights for this vulnerable group of women along the Haitian-Dominican border—especially with respect to access to health care. Father Eddy Eustache described the work to deliver mental health services to children affected by HIV which we hope can help to lessen the heavy burden that they carry. Our friends from the Fond des Blancs-St. Boniface led by Briel Leveillé discussed the community organizing and human rights awareness raising they are doing around the right to school, health and water.

These examples, learned over the two decades of PIH and Zanmi Lasante and Haiti were highlighted in presentations about the PIH ZL work in Africa.  Jean René Shema and Manzi Anatole presented the work of Inshuti Mu Buzimi.  The numbers of the “HIV scale- up” in Rwanda were impressive. More impressive yet was their conviction that the lessons from Haiti at work in Inshuti Mu Buzima are the best thing that could happen to the people of Rwanda.

From the philosophy of making a preferential option for the poor to the practical work of accompagnateurs providing medical, psychological and emotional support, our Rwandan colleagues stated the model of PIH has brought reconciliation to communities still bearing the scars of the 1994 genocide. In this medical solidarity, they told the crowd, Rwandan communities had found real human solidarity. They described an accompagnateur who is Hutu (the group responsible for the genocide) caring for a patient who is Tutsi who had lost much of his family in the genocide. Now this pair—accompagnateur and patient who needs accompaniment—have become friends.

Jonas Rigodon, a Haitian doctor who worked with ZL for five years, is now the chief physician at one of three PIH clinics high in the mountains of Lesotho. Jonas was not able to attend the forum. But his presentation of how lessons learned in Haiti have been applied in Lesotho was conveyed by Paul Farmer and PIH Medical Director Joia Mukherjee, who also described and applauded the work of the whole ZL team working in Africa.

	Access to obstetrical care, including Caesarean sections, is essential to reducing the highest rate of maternal mortality in the western hemisphere.

Reflecting the forum’s focus on women and access to obstetrical services, a panel from our Haitian surgical team was joined by three visiting surgeons—Robert Boucher (an ear, nose and throat specialist from Pennsylvania), John G. Meara (Chair of the Department of Plastic Surgery at Children’s Hospital in Boston) and Michael Steer (Chief of Surgery at Tufts Medical School)—for a discussion of how the right to health care must extend to surgery.  Lack of surgery often causes death—especially in the case of Caesarean section. But in Haiti we also see that surgeries delayed result in higher morbidity—physically and socially. We wondered together how to frame the merits of surgery as a basic right. Weighing the costs of not doing such life-saving and life-changing surgeries against the costs of doing them, we realized that both the financial and moral costs of inaction are prohibitive.

On the second day, the forum opened the doors and the agenda to the wider community.  As always about 2,000 people participated in the day. The Director of the National HIV/AIDS Program, Dr. Joëlle Daes Van Onacker, opened the day and went back to sit in the middle of the room. When she was invited to sit in front with the dignitaries, she responded, “No, I am enjoying sitting in the midst of these people. It is from their reactions and comments that I learn.”

The day highlighted panel on people’s right to self-determination with the awareness that all human rights – economic, social, cultural, political, and civil - are interrelated.  Human rights lawyer Mario Joseph, the Director of the Bureau des Avocats Internationaux (BAI) and Monika Kalra Varma, the Director of the Center for Human Rights at the Robert F. Kennedy Memorial, discussed how human rights are framed into the legal rights of Haitian people. [For Monika Varma's reflections on the Cange forum and human rights in Haiti, click here.] Other members of the panel included the first senator from the Central Department, Hon. Edmonde S. Beauzile, who emphasized how ZL and the Haitian government must work together to fulfill the rights of the people of the Central and Artibonite departments.  Lucette Fetière, a patient who coordinates ZL’s group for women living with HIV/AIDS, gave a rousing speech on the right to live with AIDS in health and dignity.

This panel also addressed the concerns of people who fear they will be displaced from their homes in order to make room for the highway running from Port-au-Prince to Hinche to finally be widened and paved. Earlier this summer, community members expressed their anxiety to ZL after their houses were numbered in red paint and marked for demolition. Road workers informed them that they will be forced to vacate. This is an especially painful issue for the people of the central plateau, many of whom were already uprooted from their homes to make way for the Péligre dam more than 50 years ago.

In 1956, with a loan from the International Bank for Reconstruction and Development (now the World Bank), a hydroelectric dam was built in one of the most fertile valleys of Haiti, the Péligre basin of the Artibonite River of the central plateau. Thousands of families, who had farmed this fertile land and lived decently for generations, were suddenly forced to leave their land. When the dam was closed, the valley flooded. With little warning the water rose rapidly to such levels that many families fled up the steep hillside with nothing but the clothes they were wearing.  All their possessions and even animals were lost. The displaced peasant farmers, many of whom are our colleagues, friends and patients at Clinique Bon Sauveur today, received no compensation for the permanent loss of their fertile land. To this day, they recount stories of the nightmare when the water rose. Cange, where we started working more than two decades ago, is a squatter settlement just north of the dam that still does not appear on maps of Haiti.

The history of this brutal displacement must not be repeated under our watch. Senator Beauzile was asked to talk to the community and the mayor to develop a plan to protect, respect and fulfill the rights of the people marked for displacement. Mario Joseph discussed the importance of infrastructural projects such as the road as a public good and part of the government’s duty to respect the right to movement and a decent life. But shelter is also a basic right, he added. A way must be found both to improve the road and to respect this basic right that was neglected in 1956.

This panel was a heated one. ZL’s Director of Operations, Loune Viaud had the difficult task of moderating both speakers and audience as we struggled to understand how a government can be held accountable for the rights it has promised to uphold—especially with regard to housing and health—when the international community has a stranglehold over its resources. 

As the moderator, Loune decided, diplomatically, to end the panel by calling forward a team of young people from Cange to perform a song about the 200 years of struggle of the Haitian poor.  The song (“Men nan men nou ta renmen mache, ak lespwi damou, L’Union fait la force…”) broke the tension and ignited a spirit of solidarity in which the Hon. Marie Laurence Jocelyn-Lassègue, Haiti’s Minister of Women’s Rights, delivered the closing speech. The Minister had not been to Central Haiti in a long time. Although she knew the great work that was happening in Cange, she did not realize how far it had spread in medical and philosophical breadth throughout Haiti.  She pledged her unswerving support to work with the Ministry of Health and Zanmi Lasante around all women’s.  In her speech she outlined the priorities of the Ministry of Women’s Rights which echoed the themes that resonated throughout the forum—women’s access to health care and education, a stand to end violence and exploitation of women, and protection of the rights of children. 
Before his closing remarks, Dr. Raôul Raphaël, the head of the Ministry of Health in the Central Department felt compelled to speak.

“As Health Commissioner of this region it is my pledge that all pregnant women will have free access to prenatal care.”---Cheers erupted.

“And we will work to increase access to free Caesarean section as it is a life-saving operation that CANNOT be sold as you would sell a side of beef or a goat.”—Massive applause ensued.

“Here in the Central Department, we will have ZERO tolerance for domestic violence and the abuse of women and children”—The crowd stayed on its feet to cheer with excitement. 

And the Minister went on to close the day remarking on the solidarity of the people in that room, on September 7th, the closing day of Zanmi Lasante’s 13th forum on Health and Human Rights.

So, this is what Zanmi Lasante and Partners in Health are all about. “Whatever it takes” may take the form of fighting for an individual patient, a community, or for basic human rights in the world.  We write this brief report to share this important gathering in the life of our patients, community members and we can say, the world, to share the sentiment here with all of the PIH family.

One international journalist was almost in tears, saying good-bye. She said: “I never experienced anything like this in my whole life and I’ve been to many places… This is the best thing that could have happened to me. Thank you, (Zanmi Lasante), for giving me this opportunity…”

Shema and Manzi, our colleagues from Rwanda, said, “This was an amazing experience! People here treat all people like people, with respect, with dignity and without the hierarchy that creates division and violence.”  Shema went on, “I see here that solidarity can indeed end structural violence.”

Tout moun se moun.

We need more gatherings like this worldwide. Period.

Men nan men ak lespwi damou ak solidarite from Cange,

Loune ak Joia.

Loune Viaud is Director of Strategic Planning and Operations for Zanmi Lasante. Joia Mukherjee is Medical Director for Partners In Health.

[published September 2007]

House Committee on Foreign Affairs
Subcommittee on Africa and Global Health

Testimony of
Joia S. Mukherjee, MD, MPH

Medical Director
Partners In Health

Assistant Professor of Medicine
Brigham and Women’s Hospital
Harvard Medical School

Health Systems Strengthening and the AIDS Pandemic
September 25, 2007

The long-awaited availability of money for HIV prevention, care, and treatment in resource-poor settings has resulted in the real possibility of stemming the enormous death toll of HIV.  However, due to decades of health system impoverishment, sickness and death among all cadres of workers due to HIV, and the flight of educated people from the developing to the developed world, there are few trained health professionals who can implement and sustain these large scale programs. This situation has been called the “healthcare worker crisis.” Yet to proffer the simple equation—“AIDS money is greater than the capacity of professionals to use it”—yields just a pinhole view of a much larger landscape. In fact, the AIDS pandemic has done nothing if not lay bare the fact that health systems—in terms of personnel, equipment, medicines, and physical infrastructure—in many developing countries were never adequate to address the basic primary health care needs of the population, let alone address a new, chronic, infectious disease—AIDS and its fueling of the tuberculosis pandemic. People in poor countries understand this. In Rwanda, our patients offer the phrase “imboni ibibazo”— a lens through which we see reality and the larger context—as a description of the AIDS pandemic.

It is to this larger context that AIDS has drawn our focus: developing countries bear 90 percent of the global burden of disease armed with only 20 percent of the world’s GDP   and 12 percent of the world’s health expenditures to combat this burden. Africa is particularly hard-hit, bearing fully one-quarter of the world’s disease burden with 3 percent of the global health workforce, who are paid less than 1 percent of global health expenditures. With such paltry resources available in these settings, how do people get care?  The answer is that they do not. For this and many other reasons, life expectancy in Lesotho is 35.1 years (compared to 76.7 years in Cuba); in Rwanda, 203 children per 1,000 die before their fifth birthday (compared to 8 per thousand in the United States) and in Malawi, 1800 women die in childbirth for every 100,000 live births (as compared with 2 in the Sweden). These rates are not unique across the continent. Some of this morbidity and mortality is AIDS-related, but much of it can be traced to inadequate health systems.

When people in resource-poor settings do access health care, approximately 60% of all health expenditures are out-of-pocket payments to private pharmacies or clinics. For the leading infectious global killers—HIV, TB, and malaria—there is no question that care should be delivered within the public sector and provided as public goods rather than as commodities; the control of tuberculosis, an airborne disease, has long been seen as a public good. Yet the public sector is absolutely inadequately resourced for the provision of basic health services, let alone chronic care for complex diseases. The majority of foreign aid directed to post-colonial African countries took the form of loans with conditions attached that were meant to develop African countries’ markets rather than invest in the public sector. Because two of the largest components of every government’s responsibility are health and education, these loan conditions, termed “structural adjustment” policies, resulted in massive disinvestment in and neglect of the health and education sectors.  National health budgets were set at shockingly low levels, on the order of $2-$5 US per capita, and included limits on the number of and compensation for public employees as well as little money for essential medicines or building and maintenance of health infrastructure. Countries subjected to these fiscal constraints had few options for responding to escalating public health needs. To compensate for the paucity of money in government coffers for health, the World Bank and the International Monetary Fund advised that public clinics should charge user fees for health services as a form of cost recovery. But in extremely poor, often non-cash economies, such fees serve as an enormous barrier to accessing care. The confluence of inadequate numbers of underpaid staff; poor infrastructure; a lack of medicines and supplies; and prohibitive user fees results in an oft-seen and grotesque sight: public clinics standing empty in the midst of the worst epidemics in the history of mankind. Equally tragic are countries such as Malawi where there are no user fees for health care and clinics are full but completely dysfunctional.  Lacking access to the tools of their trade and able to do no more than minister over the dying,  despondent health professionals have left their country to work in Europe or the United States, leaving only 350 Malawian physicians to care for a population of 16 million. 

New investments in global health, including the President’s Emergency Plan for AIDS Relief (PEPFAR), have given us the opportunity to treat and prevent HIV in resource-poor settings. Monies are available for drugs, for laboratory tests, and for prevention programs. But can and should new monies have a wider impact, beyond simply getting AIDS patients onto treatment?  The answer is yes. Unequivocally, yes. However, the money must be used strategically—not just to fund “vertical” HIV programs (clinics and services that provide care for only one disease such as TB or HIV) but to support the rehabilitation and bolstering of public health systems. A commitment to primary health is critical, as HIV programs do not work in a vacuum: the majority of people presenting to clinic, especially in rural areas, come because they are sick, not because they want to know their HIV status. Health facilities must be accessible, well-stocked, and reliable, providing decent diagnosis and treatment of common diseases, before widespread HIV testing can occur.

Let me illustrate with an example from the work of Partners In Health, an NGO affiliated with Harvard Medical School and the Harvard School of Public Health. PIH was one of the first programs to provide antiretroviral therapy free of charge in a resource-poor setting, Haiti, where we had been working since 1983. Haiti is the poorest country in the western hemisphere and also has the highest prevalence of HIV, TB, and malaria; the highest maternal and child mortality rates and a life expectancy 52 years. Despite these grim statistics, we were able to successfully acquire medicines and launch comprehensive AIDS treatment efforts just two years after antiretroviral drugs became available in the first world. Nearly all of those early patients, carried in on stretchers, are still alive today, living well, farming, working and caring for their children. This was a small initiative—just 60 patients between 1998 and 2001.  However, with the advent of the Global Fund to Fight AIDS, TB and Malaria and then the President’s Emergency Plan for AIDS Relief, PIH made a conscious decision that changed the course of our institution. We made the conscious decision that in order to get these life-saving medicines to all those who needed them, we had to deliver them through public health clinics. In 2002 PIH began to expand its services throughout central Haiti by partnering with Ministry of Health clinics and hospitals.
What we discovered was that bringing HIV services to a failing public sector clinic could reinvigorate primary health care if AIDS testing, care and treatment was integrated with other services—specifically, primary care of adults and children, women’s health, tuberculosis control and the control of sexually transmitted disease. 

The town of Hinche, Haiti, the capital of the Central Department and home to about 70,000 people, is instructive. Hinche has a hospital and outpatient clinic, both of which stood nearly empty when we first visited. The clinic was seeing 10 patients per day, and the hospital had 3-6 inpatients in its 60-bed facility. Prior to the involvement of Partners In Health, only 43 cases of HIV were found—about 25% of the 176 people tested. There was no strategy for integrating health services, bolstering primary care, tuberculosis control or women’s health.  The testing center  which had three full-time trained and paid employees simply waited passively for people to come forward for testing.

Two things about this example are striking. First of all, it was estimated that a minimum of 1,500 people were living with untreated HIV in the area; therefore, identifying only 43 new cases is appalling. One would think that the patients would be breaking down the barricades, since it was widely known that antiretroviral therapy was available free of charge. Second, the prevalence of AIDS in central Haiti is 2-4%. If 25% of the tests performed were positive, this is an indication that the test was not being offered broadly, as a screening tool, but, instead, was being offered only to those patients suspected to be infected. Broad screening is important because it offers avenues for intervention through prevention education. It also allows for earlier detection—and thus treatment—of HIV.

Recall that PIH had committed to partnering with the public sector in scaling up its work with the advent of Global Fund and PEPFAR monies. We knew that full general clinic is the best place to find HIV cases—people come to clinics because they are ill, not because they want to be tested for HIV.  This is to say nothing of the fact that the availability of general health services will have a far bigger impact on the health of the community than AIDS care alone.

With these lessons in mind, PIH’s support of the facilities in Hinche included refurbishing wards; providing essential drugs, supplies, and steady power; and improving telecommunications capacity. Working with local government officials, user fees were waived for HIV patients, TB patients, children under 5, and pregnant women,  and fees for all other patients were minimized. The Ministry of Health hired new clinical and administrative staff, whom PIH worked to train. Additionally, the compensation of existing Ministry of Health staff was increased. PIH trained a cadre of community health workers to perform active case finding of vulnerable families, deliver HIV and TB treatment in the home, and provide psychosocial support to all patients. Needless to say, the bolstered clinic, coupled with increased community support, resulted in skyrocketing utilization of services. Today the public health facility in Hinche clinic sees 300 patients per day and performs 600 HIV tests per month. Out of the 8,500 tests performed last year, only 5% were positive. More than 1,000 HIV-positive patients have been identified in Hinche and are being followed by the Ministry of Health with the support of PIH, more than a third of whom are on ART.  More than 400 patients have been diagnosed and treated for tuberculosis. The whole health system, let alone AIDS case detection and treatment, has been strengthened as a result of interest in and funding for AIDS.

We know that success is possible, but the constraints are many. We are convinced that health systems strengthening is the only way to address not only the AIDS and TB pandemics but other health crises as well. In the context of HIV program implementation, we must move from “Emergency Relief” to long term, sustained commitment to creating programs that are locally run and managed. To develop an adequate public sector to respond to the challenge of the AIDS pandemic should be the goal of such assistance.  However, to assist in building a public sector response, it is important to adequately train, retain and compensate health workers. Yet, country offices of PEPFAR still hold to the constraint, rooted in the Foreign Assistance Act, that PEPFAR monies cannot be used to compensate public sector workers. This is not true. Currently, many PEPFAR-funded projects in the field are, indeed, providing salary support for public sector workers involved in delivering AIDS care. Some experts estimate that 20% of the PEPFAR budget is spent on support for the public sector, including salaries.   However, it is often the case that interpretations of the Foreign Assistance Act result in prohibitions on public sector support. Thus, in a multitude of cases, PEPFAR money funds the private, NGO sector, resulting in the development of parallel health systems—charity and public—and further impoverishing the public health system that is the most sustainable and widespread means of delivering health care to the poor.  If donors, NGOs, universities, and governments are to work together to build or rebuild sustainable public health infrastructure, it is imperative that the responsibility for and the funding of these programs be gradually moved to the public sector. African leaders signed a pledge in Abuja, Nigeria in 2001 to commit 7% of their GDP to health; in a poor country such as Rwanda that is experiencing a growing economy, it is possible to imagine that, with time, the government will be able to cover much of the cost of a functional public health system. In countries like Haiti, however, 7% of GDP will not soon cover the cost of a functional health system. International donor money must help put in place the systems that can address not only HIV but also other diseases and primary health goals. Why not use the AIDS crisis to build something that will be sustained for generations to come?

In its first years, much of PEPFAR money was allocated to non-governmental organizations (like mine) with the notion, perhaps, that governments are inefficient or corrupt. The money was, based on the title of the program, geared toward an emergency. Today, programs are established, money has been well used, and people all over the world are receiving care within government driven national plans. It is time to shift the focus of aid to a second phase where our response is made sustainable.  With nearly 3 million people on HIV treatment in resource-poor settings around the world, it is clear that the public sector must shoulder the responsibility for treating and monitoring this and other chronic diseases and fully ensconcing AIDS treatment into the delivery of primary health care services.

To close, I’d like to make a few general comments related to PEPFAR to improve its overall impact and effectiveness in the next phase. We applaud the new financial resources that have been dedicated to helping address the HIV/AIDS crisis thus far. The achievements that have been made in getting more patients into AIDS prevention and treatment programs are laudatory.  However, it behooves us now to be more ambitious.  There are more than 6 to 7 million people today alone who need ART and fewer than 3 million of those are receiving it.  The set-up phase has been successful, but if we keep funding at this level and targets for patients on treatment low, we are not building; we are sustaining work that is less than half done. In the next ten years, with the goal of attaining universal access to treatment, 10-12 million people will need to be started and maintained on treatment. The PEPFAR reauthorization announcement from the White House only included a target of an additional 500,000 patients to be put on treatment for the next five years.  Given that the GDP of the US is fully 33% of the world’s total resources, it is reasonable to expect the US to support 33% of the cost of systems to deliver treatment to these patients. This, indeed, was the goal of PEPFAR in its first iteration,  targeting the US resources to cover the costs of treating 2,000,000 patients in the first five years.  For the re-authorization of PEPFAR to continue in this generous and fair vein of 33% of the global AIDS commitment  would mean to cover the cost of 4,000,000 people in treatment by the end of 10 years, not 2,500,000 as currently proposed.  The target of 500,000 additional people in treatment and only 30 billion USD proposed for the second five years is less than level funding for the United States’ most successful international aid program.  Thus, to meet the needs of the countries suffering, hold up the US share of international aid and build and sustain health systems to deal with this crisis, at least 50 billion USD over the next five years is necessary. 

Today we have a choice that clearly sculpts the global epidemic and the view of the generosity and fairness of the United States throughout the world.  I urge you to build on the successes of PEPFAR, to use the AIDS crisis to examine and address the illness and suffering throughout the world and not simply to preserve the first five years of PEPFAR in a museum of unrealized possibilities, but rather to continue in the visionary trajectory of using these resources to address, for the long term, the worst epidemic in the history of mankind. 

Pablo Gottret & George Schieber, Health Financing Revisited: A Practitioner’s Guide (The World Bank 2006).

World Health Report 2006: Working Together for Health (WHO, Geneva, 2006).

http://www.unicef.org/infobycountry/lesotho_statistics.html Accessed September 18, 2007.

http://www.unicef.org/infobycountry/malawi_statistics.html  Accessed September 18, 2007

The negative impact World Bank and IMF macroeconomic structural adjustment policies was compounded by poor governance decisions, corruption, and misplaced spending priorities in many developing countries.

http://www.unicef.org/infobycountry/haiti_statistics.html. Accessed September 18, 2007.

[published September 2007]

Composed and performed by Village Health Workers in Lesotho
Translated by Archie Ayeh

The message has reached all nations
Our people, the time has come
Time to fight the fiercest battle
We have to fight to defend the Basotho nation

People, young and old, take up your weapons
Let’s fight and defend our Basotho nation
Because AIDS has wiped our nation
Children are left behind as orphans

Us people living here at Ketane
God has gazed at us with merciful eyes
During this very difficult time
He donated us experts of this disease

Ntate Jonas and ‘M’e Jennifer
We thank you in a special way
Because you have shown commitment
To help the people of Ketane

They [Dr. Jennifer & Dr. Jonas] have educated and counseled the nation on HIV/AIDS
They trained the village health workers
They never shy away or hesitate to help people suffering from this disease

Quality  health care  has emerged in Ketane
On one end it’s Dr. Jonas, on the other end is Dr. Jennifer
In the middle it’s us the Village Health Workers
On one end it’s ‘M’e ‘Moso, on the other end its Ntate Kolobe (Our nurses)

People of Ketane were dying in large numbers
Mothers, fathers  and children were left as orphans
But since “The Good Lord” is merciful, a miracle occurred
He sent  us these people from America (Dr.Jonas & Dr. Jennifer)
They came to our country to help but out of all regions they chose Ketane and started their work here on the 18/07/06

They found people dead and ready to get buried, but they raised them from the dead, gave them drugs called ARVs
ARV’s defeated HIV and improved people’s immunity
As for Tuberculosis, it doesn’t even want to hear of them.
It (TB) fled, fell and drowned in Qhoasing and Ketane rivers.

They did not wrestle this beast alone, they were assisted by others,
Ntate Lesole, Kolobe and Ausi Tlaleng, the “Tolly ba thate” in Ketane.
As for the village health workers, we came in like hunters

Long live Partners In Health, so we can live well

Right here in Ketane
God has mercy on us
He granted us PIH
PIH gives us ARVs
With ARVs we can live longer
They defeat HIV, the virus which causes AIDS

We thank you God
Keep PIH for us
So we can live longer
And watch our children grow

[published September 2007]

The PIH project in Lesotho scored an important breakthrough in mid-September in its efforts to bring universal HIV prevention, testing and treatment to remote mountain communities. The Bobete health center organized its first clinic session designed specifically to encourage participation, education and testing for men.

	"
	Men have been a distinct minority in Bobete and at other health centers in Lesotho

The response exceeded their hopes, expectations and supplies of testing materials. 150 men showed up for the clinic. And at the end, 120 of them asked to be tested. That’s more men volunteering to be tested in one day than the health center had averaged for each month through the first half of the year.

The reluctance of men to get tested – or even to seek health care - has been a major obstacle to rolling out HIV prevention and care in Lesotho. Since setting up shop at the first of several mountain health centers a little more than a year ago, PIH has tested almost 5,000 people for HIV and is now caring for nearly 2,000 who have tested positive. Around 700 are now receiving antiretroviral therapy.

Those numbers are as astonishing as they are alarming, especially when you consider that only 20,000 people live in the areas served by the first three PIH health centers and that until recently testing and treatment have been embraced by only half the population — the women. Through the end of July, more than twice as many women had been tested as men, even though the percentages of men and women who test positive are virtually identical.

Within weeks after starting work in Lesotho, the PIH team recognized that far more women than men were coming in for testing and treatment. But efforts to encourage greater participation by men met with only limited success. So Dr. Nicholas Lesia, one of two local Basotho doctors now working with PIH, decided to try a different approach.

Dr. Nico (as he is commonly known) and his colleagues at the Bobete health center decided to organize special “men’s clinics.” They designed a culturally sensitive curriculum for education and discussion about HIV, attuned to men’s prevailing conceptions and fears about the disease. They divided the local communities into two groups in order to keep the size manageable and encourage participation. And they enlisted traditional chiefs to persuade men in their villages to attend.

The success of the first clinic guarantees that there will be more to follow, both at Bobete and at other PIH sites in Lesotho. In Bobete, the enthusiastic response means that they now need to organize both a men’s clinic for the second group of villages and a follow-up session for the overflow of men in the first group who wanted to be tested. And the curriculum and experience developed in Bobete are being shared with other sites in Lesotho, so that they can organize their own men’s clinics and break down a major barrier to universal access to testing, care and treatment of HIV.

[published September 2007]

Partners In Health will hold its 14th annual Thomas J. White Symposium on Saturday, October 13, in Cambridge, MA. The yearly event brings together PIH staff, family, friends and fellow activists and advocates for health and social justice for the poor.

The theme of Symposium 2007 is "If We Fail to Act: The Future of Global Health." The program features a number of inspirational speakers, including a keynote from actor/director/activist Danny Glover.

Long an outspoken champion of justice for Haiti, Glover is currently working on a feature film about Tossaint l'Ouverture and the Haitian revolution. Glover served as executive producer and made a cameo appearance in the 2006 film Bamako, a powerful indictment of international financial institutions and policies for their devastating impact on the lives and health of the poor in developing countries.

PIH co-founders Paul Farmer and Ophelia Dahl will also speak, providing an update on our work over the past year and insights into the challenges and opportunities we face in 2008 and beyond.

Symposium details

Date: Saturday, Oct. 13

Time: 3:00-5:00 pm

Location: Sanders Theatre
Memorial Hall
45 Quincy Street
Cambridge, MA 02138

Admission to the Symposium is free and open to the public. But seating is limited and will be restricted to ticketholders.

Tickets will be available on a first-come, first-served basis starting September 29 at the Harvard Box Office. They may be reserved by phone (617-496-2222) or picked up at the box office (1350 Mass. Ave., Cambridge). Some tickets may be released on the day of the event, but please keep in mind that space is limited.

[published September 2007]

Deye mon gen plis gwo mon ke Ayiti!
(Beyond the mountains there are much bigger mountains than in Haiti!)

By Joia Mukherjee, PIH Medical Director

Partners In Health began working in Lesotho in 2006.  Lesotho is a very mountainous and rural country. Only about 10 percent of the 2 million Basotho people live in the capital. The remainder live in small towns in the lowlands or extremely isolated villages in the mountains, where there are no roads, no electricity and no communications. At the time, almost no one in the rural areas of this country where the HIV prevalence is 25% knew their status or was receiving life-saving, highly active antiretroviral therapy (ART).  But since August of 2006 all that has changed in the small villages of Nohana, Bobete and Nkau. 

On August 22nd we celebrated the first anniversary of beginning HIV treatment in the mountain town of Nohana. This was no small feat and it was no small party!! 

When PIH arrived in Nohana, there was no ART available and no consistent infrastructure to support it. Rural health centers like Nohana are served by the Lesotho Flying Doctor Service (LFDS), an arm of the Ministry of Health, in conjunction with the pilots and logisticians of Mission Aviation Fellowship. Because few medical staff are willing to live in the difficult and isolated environment of the mountain clinics, the LFDS system is based on monthly visits of a medical team to the health center. This system, of course, was designed well before the AIDS pandemic. And many within  LFDS, like Nohana’s amazingly committed and talented chief nurse Me Moso, believe that the system must change to provide care that is available to all, when they need it and even closer to their mountain homes.

Enter Partners In Health (Bo-Mphato Litsebeletsong tsa Bophelo). Nohana, and later Bobete and Nkau were the perfect spots to implement a model of rural HIV/AIDS care that is based in the public sector, integrated with primary health care and connected to the village and household levels by community health workers. Nohana was the first. Village health workers (VHW) were trained and engaged in education, case finding and treatment not only for HIV, but for TB, malnutrition and other problems. Most importantly, they were considered an integral part of the team and paid for their work.

As in many countries in which PIH works, the model of community health workers existed in Lesotho prior to PIH’s arrival, but, also like many places, they were largely uncompensated volunteers. Without pay, these rural people who manage day-to-day survival by tending their land and their animals, were not able to devote the time needed to care for their community members, especially given that clinics are far from some villages, often 8 hours walk or even 10 hours by horseback. In Lesotho in particular, many VHWs had died or become discouraged due to the raging HIV epidemic.

The PIH team of Country Director Dr. Jen Furin and Nohana Clinic Director Dr. Jonas Rigodon had experienced some of these challenges before. Jen’s work in Peru had brought her face to face with the despair of families decimated by MDR-TB and was experienced at implementing treatment as not only a medical intervention, but as an intervention of hope and solidarity. Jonas, as Director of the Thomonde and then Hinche clinics in Haiti, had the experience of using HIV testing and treatment as a “Chwal Batay”—a battle horse to improve all services from the detection and treatment of tuberculosis to the treatment of children with malnutrition. Yet both Jen and Jonas tell me that they were unprepared for what they encountered in the mountains surrounding Nohana. 

The suffering of people—in isolated mountain regions where the HIV prevalence is estimated to be higher than 30 percent--was staggering. The number of orphans, rates of tuberculosis, and the disintegration of families, due to massive migration of men to work in the mines in South Africa, would be daunting to anyone. Yet the Village Health Workers who came forward were remarkable people, they participated in training and walked many hours with patients too ill to support themselves.  They understood, from the beginning, the notion of solidarity. 

Nohana also had, arguably, Lesotho Flying Doctors’ Service’s most dedicated nurse, Me Moso.  After 6 months of working with the PIH team, Me Moso turned down her planned transfer to Maseru (the capital city where her family lives) to stay and work in rural Nohana. It was this stalwart team that began the implementation of integrated HIV services and primary health care in Nohana and its surrounding, remote villages. And in August of 2006, the first patients were initiated on ART. Since the beginning of the program in Nohana more than 3,100 people have been tested for HIV, of whom more than 950 tested positive and 486 patients were started on ART with daily accompaniment by Village Health Workers. 

In addition, thousands of patients have visited the clinic for primary care, most of whom had never had access to a clinic that was open, stocked and staffed every day.  In this first year, two additional clinics, in the villages of Bobete and Nkau were also revitalized and have had a similarly profound impact on the community. It was the successes of Nohana in this first year, but also the successes of the PIH-Lesotho Ministry of Health-Clinton Foundation-Mission Aviation Fellowship-Irish Aid collaborative project in these three rural areas that was celebrated on August 22, 2007.

Soccer tournament kicks off anniversary celebration

	Me Moso gives Dr. Jonas Rigodon a traditional Basotho hat and blanket

The celebration began the night before with a staff party. The staff of the Nohana clinic—from cleaners to nurses gave toasts and sang. (can put an audio clip here)  The singing was among the most beautiful I have ever heard. Jen told me that in Lesotho, it is impossible to sing the national anthem alone. It requires harmony. What a beautiful metaphor for our work. Both Jen and Jonas received words of real love and gifts from the staff.  Both received the famous Basotho hat and Jonas was given the blanket that is worn as a coat while Jen was presented with a traditional Basotho dress. It was clear by the evening’s activity that the Basotho-American-Haitian team was one. 

The following day started with a massive soccer tournament in which teams from the villages surrounding Nohana had been invited to participate.  The PIH-Clinton gang also fielded a team—led by Drs. Nico and Jonas in the front line as well as Archie, TK, Bokang, Kose, Moses, Malebu, Kala, Paola, Albert, Bob, Jaclyn and others. 

The first round spelled disaster for the PIH-Clinton team, which suffered a 5-0 drubbing.  When I admonished Jonas for the loss he said, “But Joia, they are professionals!” Professional soccer players?? In the mountains of Lesotho?? I had my doubts. But I will have to admit that our opponents did, suspiciously, have their own jerseys and refused the tee-shirts we brought them).  Our loss proved once again, however, that treatment works. Surely many of these “professional” players were our patients. On a historical note, this isn’t the first time a PIH clinical team has lost to patients in soccer. Perhaps our most famous defeat was when the TB doctors from PIH and Tomsk prison lost a soccer match to a team of patients with multidrug-resistant TB.  I am sure they were professionals too!! 

	The PIH-Clinton soccer team, minus its secret weapon – the three-woman "12th man"

Back in Lesotho, we fared much better in the second round, winning 3-1.  We deployed a secret weapon in this game—a twelfth position on the field shared by three women,  Dr. Limpho, Dr. Mona and Dr. Joia. While we didn’t score the winning goals, I am quite sure that the twelfth man (or should I say women) razzle-dazzle played a role in the victory!! Goals by Kala Tlali, our driver in Mohahna, and Dr. Nico also helped. And the effect of the entire Nohana clinic team, led by Me’ Malehloko, singing in four-part harmony throughout the match cannot be underestimated!  But I will leave the strategic analysis to the experts. The fact is that the PIH-Clinton team was the happiest consolation game winner in the history of “professional” soccer. It should be noted, that throughout the match Jen quelled her deep desire to play soccer and kept the clinic running!!

Pomp, circumstance, speeches and song

In the afternoon of August 22, the pomp and circumstance began. We heard, from early in the day, the sound of the planes.  All five Mission Aviation Fellowship planes made several trips each bearing our guests—our good friends from Irish Aid, more staff from LFDS, Lesotho’s Permanent Secretary for Health. Then helicopters began to descend on this small mountain village, bringing Congressman Jim McDermott of Seattle (who was at the original NIH-sponsored Models to Implementation Forum in Cange, Haiti, in 2003!), our good friend, former head of the Lesotho Clinton team and now Minister of Health Mphu Ramatlapeng, the US and Irish Ambassadors, and, along with many other dignitaries, the Prime Minister of Lesotho Pakalitha Mosisili.

Before the ceremonies began, there was some time for mingling and seeing the new facility at Nohana.  Lesotho’s Secretary General of Health spoke to Drs. Nico Lesia and Limpho Ramangoaela our Basotho doctors (see Paul’s notes from Lesotho) and said, “ Thank you for returning to serve your people and your country, we aim to find more people with your spirit and commitment. Will you help us find them?” The Secretary General gave them his personal cell phone number and encouraged Nico and Limpho to work with him on recruiting others to come home. When he asked how their experience was, Limpho replied, “Work is so much more meaningful when you serve others and serving others is so much more meaningful when you are in your own country, with your own language and your own culture.”   

A crowd of more than 2,500 people had assembled at the Nohana health center to celebrate this day and to welcome these distinguished visitors. Many of those in attendance were themselves patients and Village Health Workers, all of whom had invested much in the last year in the notion that health and solidarity can build community. The ceremonies started with a prayer by Father Francis of Nohana. Father Francis reminded the attendees that health has physical, spiritual and mental dimensions and that building a community through the provision of health care addresses all those aspects of health and is truly God’s work. He remarked on the labor of love that is performed daily by the staff—from those who clean the grounds, to the VHWs who accompany patients to the doctors and nurses who serve Nohana. 

	Village Health Workers singing during PIH-Lesotho's anniversary celebration.

Several dignitaries spoke about the amazing progress that has been made in Nohana, including Paddy Fey, the Irish Ambassador to Lesotho, who delivered his address in beautifully spoken Sesotho.  Congressman Jim McDermott said in his work to support the Global Fund and the Millenium Challenge Corporation he never imagined what this money could do for rural Lesotho. A group of Village Health Workers sang a song thanking Dr. Jonasi and Dr. Geneva (PIH Country Director Jen Furin’s new name). (Click here for the lyrics of their song.) They were followed by Paul Farmer, who praised the leadership of Jen Furin and Nohana Clinic Director Jonas Rigodon. Paul also remarked on the amazing solidarity of the team that has been built in Nohana in just one year. Two patients testified to the gathered crowd how their lives have been changed not only by the availability of antiretroviral therapy but by the caring, concern and friendship of the whole team. 

Village Health Worker speaking at Nohana anniversary celebration

Speaking on behalf of her colleagues and the community, a Village Health Worker addressed many of her remarks specifically to the Prime Minister as she proudly declared, “Mr. Prime Minister, we appreciate that you have come here to honor our work.  And I want to tell you, on behalf of the Village Health Workers, that we are not opposed to hard work. We love our country and our people. We will walk through these mountains until the soles of our shoes are finished. But we need to be paid. When PIH came, they realized the merits of our work, they included us in the plan and paid us for our labor. The program you see today is our work. When we come to clinic, it is a sharing experience.  Please, Mr. Prime Minister, tell your government that Village Health Workers must be paid if we are to change the situation [with HIV] in our country.  We don’t need to be wealthy, just respected.  And if you are committed to this work you will bring us telecommunications and infrastructure. If we had cell phones, we could help so many more people who suffer in isolation. And if there were roads, our burden would be lighter.” By this time, the entire crowd was on their feet cheering the words of their community member, colleague and friend as she respectfully but boldly addressed the Prime Minister of Lesotho, who was visiting Nohana for the first time. 

A parade of Basotho horsemen on beautifully decorated horses came down from the mountains and bowed before the Prime Minister. And when he spoke, it was clear that the work, the ceremony and the words of the patients and VHW had profoundly moved him.

 “What I see here is remarkable commitment,” Prime Minister Mosisili said. “The parliament is very interested in the issue of health and delivering health to the rural areas. However, it is difficult to imagine how this can be done.  Today, I see. I see the role of people themselves in delivering their community back to health. Yes, you must be paid, all of you Village Health Workers who serve your fellow countrymen. You have my promise that I will work for your just compensation.”  The crowd was visibly stunned by the direct response of the Prime Minister to this local health worker’s words. The Prime Minister closed the ceremonies stating that Nohana was a model of hope of what can be done in Leostho.

When the day ended, an exhausted PIH team watched the stars as they appeared in Nohana’s jet black sky. The same stars were there one year ago. But now the earth has changed.

[published September 2007]

By Paul Farmer

Valiant is the word that comes to mind when I think of Lesotho. I see courage and strength manifest in this small country’s people, some of whom PIH is beginning to serve through clinics and projects. Valiant too are the growing number of people from the Ministry of Health and its NGO partners, who are accomplishing these projects in spite of adverse circumstances. Lesotho has one of the largest burdens of HIV in the world and, consequently, may have the world’s highest incidence of tuberculosis. (TB epidemics almost invariably accompany AIDS.)

	Doctors making a home visit in Lesotho

This beautiful country is called Africa’s “kingdom in the sky” for good reason. Even the lowlands are 3000 feet above sea level, and far more striking are the tall ranges of treeless mountains, which in winter (it is winter now) are covered with snow on their southern faces. The very settlements we seek to serve are spread out across this forbidding terrain, making travel to clinic arduous for the patients; home visits by staff, inexperienced unless they’re mountaineers, are also difficult. These challenges only stiffen the resolve of PIHers and their local partners, continuing a commitment first undertaken while PIH co-founder Jim Kim was working at the World Health Organization.

When in 2005 PIH and the Clinton Foundation, along with local partners, launched a rural AIDS initiative in three African countries, we knew we would have to do three things at once: take care of the sick; face the “human resources” crisis through training and working alongside of African colleagues; and rebuild public infrastructure destroyed (as in the case of Rwanda) or simply not equipped for the advent of a new disease, AIDS, and the resurgence of an old one, tuberculosis. We also knew that we’d have to do all of this while attending to the innumerable other health problems faced by undernourished rural people who had never had much in the way of primary health care, to say nothing of treatment for AIDS or, in the case of Lesotho, drug-resistant tuberculosis.

Lesotho, with its terrain, the dimensions of these twinned epidemics, and the near-total lack of physicians in rural areas (there is not a single medical school in the country) posed the greatest challenges for the Clinton-PIH Rural Health Initiative. Within Lesotho, the nine sites in which we are to work are not contiguous, but rather scattered across the high reaches of the east and south. Many are accessible only by plane or on horseback. Yet after only a year of operations, PIH-Lesotho, led by Dr. Jennifer Furin, has attained and surpassed many of our goals in places where few thought it possible. Spurred by a deadly outbreak of extensively drug-resistant TB (XDR-TB) in the neighboring South African province of Kwazulu-Natal, a second program to treat and prevent drug-resistant TB has also already begun, funded by the Open Society Institute. A brief July visit to the mountains and to the capital city of Maseru affords me the chance to update supporters and friends of PIH-Lesotho.

Baptism by Fire: The New “OR” in Nkau
When Jennifer Furin joined us in Rwanda for a June meeting, she was especially pleased to give us the news: finally, PIH boasted two young Basotho physicians, Dr. Nico Lesia  and Dr. Limpho Ramangoaela. Having finished their training at Bethlehem Hospital in Orange Free State, South Africa, both wanted to return to serve their own people. During a weekend clinicians’ retreat in the town of Nkau, Dr. Limpho told us how they came to PIH. She went to see  Dr. Mphu Ramatlapeng, who headed the Clinton Foundation’s work in Lesotho at the time and has since been named the country’s Minister of Health, and said, “I want to come back home.” With the frankness for which she is famous, Dr. Ramatlapeng replied, “Are you serious? If so, do you know any other recent graduates from Lesotho who wish to return?” Dr. Limpho said she did. Soon both she and Dr. Nico would find themselves high up in the mountains and grateful for their good and broad medical educations.

I saw first-hand how effective their education had been, since the clinicians’ retreat was interrupted by a number of emergencies. During a single afternoon, we saw more than one type of trauma. A young woman with cerebral palsy who had been raped was brought in by her mother because the family feared (correctly as it turned out) that she was pregnant.

	Stitching by candlelight in Nkau

Shortly thereafter, as the sun was setting, a young man named Tseliso managed to stagger through the doors hours after a machete attack. He had serious wounds in his head, back, and wrists; the lacerations went to the bone. He needed medical care desperately and, as chance would have it, there were six doctors that day in a village where normally there are none. A few minutes after their arrival, Tseliso and his brother (also injured in the attack) were being cleaned and stitched up by Drs. Nico and Limpho, and also by PIH’s Dr. Mona Haidar. Because Tseliso’s injuries required careful cleaning and over 200 stitches, the doctors were soon sewing by candlelight. Without narcotics on hand, the patient received only local anesthetic, but he made no complaint except to say, even before the suturing was done, that he was hungry.

Tseliso after 200 sutures and multiple bandages

It took a couple of hours to patch Tseliso up, but his injuries would require further skills, since at least one of his wrists had been broken during the attack. Jen arranged to have him airlifted on Monday to Queen Elizabeth II Hospital in Maseru to see one of the two orthopedists in the country. After the patients were tucked in for the night, Dr. Nico told us what had happened. At 8 o’clock that morning, the two brothers were attacked by men who had been grazing cattle on their land without permission. (This made me think of the nineteenth century Boer incursions into these regions for the same purpose: to take over Basotho grazing lands.) The usual arrangements stipulated that the cattleherders go to the chief’s kraal to pay a grazing fee. Instead,Tseliso and his brother awoke one day to find strangers and cattle on their land, and, following convention and customary law, asked them to leave. The next day, Dr. Nico explained, they were attacked at their home by a group of men with machetes. Left bleeding and in great pain, they had to walk three hours from their home village to the clinic in Nkau.

	The Nkau operating room team celebrates

Dr. Mona has been in Lesotho for six months, and has seen plenty of trauma. This was, she said, a more aggressive assault than any she’d seen, with the exception of a man killed by an axe blow to the head. High unemployment, poverty, labor migration back-and-forth to South Africa, and substance abuse conspire to create an environment in which the PIH doctors expect to see trauma on a regular basis. Tseliso and his brother were lucky, in a sense. Though gravely injured, both can expect to recover completely.

Home visits

	An AIDS patient and her accompagnateur near Nkau

The next day was dedicated to home visits, an activity conducted at all PIH sites. While Jen took off on horseback to see a critically ill patient hours in one direction, I had the privilege of spending the day walking to severely ill AIDS patients in another. I followed Nico and Mona. Although the patients we visited were very ill, all were responding to therapy. It was a long and satisfying hike, despite some haunting scenery of abandoned houses and mission schools. The population in rural areas of Lesotho is shrinking, as people migrate to cities in search of work and HIV has reduced life expectancy from 60 years to less than 40.

Later that day the team celebrated a successful candlelit surgical intervention, rewarding home visits, and a fruitful retreat. Dr. Limpho revealed that she had, in addition to her clinical skills, a good deal of talent as a chef. Jen had bought a sheep for her staff and visitors. As we were enjoying barbecued mutton, one of the village elders, who told us he was 73 years old, praised the doctors and nurses in straightforward terms: “Never before have we had doctors and nurses live among us up in the mountains. You are a gift from God.”

In Maseru
The next morning, with the help of our friends and partners in Mission Aviation Fellowship, we were able to airlift Tseliso to the country’s main hospital (the partnership between PIH and MAF was profiled recently by the Baltimore Sun. The emergency room was crowded with all sorts of patients, some of them seeking, I suspect, primary care; others came with wounds. Without Dr. Nico, it would have been hard to wade through the crowd and find the right place to wait. After we got Tseliso settled on a bench, referral letter in hand, Nico went to find a boy who’d been referred for surgical management of chronic osteomyelitis. This child had been sent to the hospital from the mountains and was happy to see his doctor. Every time I heard Nico and Limpho speak to patients and family without the help of a translator I felt a deep satisfaction. PIH’s efforts in a country with a handful of doctors could not have been launched without people like Zanmi Lasante’s Dr. Jonas Rigodon (who has written in these pages about his work in Nohana). But in addition to the pride we take in South-South collaborations between Haiti and the African sites in which we work, there is satisfaction in knowing that we are also able to reverse, in some measure, the brain drain that has taken so many doctors and nurses away from Africa’s poorer countries. The rural reaches of these countries have never had resident medical professionals: this local brain drain, too, we are seeking to reverse.

Finally, with specimens dropped off in the laboratory for testing, we went to the new PIH office in Maseru. As Dr. Nico sat down in front of a computer, he said something I won’t soon forget: “Doing this work as a doctor up in the mountains makes me feel very lucky. To fight for access to health care for the rural Basotho seems to me to be the best job a doctor could have.”

Being in Maseru also allowed me to meet other new members of the PIH team assembled by Jen. Our other major endeavor apart from the rural initiative has been to introduce to Lesotho a sound prevention and care program for multidrug-resistant tuberculosis (MDR-TB). Although we still don’t have a good sense of just how big a problem MDR-TB is in Lesotho, it’s clearly a significant threat to effective TB control here. And although we’ve had a great deal of experience treating MDR-TB in Peru, Russia, and Haiti, there’s an enormous complication in Lesotho: most patients afflicted with MDR-TB, a lethal disease on its own, also have HIV infection. It’s not possible to tackle one disease without tackling the other. And handling either MDR-TB or AIDS requires a mix of clinical acumen and what are termed “programmatic skills,” which means the ability to strengthen public health programs aimed at both prevention and care. This is complex and difficult work, quite different from stitching up an injured patient. Across the world, few people have the sort of training and experience needed to take on these colliding epidemics.

Spending time seeing MDR-TB patients with PIH doctors Kwon-jeun Seung and Hind Satti brought these lessons home. We were in Botsebelo, a clean and well-constructed facility that will soon serve as Lesotho’s national referral center for MDR-TB and also, we hope, as a national center for training health providers in the effective prevention and care of this disease. Most of the patients we saw had been laborers in South Africa, often in the mines; all but one had both drug-resistant TB and HIV infection. Each of them had been treated previously, often over the course of years, with regimens that would have cured drug-susceptible TB. Some had been treated in South Africa. None had been cured.

This reservoir of “chronic” patients in Lesotho will prove daunting, but the PIH team there, especially Jen, has long experience in seeking to treat chronic MDR-TB patients at the same time that efforts are made to speed up diagnosis and proper care of MDR-TB. Proper care, in this setting, means top-of-the-line regimens that might cure even highly drug-resistant strains, even among patients also afflicted with HIV disease. At the same time, the MDR-TB project will seek to help the Ministry of Health to “retrofit” the country’s network of hospitals and clinics to make them safer for patients and their families. TB is too often an infection acquired within hospitals, clinics, and other congregate settings. More South-South collaboration may prove important in Lesotho: the PIH-Peru team (Socios En Salud) has special expertise in infection control and will be providing technical assistance here; the PIH-Haiti team, as noted, has already made an important contribution to PIH-Lesotho in the person of Dr. Jonas, who in August will celebrate a year in service to the people living around Nohana. He often reminds me that, on our first day in the mountains of Lesotho, in the town of Nohana, it began to snow.

All of PIH-Lesotho will be celebrating a birthday on August 22, when co-workers from Lesotho, Rwanda, Malawi, and Boston join the Minister of Health, Dr. Ramatlapeng, the Clinton Foundation, the Irish Government (which has funded much of our work in Lesotho), and many other partners and supporters in the same town, Nohana. Nohana has been transformed in many ways: the facilities there have been retrofitted for infection control; a new clinic has been built; hundreds of patients with AIDS and TB are receiving world-class care; and tens of thousands have received basic health care services, which in Lesotho often includes screening for HIV infection. All of this has occurred in Ministry of Health facilities.

I will be going back to Lesotho from Rwanda in a few weeks, and I can’t wait to be back here. PIH-Lesotho is in many ways the heart of PIH, no less than Haiti: the people who live here have struggled for centuries to improve their lot and the lot of their children. They have sometimes served larger causes, as have the Haitians: as Haiti supported nineteenth-century struggles against slavery, so too did Lesotho serve as a place in which the struggle against apartheid might survive. And at the end of these struggles, both Haiti and Lesotho have been left with less than was owed them by what should have been a grateful world. But in Lesotho, as in Haiti, the spirit of resistance survives and inspires all of us to move forward against all odds.

[published August 2007]

	Earthquake destruction in Pisco, Peru

A rapid-response medical team from Socios En Salud (SES), PIH’s sister organization in Peru, has found widespread destruction but no confirmed deaths among our patients in the area devastated by a powerful earthquake. The quake destroyed the homes of more than half of our 115 patients in the region south of Lima and several lost at least one family member. Most have no access to clean water or electricity. SES continues to search for a number of patients who have not yet been located, even as we mobilize medicine and other emergency supplies for those who have.

On Wednesday, August 15, a tremor registering 7.9 on the Richter scale leveled 85 percent of the buildings in the coastal town of Pisco, Peru, killing more than 500 people and leaving 100,000 homeless. By the next day, SES had dispatched a team of doctors, nurses, and community health workers to the scene. Their mission: to find all of our patients in the area being treated for multidrug-resistant tuberculosis (MDR-TB) and the SES staff who cared for them; to make sure their treatment is not interrupted; and to assess what will be needed to help our patients and the community get back on their feet. Although slowed by the collapsed bridge connecting Pisco to the Pan American highway, the SES team was among the first to arrive ready to provide relief, guidance, and a little bit of hope to survivors.

	A member of the SES team (right) consults with hospital staff in Pisco

They found a scene of devastation. All that remains of the Pisco city hospital is a pile of rubble. The larger regional hospital was also severely damaged. Tents have been pitched in the courtyard to treat the injured. Those health centers that are still standing have no water or electricity. Many have already run out of basic medications including ibuprofen and antibiotics. SES was able to contribute badly needed medicine, food, clothing, and blankets. The team also met with the regional hospital’s TB team in order to determine how best to continue patient care. 

Immediately after returning to Lima on August 19 (bringing two seriously injured victims with them), the SES team started preparing a second group for what they would find when they returned to Pisco a few days later. 

“People have lost everything," warned Dr. Leonid Lecca, SES Coordinator of Clinical Projects and a member of the team of first responders. "It’s one thing to see all of this on the news, but it’s another to be there. Pisco looked as though it’s been bombed, and they keep finding more victims in the debris.”

	SES staff members (center) help distribute emergency supplies to earthquake victims in Pisco

Just a week after the earthquake hit, on August 22, the second SES team arrived in Pisco and the surrounding towns, where they will continue to search for missing patients and their families.  When they are found, we will ensure that they have the medications, supplies, and support they need to rebuild their lives. 

We are gratefully accepting donations to help us in these efforts. To make an online donation for earthquake relief efforts, click here to go to a secure server at Entango, our online donations partner, and select “Peru Earthquake Relief” in the drop-down menu for “Program.” 

Contributions can also be made by check.  Please specify “for earthquake relief” in the memo line and send them to:

Partners in Health
Attention: Rachel Ross, Peru Project Manager
641 Huntington Ave
Boston MA 02115

[published August 2007]

PIH's Institute for Health and Social Justice helps build movement for health and rights

More than 10,000 people from across the United States and around the world converged in Atlanta, Georgia, earlier this summer for the first-ever U.S. Social Forum.  Nearly a thousand workshops, plenaries, concerts, and film screenings addressed the theme “Another world is possible. Another US is necessary.”

Based on the model of the World Social Forum, the U.S. Social Forum was a gathering of activists, community leaders, students, and professionals committed to creating a more just and sustainable society. Critical social issues ranging from global warming to militarism to dismantling racism led to an engaging exchange of ideas. 

At the forum, the Institute for Health and Social Justice (IHSJ), the education and advocacy arm of PIH, helped lead a four-day course titled “Promoting Health for All,” which explored the connections between politics, economics, oppression, and health. Over 40 participants discussed a broad range of topics that affect health and access to health care in the U.S., including trade, debt, war, and discrimination. 

The IHSJ joined with the People’s Health Movement and other health rights groups to offer the course under the banner of the International People’s Health University. The Hesperian Foundation, Physicians for Social Responsibility – Iowa, and Doctors for Global Health also co-sponsored the course.

Drawing on a wealth of personal knowledge and experiences, course faculty and participants outlined how the current US health care system fails to meet the needs of the most vulnerable—people living in poverty, people without insurance, people of color, women, and children—and projects that example as a model for the world.

For many of the participants, these issues were not abstract concepts, but challenges they and their communities struggle to overcome every day. 

One participant, a practicing nurse who works with migrant farmworkers in Florida, spoke of her own childhood as an undocumented farmworker, and the many threats to health these workers face every day. 

“You’re exposed to pesticides and other chemicals on your job.  Then maybe you get sick, but you can’t get to the doctor because you live on your boss’s farm with no transportation.  Finally your boss sends you to the doctor with a company translator.  The translator hears everything you say and can change it when he translates for the doctor.  You have no control and no confidentiality,” she said. “If you try to make any trouble, or you don’t get better, your boss will have you deported.”

Other participants spoke of their experiences with racism, homelessness, and poverty, and how these barriers prevented them and their loved ones from receiving the care they needed.

The course included presentations and working groups intended to initiate popular campaigns for the US-based chapter of the People’s Health Movement.  Working group topics included trade and health, health of underserved communities, militarism and environmental health, and advocating for the right to health.

Though the People’s Health Movement has helped many countries around the world build powerful coalitions to advocate for health issues, few people in the US are familiar with the group’s work.

“What happens here affects the rest of the world.  If we want to change unjust trade regimes and international policy that denies poor people around the world the right to health care, we have to start at home,” said Hesperian Foundation Executive Director Sarah Shannon.

She related a story from a recent international meeting of the People’s Health Movement in Bhopal, India. 

“In one of the sessions, I was seated next to a woman from a very rural area of Bangladesh.  She was a poor woman, dressed in a faded sari and plain sandals.  When I introduced myself, she said, ‘Oh!  You are from the United States!  It is good you are working to build the People’s Health Movement there.” Shannon said. “The woman smiled and took my hand.  ‘We all need a movement for right to health in the United States,’ she continued, looking directly into my eyes.  ‘Please, if there is anything I can do to help you, tell me.  I will do anything I can to help you.’”

* * *

More information on the international People’s Health Movement can be found at www.phmovement.org.  For information on the US chapter of the People’s Health Movement, please visit www.phm-usa.org.  The next International People’s Health University course will be held in Savar, Bangladesh in November 2007.  The course outline and application is online at http://www.phmovement.org/iphu/en/node/38.

[published August 2007]

	Solar panels at a PIH clinic in Rwanda

Like all modern medical centers, the five rural health clinics in eastern Rwanda operated by Partners In Health need reliable power 24/7. But unlike other off-grid facilities, each of these centers is powered by a hefty 4.4-kilowatt solar photovoltaic system designed and installed by the Solar Electric Light Fund (SELF). The solar systems have been up and running since February 2007.

The five clinics represent a number of “firsts.” For PIH the project was its first foray into Africa and its first use of solar power. Also, this is the first time SELF has extended the solar technology envelope to supply such large amounts of electricity to rural health centers. This PIH project is supported by the Rwandan Ministry of Health and the Clinton HIV/AIDS Initiative, among other donors and nongovernmental organizations.

At the five clinics—in Mulindi, Rusumo, Rukira, Nyarabuye, and Kirehe—solar power systems supply electricity for state-of-the-art laboratories, refrigeration, and computer recordkeeping and communication, including satellite dishes to transmit data. In the laboratories, solar electricity powers microscopes, blood analysis machines, centrifuges, portable X-ray machines, and sterilization devices. The systems also provides extensive lighting, as these are 24-hour facilities with patient wards.

Solar vs. Diesel

This PIH/SELF partnership might never have happened if SELF had not persuaded the PIH staff to question the time-honored proverb, never look a gift horse in the mouth.

PIH had planned initially to use diesel generators that had been donated by the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, SELF staff assessed the Rwanda sites to determine the energy needed and the feasibility of solar power. Their analysis persuaded PIH that solar would be a better long-term solution to meet the electric power needs of its rural health centers. Solar does not emit carbon dioxide or other greenhouse gases, and while upfront capital costs are higher, solar is ultimately less expensive over time, and more reliable and sustainable.

“The generators might be ‘free’, but diesel fuel costs would be a constant burden, assuming fuel is available,” explained SELF Executive Director Bob Freling. “Currently, in fact, there is a national shortage of diesel in Rwanda. Further, diesel is a petroleum-derived product, so even if obtainable, its cost will rise with the price of oil, which will always be unpredictable, subject to the whims of the market, availability of supply, and geopolitical constraints.”

	Installing a solar panel at a PIH clinic in Rwanda

But solar power cannot be disrupted in this way. As long as the system is properly installed and maintained—and as long as the sun emits energy—solar is the most reliable source of power for rural communities not connected to a national utility grid.
The reliability argument won PIH over to solar. In a hospital setting, where procedures are conducted all the time, reliable power is paramount. SELF designed solar-hybrid systems that rely on solar to meet 90 percent or more of the clinics’ needs, with generators providing back-up power during prolonged periods of rain or extra-heavy electricity usage.

A key feature of SELF projects is that they must be locally sustainable. For the five clinics, SELF trained local staff to look after the solar systems. In addition, SELF has been working with the Rwandan Ministry of Health and the Kigali Institute of Science and Technology to develop a national training program for installing and maintaining solar electric systems.

The Power of Partnership

“This is a great example of the power of partnership,” Freling said. “Two nonprofit organizations with different but overlapping agendas—health care for the poor and sustainable energy for the developing world—came together; SELF provided a service that enables PIH to fulfill its mission in an economical, sustainable, nonpolluting, carbon-free way.”

SELF raised about 80 percent of the funds for the solar power project. Although this amount was a small fraction of the millions of dollars PIH and donors have invested in the Rwanda health centers, it was nonetheless critical.

	Wiring the solar power system

“What more could we ask for?” asked Christian Allen, who works on PIH’s Electronic Medical Records system in Rwanda, another key component of the PIH model that depends on reliable electricity. “They asked us what we needed, went out and found the money to pay for it, and then came here to install it and teach our people how to use and maintain it.”

More broadly, SELF’s aim is to act as a catalyst to help PIH and other international organizations rethink their power strategy when they plan for community improvements in rural areas, from health care to education to economic development.

“Choosing solar electrification over diesel-powered generators represents a paradigm shift in the thinking of those in the international development sector,” Freling said. “SELF’s success with these projects will help create results-oriented, nonpolluting, sustainable solutions that are replicable on a large scale.”

[published August 2007]

“Jeanette was so sick,” said Dr. Joseph Mucumbitsi, a Rwandan pediatrician. Bedridden for months, the 14-year-old only weighed about 65 pounds. Her heart, weakened and scarred from an infection, could not effectively pump blood to the rest of her body, and she was slowly suffocating.

Eight-year-old Louise was also struggling to survive. Her swollen body was wracked by recurrent asthma-like spasms in her lungs and persistent coughing. 

Both girls suffered from rheumatic heart disease (RHD), a grim and all too common diagnosis in their Rwandan community. What was uncommon was the international effort to save them on the part of PIH's Rwandan partner organization Inshuti Mu Buzima, the Salam Center for Cardiac Surgery in Sudan, and an Italian humanitarian organization called Emergency.

	Jeanette before undergoing surgery in Sudan

Both girls faced almost certain death without heart surgery, something that no medical facility in Rwanda—or in most African countries—could safely provide. So PIH and Emergency arranged for them to travel to Sudan, where the Salam Center for Cardiac Surgery had opened earlier this year in the capital city of Khartoum. Built by Emergency, the state-of-the-art facility provides health care for free to the people of the region.

At the Salam Center, doctors struggled to fix Jeanette’s damaged valve, but the tissue had already been scarred beyond repair. So they replaced the valve with a new temporary one, which they hope to exchange for a more permanent one in several years. Louise also received a new valve.

Nurse Eric Kamanayo with Jeanette before surgery

“It’s very amazing to see how they have improved,” says Eric Kamanayo, a nurse who accompanied the girls to Sudan. “Louise is now able to run 100 meters without stopping. This is unbelievable but true!” Louise has already gained more than four pounds, while Jeanette has put on an amazing 15 pounds since the surgery.

These two girls were incredibly fortunate. At the King Faisal Hospital in Kigali, the Rwandan capital, Dr. Mucumbitsi sees many other children from around the country in similar conditions die every year. One reason is a lack of access to the needed medical treatments.

Currently, there are only a handful of hospitals that can perform cardiac surgery in all of sub-Saharan Africa. In comparison, North America boasts more than 4,000 such facilities. And even if a patient is fortunate enough to receive the opportunity to go to one of the few cardiac surgery facilities, it might be too late by the time all the logistical details can be arranged. Two other young girls died earlier this year as Dr. Mucumbitsi desperately tried to find a place to send them for surgery. “The process took so much time that they couldn’t survive long enough to be saved,” he said. “One of them died just one day before her flight to Israel.”

An even larger problem is widespread lack of access to basic medical care. Jeanette and Louise both had heart damage that could easily have been prevented, says Dr. Gene Bukhman, a PIH cardiologist who works at the Brigham & Women's Hospital in Boston and the Department of Social Medicine at Harvard Medical School. His goal is to develop ways to deliver quality cardiovascular care in resource-poor settings.

RHD results from untreated Streptococcal infections. These bacteria, which commonly cause strep throat and skin infections like impetigo, can be cleared up with a simple course of antibiotics like penicillin. If left untreated, however, the body’s immune system can start to attack its own heart valves in a mistaken attempt at self-defense, leading to RHD.

	Louise after surgery in Sudan

In countries like the U.S., children with sore throats and skin infections are usually quickly diagnosed and treated. But in poor countries like Rwanda, medicine and diagnostic tools are not readily available, hospitals are often far away, and quality medical care is usually too expensive for most citizens. So when children like Louise and Jeanette catch a sore throat, there are no services to prevent this simple infection from progressing to RHD. As a result, nearly half of the 16 to 20 million people affected by the disease worldwide live in poverty-stricken sub-Saharan Africa. Dr. Bukhman came across at least eight RHD patients in need of heart surgery during a month in Rwanda, along with about 60 other patients in need of medical treatment for advanced heart failure. 

This year, Rwanda joined other African countries in the ASAP initiative (Awareness, Surveillance, Advocacy, and Prevention) to challenge the RHD problem. Dr. Mucumbitsi helped create the Rwandan Heart Foundation. With the help of PIH, the Rwandan government, and other organizations, he hopes to create an in-country medical center that can safely provide heart surgery to those in need, a penicillin program to help protect those fighting infections, as well as local programs for identifying and treating strep throat and skin infections before they progress into life-threatening conditions.

	Jeanette and Louise after surgery in Sudan

“We have the opportunity to help some of the sickest patients,” says Dr. Bukhman. “We need to take on RHD in an aggressive way.”

As for Jeanette and Louise, both girls are now back with their families in Rwanda and looking forward to starting school. One of the doctors in Sudan has offered to help them with school fees and supplies. 

“Those are two children saved because they had the chance to be sponsored by Partners in Health,” says Dr. Mucumbitsi.

[published August 2007]

	PIH community coordinator Likhapa Ntlamelle (right) talking with two MDR-TB patients

Barely five months after Partners In Health and the Open Society Institute announced plans to create a model for treating overlapping epidemics of multidrug-resistant tuberculosis (MDR-TB) and AIDS, the program in Lesotho is up and running. At least 21 patients have already started receiving the complex combination of drugs needed to treat MDR-TB. In addition, most of the work had been completed to equip and train the national tuberculosis laboratory to perform the lab tests needed to diagnose cases of drug-resistant TB, and to turn a dilapidated hospital into a state-of-the-art center for TB treatment.

With nearly one-third of its adult population infected with HIV, Lesotho may have the world’s highest incidence of tuberculosis as well. TB epidemics almost always shadow AIDS in populations where many people’s immune systems have been weakened by HIV. Evidence to date suggests that about one in three cases of TB in Lesotho is resistant to at least one drug, and more than 75 percent of patients with TB are also infected with HIV.

Although the exact scale of the epidemic is not yet known, Dr. Salmaan Keshavjee, a physician at Brigham and Women’s Hospital who is the Deputy Country Director of PIH's program in Lesotho, estimates that 1,000 to 1,300 people in Lesotho may currently be living with and infecting others with MDR-TB. “Even if you find half of that,” he says, “500 cases a year is an overwhelming number for a country the size of Lesotho,” with a total population of barely two million. In comparison, PIH’s partner organization in Tomsk, Russia, sees 300 to 400 cases of MDR-TB a year.

MDR-TB is particularly dangerous and difficult to treat for many reasons. The typical first-line drugs for TB are ineffective against these strains, forcing MDR-TB patients to take second-line drugs that are more costly, carry extensive side effects, and must be taken every day for up to two years. If the medications are not taken consistently, the disease can develop resistance to these drugs as well, fueling the spread of even more deadly strains known as extensively drug-resistant TB or XDR-TB. An outbreak of XDR-TB in the South African state of Kwazulu-Natal, just across the border from Lesotho, killed 52 of 53 HIV-infected patients in 2006, prompting fears that the disease could prove untreatable and uncontrollable in populations with high rates of HIV. OSI’s $3 million grant to PIH aims to build on our success at treating MDR-TB in Peru and Russia to develop, test, and disseminate a model for treatment of drug-resistant TB in areas with high prevalence of HIV.

By the end of August, 21 patients in Lesotho had already begun the complex drug regimen for MDR-TB, which is just one part of the comprehensive approach used successfully at other PIH sites. The program also includes food support, as well as frequent visits and support from community health workers, says Dr. Hind Satti, the director of PIH's MDR-TB program in Lesotho, based in Maseru, Lesotho’s capital city.

In the coming weeks, the project plans to supply drugs and services to 40 patients, and hopes to scale up to a total of 100 patients by the end of this year, says Dr. Satti. PIH staffers worry that this will only be a drop in the bucket. “If we identify another 100, what’s going to happen to them?” asks Dr. Keshavjee.

Although eager to include more patients in the drug treatment program as quickly as possible, Dr. Keshavjee also acknowledged that the process will be more complicated than just putting patients on medication. “We need to scale up properly so that these people can get appropriate care in a manner that won't lead to the creation of more resistant strains,” he explained. “We need the resources to provide high standard community-based treatment, using the accompagnateur model [in which community health workers provide directly observed therapy and psychosocial support] that we have used in Haiti, Boston, and elsewhere.”

	With new equipment and training, the national TB lab in Lesotho will be able to test for MDR-TB instead of sending samples to South Africa

To tackle this challenge, the program first requires equipment and staff to effectively identify patients with drug-resistant strains of TB, and monitor the progress of treatment. To do this, PIH is working with the Ministry of Health and the Foundation for New and Innovative Diagnostics (FIND) to build the capacity of Lesotho’s national TB laboratory. A lab in South Africa currently processes samples for Lesotho patients, problems with shipping specimens and receiving results are common. Also, the South African lab can only handle a small portion of what’s needed to run a truly effective program. Renovations and new equipment, such as a state-of-the-art negative-pressure ventilation system and a rapid culture machine operated by lab technicians who have been trained and hired locally will all help Lesotho’s lab become a vital resource for the MDR-TB treatment program. FIND has sent a full-time lab specialist to help develop this essential laboratory capacity.

Other new and important resources for the treatment program include a refurbished TB clinic and a hospital to help identify and care for extremely ill patients. These renovations include methods of minimizing the risk of TB patients infecting others, such as a a state-of-the-art ventilation system, a waiting room for TB patients separate from the general outpatient waiting area, and a TB unit separate from the HIV unit to protect patients with weakened immune systems. Other improvements include a new pharmacy.

Training health workers to treat MDR-TB patients is another important component of the program. Earlier this summer, about 75 health professionals from three regions of Lesotho received training, said Dr. Satti. She hopes that in the next few years, the program will create a training manual and establish public training centers for regions throughout the country.

In the future, PIH hopes that the program will become a model that can eventually be scaled up on a national level. But ultimately, MDR-TB is a global problem, says Dr. Keshavjee. The aim is not just to create a successful program in Lesotho but to develop and test a standard that the global community can work together to implement internationally. “This problem is not going to go away, it’s only going to get bigger,” he says, “It has to be the international community working together to come up with a solution.”

[published August 2007]

FACE AIDS, a student organization that has already raised more than half a million dollars for Partners In Health, is expanding its support to work directly on projects that will create incomes for our patients in Rwanda. Katie Bollbach, one of the three founders of FACE AIDS, stopped off in Boston on her way to Rwanda in July to brief PIH staff on what has been accomplished and where they hope to go from here. She said FACE AIDS is “so excited to be working with Partners In Health in Rwanda this year. Your mission-driven work has inspired us for years and so it’s an honor to be able to get to work alongside you.”

Katie will be staying at our Kirehe site in Rwanda for the next eight months. There she will set up small income-generating projects. In the beginning she will work with people from three or four local AIDS associations to make AIDS-awareness pins that will be sold in the U.S. The initial group will include about 40 people, some of whom are patients at the clinic in Kirehe.

The pin program, however, is just a launching pad for creating a variety of sources of income for people in Kirehe. Katie hopes to set up microfinance programs, help acquire small loans and grants for members of the associations, and coordinate trainings in conjunction with organizations such as Opportunity International to provide people with more extensive job support.

The pin program also serves as a source of fundraising for PIH and a way to raise awareness about the AIDS epidemic. Melissa Gillooly, PIH's Rwanda Project Manager, says of FACE AIDS, “They are student-started and student-run and they have really shown what a committed group of students can achieve. The amount of knowledge and excitement they have acquired to pass along to other students is incredible. We’re very lucky that they’ve chosen PIH and we’ve learned many skills from them on how to engage students.”

As part of its campaign to raise $1 million for PIH, FACE AIDS sells the AIDS pins and gets matching donations from businesses, including the investment firm, Sterling Stamos, and the designer company, Liz Claiborne. The projects Katie will launch in Kirehe are based on work she and her fellow students started in refugee camps in Zambia.

Katie, and two other Stanford students, Jonny Dorsey and Lauren Young, went to work in the summer of 2005 for an organization called FORGE (Facilitating Opportunities for Refugee Growth and Empowerment) in a refugee camp in Zambia. It was there that these three students came face to face with AIDS.

They met Mama Katele, an HIV-positive woman and the only person in the camp of 24,000 refugees who was willing to talk openly about her HIV status. Their friendship changed the face of their work in Zambia and their lives in the years to come. They had come to Zambia to work on several development projects—literacy, female empowerment, and orphan care. They soon discovered that AIDS affected all these areas. If they wanted to do effective development work, they would have to tackle HIV.

They took off time from their studies the following year to launch an ambitious two-pronged effort – to give their friends in Zambia a source of income and, at the same time, to raise money to make care and treatment available for AIDS patients throughout Africa. They had the idea of making AIDS-awareness pins because it was something that even people like Mama Katele, who had advanced AIDS and was already very weak, could still do. They expanded this work to two other refugee camps and surrounding communities.

Realizing the limitations of this type of income-generating activity, they also created training programs to help people start new businesses. This effort was financed with money the Zambian group had saved from making the pins. Katie was in charge of work on the ground in Zambia, while Jonny and Lauren took care of mobilizing students back home to deal with the other sides of their ambitious project: fundraising and awareness.

The organization has now spread to 110 schools—both universities and high schools—around the United States, all helping to raise money and commitment to battle HIV/AIDS. As Ed Cardoza, PIH’s Director of Development, says, “FACE AIDS has engaged students, has put a practical spin on what we can do, and what schools and communities can do” to help fight AIDS in Africa.

When asked what had surprised her most in working with FACE AIDS, Katie said “the whole thing—how successful and how quickly everything has happened. Just by word of mouth we’re helping to mobilize a whole generation of people to tackle AIDS. What began from just wanting to help some women in Zambia earn an income has turn into something much larger.”

For more information about FACE AIDS and how you can help, visit http://www.faceaids.org.

[published July 2007]

Patrick Autissier rode his bike to victory on June 22 in the “World’s Toughest Race”, the solo Race Across America (RAAM), raising over $12,600 for Partners In Health along the way. In just 12 days, Patrick pedaled from Oceanside, CA, to Atlantic City, NJ, covering 14 states and 3050 miles. He crossed the finish line with only 10 minutes to spare. The first Frenchman ever to participate in RAAM, and an HIV researcher at Beth Israel Deaconess Medical Center, Patrick showed once again how one person who combines talent and commitment can really help make a difference in the world.

	Patrick Autissier celebrates with his team after completing the 3,000 mile Race Across America

Patrick has raised money for PIH while participating in RAAM for the past two years. When he first learned of RAAM, he found himself “fascinated” but later decided that beyond the amazing personal challenge, “it would be a shame to do the race without helping people”. He heard about PIH from a friend and was “amazed by the work” and after reading Mountains Beyond Mountains found himself also “fascinated by Paul Farmer He decided to use his athletic skills to help PIH help those most in need.

“People often wonder what they can do as individuals to help PIH further its mission in tending to the most destitute sick," says Ed Cardoza, Director of Development at Partners In Health. "One of the ways individuals can have significant impact is by using a challenging event to raise funds for PIH and to use the event as a way to advocate for our work."

“Patrick has chosen to do this par excellence by participating in the solo RAAM," Cardoza continued. "In doing so he became one of only 153 men around the world to officially finish the race since 1982. This difficult journey, when linked to the difficult hardship of our patients, becomes an act of solidarity. Patrick has not only brought significant funds for our patients, he has used the race, his website, his newsletters, as a way of drawing support and interest to issues from which many simply avert their gaze.”

Patrick certainly has not averted his gaze. This is the third year in which he has helped fundraise for causes that are important to him.

“What makes Patrick an extraordinary person is that he wants to use this gift, this athletic ability he has, not for his own victories, but to raise awareness about and money for the long journeys through which many people struggle everyday. If all athletes had this kind of social consciousness, the world would most certainly be a better place,” says Dr. Joia Mukherjee, PIH’s medical director. Besides raising money this year for PIH and for another organization, Nashoba Learning Group, Patrick has done fundraising every year he has cycled in RAAM.

In 2005, Patrick participated in RAAM solo but dropped out of the race half way through. In 2006, he started a team, “Athletes Racing for Charity” (ARC), dedicated to partnering athletes with their favorite charities. Team ARC finished second in the four-man team category by completing the race in a little over 6 days and 13 hours.

Race Across America, held every year, is a frantic pull to the finish line over more than 3,000 miles of mountains and prairies, steamy summer days and sub-freezing nights high in the Rockies. Solo and team riders have “crews” that follow them to make sure they stay healthy and to provide them with mechanical assistance, moral support, and food. This year Patrick had nine crew members, including his wife and daughter.

Racers stop only briefly to eat and sleep. In the first 24 hour stretch of this year’s race, Patrick biked 341 miles and slept for only half an hour. More typical day, however, consisted of more than 20 hours in the saddle, fueled by two to four hours of sleep and 8,000 to 10,000 calories of food. Patrick got those calories from a combination of normal meals, like pasta salad and hamburgers, and liquid meals packed with calories.

What’s next for Patrick? He says he is going to focus on triathlons for the next year or so in order to spend more time with his family. “Training and preparing a race like RAAM is huge and adding fundraising makes it even more difficult to do”, says Autissier. But he plans on participating in RAAM again in 2009 and will continue fundraising for worthy causes.

You can learn more about Patrick and donate to PIH or to his other fundraising effort, Nashoba Learning Group, by letting your fingers do the cycling to his website.

[published July 2007]

In the independently produced action movie "The Minx," a modern-day Robin Hood steals from the rich and gives to the poor. During the first six weeks that the movie is available on DVD, the producers of "The Minx" are giving to support health care for the poor in real life by donating $1 of every sale to Partners In Health.

"Although I conceived of The Minx primarily as a light-hearted entertainment, I also wanted audiences to think about the discrepancy between the world's rich and poor," writer/director Michael Glover Smith explained. "I feel very strongly that everyone should have access to primary health care and supporting Partners in Health is a wonderful way to contribute to that cause."

The movie stars Mia Park as Linnea Chang, a mild-mannered tobacconist by day who dons the costume and persona of "The Minx" to rob major corporations by night. The DVD is available online from Singa Home Entertainment. PIH will receive $1 for every DVD sold through June 30, 2007.

Director Smith mentioned that he had gotten the idea after hearing that one of his favorite rock bands, Arcade Fire, has been donating $1 (or £1 or 1 euro) to PIH for every ticket sold during its tours of Europe and North America. Contributions to PIH from the European tour totaled more than $50,000.

[published May 2007]

by Dr. Jonas Rigodon

I first arrived to Nohana in early August 2006. The clinic was bustling and I could tell that it was only going to get busier with time.

The head nurse, M’e Moso came to see me one day. She wanted to tell me about a Village Health Worker who had come to see her recently. This Village Health Worker told M’e Moso of all the people in her village who were sick. M’e Moso was timid to ask, but wondered if our team was available to make home visits. I told her that, indeed, that was part of our job in providing health care in rural settings. If people couldn’t come to clinic, we would go to them. Fortunately, Keith [another PIH doctor who is now our country director in Malawi] had also come to Lesotho to lend a hand as we were starting up. I knew that he could take care of things at clinic while I made my first home visit on a weekday.

Having just arrived, I was unfamiliar with the terrain of the Nohana area. This was the second week of August, the middle of winter here in Lesotho. We didn’t have a vehicle at the site yet. But even if we did, it wouldn’t have made much difference considering that most of these roads are only navigable by foot or on horseback. I asked M’e Moso how long it would take to travel to this village. She  replied that it would take six hours by horse. I began my journey right away, because I knew that this might quite literally be a matter of life and death.

I asked one of our translators, Lesole, to accompany me. We rented two horses. It had been a while since I had been on a horse. It took a while for me to remember what it was like to ride a horse again. Even then, this ride was not like any I remembered. The steep mountains made for slow and rough riding. It was treacherous to say the least. Six hours later, we arrived at the village and the first person I went to visit was a young woman named Mathabo Posholi.

When I entered her house, Mathabo was too ill to sit up on her bed to greet me, though I knew she wanted to. She was coughing a lot and was extremely thin. Her skin-tone was not a healthy colour, most likely from anemia.  Because she wasn’t able to move, I couldn't weigh her but I estimated her weight to be only around 35 kg (less than 80 pounds).

At that time, Mathabo was 35 years old. She had lost her partner over seven years ago, most likely from AIDS. She had pulmonary TB three years ago and had been treated for pneumonia several times. Her symptoms included severe weight loss, coughing, night sweats, diarrhea, thrush, loss of appetite and loss of skin tone.

She gave her consent and I tested her for HIV. Her test showed positive. I also diagnosed her to have esopharyngeal candidiasis (an opportunistic yeast infection) and TB, so I started her immediately on TB medication and Fluconazole. I drew her blood to send for a CD4 count and gave her some money for food.

Unfortunately, we never received the results of her CD4 test. As I soon learned, many samples never make it to the lab. They simply disappear somewhere along the line of drawing samples, coordinating them, shipping them down with the pilots, then couriering them to the central lab in Maseru. Even when samples do get to the lab, the results often fail to make the reverse trip back to us in the mountains.

Two weeks after seeing Mathabo, I was visited by her Village Health Worker at the clinic. She reported to me that Mathabo was doing much better already. She had an appetite now, her fever had subsided and her cough had improved as well. I sent the Village Health Worker back with more medications and more food.

Another month passed before the Village Health Worker came to see me again. She said that Mathabo wanted to come in to the clinic but didn’t have enough money to rent a horse. She asked if we could help. I gave her money to give to Mathabo and two weeks later, Mathabo came to clinic to see me.

When she first stepped into the room, I didn’t recognize her.  I had to rely on the Village Health Worker to vouch that this was Mathabo. Her complexion was much improved and she had gained some weight. Although we still didn’t have a CD4 result for her, I decided that she was ready to begin ARVs. She no longer had any of the symptoms she had over a month ago and she weighed 46 kg (102 lbs).  I took another blood sample to send to Maseru for a CD4 count and enrolled her into our food program, where each patient gets enough food every month to feed him or herself plus four family members.

I have been greatly impressed by Mathabo’s rapid recovery. It is the first time I have ever witnessed anything quite this dramatic. Even in Haiti, I didn’t have patients like this. I am happy to report that today, eight months after she began treatment, she is doing very well.

We recently had a little event at the clinic and Mathabo asked me if she could speak to the larger audience about her experience. She said “I want to talk to people who are sick and have HIV and tell them that they have to take their medicine. Today, I am alive because I took my medicine. I also want to thank the PIH team for all their efforts and for caring about the people in the mountains of Leostho. I never believed this day would ever come. Thank you.”

Dr. Jonas Rigodon is Chief Physician at the PIH health center in Nohana, Lesotho.

[published May 2007]

Advocacy on behalf of social justice—standing up for those who cannot do so for themselves—is one of our oldest activities, one of the cornerstones of our agenda of service, training, advocacy, and research. Sometimes working quietly and behind the scenes, sometimes speaking out publicly and vociferously, we have given our support to a wide variety of issues relating to health, human rights, and equality of access to health care. From the halls of Congress and the boardrooms of international policymaking bodies to local rallies on the Boston Common and late-night envelope-stuffing parties, we have shown our commitment to health care for the poor in myriad ways.

Since the beginning of 2007, PIH has ramped up its advocacy activities aimed at having an impact on policy and funding priorities within national and international decision-making bodies. PIH staff have testified in Congress, participated in high-profile press conferences and taken a leading role at meetings organized by the World Health Organization (WHO) in Geneva. Recent advocacy efforts have focused on increasing awareness and funding to address both the health worker crisis in Africa and the global spread of extensively drug-resistant tuberculosis (XDR-TB).

Mobilizing to address the health worker shortage in Africa

PIH has worked closely with the office of Senator Richard Durbin (D-IL) in crafting legislation to address the crippling shortage of health care workers in Africa. According to recent WHO estimates, the region needs at least 1.5 million more healthcare workers, including more than 800,000 doctors, nurses and midwives. PIH has been influential in educating Congress that failing to address this crisis will undermine efforts to treat and prevent HIV/AIDS, reduce child and maternal mortality, and accelerate economic growth and development.

"Increased funding from governments and private donors to expand health services holds the promise of saving millions of lives in Africa," Paul Farmer pointed out. "But a severe shortage of health workers on the ground represents a tight bottleneck slowing the flow of resources to patients who need them."

In particular, PIH has emphasized the invaluable role of community health workers in providing the kind of community-based care that can reach the destitute villages and people who suffer most from poverty and disease. PIH has worked with Senator Durbin's office to incorporate language specifying support for paid community health workers into the African Health Capacity Investment Act. The bill was filed by a bipartisan group of Senators on March 7 and has been referred to the Senate Foreign Relations Committee. Its provisions include funding to help train, recruit and retain doctors, nurses and community health workers, especially in rural areas. The bill also requires the President to develop a coordinated strategy to promote health care capacity in Africa.

PIH's advocacy on behalf of community health workers has not been confined to Washington. In February, Dr. Wesler Lambert of Zanmi Lasante (PIH's partner organization in Haiti) participated in a two-day consultation on "Task Shifting" in Geneva organized jointly by the WHO and the Office of the US Global AIDS Coordinator. The meeting focused on developing a regulatory framework to support recruiting, training, and employing members of the community, including people living with HIV, to take on a wide range of tasks in prevention, testing, care and treatment of HIV. Dr. Lambert was asked to serve on an advisory group that will help develop guidelines to be submitted in November.

Responding to the threat of XDR-TB in HIV-affected areas

Another focus of PIH's reinvigorated advocacy work has been the emergence of extensively drug-resistant tuberculosis. While warning of the devastating impact the disease could have and calling for increased resources to fight it, PIH has rebutted what PIH Medical Director Joia Mukherjee calls "the myth that XDR-TB is untreatable." In fact, as PIH co-founders Paul Farmer and Jim Yong Kim pointed out during a recent press conference, PIH and our partner organizations in Peru and Russia have successfully treated numerous cases of what is now being called XDR-TB. What is new is the eruption of XDR-TB in southern Africa, where as much as one third of the adult population is infected with HIV.

On March 21, Joia Mukherjee testified on the burgeoning XDR-TB crisis before the U.S. House Foreign Affairs Sub-Committee on Africa and Global Health. She was joined by Mario Raviglione, director of the Stop TB Department of the WHO; Julie Gerberding, director of the U.S. Centers for Disease Control and Prevention; Kent Hill, Assistant Administrator for Global Health at USAID; and Ambassador Mark Dybul, the U.S. Global AIDS Coordinator.

After the government officials relayed the latest statistics on the epidemic, Dr. Mukherjee shared PIH's experiences with treating drug-resistant TB. Based on that experience, she concluded, "XDR-TB does not need to be a death sentence. If we can combine good infection control, good prevention strategies, and good therapy, we know from our past experience that we can curb this epidemic and save thousands of lives." She called on Congress to support the WHO's call for at least $650 million in emergency funding worldwide and Archbishop Desmond Tutu's appeal to the U.S. to provide $300 million in 2007.

Advocacy coordination across PIH's "four pillars"

This recent upsurge in advocacy work was spurred by concerted efforts to reinvigorate the Institute of Health and Social Justice as PIH's advocacy arm and to strengthen coordination on policy and advocacy with the other institutional pillars of our work – the Division of Social Medicine and Health Inequalities at the Brigham and Women's Hospital, the Department of Social Medicine at Harvard Medical School and the François-Xavier Bagnoud (FXB) Center for Health and Human Rights at the Harvard School of Public Health. PIH and the FXB Center have formed a joint Policy and Advocacy Coordination Group that meets regularly and has helped coordinate several legislative initiatives.

[published April 2007]

	The second edition of PIH's HIV manual was published in August 2006

PIH has launched an interactive, on-line edition of The PIH Guide to the Community-Based Treatment of HIV in Resource-Poor Settings.

"The new website allows visitors to share insights about the manual and experiences in the field, to ask questions of each other, to answer others' concerns, and to foster a community of care," explained PIH Medical Director Joia Mukherjee, editor-in-chief of the manual.

The online-manual is the first module of a larger project – a warehouse of PIH tools, resources and guidelines for global health delivery to be known as the "Partners In Health Model On-Line." Future modules will share practical information and user insights on all aspects of delivering community-based care, ranging from clinical guidelines to training materials for patients and community health workers to project management tools and techniques.

"This on-line manual is distinctly a work in progress," Mukherjee said. "We intend to keep it that way. Our long-term goal is to build a knowledge community, a community where people working to ensure quality health care and social justice for the poor can exchange comments, questions, lessons and examples drawn from their own experience, both with Partners In Health and with each other. We expect that exchange to enrich all of our work, as well as future editions of the manual."

[published April 2007]

By Lydia Flier, 2010 PIH Summer Intern

	Teboho talks with PIH-L social workers.

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

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

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

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

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

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

Rwanda

	IMB assists more than 700 orphaned children in Rwanda.

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

IMB supports these children by providing food packages, clothing, health insurance coverage, as well as emotional support. Long-term support includes paying for school fees and materials, and ensuring access to housing. Additionally, IMB holds a a three-day youth forum each year around World AIDS Day in December and invites most of these children to participate in HIV education workshops, as well as creative and cultural forums. [http://www.pih.org/news/entry/world-aids-day-2008/#].

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

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

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

Malawi

	More than 1.1 million orphans live in Malawi

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

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

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

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

Lesotho

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

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

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

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

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

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

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

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

Read more about PIH’s work in Africa.

Tuberculosis infection is present in 1.8 billion people worldwide.  With the advent of multi-drug therapy in the 1970s, the treatment of tuberculosis with a “short course” of drugs was possible, and tuberculosis became the first disease whose treatment (and not only prevention) was adopted by the public health community.  Since that time, tuberculosis treatment has been under the purview of national governments using the recommended “DOTS” strategy (Directly Observed Therapy Short Course)--a course of six to eight months of therapy with multi-drug regimens and observed therapy to prevent the development of resistance.  However, as with any infectious disease, resistance to antibiotics develops, and this has been the case for tuberculosis since the first anti-tuberculosis drug, streptomycin, was discovered in 1945. 

Multi-drug resistant tuberculosis (MDR-TB) is defined as a strain of tuberculosis that is resistant to the most potent drugs—isoniazid and rifamipin. In addition, some strains of TB have developed resistance to an even broader array of drugs and have been dubbed extensively drug-resistant (XDR), defined as MDR with additional resistance to a fluoroquinolone and an injectable drug. When the tuberculosis organism is replicating in the body in the presence of low levels of drugs due to irregular or inadequate treatment, resistant mutants of tuberculosis are selected.  Once an individual has a strain of drug-resistant tuberculosis, he or she may transmit the strain to others.

XDR-TB has already been found in 28 countries on six continents, including all of the G8 countries.  There has been great progress made in recent years to address the emergence of MDR-TB, but the existing plan to fight this disease will need to be broadened and strengthened to tackle XDR-TB and HIV co-infection.

What is different now? 

Several issues have converged to draw attention to the specter of resistant tuberculosis.

First, people with HIV are exquisitely sensitive to contracting tuberculosis, developing active and progressive tuberculosis infection and dying if the correct anti-tuberculosis drugs are not given promptly.  What sparked the current global concern over XDR-TB is that in the South African province of KwaZulu-Natal, where HIV prevalence is high and immunity to tuberculosis is weaker, these highly resistant (XDR) strains were transmitted from person to person. The linkages between TB and HIV programs are critical, and all persons with HIV should be carefully screened for TB. Similarly, all individuals presenting with tuberculosis should be offered an HIV test and the barriers to HIV testing (both logistical and financial) should be minimized. 

Second, we know that HIV treatment—with highly active antiretroviral therapy (ART)--improves the immunity of people living with HIV and decreases their likelihood of developing active TB if they are exposed to a TB strain of any kind. This therapy has been terribly delayed in resource-poor countries due to insufficient resources and lack of political will. Redoubling the effort to effectively diagnose HIV and treat and retain those who need ART is needed to impact individual mortality from tuberculosis and the spread of drug-sensitive and drug-resistant tuberculosis.

Third, the spread of XDR-TB is a consequence of a woefully inadequate health care infrastructure, one that is insufficient to prevent the spread of XDR-TB, facilitate its prompt detection, and administer its appropriate treatment. In dilapidated clinics and hospitals, tuberculosis easily spreads in crowded and poorly ventilated wards. The severe shortages of health workers caused by poor pay, immigration to other countries (so-called “brain drain”), and attrition from AIDS sap the manpower needed to address this epidemic. Investments in health workers and health facilities are fundamental to any effort battling TB and HIV/AIDS.

Fourth, diagnostic capacity is needed. Almost nothing has been invested in providing laboratories in resource-poor settings—such facilities were deemed too costly by the conventional public health approach.  Yet drug resistance can only be diagnosed by culturing the tuberculosis organism. Safe and modern laboratories must be built and technical staff trained to find XDR and facilitate its treatment and control. 

Finally, our world is gripped with two interrelated pandemics—HIV and TB—and the prevention, control and treatment of these diseases require long-term, community-based therapy. Such ambulatory treatment assures adherence to and completion of the prescribed treatment, improving outcomes and preventing the development of resistance. It also decreases the concentration of infectious people in congregate settings. Community health workers are best suited to provide this type of therapy, but this class of health workers does not exist in most places in the world and where they do, they are often asked to serve as volunteers, resulting in high attrition rates and the need for constant retraining.  Developing a global cadre of health workers of this type is critical to tackling these pandemics.

Is it treatable?

In southern Africa, death rates among people living with HIV in South Africa who acquire XDR-TB have been estimated at around 85 percent.  This is not because XDR-TB is untreatable, but rather because in most places, patients infected with XDR-TB have not been promptly diagnosed and correctly treated. This failure to provide services has led to the myth that XDR-TB is untreatable or a death sentence.

Our organization, Partners In Health, affiliated with the Brigham and Women’s Hospital and Harvard Medical School, has been successfully treating MDR-TB since 1994 in Haiti, Peru, Russia, and most recently in Rwanda and Lesotho.  Socios en Salud, our “sister organization” in Peru, arguably has more experience in MDR-TB than any other organization in the world, having treated over 10,000 cases of MDR-TB.  As early as 1996, we documented high levels of resistance in some of these cases, which would now by definition be labeled XDR-TB. In Peru, however, the highly resistant nature of many of the strains did not garner the same type of media attention because of the low prevalence of HIV. In such settings, the spread is not as rapid as in southern Africa, where a high proportion of the population has HIV and has not received antiretroviral therapy.

What is needed?

Treatment is possible but it depends on prompt diagnosis and timely administration of appropriate therapy and sustained treatment for 2 years.  This requires health care workers who are trained to have a suspicion for drug-resistant TB, HIV testing linked to tuberculosis control efforts, a laboratory that is capable of making the diagnosis, health care workers that can prescribe and follow up the treatment for both XDR-TB and HIV, and a cadre of community health workers that can assure adherence to the drugs in the community. If hospitalization is needed, the treatment and control of XDR-TB require hospital wards with adequate ventilation and staffing.  

To combat XDR-TB, the World Health Organization (WHO) is calling for at least $650 million globally in immediate emergency funding for the purchasing of drugs and diagnostics, and some immediate infection control.  Experts and global leaders like Archbishop Desmond Tutu of South Africa have been calling on the United States to provide $300 million this year because we simply cannot wait another year to jumpstart these efforts. These figures do not capture all of the broader needs of TB treatment and lab strengthening that is needed to both treat and prevent XDR-TB. In fact, to strengthen basic TB control, the WHO-estimated cost is $5 billion annually, in addition to the immediate funds needed to address XDR-TB. 

The PIH Experience

I would like to offer some optimism in the midst of the pessimism that all of us feel sometimes in thinking about an airborne disease that is very difficult to treat.  In Peru, the Socios en Salud and Partners In Health collaboration started in 1996 as a primary health care project. Within one year, much to our surprise, we had diagnosed hundreds of patients with MDR-TB.  At that time, MDR-TB was considered “untreatable” in poor countries.  Led by Dr. Jaime Bayona in Peru, what began as a pilot project of an NGO with only a handful of patients became a full-scale national program. It is now the largest MDR-TB treatment program in the world and is run by the Peruvian Ministry of Health with close collaboration with Dr. Bayona and his team. Then and now, community health workers play a critical role in providing directly observed therapy and what we call accompaniment—home visits to assist in adherence, but also to provide social support and to serve as a liaison to the health system.

Similarly, in 1998, we were invited into the former Soviet Union to treat tuberculosis inside the penitentiary system in Tomsk Oblast, western Siberia. About a quarter of the people with tuberculosis in the prison systems were dying of MDR-TB. With our partners in the prison, under the leadership of Dr. Sergey Mishustin, the prison introduced infection control and comprehensive TB treatment for all TB, including drug-resistant TB. The death rates inside that prison dropped to zero within 2 years.  As this program is “scaled out” into the civilian sector, community health workers are instrumental in the provision of therapy in this remote rural area.

Though extremely difficult, it is possible to treat highly drug-resistant TB. With political will, meaningful partnerships, training of health workers (including at community level) and investments in laboratory and health infrastructure, it can be done.  The new twist is that when HIV and TB collide--especially when HIV and drug-resistant TB collide--there is an even more urgent need to intervene effectively because HIV speeds up the process and makes epidemics of TB, especially drug-resistant TB, faster and more lethal. 

That is what we are seeing in southern Africa.  Some of the data that we have seen from the South African province of KwaZulu-Natal, which borders the landlocked country of Lesotho, show very high death rates from drug-resistant TB among patients with HIV who are on therapy for HIV.  This has led to the incorrect perception that drug-resistant TB is untreatable.

The reality is that HIV was being treated effectively with antiretroviral therapy, but TB infection was left untreated. Until we bring effective therapy for both MDR-TB and HIV together, we will not see the results we want.  A program to treat XTR-TB that we are launching in Lesotho with the support of the Open Society Institute and the Ministry of Health of Lesotho builds on a decade of experience, but it will also face new challenges because of the high rates of HIV and co-infection. 

It is all the more urgent for us to develop strong infection control programs that move therapy, whenever possible, into the community.  Good community-based care has many positive aspects, one of which is to avoid having infected patients congregate inside treatment facilities--what we call “nosocomial infection” in public health jargon. To some extent, we need to use hospitals to treat this disease, but we have to make the hospitals safe for our patients so that they do not become infected or re-infected. 

XDR-TB does not need to be a death sentence.  If we can combine good infection control, good prevention strategies, and good therapy, we know from our past experience that we can curb this epidemic and save thousands of lives. 

Joia Mukherjee is Medical Director of PIH, Director of the Institute for Health and Social Justice, and Assistant Professor of Medicine at Harvard Medical School and the Brigham and Women's Hospital in Boston.

[published April 2007]

	A community health worker distributes medications in Haiti

For years, Partners In Health has advocated for accompaniment – medical, social and economic support provided by paid community health workers – as the key to delivering quality health care in poor communities. For much of that time we encountered skepticism from global health experts and policymakers accustomed to relying on universiity-educated consultants and doctors rather than on locally trained villagers. Now the tide has turned. Confronted with the double-barreled crisis of pandemic disease and a catastrophic shortage of trained health personnel, the international aid community has embraced “task-shifting” to community health workers and other paraprofessionals as the only way to meet the challenge, particularly in Africa. PIH and our Haitian partner organization, Zanmi Lasante, have taken a leading role in developing international guidelines for task-shifting and the role of community health workers.

The World Health Organization (WHO) was the first agency to raise the alarm about the worldwide health worker shortage. In 2003, when the agency began to roll out its 3 x 5 AIDS treatment program (with a goal of treating 3 million people infected with HIV/AIDS with antiretroviral therapy by 2005), it was confronted with a dramatic absence of health infrastructure in the areas the programs was designed to serve. Antiretroviral therapy could not be administered without a network of nurses, doctors, community workers, and lab technicians. But in most African countries, these medical personnel were nowhere to be found, especially outside the capital cities.

It is now widely recognized that the world is experiencing a chronic shortage of trained health workers—one felt most acutely in those countries that are experiencing the greatest public health threats. In fact, the shortage of human resources has replaced finance issues as the most serious obstacle to implementing national treatment plans. WHO estimates that more than 4 million health workers are needed around the world to fill the gap between what is there and what is needed.  Sub-Saharan Africa alone faces a shortage of more than 800,000 doctors, nurses, and midwives, and an overall shortage of 1.5 million healthcare workers.

The causes of the shortage of health workers are complex, as noted in a recent PIH Action Alert. The HIV pandemic itself has been a major factor, both because it has greatly increased the need for health care and because it has decimated Africa’s healthcare workforce. In South Africa, it is conservatively estimated that 16 percent of healthcare staff are HIV-positive. In Malawi, the government expects to lose three percent of its already understaffed and underfunded health workforce to the disease each year.

There are many other reasons to account for the critical shortage of health workers, including: a lack of sufficient and relevant training capacity to produce the number of health workers required; an inability to retain health workers due to poor working conditions and meager salaries, often caused by restrictions on public sector spending imposed by international donors and financial institutions; and, lastly, "brain drain" – the large-scale emigration of health care workers seeking better paying and more satisfying jobs in countries with greater resources, such as the United States, England, and Canada. To cite one striking example, there are more Malawian doctors practicing medicine in Manchester, England, than in all of Malawi.

WHO has acted to address this barrier to universal access to care. In May 2006, a new global partnership – the Global Health Workforce Alliance (GHWA), hosted by WHO – was formed to address the worldwide shortage of nurses, doctors, midwives, and other health workers. Its stated goal was to increase the number of qualified health workers rapidly in countries experiencing shortages. Last August, the agency announced a new global strategy – Treat, Train, Retain (TTR). This broad, multifaceted AIDS health workforce plan is being undertaken under the umbrella of the Global Health Workforce Alliance and has been designed to involve the key stakeholders in human resources for health.

One of the primary working groups set up by the GHWA under this strategy was an 11-member task force – the Joint WHO/OGAC Technical Consultation on Task Shifting – made up of representatives from HIV programs and human resources departments from Ministries of Health, professional associations, academic institutions, and others. This task force has been charged with promoting increased investment in educating and training health workers in developing countries and boosting international support for practical strategies to address the shortage. Initially it will deal with the key elements of a regulatory framework to support in-country implementation of task-shifting. The task force will also focus on the need and scope for financial and technical support worldwide; the links between training institutions and universities in developed and developing countries; and innovative use of technology for distance education.

	Dr. Wesler Lambert

PIH is represented on this task force by Dr. Wesler Lambert, HIV/AIDS and Maternal and Child Health Program Advisor for Zanmi Lansante in Haiti. The task force met for the first time in February 2007 in Geneva to discuss the need for a draft regulatory framework for task-shifting that can be validated at the country level before being recommended to countries and to agree on a series of steps towards the development and the implementation of certification and credentialing mechanisms to support task-shifting for HIV service delivery in affected countries.  The task force will meet again in June, in Rwanda, and is scheduled to present its initial recommendations to GHWA in the fall of 2007.

[published April 2007]

	Folder userd for MDR-TB training of Latin American nurses

With more than a decade on the frontlines against MDR-TB, PIH's partner organization in Peru, Socios En Salud (SES), has earned global recognition both for innovating effective, community-based treatment for the disease and for training other health professionals how to do it. In recent months they have redoubled their training activities, sending teams to Haiti and Africa and collaborating with the Peruvian Ministry of Health to offer training for nurses from throughout Latin America.
In December, as SES was marking its tenth anniversary, a team of two nurses, a doctor, and a translator traveled to Haiti at the request of their colleagues at Zanmi Lasante (ZL). Over the course of four days, they trained 25 doctors and nurses, both from the Ministry of Health and ZL, in delivery of integrated, community-based care for MD-TB patients. At the end of an intensive round of lectures, role playing, interactive discussions, field visits and videos, almost 100 percent of the participants said they now felt equipped to manage treatment of an MDR-TB patient.

The overwhelming success of the training inspired the PIH Lesotho team to invite SES to train local doctors, nurses and community health workers in treating the disease. PIH Lesotho has encountered extremely high rates of TB in HIV patients, and has asked for SES’s guidance in handling the outbreak. The Peruvian team plans to visit Lesotho for three weeks this spring.

Dr. Jaime Bayona, SES’s founding director has also been on the road recently. In late March, he returned from Zambia, where the Ministry of Health had asked him to share his expertise in directing large scale community-based MDR-TB treatment projects. He helped them prepare an application for funding to expand their MDR-TB program from the Green Light Committee, which is responsible for determining whether projects comply with guidelines to receive the second-line drugs needed to treat MDR-TB.

While they are traveling to train health professionals abroad, the SES team continues to offer trainings in Lima to Ministry of Health staff as well as other Latin American doctors and nurses. With financial support from the Global Fund, they hosted a group of nurses from several Latin American countries in March. The nurses have been trained in MDR-TB management, and will now be able to share that knowledge with colleagues in their home countries.

SES is also still at the forefront of MDR-TB advocacy efforts. In Lima, they are making World TB Day the climax of a month-long campaign to mobilize awareness and involvement in the fight against TB. Activities include an exhibit of 41 photos of current and former patients and of SES's work entitled “Danos una mano, hagamos que la TB sea sólo fotografías” (Give us a hand, let’s make TB exist only in photos). The exhibition, presented in the district of Miraflores, and will help raise awareness, as well as local funds for SES’s work.

In addition, SES is participating in multiple World TB day events on March 23 and 24. Organizations working with TB and MDR-TB from across Peru will gather in Lima to call attention to the progress that has been made in fighting the disease, as well as the need to continue our efforts to improve diagnosis and treatment. SES will distribute educational materials about their work as well as information about how to become more involved in the struggle against TB. Two professional mimes will help SES attract a

[published March 2007]

	Examining a chest x-ray in Peru.

For more than a decade, Partners In Health has pioneered successful, community-based treatment of multiple drug-resistant tuberculosis (MDR-TB) and AIDS and has helped overturn policies that had accepted these diseases as untreatable "death sentences" in poor countries. Now, with help from a $3 million grant from the Open Society Institute (OSI), PIH is taking on another epidemic that has been widely described as "incurable" and that threatens to reverse recent progress in combatting HIV/AIDS – extensively drug-resistant tuberculosis or XDR-TB.

At a March 14 press conference, billionaire financier, philanthropist and OSI founder George Soros joined PIH co-founders Paul Farmer and Jim Yong Kim to announce plans to develop, test, and disseminate a model for treatment of drug-resistant tuberculosis in areas with high rates of HIV infection and AIDS. OSI's $3 million donation to PIH and the Brigham and Women's Hospital will be used to jumpstart a project in Lesotho, right next door to the South African province of KwaZulu-Natal where a widely reported outbreak of XDR-TB killed 52 out of 53 HIV-infected patients.

The project will start in the capital city of Maseru. A small building near the country's largest hospital is being renovated to serve as an in-patient facility that will provide effective treatment and infection control to prevent transmission of XDR-TB to other HIV patients. Plans are also in the works to build up laboratory capacity so that drug-sensitivity testing can be done quickly and accurately in Lesotho, rather than relying on sending sputum samples to South Africa and waiting months for the results. Once that diagnostic infrastructure is in place, the goal is to move treatment rapidly out of the hospitals, out of Maseru and out into the communities and rural areas where patients live.

As Jim Kim pointed out, "We're actually working in rural areas right now in Lesotho. And we believe that this treatment does not require hospitals. In fact, you want to stay away from hospitals as much as possible and provide treatment on a community-based level [in order to reduce transmission within clinical facilities]. So it'll start in Maseru but we believe that we must offer it throughout the entire country."

Press reports have frequently characterized XDR-TB as a new and virtually untreatable disease. Farmer and Kim emphasized that it is neither. Farmer pointed out that the lethal Kwazulu-Natal outbreak proved not that the disease is "untreatable" but that it was "untreated." The patients who died were all infected with HIV and many were receiving antiretroviral therapy. But they were never treated for drug-resistant TB. They received only standard treatment for drug-sensitive TB. By the time test results confirmed that they had XDR-TB, all but one of the patients had died.

XDR-TB is defined as tuberculosis that is resistant to the two main first-line drugs (as is the more widespread MDR-TB) and at least three of the six classes of second-line drugs used to treat MDR-TB. PIH has been treating patients with MDR-TB successfully for more than a decade. Among those patients, a significant proportion proved to be resistant to three or more classes of second-line drugs as well.

Socios En Salud, PIH's partner organization in Peru, started treating an epidemic of MDR-TB in the slums of Lima in 1985. Although the term had not yet been coined, about 20 percent of the first group of patients treated by Socios En Salud would now be defined as suffering from XDR-TB. Among that first cohort of patients, SES achieved overall cure rates of more than 80 percent, including better than 65 percent among patients suffering from what would now be called XDR-TB.

Based on that experience, Farmer and Kim stated with confidence that XDR-TB is neither new nor untreatable.

What is new, what complicates treatment and makes recent outbreaks of XDR-TB a potentially catastrophic public health emergency, is the eruption of XDR-TB in southern Africa, where as much as 30 percent or more of the adult population are infected with HIV.

"The new twist is one that we predicted, and many others did as well," Farmer stated. "That is that when HIV and drug-resistant tuberculosis collide, there is going to be an even more urgent need to intervene effectively because HIV really speeds up the process and makes these epidemics faster and more lethal."

Nevertheless, Farmer insisted, "We have no doubt as clinicians – as people who have taken care of patients – that we can successfully treat highly drug-resistant TB among patients co-infected with HIV. We've done it in Peru and Haiti. The bulk of our experience is with HIV-negative patients. But among those who do have co-infection, we've had excellent results."

"What happens when you go from having a small minority of your patients co-infected with HIV to the majority?" he added. "That's going to be the big challenge. But clinically, case by case, I think we know what to do. And if we do it correctly, most of them will get better."

Treating XDR-TB effectively and preventing it from spreading rapidly in areas with high HIV prevelance depends on strengthening capacity in three main areas, Jim Kim explained:

• laboratories and diagnostics;
• infection control; and
• effective treatment protocols for people who need to take medications for both XDR-TB and HIV.

Improved diagnostics and laboratory capacity are needed so that XDR-TB cases can be identified rapidly and treatment with effective second-line drugs can start within days, not months.

"Using slower methods, it can take three months, which is obviously unacceptable in this kind of outbreak," explained Dr. Salmaan Keshavjee, a PIH doctor and tb expert who will play a leading role in the Lesotho project. "Our hope in working with partners and building lab capacity in Lesotho is to get it so that a rapid diagnosis can take place within a few days and then within three weeks we can have the final susceptibilities to make sure that patients are getting exactly the right treatment."

Effective infection control measures, such as separate wards and ventilation systems are essential to keep air-borne tb germs from spreading like wildfire in hospitals, clinics and other institutions, particularly among HIV patients and others with weakened immune systems. Transmission within medical facilities has proven to be one of the main engines for the spread of drug-resistant tuberculosis. The best protection against it, long practiced and advocated by PIH, is to get treatment out of hospitals and into the patients' homes and communities. This community-based approach has been a lynchpin of PIH's success in treating MDR-TB in Peru and HIV in Haiti and Rwanda. And it will undoubtedly be a defining feature of the model for treatment of HIV-TB co-infection developed in Lesotho.

As to the treatment protocols themselves, "there aren't that many therapeutic options really," Paul Farmer points out. "The medications that we have, people agree on what those medicines are and, by and large, on the dosing and duration of therapy."

What do need to be tested, documented and disseminated, Jim Kim explains, are guidelines for precisely how the few medications available for XDR-TB can be delivered most effectively for people infected with HIV.

"First, when we're dealing with second-line tuberculosis drugs that do have side effects," Kim said, "we really need to work out in a very clear fashion how to deliver those drugs along with antiretroviral medications. We will have to develop these treatment guidelines in the next couple of years.

"The vision," he concluded, "would be that we would quickly develop a working model in Lesotho. WHO [the World Health Organization] would be working hand-in-glove with us, and when the treatment guidelines are available they would be immediately distributed. Lesotho would become a center of innovation and excellence and would be used as a training site for other countries interested in developing similar kinds of programs."

[published March 2007]

	PIH's EMR system in use in Peru

This summer, students around the world have the opportunity to participate in an exciting collaboration between OpenMRS and Google, Inc., to help develop an open-source medical record system that improves the care of patients with HIV/AIDS, tuberculosis and malaria. But they only have until March 24 to apply.

PIH was one of two organizations that founded OpenMRS in 2004, along with the Regenstrief Institute, a world-renowned leader in medical informatics research. The OpenMRS system builds on lessons learned from the PIH Electronic Medical Records (EMR) system used in Peru and Haiti. And the new PIH EMR 2.0 that was recently rolled out in Rwanda is built on top of the OpenMRS framework.

The Google Summer of Code 2007 program will pay stipends of $4,500 apiece to allow as many as 10 promising student software developers to spend their summer vacation writing new code for the OpenMRS. The OpenMRS has already been implemented in several African countries, including South Africa, Kenya, Rwanda, Lesotho, Uganda, and Tanzania.

During the 12-week program, student programmers will work directly with assigned mentors from PIH and the Regenstrief Institute to complete their choice of a variety of focused development tasks laid out by the OpenMRS collaborative.

The OpenMRS team summed up what it is looking for in four bullet points:

• Energetic developers looking to make a difference in their world
• Java experts (experience with J2EE technologies – Hibernate, Spring, MVC frameworks)
• Knowledge of design patterns (MVC, Front Controller, Singleton, Factory)
• Skills with talking and making sense when you write and stuff like that or something else ... you mean, communication skills?

For more information about OpenMRS and descriptions of projects that might be undertaken as part of the Summer of Code, visit soc2007.openmrs.org.

Applications must be completed by March 24, so if you are interested, do it NOW.

[published March 2007]

PIH calls for support for U.S. funding to train and retain health care workers in Africa

Over the past few weeks, Partners In Health has been hard at work with colleagues at other organizations and in Congress to get a piece of legislation introduced that addresses the catastrophic shortage of health care workers in Africa. The final text of the bill incorporates ideas and language that we urged the drafters to include, recognizing the critically important role of paid community health workers. Now the drafting is over, the bill has been filed, and it is time to pitch in to get it passed.

Starting on Friday, March 9, we're working to generate thousands of emails and calls to the Senate supporting the bill. Call your Senators and encourage their support of the African Health Capacity Investment Act of 2007. You can reach your member by calling 202-224-3121 (connecting to all offices).

	Village health worker training in Lesotho

In Sub-Saharan Africa, a mere 3 percentof the world's health workers struggle against all odds to combat 24 percent of the global disease. Millions of people in Africa are suffering and dying from HIV/AIDS and other preventable and treatable diseases. In early March, Senator Richard Durbin (D-IL) introduced the African Health Capacity Investment Act of 2007, which would help African countries to develop a stable health infrastructure and better address their health crises.

The time to act is now. Please call and email both of your Senators and ask them to co-sponsor the African Health Capacity Investment Act.

Please ask both of your Senators to:

• Co-sponsor the African Health Capacity Investment Act of 2007;
• Work with Senate colleagues to pass the bill quickly and ensure that Congress appropriates at least $150 million for the African health workforce this year, by including at least that amount in their appropriations "wish lists."

The original co-sponsors of the African Health Capacity Investment Act include Senators Durbin, Bingaman (D-NM), Coleman (R-MN), Dodd (D-CT), Kerry (D-MA), and Feingold (D-WI). If one of the preceding is your Senator, you may contact them to thank them for their support of the Act and encourage their dedication to passing and appropriating full funding for the bill.

For maximum impact, please follow up your calls with emails to your Senators.

If you would like to see sample text for a letter to your Senator or to read some background information before placing a call or writing an email, read on.

Sample letter

Dear Senator __________________,

I am writing to respectfully urge you to co-sponsor the African Health Capacity Investment Act, and to help make sure it passes quickly with the full amount of funding appropriated.

In Africa, people are dying unnecessarily because there are simply not enough doctors, nurses, pharmacists, and other health care workers. The World Health Organization has identified 57 countries, including 36 in Africa, facing critical shortages of health workers that make them "very unlikely" to achieve goals in fighting diseases like AIDS and malaria and reducing child and maternal mortality. In Africa, a mere 3% of the world's health workers struggle against all odds to combat 24% of the global disease burden.

The causes of the shortage are complex, and include HIV/AIDS, poor working conditions, insufficient capacity to train new health workers, the overall lack of funding for health, ceilings on government wage bills, and the "brain drain" of health workers to countries like the United States, which need to do more to address their own health worker shortages. A recent estimate of the funds needed to double the health workforce in sub-Saharan Africa placed the cost at an additional $2 billion in the first year, and more in ensuing years.

Strengthening the health workforce in Africa will bring enormous health benefits to millions of people and save untold numbers of lives. That is why I am asking you to co-sponsor the African Health Capacity Investment Act, and to ensure that it passes and is fully funded this year. To help ensure full funding, I hope that you will include in your appropriations "wish list" at least $150 million for Africa's health workforce.

Thank you.

Background information

The World Health Organization has identified 57 countries, including 36 in Africa, where the current level of health workers make it "very unlikely" to achieve health-related Millennium Development Goals, internationally agreed upon goals on reversing the spread of AIDS, malaria, and other major diseases, and significantly reducing child and maternal mortality. A recent estimate of the funds needed to double the health workforce in sub-Saharan Africa placed the cost at an additional $2 billion in the first year, and more in ensuing years.

In Africa, people are dying unnecessarily because there are simply not enough health care workers. Health workers--nurses, doctors, pharmacists, community health workers, laboratory technicians, physician assistants, nurse assistants, mental health workers, and many more-are at the core of health systems everywhere, diagnosing and treating diseases, educating and caring for patients, and developing and implementing policies and strategies to combat disease. But in sub-Saharan Africa, a mere 3% of the world's health workers struggle against all odds to treat 14% of the worlds population and combat 24% of the global disease burden. The World Health Organization estimates that sub-Saharan Africa is suffering a shortage of more than 800,000 doctors, nurses, and midwives, and an overall shortfall of nearly 1.5 million health workers. At present, sub-Saharan Africa has little over 1 million health workers, and fewer than 600,000 doctors, nurses, and midwives.

The causes of the shortage of health workers are complex, and include HIV/AIDS, which is decimating much of the continent's workforce. In South Africa, it is conservatively estimated that 16% of the existing health workforce are HIV+ and in Malawi the government assumes they will lost 3% of their health workforce each year to the disease. Additionally, there is a lack of sufficient and relevant training capacity to produce the number of health workers required; an inability to retain health workers due to poor working conditions and lack of funding for adequate salaries, sometimes due to wage caps imposed by the International Monetary Fund; and "brain drain," the large-scale emigration of health care workers seeking better paying and more secure jobs in countries with greater resources such as the United States, England, and Canada.

If the international community is committed to reaching universal access to prevention, treatment, and care, governments must show leadership in addressing the health workforce crisis. Today, you can be part of the solution.

[published March 8, 2007]

"One day, one party, one cause" – Stanford Dance Marathon raises $150,000 for PIH

They could have danced all night. And they did. More than 900 students at Stanford University joined together in early February to stage a 24-hour dance marathon that raised more than $150,000 for Partners In Health.

	Dancing for dollars and solidarity

Roughly 350 students began dancing at noon on Saturday, February 10, kicking off the third annual Stanford Dance Marathon. Fueled by music and entertainment, ample supplies of food and water, and encouragement from more than 500 marathon “moralers,” the dancers were able to stay on their feet until midday on Sunday. And then the tired and footsore marathoners were able to tally up the proceeds and celebrate having surpassed by far their target of $100,000.

“The best part was the incredible sense of accomplishment you feel when you finish and hear how much money has been raised,” said Jen Brown, a member of the Executive Planning Team for the marathon. “To have planned an event that connects the people to a cause is exciting.”

The marathon capped months of organizing on the Stanford campus and was coordinated with other activities focusing on issues of global health. Awareness was heightened by selection of Mountains Beyond Mountains as required reading for all incoming freshmen and by the activities of FACE AIDS, a student-run non-profit that has set a goal of raising $1 million for PIH.

How did the dancers raise all that money? The Executive Planning Team began by soliciting corporate and in-kind donations of $1,000 or more. They also organized a mini-carnival to attract support from the community during the event. Children and families from the Palo Alto area paid a small admission fee to play carnival games, watch the dancers, and learn about Partners In Health.

In addition to all the outreach by the Planning Team, each of the dancers was required to raise a minimum of $140—the cost of a year’s supply of antiretroviral therapy for one AIDS patient. Moralers were asked to raise between $35 and $50 each.

Besides dancing and having a good time for a good cause, participants in the Dance Marathon were able to learn about HIV/AIDS, tuberculosis, malaria, and Partners In Health’s work for health and social justice through educational displays.

Thank you, Stanford Dance Marathon, for your support for Partners In Health and your solidarity with the destitute sick.

[published March 8, 2007]

The Institute for Health and Social Justice (IHSJ) – the research, education and advocacy arm of PIH – has launched a campaign to galvanize knowledge, awareness, and action to combat pandemic coinfections of hunger, malnutrition and disease.

The first round of activity in this campaign is a series of seminars to be held in the Boston area, organized jointly with the Friedman School of Nutrition at Tufts University and the François-Xavier Bagnoud Center for Health and Human Rights.

The first seminar in the series features Dr. Nevin Scrimshaw, an internationally renowned scholar who literally wrote the book (or books) on the connections between hunger, malnutrition, illness, and death. Dr. Scrimshaw headed the Department of Nutrition and Food Science at MIT for many years, organized and led the World Hunger Programme at the UN University, was awarded the World Food Prize in 1991, and remains a leader in the field as a professor emeritus at MIT and a member of the faculty at the Friedman School. The seminar will take place on Thursday, March 8, at 4:30 pm in Room G2 of the Kresge Building at the Harvard School of Public Health, 677 Huntington Avenue, Boston.

In addition to the seminar series, the IHSJ is organizing a gathering of leading experts and activists on hunger and health to take place in early May. That meeting will help set the agenda for the IHSJ's research and advocacy work over the coming months and will lay the groundwork for a major symposium to be held in the autumn.

[posted March 5, 2007]

Photo by Steve Cohen

Arcade Fire sparks support for PIH – Canadian band raises issues and funds

The Arcade Fire, a Montreal-based “indie” rock group, is making a name for itself not only as one of Canada’s hottest bands but as advocates and fundraisers for global health equity. Most visibly, they provided the music—free of commission—for a series of television advertisements to boost sales during the holiday shopping rush of the “(PRODUCT) RED” campaign to raise funds for the Global Fund to Fight AIDS, Tubeculosis and Malaria. But they didn’t stop there. At the end of December, they dedicated proceeds from the iTunes release of the first single from their eagerly awaited new album to Partners In Health. And most significantly for us, the band has committed to give PIH $1.00, £1.00  or €1.00 of every ticket sold on their upcoming European and North American tours.

After learning about PIH by reading Tracy Kidder’s Mountains Beyond Mountains and Paul Farmer’s Pathologies of Power, Win Butler and Régine Chassagne, the husband-wife duo who formed The Arcade Fire in 2003, contacted us about their desire to help. Although the band’s interest in PIH is relatively new, their dedication to promoting understanding of Haiti’s complicated history and solidarity for its long-suffering people is not. Régine’s Haitian background has influenced the band’s music significantly. The song “Haiti” appeared on their first album, Funeral. The lyrics are indicative of Régine’s deep personal bond with the country: “Haïti, mon pays, wounded mother I'll never see. Ma famille set me free. Throw my ashes into the sea…” In addition to expressing the issues through their music, Win has used his online journal (link) to write snippets about Haiti’s historical relationship with France and the United States and to encourage support for Partners In Health.

With the release of The Arcade Fire’s second album, Neon Bible, in March 2007, they will be touring both in Europe and North America. Following a series of warm-up concerts in London, Montreal and New York through the middle of February, the band will tour Europe from March 7 through April 7, with appearances in the Ireland, Scotland, England, Sweden, Norway, Denmark, France, Germany, Holland and Belgium. Dates and locations for the North American leg of their tour have not yet been finalized.

But wherever they go, they intend not only to entertain their fans but to educate them about the major global health issues of our time—from the weakening of the Global Fund to the structural violence that has plagued Haiti and other poor nations for years, causing major public health disasters.

[posted January 2007]

From zero to 160 in six months. For acceleration in treatment of HIV patients in an area where more than half the adult population may be infected, those are impressive numbers. And they represent just one striking measure of the remarkable record of achievements racked up by Partners In Health during our first six months working high in the mountains of the southern African country of Lesotho.

At the beginning of January, PIH’s project in Lesotho – known as Bo-Mphato Litsebeletsong tsa Bophelo in the national language, Sesotho – marked the completion of its first half year of work at the mountain health center in Nohana. At the same time, the project was gearing up to begin training and treatment at a second remote mountain site before the end of January. The first round of intensive training for village health workers in Bobete was scheduled for January 25-27, with testing and treatment to begin almost immediately after that.

The project’s achievements during our first six months in Nohana are breathtaking, as are the mountains and other obstacles that had to be surmounted to get there. By the end of December, the list of accomplisments included:

• more than 1,300 people tested for HIV
• nearly 600 HIV and tuberculosis patients diagnosed, monitored and receiving care and treatment
• 165 AIDS patients enrolled on antiretroviral therapy, including eight children under the age of 14
• a new waiting room constructed for patients who previously had to wait outdoors, often after traveling several hours on foot to reach the clinic
• one doctor in residence and frequent visits from other physicians at a clinic formerly staffed exclusively, and somewhat sporadically, by a nurse and nursing assistants
• more than 100 village health workers trained to help identify, educate, test and treat HIV patients in their communities, including 60 who have been employed as key participants in bringing community-based care to the 60 villages served by the Nohana clinic
• more than 50 patient visits per day at the Nohana clinic
• a contract with the World Food Program to provide food packages consisting of corn meal, beans, cooking oil and a nutritious corn-soy blend to HIV and TB patients and their families.

Steep challenges in the high mountains

The challenge could hardly have been more daunting, both medically and geographically. With the world’s third highest rate of HIV infection, Lesotho has more than 320,000 people living with HIV out of a total population of only 2 million. Only 10 percent of AIDS patients who need antiretroviral drugs are receiving them.

Roughly one-third of Lesotho’s people live in isolated mountain villages, often accessible only on foot or on horseback. They are almost completely cut off from health care but not from the HIV epidemic, driven by poverty that forces nearly one out of three Basotho men to migrate to South Africa for work. For 11 months of the year, they toil in the mines, cut off from their families and living in crowded worker hostels where they are at high risk of infection with HIV, tuberculosis, and other diseases. When they return home for the holidays, all too often they bring deadly diseases with them.

Estimates and testing results suggest that more than 50 percent of adults in mountain areas may be infected with HIV. These same  areas had been largely ignored by efforts to scale up treatment for HIV until the Lesotho government invited PIH and the Clinton HIV/AIDS Initiative to create a model for bringing care to people in the mountains.

From day one in Nohana, PIH has moved not just to scale up HIV testing and treatment but to strengthen health care and health status overall by implementing all “four pillars” of our HIV Equity Initiative. That means embedding HIV treatment within a comprehensive, community-based model of care that: provides primary health care; advances care of tuberculosis (the leading cause of death among HIV patients in Africa); emphasizes women’s health; and improves screening and treatment of sexually transmitted infections.

Building a model of community-based care

When PIH arrived in Nohana, all four pillars needed to be built almost from scratch. Until our arrival, the one-room health center offered limited testing but no treatment for HIV. It had no infectious disease clinic, no waiting room, and a poorly stocked pharmacy the size of a small closet. Despite obvious signs of a major epidemic of tuberculosis, only five patients had been diagnosed and treated for tb during the entire year prior to our arrival.

Now, says Dr. Jonas Rigodon, all that has changed. Dr. Jonas, a Haitian doctor now based full-time in Nohana, reports that, “The infectious disease clinic is functional. We have almost 600 HIV and TB patients enrolled in follow-up. We have increased and trained the staff and we now have stocks of essential medicines.”

Much remains to be done to improve facilities and reach more patients. For example, Jonas and his colleagues still face great difficulties in getting lab results to confirm tuberculosis diagnoses.

“More than 90 percent of sputum results are never sent back to us,” he reported, and x-rays are often so poor they cannot be used. “We need a chest x-ray machine and a lab and lab technician to serve all the PIH sites,” Jonas said.

The list of needs hardly stops there. But the record of accomplishments has kindled confidence that needs will be met, lives will be saved and the model of Nohana can be replicated at other mountain clinics.

Dr. Jonas recounted a striking example from his early days in Nohana:

“One of the village health workers came to me,” he recalled. “She said, ‘I know a patient who is too sick to come to the clinic. Do you think you could go to her house?”

“‘No problem,’ I said.”

“You will have to ride a horse six hours to get there,’” she told me.

“No problem,” I said.
“When we got there, the woman was so weak she could not even sit up in her bed. We started her on treatment that same day. And six weeks later, she was back on her feet and eager to come to the clinic. We helped rent a horse for her and she came.”

As PIH completes its first year in Lesotho, similar stories are now unfolding both in Nohana and at our second site in Bobete.

[posted January 2007]

For PIH and our partner organizations on four continents, 2006 was another year of daunting challenges and striking achievements.

For the second consecutive year, we launched a new project, this time in Lesotho, at the very heart of the AIDS pandemic in southern Africa. Working at a remote mountain clinic, in an area where more than half the adult population may be infected with HIV, we succeeded in testing more than 1,000 people and enrolling almost 200 on treatment within barely six months.

We also strengthened and expanded our operations in countries where we have been working for many years. We constructed and inaugurated new facilities in Peru, Haiti and Rwanda. We substantially increased the numbers of patients we serve and initiated major new programs to serve them better. In Peru, for example, we built on our experience and success in community-based care for tuberculosis to launch a program for patients infected with HIV. And in Russia, for the first time, we trained and hired community health workers to bring care and social support to the most vulnerable patients in their homes.

Some of the highlights of the year at our various sites are described below. For more details on individual countries, click on the sub-titles below or the links in the column to the right.

Expanding the HIV Equity Initiative and opening new clinical facilities in Haiti

In 2006, Zanmi Lasante expanded its groundbreaking HIV Equity Initiative beyond the Central Plateau to two new sites in the Artibonite region of Haiti. The Artibonite clinics were rapidly scaled up to offer people living with HIV the same PIH model of comprehensive care—including accompaniment, socioeconomic support, and free medical care—that has proven so successful since Zanmi Lasante launched the HIV Equity Initiative in 2000 and extended it throughout the Central Plateau. 

	Inauguration of the new Zanmi Lasante facilities at Cerca La Source

In August 2006, Zanmi Lasante and the Haitian Ministry of Health inaugurated a medical center in the Central Plateau town of Thomonde. This new facility provides comprehensive primary care and HIV/AIDS services to an average of 200 patients per day. During 2006, ZL also officially inaugurated a new clinic in Cerca La Source, a new pavilion in Hinche and the Sante Fanm women's health center in Cange.

Improving and expanding DOTS-Plus and providing HIV care in Peru

	Delivering DOTS-Plus in the community

Throughout 2006, SES worked with local ministries of health to expand treatment for MDR-TB patients both within and beyond Lima. In Arequipa, a major city in the south, the Regional Health Directorate committed to working with SES to expand and improve MDR-TB care. Patients are already enrolling in the DOTS-Plus program there. In Lima, almost 500 of our patients were declared completely cured; another 500 are still receiving medical treatment as well as nutritional, social, and economic support. SES sponsored weekly group therapy sessions over the course of the year, as well as thoracic surgeries for 77 patients. Finally, the committee responsible for decisions regarding treatment protocols has been expanded to include additional health and social service professionals; they will provide a more balanced and comprehensive view of TB treatment and decision making.

While continuing its longstanding work with MDR-TB, SES has taken on an important role in scaling up treatment for HIV, particularly among patients co-infected with TB and HIV. 79 HIV-positive patients are now receiving comprehensive care through the SES HIV program; at the end of 2006, 94 percent of these patients were clinically stable and had an undetectable viral load. The HIV team works with 17 volunteer health workers who administer life-saving antiretroviral drugs to patients and give them critical emotional, economic, and nutritional support. The team also works in tandem with the Ministry of Health’s National HIV program to improve patient enrollment and adherenced to treatment.

Improving facilities and strengthening pediatric care in Rwanda

During 2005, PIH had succeeded in transforming the broken-down facility in Rwinkwavu from a collection of crumbling buildings with no electricity, no doctors, few medicines and only a handful of overworked nurses into a functioning district hospital. In 2006, we continued to improve facilities and services at the hospital with the addition of a new pediatric ward and a functioning operating room.

	The new pediatric ward at Rwinkwavu Hospital

Rwinkwavu Hospital opened its pediatric ward and inpatient malnutrition center in February 2006, with support from the Clinton Foundation and UNICEF. The 30-bed pediatric care center serves as a referral facility for complicated pediatric cases from all six PIH Rwanda sites.

PIH Rwanda enrolled over 150 children living with AIDS on lifesaving ART and instituted comprehensive prevention of mother-to-child transmission (PMTCT) programs at all six clinical sites in 2006.  Children living with AIDS and their families meet for monthly pediatric counseling groups, where PIH Rwanda staff provide education and psychosocial support.  Around Rwinkwavu, PIH Rwanda staff and patients conduct HIV education programs at local primary and secondary schools, with plans for expansion in 2007.

Training doctors nationwide and reaching out to the neediest patients in Russia

Working in collaboration with the Russian Ministry of Health and the World Health Organization, PIH Russia led three comprehensive training sessions on management of multidrug-resistant TB for doctors from the Russian medical system. Two sessions were held near Moscow and one in Novosibirsk, Siberia, providing training to 213 physicians representing 80 percent of the territory of the Russian Federation. With continuing support from the Eli Lilly and Company Foundation, two more sessions are planned in 2007 to extend training to the entire country.

In November, PIH Russia and Tomsk Oblast TB Services launched a new pilot outreach program to improve treatment adherence and support for the poorest and most neglected MDR-TB patients in the region. The "Sputnik Program" marks the first use in Russia of what has long been a key component of PIH's model of care in other countries – recruiting, training and paying community health workers to provide directly observed therapy and comprehensive social, nutritional and medical support.

Providing access to lifesaving treatment for HIV and tuberculosis in Lesotho

	A village health worker delivers medication to an HIV patient in Lesotho

In July 2006, PIH Lesotho started its first 16 AIDS patients on antiretroviral therapy (ART) at the Nohana Health Center. As news of the remarkable recovery of these patients spread throughout the area, the number of people seeking HIV testing or treatment at the Nohana Health Center increased dramatically. Within just six months, more than 170 patients were receiving ART at the Nohana Health Center and over 450 were enrolled in pre-ART care.

Testing in Nohana has confirmed high rates of tuberculosis and of HIV-TB coinfection. Although the National Tuberculosis Program offers limited support for diagnosis and treatment, PIH has identified almost 100 active cases of TB, among whom more than 90 percent are coinfected with HIV. Outbreaks of multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB) in neighboring South Africa raised concern about drug-resistant tuberculosis in Lesotho. In response, PIH Lesotho partnered with the National Tuberculosis Program of Lesotho to conduct a rapid survey of two Lesotho districts bordering the affected region of KwaZulu-Natal Province, South Africa, during October and November of 2006.  The survey will provide a snapshot of the extent of MDR-TB and XDR-TB in Lesotho.

Scaling up health promotion and expanding access to care in Boston

During 2006, enrollment into PACT health promotion and directly observed therapy for HIV patients increased by 115 percent. PACT staff began an extensive outreach campaign designed to reach patients who have experienced difficulty adhering to treatment and accessing care and could benefit from PACT services.

PACT services expanded from the inner-city neighborhoods of Dorchester and Roxbury to serve the greater Boston area, as PACT developed new partnerships with healthcare providers to reach more of the area’s most vulnerable communities.

In addition, PACT staff traveled to Puerto Rico, New York City, Miami, and Wisconsin to engage in new collaborations with groups interested in replicating the PACT model of health promotion.

Building a network of community health promoters and expanding community education and outreach in Chiapas

In 2006, staff from EAPSEC (Equipo de Apoyo en Salud y Educación Comunitaria, the PIH-supported project in Chiapas, Mexico) trained 137 health promoters to work in 11 municipalities and 83 communities across four regions of Chiapas, serving an area of approximately 16,900 people.

EAPSEC health promoters led a record number of educational community health talks in 2006, on subjects ranging from potable water, hygiene, and construction of sanitary latrines to nutrition and mental health issues.

[posted January 2007]

After starting to work in Lesotho in June, PIH moved rapidly to implement key components of our model of comprehensive community-based care. We trained dozens of community health workers, scaled up testing and treatment for HIV, provided food to patients and families suffering from hunger and malnutrition and worked to reinforce the public health sector. Highlights of PIH’s work in Lesotho during 2006 included:

Training village health workers: In June 2006, staff from PIH Lesotho led the first village health worker training at the Nohana Health Center, our first clinical site in Lesotho. More than 75 village health workers from the Nohana area participated in the training, which focused on HIV/AIDS care, prevention and treatment. During the following months, additional training sessions were conducted in Nohana, and in October a first round of training was carried out with village health workers in Nkau, another mountain community where PIH plans to start working in 2007.

	A village health worker delivers medication to an HIV patient in Lesotho

Providing access to lifesaving treatment for HIV/AIDS: In July 2006, PIH Lesotho started its first 16 AIDS patients on antiretroviral therapy (ART) at the Nohana Health Center. As news of the remarkable recovery of these patients spread throughout the area, the number of people seeking HIV testing or treatment at the Nohana Health Center increased dramatically. Within just six months, more than 170 patients were receiving ART at the Nohana Health Center and over 450 were enrolled in pre-ART care.

Committing to support the public sector: On November 2, 2006, PIH co-founder Dr. Jim Yong Kim flew to Maseru, Lesotho, to meet with the Minister of Health and sign a Memorandum of Understanding between the Ministry of Health and Partners In Health.  PIH is committed to serving alongside the Ministry of Health in Lesotho to bring community-based primary care and treatment for HIV and tuberculosis to mountainous rural areas.

Delivering food to the hungry in Nohana: On November 16, 2006, a first shipment of food was delivered to Nohana Health Center under an agreement between PIH and the World Food Program that will provide nutritional support to HIV patients and their families.

Improving treatment for tuberculosis and seeking out cases of drug-resistant TB: Testing in Nohana has confirmed high rates of tuberculosis and of HIV-TB coinfection. Although the National Tuberculosis Program offers limited support for diagnosis and treatment, PIH has identified almost 100 active cases of TB, among whom more than 90 percent are coinfected with HIV. Outbreaks of multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB) in neighboring South Africa raised concern about drug-resistant tuberculosis in Lesotho. In response, PIH Lesotho partnered with the National Tuberculosis Program of Lesotho to conduct a rapid survey of two Lesotho districts bordering the affected region of KwaZulu-Natal Province, South Africa, during October and November of 2006.  The survey will provide a snapshot of the extent of MDR-TB and XDR-TB in Lesotho.

[posted January 2007]

Recovery from the devastation of Hurricane Stan and continuing empowerment of community health promoters were the main themes of 2006 at EAPSEC (Equipo de Apoyo en Salud y Educación Comunitaria), a PIH-supported project in Chiapas, Mexico.

Highlights of EAPSEC's activities in 2006 included:

Building a network of community health promoters: In 2006, EAPSEC staff trained 137 health promoters to work in 11 municipalities and 83 communities across four regions of Chiapas, serving an area of approximately 16,900 people.

Providing medical care to hurricane victims: EAPSEC continued to support and staff two additional emergency clinics in Belisario Dominguez and Honduras, two of the communities hardest hit by Hurricane Stan. EAPSEC hopes to continue support for these clinics as long as community needs persist.

Initiating South-South collaborations: Together with Socios En Salud, PIH’s sister organization in Peru, EAPSEC initiated a Chiapas-Peru collaboration to share best practices regarding training of health promoters.  EAPSEC anticipates further collaboration in the coming year.

Community education and outreach: EAPSEC health promoters led a record number of educational community health talks in 2006, on subjects ranging from potable water, hygiene, and construction of sanitary latrines to nutrition and mental health issues.

Assessing community health needs: EAPSEC and PIH continue to share technical and medical expertise to support the health of people in Chiapas. In 2006, EAPSEC hosted Dr. Dan Palazuelos, a resident in the PIH-affiliated Global Health Effectiveness residency at the Brigham and Women’s Hospital, who piloted a community epidemiological survey to evaluate community health needs in Chiapas.

[posted January 2007]

During 2006, the PACT project scaled up enrollment in HIV care, significantly expanded its outreach in the Boston area and established collaborative relationships that could lead to replication of the PACT model in several other communities around the United States.

Highlights of PACT activities in 2006 included:

Scaling up health promotion: During 2006, enrollment into PACT health promotion and directly observed therapy for HIV patients increased by 115 percent. PACT staff began an extensive outreach campaign designed to reach patients who have experienced difficulty adhering to treatment and accessing care and could benefit from PACT services.

Expanding access to care: PACT services expanded from the inner-city neighborhoods of Dorchester and Roxbury to serve the greater Boston area, as PACT developed new partnerships with healthcare providers to reach more of the area’s most vulnerable communities.

Designing tools to help overcome barriers to care: PACT staff developed a culturally-competent curriculum to train community residents as health promoters . The curriculum teaches promoters and patients problem-solving skills needed to overcome common barriers to treatment adherence faced by the communities served by PACT.

Replicating the model throughout the US: PACT staff traveled to Puerto Rico, New York City, Miami, and Wisconsin to engage in new collaborations with groups interested in replicating the PACT model of health promotion.

Taking the message to the streets: From May through September 2006, Fuerza Latina Peer Prevention Leaders engaged in more than 700 street outreach encounters for community health education. The most popular topics were prevention of HIV and Hepatitis C. More than 100 of these encounters resulted in Fuerza leaders accompanying clients to a healthcare facility—most commonly to drug detoxification programs or HIV counseling and testing. 

Fuerza Latina recognized by the Brigham and Women’s Hospital: On October 20, Fuerza Latina and invited guests celebrated the graduation of nine new Peer Prevention Leaders at the Brigham and Women's Hospital.  The Leaders were presented with certificates of graduation for Core Curriculum and Leadership Development Training. In addition, 14 individuals received certificates of appreciation in recognition of their contribution to the community.

[posted January 2007]

During our second year in Rwanda, PIH and our Rwandan partner organization Inshuti Mu Buzima (IMB) continued to renovate and expand our clinical facilities, scaled up our comprehensive HIV care program dramatically, more than doubling the number of patients on antiretroviral therapy, and expanded our support for nutrition, housing and other social and economic needs.

Highlights of 2006 included:

Renovation of Rwinkwavu District Hospital: During 2005, PIH had succeeded in transforming the broken-down facility in Rwinkwavu from a collection of crumbling buildings with no electricity, no doctors, few medicines and only a handful of overworked nurses into a functioning district hospital. In 2006, we continued to improve facilities and services at the hospital with the addition of a new pediatric ward and a functioning operating room.

Improving staffing and facilities at other sites: In addition to Rwinkwavu Hospital, PIH works at five other sites in southeastern Rwanda, including four health centers in Kirehe health district serving a population of more than 350,000 people. After initiating HIV testing and treatment at these facilities in 2005, PIH took steps in 2006 to establish the staffing and facilities needed to implement our full model of comprehensive community-based care. A clinical team headed by the PIH Rwanda Project's medical director, Henry Epino, took up residence at the Kirehe health center. Clinical and laboratory facilities in Kirehe have been expanded, pending construction of a new district hospital in 2007 by PIH and the Rwandan Ministry of Health.

	The new pediatric ward at Rwinkwavu Hospital

Building infrastructure to support children’s health: Rwinkwavu Hospital opened its pediatric ward and inpatient malnutrition center in February 2006, with support from the Clinton Foundation and UNICEF. The 30-bed pediatric care center serves as a referral facility for complicated pediatric cases from all six PIH Rwanda sites.

Inauguration of Rwinkwavu Hospital operating suite: In October 2006, Rwinkwavu Hospital officially opened its fully renovated operating room. Prior to renovations, emergency obstetrical cases had to be transferred to the closest hospital—more than an hour away.  Doctors at Rwinkwavu Hospital can now perform emergency obstetrical Cesarean sections, and hope to expand surgical services in 2007. 

Expanding access to ART: The HIV treatment program continues to expand, with more than 2,000 patients enrolled on antiretroviral therapy (ART). Patients are visited daily by more than 800 community health workers, trained by Inshuti Mu Buzima to distribute medications and provide social support.  

Providing comprehensive care for children with HIV/AIDS: PIH Rwanda enrolled over 150 children living with AIDS on lifesaving ART and instituted comprehensive prevention of mother-to-child transmission (PMTCT) programs at all six clinical sites in 2006.  Children living with AIDS and their families meet for monthly pediatric counseling groups, where PIH Rwanda staff provide education and psychosocial support.  Around Rwinkwavu, PIH Rwanda staff and patients conduct HIV education programs at local primary and secondary schools, with plans for expansion in 2007.

Nutritional support for patients with HIV and TB: Food security and proper nutrition are essential to successful HIV treatment.  In 2006, PIH Rwanda distributed more than 1,500 food packages per month to HIV and TB patients and their families, and signed an agreement with the World Food Program for another 1,000 per month. To improve food security and nutritional status community-wide, our partners in the Clinton Hunter Development Initiative launched agriculture programs in the area around Rwinkwavu to distribute maize and bean seeds and cassava cuttings while providing education to local farmers.

	One of dozens of new houses contructed in Rwanda during 2006

Supporting social and economic rights: Inshuti Mu Buzima’s Program on Social and Economic Rights continued and expanded its work to improve access to decent housing, schooling and opportunities to earn a living. During the course of 2006, IMB built more than 35 houses, paid secondary school fees for almost 400 students who would otherwise have lbeen unable to go to school, established a carpentry and welding workshop that provides both jobs for local residents and furnishings for IMB clinical facilities. In addition, IMB dispersed 40 microcredit loans to income-generating projects for associations of HIV patients in Rwinkwavu and Kirehe.

[posted January 2007]

	Delivering DOTS-Plus in the community

Improving and expanding DOTS-Plus: Throughout 2006, SES worked with the Peruvian Ministry of Health and with local health officials to expand treatment for MDR-TB patients both within and beyond Lima. In Arequipa, a major city in the south, the Regional Health Directorate committed to working with SES to expand and improve MDR-TB care. Patients are already enrolling in the DOTS-Plus program there. In Lima, almost 500 of our patients were declared completely cured; another 500 are still receiving medical treatment as well as nutritional, social, and economic support. SES sponsored weekly group therapy sessions over the course of the year, as well as thoracic surgeries for 77 patients. Finally, the committee responsible for decisions regarding treatment protocols has been expanded to include additional health and social service professionals; they will provide a more balanced and comprehensive view of TB treatment and decision making.

Advancing information systems: In May 2006, the National TB Program declared they would utilize the PIH Electronic Medical Records System to track treatment of MDR-TB patients. This collaboration with the Ministry of Health will further the transfer of responsibility for TB care to the public sector, and will continue to improve quality of care among MDR-TB patients. In addition, a laboratory system that will allow patients to receive better treatment more quickly was implemented in 12 health centers throughout Lima. SES also upgraded its own online abilities this year, implementing intranet and pharmacy systems, through which staff can report and track program progress.

HIV/AIDS care: 79 HIV-positive patients are now receiving comprehensive care through the SES HIV program; at the end of 2006, 94 percent of patients were clinically stable and had an undetectable viral load. The HIV team works with 17 volunteer health workers who administer life-saving antiretroviral drugs to patients and give them critical emotional, economic, and nutritional support. The team also works in tandem with the Ministry of Health’s National HIV program to improve patient enrollment and adherence to treatment.

Building on our success: In 2006, SES took on not only direct patient care but also strengthening the Peruvian health care infrastructure. SES supported the construction and maintenance of two operating rooms dedicated to surgeries for MDR TB patients, two in-patient hospital wings for TB and MDR-TB patients, a national reference laboratory for diagnosis of MDR-TB, and an ambulatory care wing for a regional hospital. In addition, we improved five healthcare facilities located in high-risk areas for TB transmission; we refurbished hospital rooms, exam rooms, and waiting rooms in two hospitals and three local health centers.

Telling our story: SES published 3 books (The PIH-EMR Manual, the Nurses’ Guide to MDR-TB and DOTS Plus, and Conquering MDR-TB: Stories of 20 Former Multi-Drug Resistant Tuberculosis Patients) and six articles in scholarly publications ranging from the International Journal of Tuberculosis and Lung Disease to The Journal of the International Association of Physicians in AIDS Care.

Education and training: Not only did SES continue to train fellow Peruvian healthcare professionals in the management of MDR-TB, we also collaborated with our colleagues in Haiti to provide a two-day training program to the Haitian Ministry of Health. SES doctors and nurses (along with one intrepid translator) traveled to the Zanmi Lasante training center in December 2006, and shared their 10 years of experience with their Haitian counterparts. We also adapted the curriculum developed by our Boston-based PACT colleagues for our HIV community health workers, and conducted our first trainings in community-based HIV/AIDS care.

[posted January 2007]

Zanmi Lasante continued to deepen and broaden its services to the poor of Haiti in 2006, inaugurating new facilities, programs and partnerships. Even as Zanmi Lasante mourned the tragic death of Jean Gabriel fils, who had led and inspired construction of dozens of new homes and other activities of the Program on Social and Economic Rights (POSER), ZL staff found new resolve to carry on his commitment to social justice.

Highlights of ZL’s accomplishments in 2006 included:

Expanding the HIV Equity Initiative: In 2006, Zanmi Lasante expanded its groundbreaking HIV Equity Initiative beyond the Central Plateau to two new sites in the Artibonite region of Haiti. The Artibonite clinics were rapidly scaled up to offer people living with HIV the same PIH model of comprehensive care—including accompaniment, socioeconomic support, and free medical care—that has proven so successful since Zanmi Lasante launched the HIV Equity Initiative in 2000 and extended it throughout the Central Plateau. 

	Inauguration of the new Zanmi Lasante facilities at Cerca La Source

Opening new clinical facilities: In August 2006, Zanmi Lasante and the Haitian Ministry of Health inaugurated a medical center in the Central Plateau town of Thomonde. This new facility provides comprehensive primary care and HIV/AIDS services to an average of 200 patients per day. During 2006, ZL also officially inaugurated a new clinic in Cerca La Source, a new pavilion in Hinche and the Sante Fanm women's health center in Cange.

Fortifying human resources for child survival: With the support of the U.S. Agency for International Development (USAID), Zanmi Lasante expanded its child survival and maternal health programs in 2006 to cover all ZL satellite sites. ZL hired and trained new staff to work on pediatric programs in clinics and expand community outreach activities. With ZL staff running mobile vaccine clinics, rally posts and door-to-door distribution, access to childhood vaccinations increased dramatically. In addition, approximately 70-80 traditional birth attendants per site received ongoing monthly training in safe delivery care. 

	Distributing school lunches

Treating child hunger with food: Zanmi Lasante rolled out an extensive child nutrition program in the Central Plateau in 2006, with support from the Johnson and Johnson Foundation, Meds and Food for Kids, and the World Food Program. More than 17,000 children now receive daily school lunches free of charge through the program. ZL also began local production of nutritionally fortified therapeutic food for malnourished children in November 2006.  

Continuing Ti Jean's work – building houses:  Colleagues and friends of Jean Gabriel fils (Ti Jean), who had led and inspired Zanmi Lasante’s Program on Social and Economic Rights (POSER), promised that Ti Jean’s tragic death on May 28 would not derail his life work of building new homes for destitute people in the Central Plateau. And they kept their promise. As 2006 came to an end, POSER was nearing completion of the last of 70 houses that had been identified as top priorities for the year. Throughout the Central Plateau, hundreds of sturdy houses attest to Ti Jean’s tireless commitment to social and economic rights for the poor.

[posted January 2007]

Serving lunch at a school canteen in Haiti

For years, parents in central Haiti faced a terrible choice.They could send their children to school with empty stomachs, in the hope that they might gain the skills to someday escape poverty. Or they could keep them at home to work in the family gardens, to help produce much-needed food for right now. 

No longer. Thanks to the dedicated efforts of Zanmi Lasante’s child nutrition program, more than 17,000 children at 28 schools in central Haiti receive piping hot lunches every day—free of charge. Local cooks employed by the program prepare the nourishing meals from hundreds of giant sacks of rice and beans, distributed regularly by Zanmi Lasante (ZL) as part of the expanding struggle to eradicate child malnutrition from Haiti’s impoverished Central Plateau.

The broad smiles of the children are mirrored by their teachers, who know the tremendous impact this program has had on their schools. Now that parents no longer have to choose between education or food for their children, school attendance has increased significantly. And so have the attention spans and classroom performance of the children once they get to school.

“Before the lunch program started, many of my students would come to school hungry or wouldn't come at all,” recalls one teacher. “Since we began giving daily meals, they hardly ever miss a day and their academic performance has improved dramatically.”

"The program is one of the cornerstones of our commitment to social support in the Central Plateau,” notes PIH’s Food Assistance Coordinator Elisabeth Berger. “Its strength is that it takes a proactive community-based approach to preventing child malnutrition, ensuring that children won’t have to come into our clinics as patients."

Mounting a community-based drive to eradicate hunger

The school lunch program is just one component of ZL’s comprehensive, community-based approach to eradicating hunger in the Central Plateau. In towns and villages throughout the area, community health workers and clinicians from Zanmi Lasante teach families to recognize warning signs and seek out children with telltale symptoms. 

Throughout Haiti, hunger and malnutrition cripple and destroy the lives of poor people—especially children—at an astonishing rate. Nearly half of all Haitians are undernourished.  A recent study by ZL found that 92 percent of families living in Haiti’s Central Plateau suffer from extreme food insecurity.  And close to 50 percent of families in this area must feed their families on an income of less than 500 Haitian gourdes a month—just $12.50. 

Chronic malnutrition weakens the body’s resistance to disease, leading to a downward spiral of sickness and poverty for parents and their children that too often ends in early death. In young children, whose bodies are still developing, chronic malnutrition stunts physical and intellectual development, causing irreversible harm that may follow a child through life. 

When ZL health workers encounter a child suffering from malnutrition, they refer the child’s family to the nearest ZL clinical site.  There, malnourished children receive high-energy therapeutic feeding formulas until they regain a healthy weight. 

The family is also paired with a community agronomist who visits their home regularly, providing advice and assistance for improving their home garden.  This comprehensive support is vital to addressing the conditions of poverty and food insecurity that first caused the child to become malnourished. 

Agricultural projects help improve nutrition and incomes

Agricultural projects are increasingly important to ZL’s battle against hunger in the Central Plateau.  Beginning in November 2006, ZL started local production of its own high-energy therapeutic foods for children hospitalized with severe malnutrition. 

Through an innovative collaboration with a team of Haitian agronomists, the main ingredients for the therapeutic foods—peanuts, corn, rice, and beans—are grown for ZL’s child nutrition program at a nearby farm. Vitamins and minerals are then added and the foods are processed into fortified peanut butter and akamil, a high-protein porridge.

These locally-produced therapeutic foods provide the energy, protein and vitamins found in more expensive commercial brands—at a fraction of the cost. By growing and processing the food locally, ZL bolsters the local economy while also demonstrating the value of local resources in supporting community health.

ZL’s efforts to produce therapeutic foods locally were inspired and assisted by Meds and Food for Kids (MFK), a non-governmental organization working in northern Haiti that has developed a “ready to use therapeutic food” called Medika Manba © -- a fortified peanut-butter therapy. A successful pilot program with Medika Manba at two Zl sites confirmed findings from studies in Africa that showed this kind of treatment to be highly effective for child malnutrition. With technical assistance from MFK, ZL then began growing peanuts and preparing our own version of fortified peanut butter.

In the first two months of distribution, more than 30 children recovered from severe malnutrition with ZL’s locally produced therapeutic foods. In 2007, ZL will scale up its production to supply more than 2,000 children in need of nutritional support. 

Expanding food production at the ZL farm will offer yet another opportunity to improve food security in the Central Plateau. In partnership with Zanmi Agrikol, the team of Haitian agronomists who manage the farm, the land will serve both to produce nutritious food and to provide hands-on training for local farmers in techniques that can improve crop yields. 

These trained farmers will serve as ajan agrikol, or community agronomists, visiting malnourished children in their homes and working with their families to improve their gardens. 

Contending with unfair trade policies

Although training local farmers and providing emergency food support can help alleviate hunger in Haiti, many of the greatest causes of persistent food insecurity lie outside the country’s borders. As recently as the mid-1980s, Haiti was self-sufficient in production of rice, the staple food.  But trade agreements that opened Haiti’s markets to imported rice—mainly from the US—have progressively weakened the position of small-scale Haitian farmers. 

In 1995, under pressure from the International Monetary Fund (IMF), Haiti was forced to reduce its tariffs on US-grown rice from 35 percent to 3 percent, far below the regional Caribbean average of 25 percent. At the same time, corporate US rice producers continue to benefit from farm subsidies averaging $1 billion a year and rely on heavily subsidized water to grow a wetland crop in parts of California that would be a desert without irrigation. As a result, US producers can afford to export rice at prices below their real costs of production, making it almost impossible for small farmers in countries like Haiti to compete without some form of protection. From 1994 to 1995, the amount of rice Haiti imported from the US more than doubled.

Though the influx of cheap US rice helped lower food prices in the short term, it decimated Haiti’s agricultural sector. Most of the money spent on imported US rice has not stayed in Haiti, but instead gone to US rice growers—draining the Haitian economy. 

Haiti has closely followed the prescriptions of the international finance community for over a decade, earning the ranking of “least trade restrictive” country in the Caribbean by the IMF. Yet Haiti remains the poorest country with the hungriest population in the western hemisphere. 

While working to provide food for hungry people, Zanmi Lasante continues to call for the end of unjust agricultural and trade policies imposed upon Haiti by international financial institutions, so that children in Haiti may attend school without worrying where they will find their next meal. 

[posted December 2006]

Denizard Wilson — Profile in courage and commitment
AIDS patient is messenger of hope

	Denizard Wilson with his wife, Douze Marie Chantale.

More than 13 years ago, Denizard Wilson was diagnosed with AIDS. Soon he was too sick to continue working in Port-au-Prince, too poor to afford medical care, fearful that time was running out. Then he heard about Partners In Health, moved back to his hometown in the Central Plateau and went to PIH for treatment.

“Since I have been with Partners In Health, I have never been sick again—not the kind of sickness I had known,” Wilson says.

Today the proud father of two healthy daughters works as a motorcycle messenger at one of PIH’s seven hospitals. He carries patient blood samples over dirt roads, and tracks down patients who miss appointments.

“I have a message for these patients, and for my family, and for everyone, infected or not,” he says. “As long as we are alive and have access to drugs, there is hope.”

Here is Denizard's own account of his experience and his message.

*       *       *

I was on a bus on my way to Port au Prince when I heard a woman talking badly about AIDS, spreading rumors. I could not let her say those things anymore, so I said to her, “I am infected.”

She didn’t believe me. “Liar,” she said.

So I took my medications from my bag and held them out in my hand for her to see. Because I have this virus in my blood, I take medicine every day. I have a community health worker who brings my medication to me every morning. Before I plan to travel anywhere, I tell my community health worker and my doctor, and they give me the pills to take with me. I explained all of this to her and the rest of the people on the bus.

“Are you lying to me?” she asked.

I replied, “You will not find one single human being who would choose to be infected by this disease. Why would I lie about this?”

Apart from the kidnapping and the political problems that we have in Haiti, there is a terrible epidemic that is sweeping through our country. Wherever I go, I try to spread this message: AIDS can touch anyone anywhere.

I am a motorcycle messenger for Partners In Health. I work in a village called Thomonde at one of their seven hospitals in Haiti’s Central Plateau. I carry patient blood samples over dirt roads, and doctors send me to find patients who stop coming in for appointments, or patients who think that an HIV positive diagnosis means their life is over. I have a message for these patients, and for my family, and for everyone, infected or not: as long as we are alive and have access to drugs, there is hope.

On October 4, 1993 I was diagnosed with AIDS. I had a job in an office in Port au Prince. I was making some money and advancing in my job. I started getting weak, though, and I kept getting admitted to the city hospital. I had health insurance, but it was not covering my medical expenses. Every time I began to recover my strength, I would fall ill again. At first I tried to hide my sickness from my boss. I was afraid he would fire me if he knew that I was HIV positive. But this sickness does not know how to hide.

There came a point when I had spent all my money and could not bear this virus anymore. I finally told one of my directors that I was infected. He told me about Partners In Health—that they had a good hospital in the Central Plateau with free health care. So I moved back to Thomonde, the place I was born, to be closer to the hospital. For the 13 years that I have been with Partners In Health, I have never been sick again—not the kind of sickness I had known.

	Denizard Wilson with his daughters Marie-Estherson Wilson and Stephanie Wilson. Both girls are HIV-negative, thanks in part to Zanmi Lasante’s Prevention of Mother-to-Child Transmission (PMTCT) Program.

My wife is also infected. We thought that my seven year old was HIV positive when she was born. At that time, there was no program to prevent mothers from giving the virus to their babies. Thanks to God, though, we know now that she is HIV negative.

By the time my wife was pregnant with my second daughter, though, Partners In Health had started a program to prevent the AIDS virus from being passed from mother to child. The hospital gives us infant formula every month so that she will not be infected by her mother’s breast milk. Now she is four months old, and we are waiting for the test result to see if she is infected.

There are scientists and researchers searching for drugs, and I know they will find a cure for us. That day is not far away. My community health worker used to give me three different drugs. I do not know what the medicines are called, but I know that I used to take one big pill and two small pills. Now, I only have two pills, and someday those two pills will become one. Finally, there will come a day when I will not have to take any pills at all. I know that. I feel that.

Medications have slowed the virus down, but there is no cure yet. I have a message for all the youth who are uninfected: go to school before you enter into sexual relations. It is your right to wait until you are the appropriate age to be intimate with a partner. Do not give your body to just anybody. Before you give your body to someone, ask yourself, do I know this person?

And to those of you who are infected, protect your partner. The AIDS virus is like a poison, and to give it to someone else is like a crime. I do not want to make anyone die before it is their time. Remember to keep your promise, the 2005 World AIDS Day theme. I keep my promise to my wife because I do not want to make anyone else sick. Every time you enter into sexual relations with someone, even with a condom, you are taking a chance. One decision that you make now can affect your children and their children for generations to come.

Maladi pa tonbe sou pyebwa, se sou moun li tombe. This sickness does not fall on trees, as the Haitian expression goes, but on people. I would not like for even one single living creature to become infected with this disease—not an animal, not even an insect, let alone a human being.

I want to ask all the people and organizations that are supporting Partners In Health to keep helping them so that they can give more people a chance at life, like me. I ask all the drug companies to lower the price of the medications because there are thousands and thousands of people who still do not have the chance to take medicine because they cannot even afford to buy food.

On that October day when I first learned that I was infected, there is something I had not yet realized: when a person is infected, that does not have to mean that life is over. Dr. Almazor, one of my doctors, would always encourage me when I felt depressed. He would tell me that even though I am infected, right now there is someone else who is dying, and there is someone else who is being buried at this moment. But me, I still have work to do.

Thanks to Partners In Health, and the medication they give me every day, I am alive. I have a different life, but it is life, nevertheless, and I will protect the rest of the days I have been given, thanks to God, and thanks to Partners In Health.

The only way I would be scared would be if Partners In Health did not exist. As long as they are here, I am alive. And as long as I am alive, I will have hope, and as long as I have hope, I will continue to spread this message.

(Interview facilitated and translated from Haitian Creole to English by Elizabeth Whelan, edited by Louise Ivers and first published in the AIDSLink electronic newsletter, published by the Global Health Council – www.globalhealth.org/publications).

[posted December 2006]

	Dr. Augustine Gatera and nurse Aimé Kipendo with one of the first patients in the Rwinkwavu operating room.

Scalpel, please. After months of construction, training, and procuring equipment and supplies, the operating room at Rwinkwavu Hospital in Rwanda is open for business. The first operation was performed on October 11 by Dr. Augustin Gatera -- an emergency C-section on Cyakimwe Verema, a 30-year-old suffering from cervical dystocia.

As part of the standard Rwandan medical curriculum, all doctors are trained in both general medicine and surgery. Prior to working with Partners In health, Dr. Augustine worked at Byumba District Hospital in the obstetrical and gynecology dept followed by a year of specialized training in surgery at Butare University Hospital. Along with Dr. Augustine, the Medical Director of Rwinkwavu District Hospital, Dr. Adolphe Karamaga, is also now regularly performing emergency obstetrical operations. During their first five weeks in operation, the surgical team performed 26 emergency obstetrical operations..

	Proud mother Cyakimwe Verema looks on as Dr. Augustine holds the first baby delivered in the operating room.

Being able to provide obstetrical surgery could save hundreds of lives in an area where maternal mortality rates are high and transportation to hospitals in other districts is not readily available. Rwanda’s maternal mortality rates remain among the highest in the world with approximately 1071 deaths per 100,000 live births. According to the 2005 Maternal, Neonatal and Child Health Assessment in Rwanda, only 7.2 percent of births in Rwanda occur in facilities capable of emergency obstetrical care and only 1.1 percent of births are performed by cesarean section.

The capacity of the Rwinwkavu Hospital maternity department and operating room will continue to be developed to help meet the overwhelming demand and need for improved obstetrical care. Currently the hospital has between 40-50 births a month. There is already a need for expansion of the maternity ward and delivery room. In addition to increasing space, Dr. Augustine has identified immediate needs for ultrasound capacity, incubators and aspirators.

For now, the Rwinkwavu Hospital operating room is concentrating on emergency obstetrics. In 2007, PIH country director Michael Rich says he would like to expand operations to include hysterectomies, exploratory laparotomies, orthopedic surgery and amputations.

[posted December 2006 ]

Partners In Health representatives from four continents traveled to Paris, France, for the 37th World Conference of the International Union Against Tuberculosis and Lung Disease (The Union) from October 31 through November 4, 2006. PIH affiliates from Peru, Russia, Rwanda, and Boston presented their experience integrating community-based care for tuberculosis and HIV and using innovative technologies to test for drug resistance and manage patients' medical records.

The PIH delegation included clinicians, public health researchers, and medical information technology developers involved in diverse aspects of care for people living with tuberculosis (TB). Collaborators from the Peruvian Ministry of Health also presented at the Union conference.

Key presentations by PIH affiliates included the importance of utilizing community health workers to integrate TB and HIV care, strategies for early detection of drug-resistant tuberculosis, and evaluation of electronic record systems to maintain comprehensive records of patient care and streamline medication supply orders. 

PIH also presented findings from its work with patients suffering from strains of tuberculosis that are resistant to two or more of the most common medications used to treat TB, termed multidrug-resistant TB (MDR-TB). A poster presentation by the PIH Russia team examining risk factors for developing MDR-TB in Tomsk, Russia, drew attention at the conference.

“Our presentation showed that hospitalization was the greatest risk for acquisition of MDR-TB,” explained Dr. Salmaan Keshavjee, a physician at Brigham and Women’s Hospital who works with PIH projects in Russia and Lesotho.

“The policy implications of this work—especially in the countries of the former Soviet Union, where hospital-based treatment is the standard—are great,” concluded Dr. Keshavjee.

The theme of the Union conference was “Strengthening human resources for better lung health,” to address what conference organizers called “a human resource crisis” in the health care systems of many developing countries.

“Without building health infrastructures, it will be very difficult to build successful programs and reach out to the peripheries where the patients stay,” affirmed Dr. Amsa El Sony, President of the Union in an interview for the Kaiser Foundation. 

Eliminating poverty is also a key factor in retention of medical staff and supporting health infrastructure in developing countries, Dr. El Sony added.

One way Partners In Health addresses the shortage of professional health personnel in developing countries is by employing a network of community health workers, who accompany patients during treatment for complex illnesses, including TB and HIV/AIDS.

“PIH's approach has been to develop a cadre of health workers, drawn from the communities themselves,” said Dr. Keshavjee. “The idea of accompaniment builds on the widely-used community health worker model, adding the dimension of solidarity with the patients.”

In several conference sessions, representatives from Partners In Health, as well as Doctors Without Borders, emphasized the importance of paying community health workers adequately.

Other issues raised at the conference included the recent emergence of extensively drug-resistant tuberculosis, or XDR-TB, and the role of HIV/AIDS in fueling the spread of tuberculosis globally, particularly in sub-Saharan Africa. 

As drug-resistant strains of tuberculosis continue to spread, developing a research agenda for clinical trials of new TB medications is critical, noted Dr. Carole Mitnick, a researcher with PIH projects in Peru and Russia and instructor at Harvard Medical School.

“PIH’s community-based model can accelerate the delivery of promising new agents through clinical trials, routine care and compassionate use,” Mitnick added. “Our presence and that of the HIV activist community has helped pressure TB drug developers to consider creative, rapid approaches to increasing access to new agents.”

The mission of the Union is to prevent and control tuberculosis, lung disease, and related health problems, with a particular emphasis on low income countries.  The Union’s World Conference aims to gather and disseminate knowledge on tuberculosis and other lung diseases, and to link researchers, national governments, civil society groups, and the World Health Organization.