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Research: Improving Breast Cancer Outcomes for Patients in Haiti

jdelzo — Thu, 28 Oct 2021 13:50:25 +0000

Research: Improving Breast Cancer Outcomes for Patients in Haiti jdelzo Thu, 10/28/2021 - 09:50

Earlier detection, diagnosis, and treatment can save lives

Dr. Joarly Lormil, an internal medicine and oncology physician, and Dr. Erwine Dina Jeune, an OBGYN medical resident, meet with a 35-year-old patient with breast cancer in 2018. Photo by Cecille Joan Avila / PIH

In Haiti, breast cancer is the most common form of the disease among women, as it is worldwide. But there’s a key difference: a higher percentage of women will die from breast cancer in the Caribbean nation than most other countries.

While many factors may contribute to this, including that Haitian patients are often diagnosed at later stages, there is limited research detailing how these factors play a role in Haiti. To gain a better understanding of the situation and to assess care delivered at Hôpital Universitaire de Mirebalais (HUM), researchers from Zanmi Lasante—Partners In Health’s sister organization in Haiti—alongside co-collaborators from several institutions in the United States, conducted a comprehensive assessment.

Their findings, which were published last year in The Oncologist, include many important takeaways, with the most encouraging being that basic breast cancer treatment can lead to better outcomes in Haiti, especially when patients are diagnosed and treated early.

“We wanted to highlight the fact that we can treat cancer in Haiti. It’s feasible but you need the right resources,” says Dr. Ruth Damuse, clinical care coordinator in HUM’s oncology department and co-author of the study.

Their research is the first published assessment of cancer care at HUM since the program (which began in Cange in 2011) moved to the hospital in 2013, the same year the 350-bed, world-class teaching facility opened its doors. HUM has the country’s only public oncology center capable of diagnosing and caring for patients and offering both therapeutic and surgical treatments.

As the oncology department at HUM becomes more widely known, patients—80% of whom have breast cancer—have come from all around the country for care.

A Closer Look

The study included data from 341 female patients with nonmetastatic breast cancer who started treatment at HUM from 2012-2016. Damuse and her colleagues measured “event-free survival” in patients, meaning how much time elapsed before the patient had either a recurrence of cancer, a new tumor, disease progression, or death from any cause. They also reviewed the type of care provided by HUM, taking into consideration what treatments were administered, the time it took for patients to receive that treatment, and the treatment’s duration.

Of those patients, 81.5% received curative surgery, or removal of the breast where a tumor was found. (Breast-conserving surgery is not performed in Haiti at this time since it requires patients to receive radiation therapy, which is not available in the country.) Pre- and post-surgical therapies such as chemotherapy were provided to shrink the tumor, and some patients also received further chemotherapy and hormonal therapy after surgery. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 experienced progression of the disease.

Of the patients that had up to 3 years of follow up, over 60% were alive and free of disease.

Most patients tended to have more advanced disease at the time of diagnosis—a rate that was even higher than previous studies conducted across Haiti had indicated. The authors believe one reason was the lack of nationwide breast cancer early detection programs. And many of the patients appeared to get breast cancer at an earlier age than patients in the U.S., which previous studies have also found.

Lead author Dr. Temidayo Fadelu, PIH’s oncology advisor, says an explanation is illusive and needs further research. “You have an overall younger population, and then you have the possibility that the biology of cancer might be different in a population of African descent. Overlaying that is likely referral bias.”

In other words, he wonders: “Is it possible that older patients are having cancer but not making their way to our facility?”

The study helped researchers pinpoint several important obstacles to care that will be useful in identifying areas of improvement. For example, researchers found that many patients experience delays when they go to other facilities. When patients wait until their disease has advanced, it becomes more difficult to treat their cancer and more likely that they will have a negative outcome.

Damuse said that patients are oftentimes resistant to seeking care for several reasons: stigma related to breast cancer, fear that a mastectomy will make them less feminine, or because they believe breast cancer is a death sentence. In some cases, patients are skeptical of modern treatments. And in rural areas, she says, people tend to be unfamiliar with hair loss associated with chemotherapy or have never heard of a breast being removed to save a patient’s life.

Diagnosis is also challenging. For most of the study period, there was very limited access to pathology services and patient samples had to be sent to the U.S. for a diagnosis. In Haiti, clinicians evaluate the extent of the cancer using a chest x-ray and ultrasounds, but other tests common in higher-income countries such as CT scans, nuclear studies, MRI, and PET scan machines are not readily available.

Marana Toussiant was treated for breast cancer by Dr. Ruth Damuse at HUM where she underwent a mastectomy and eight months of chemotherapy. She often talks about her experience. "People think that if you get cancer, you will die," Toussiant said in 2018. Yet she points to her own case and simply tells them "that’s not true." Photo by Cecille Joan Avila / PIH

Implementing Changes at HUM

Since conducting the study, the team has worked hard to improve the scheduling system and follow up with patients, with the goal of making sure patients continue treatment.

Dr. Joarly Lormil, oncology care coordinator at HUM, has seen thousands of patients in his practice. He estimates that, at the moment, about 150 patients are actively receiving chemotherapy at HUM. Lormil treats patients with all kinds of cancers, but the majority are patients with breast cancer. He has seen firsthand how harmful it can be when patients delay treatment.

Lormil recalls seeing a patient in her early 30s who was diagnosed with breast cancer and was a candidate for surgery. However, she was newly married and reluctant to have her breast removed. Nearly a year later, “we finally convinced her to receive the care,” he says. But then the earthquake struck, further delaying her surgery. Two more months passed. Finally she had the surgery and is doing well now, but is at higher risk for further complications and recurrence of her disease.

As the oncology team continues to increase its capacity to care for and treat patients in Haiti, increasing its staff and eventually bringing in new technology and treatments will improve patient outcomes, but all this comes at a significant cost.

Nonetheless, Lormil is optimistic: “Most men and women with breast cancer can get cancer care, including palliative care.”

Take the recent example of a nurse working in HUM’s maternal health unit, who discovered she had breast cancer. When she first got treatment, she felt ill from chemotherapy, but is doing better now. She is free from cancer, says Lormil, adding that the nurse has been sharing her experience with her co-workers and patients.

“She is the embodiment that, if you receive care early,” he says, “you can be free of cancer.”

Moving Forward

The research team identified gaps and areas for improvement, such as increasing the percentage of patients who receive surgery, the proportion of patients who get estrogen receptor testing, and the use of chemotherapies before and after surgery. The team also hopes to reduce the number of patients who fail to follow up and decrease system delays for patients.

As a result of the study, HUM staff are now working with local partners on initiatives to teach women how to perform self-breast exams. Clinicians are also providing information and support to patients with the goal of overcoming stigma around cancer care. Further studies are recommended to better understand why there are high rates of breast cancer in Haiti, and why Haitian women seem to get breast cancer at a younger age.

The study’s findings have already helped raise the standard of care for breast cancer patients at HUM. For example, the hospital now has a full-time surgeon integrated in the oncology team and dedicated to providing expedited access to surgery.

Damuse says the study has given the team confidence and proven the success of HUM’s oncological care model, which can serve as a blueprint for cancer care across Haiti and other developing countries.

“The study,” she says, “shows that we can improve cancer care in Haiti going forward.”

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University Hospital Resident Finds Calling in Oncology, Leads Department

jdelzo — Thu, 04 Feb 2021 18:55:55 +0000

University Hospital Resident Finds Calling in Oncology, Leads Department jdelzo Thu, 02/04/2021 - 13:55

He began working at HUM as an internal medicine resident in 2014

Dr. Joarly Lormil at University Hospital in Mirebalais, Haiti in January 2018. Photo by Cecille Joan Avila / PIH

Unlike many physicians, Dr. Joarly Lormil did not have a desire to become a doctor from a young age. In fact, he thought he would study engineering or economics because of his exceptional talents in math and physics. During university, he took some time to think about what he wanted to do, and he landed on medicine.

He stuck by this choice and went on to attend medical school at Université Notre Dame d'Haïti in the capital, Port-au-Prince. Initially unsure of his specialization, Lormil discovered his interest in oncology while participating in clinical rotations at Hôpital Universitaire de Mirebalais (HUM), a 350-bed teaching facility, home to one of Haiti’s largest medical residency programs and supported by Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti.

“I really liked it because it’s one of the departments where you can see your results,” he says. “When you succeed, even with palliative care, you make so much of a difference. It’s really life or death and I liked oncology because of that.”

As the end of his residency neared, a position opened in the oncology department. He filled it just one week after completing his residency in September 2017. Now, he’s the care coordinator in the department—a position he says is a 24/7 job, because time is of the essence, especially for patients undergoing chemotherapy.

“I knew from the beginning that to achieve a certain level of standard of care, to get as close as I could to that standard of care, ZL was the place to be,” says Lormil. “Of course there are a lot of challenges, but I think it’s a goal worth fighting for and it is achievable. My new position as care coordinator put me in a good spot to aim for that.”

HUM as it’s known locally, is one of the only facilities in Haiti that provides free cancer care and psychological support for adults—services that otherwise would be out of reach for families who live on less than $2 a day. Demand for cancer care remained steady throughout 2020, Lormil says, despite ongoing political unrest in the country and fears of contracting COVID-19. From January through July 2020 alone, more than 200 patients were in cancer care each month and attended to by Lormil and three other physicians, seven members of the nursing team, and four members of the psycho-social team.

Lormil wasn’t surprised by his department’s steady flow of patients: “The demand is so disproportionate compared to the care offered in the country that we will always find patients seeking care here.”

“There Is Care Available”

One of the patients Lormil examined during his first month as an attending physician in October 2017 was a young woman with advanced stage 4 breast cancer that had spread to her bones and liver. He was shocked to learn the mother of three was only 29—just a few months older than he was.

“It was sad to see a person my age, who I had so much in common with, diagnosed with cancer,” says Lormil. “What was even sadder is that she felt she needed to go to another country to get care and it did not go well.”

The woman originally underwent surgery at HUM, then chose to go elsewhere for follow-up care. A couple months later, she returned in worse condition and was confined to a wheelchair.

“It was really moving that she came back. We managed to give her good care with the expertise of our cancer partners and she improved,” says Lormil.

She was no longer in a wheelchair and was overall more active and happier. “I want to get the word out there that there is care available in Haiti,” says Lormil. “We are here and we are doing something.”

When the woman passed away in 2020, Lormil found himself thinking about the what ifs. Perhaps if she sought out their care earlier, she would still be alive today, he wonders.

Dr. Joarly Lormil with a 35-year-old patient who came in for her first oncology visit on January 25, 2018. Photo by Cecille Joan Avila / PIH

Growing to Meet Demand

Like that young mother, approximately 80 percent of patients Lormil and his team care for have breast cancer. The remaining patients have gastrointestinal cancers, chronic myeloid leukemia, and gynecological cancers, including cervical cancer. Typically, the team sees between 25 to 30 patients per day, but that number is steadily increasing.

In 2013, the oncology team conducted 843 consultations. Within six years, that number had tripled, and it became clear the department required more space for patient care and consultations. In April 2018, the oncology team moved to a newly renovated space on hospital grounds, the Roselene Jean Bosquet Center, named after one of the first cancer patient ZL clinicians cared for in Haiti.

Lormil predicts the number of oncology patients will rise even more, as the team continues to improve their skills through training, increased opportunities for cancer screenings at the hospital, mobile clinics and other patient centered programs, as more people become aware of the care available at HUM. And yet, he acknowledges how far they have come.

“It’s rewarding when you forget about a patient because they need to come less frequently, say every six months. Then, when they come, they’re cancer-free,” says Lormil. “After three years, it’s starting to happen to me a lot. I see patients that I took care of in 2018 who are now healthy and happy.”

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Seven-Country Study Examining COVID-19 Impacts on Health Services

mlawrence — Thu, 13 Aug 2020 22:45:46 +0000

Seven-Country Study Examining COVID-19 Impacts on Health Services mlawrence Thu, 08/13/2020 - 18:45

Lab professionals working with Socios En Salud, as Partners In Health is known in Peru, complete tests for COVID-19.

Courtesy of Socios En Salud

A new study in seven countries supported by Partners In Health is using routine health data to look for abnormal spikes in ailments that could be related to COVID-19, such as respiratory infections or pneumonia, and assess whether people are changing how they use health services amid the global pandemic.

A lack of reliable data can be an enormous roadblock for understanding the burden of disease and changes in the use of health services during a public health crisis, severely affecting countries’ ability to plan effective responses.

COVID-19 also threatens to undermine care and outcomes in important health areas such as maternal health, family planning, childhood vaccinations, HIV, TB, and malaria, along with treatment of non-communicable diseases such as cancer. That threat is particularly severe in low- and middle-income countries, where limited resources may be diverted from those areas to battle COVID-19.

Additionally, fear of contracting the disease can prevent people from seeking care at health facilities, creating further risks of untreated health problems.

Clinical and research leaders from PIH teams in multiple countries are undertaking the new study to examine and address these gaps, in collaborative with Dr. Michael Law of the University of British Columbia and Dr. Bethany Hedt-Gauthier of Harvard University.

The Canadian Institutes for Health Research (CIHR) are providing technical support and funding. The institutes also are supporting postdoctoral researcher Dr. Isabel Fulcher, who has been leading the development of data and analytic methods for the project for several months.

By working with routine health data that is already collected, Drs. Law and Hedt-Gauthier hope to overcome COVID-19 testing restraints and provide a much-needed source of data on COVID-19 in low- and middle-income countries.

PIH Canada recently spoke with Dr. Law about the study.

What are the study’s objectives?

The study has two key objectives. The first is to perform syndromic surveillance to detect early signs of a COVID-19 outbreak, and the second is to investigate potential declines in health service use to design and target interventions. Each of these objectives will be carried out in the following seven countries: Haiti, Lesotho, Liberia, Malawi, Mexico, Rwanda, and Sierra Leone.

Why were these seven countries chosen?

Actually, the seven sites were already working together and had identified these two topics as a priority. The CIHR funding call provided an opportunity for us to rally resources to respond to these identified needs.

Because each of these countries are PIH sites, the other important aspect here is that it allows the research project to rapidly scale since we already have the existing relationships and infrastructure within the country to do that. Our research team has really benefitted from the leadership of Jean Claude Mugunga, a deputy chief medical officer at Partners In Health, and Harvard Professor Megan Murray, who is also a PIH Research Director, who have been coordinating cross-site research for COVID-19-related work more broadly.

Excitingly, this is the most countries that have participated in a single PIH research project at the same time to date.

Pontmain Health Centre in Leribe District, Lesotho, in 2018. (Photo by Cecille Joan Avila / PIH)

What exactly is syndromic surveillance? Is it a replacement for testing?

Syndromic surveillance is essentially a way to use the data that we have. We know these routine data are being collected, we know they are being assembled. And so, the hope is that those will be useful for being a ‘canary in a coal mine’ in helping highlight when testing might be necessary.

Syndromic surveillance is especially important in low- and middle-income countries, where testing is both limited and expensive. And while not a replacement for testing, it serves as more of a complementary procedure in which you can glean information on where potential hotspots of COVID-19 may be occurring to target your testing, and subsequently focus health care efforts. For example, if you see a spike in a region with people showing up with respiratory issues, then you might think that would be an area you would like to focus on more closely.

Why look at other non-COVID-19 health outcomes?

With the rise of COVID-19 cases, it is likely that people will be more reticent to seek out health care services at a facility where they fear COVID-19 may be spreading. This study is particularly focused on comparing the number of individuals receiving care for things like maternal health, family planning services, childhood vaccinations, and malaria treatment to expected numbers pre-pandemic. If it turns out there is a decline in the use of these services, there can be a lot of downstream impacts. After all, these are services that are really important to protecting and producing population health in these settings.

The benefit of this data-forward approach is that you can go full circle with it. In other words, you can see where problems are coming up and target a policy towards those problems. Then, the real advantage of using routine data is that you can turn around and evaluate the impact of those policies that you have put in place.

There is evidence to show that this approach works. We did some work in the past with the Ebola virus outbreak in the Democratic Republic of the Congo and found that when we instituted a free care policy after the virus outbreak, visits to health facilities actually increased. So, there are policy measures you can take to try and ensure that people don’t stop seeking out health care that we would otherwise want them to continue on with.

What will this study ultimately accomplish?

The fundamental goal of this research project is to support the national COVID-19 responses in these seven countries. The study will provide ways of using data to identify hotspots and deal with some of the secondary consequences of COVID-19.

But there is also the hope to take it one step further by using this study to help demonstrate the value of health data as countries continue to invest in data collection and use. What is going to happen in the coming months with regard to COVID-19 in low- and middle-income countries will largely depend on the policy responses, which in turn are heavily reliant on the data.

As a result, it is critical that we recognize the importance of data and policy working hand-in-hand to tackle the COVID-19 pandemic and bring it under control.

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Now, she's seen her eldest daughter graduate college and is holding a grandson she once thought she would never meet.

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Research: Rwanda Referral Program Saving Cancer Patients’ Lives

mlawrence — Fri, 29 May 2020 19:03:21 +0000

Research: Rwanda Referral Program Saving Cancer Patients’ Lives mlawrence Fri, 05/29/2020 - 15:03

Dr. Cyprien Shyirambere, director of oncology for Inshuti Mu Buzima, as PIH is known in Rwanda, fills out paperwork after seeing patients for follow-up care in the oncology ward at Butaro District Hospital, in 2016. The hospital's radiotherapy referral program saved more than 100 lives in a period from 2012-15, a recent study has shown.

Cecille Joan Avila/PIH

Clinicians for Partners In Health in Rwanda saved more than 100 lives with a vital referral program that enabled cancer patients to access radiotherapy when none was available in the country, a study shows.

The program at a PIH-supported hospital in Rwanda’s Northern Province supported patients’ care, transportation, and housing at the Uganda Cancer Institute in Kampala, Uganda’s capital.

Without the referral, patients may not have been able to access radiotherapy, often a crucial component of cancer treatment.

Dr. Cyprien Shyirambere, director of oncology for Inshuti Mu Buzima, as PIH is known in Rwanda, said nearly 60 percent of cancer patients need radiotherapy at some point in their care.

“Radiotherapy is just as important as the other modalities of cancer treatment, and with this study, we’ve shown that, even for a rural facility, referring patients outside the country is a feasible option, through rigorous selection and effective collaboration with radiotherapy centers in the region,” Shyirambere said.

The referral program began in 2012, shortly after the Butaro Cancer Center of Excellence opened its doors at the PIH-supported Butaro District Hospital. The cancer center provides patients from across the country, and even from neighboring countries, with access to comprehensive cancer care, including histopathology services (microscopic examination of tissue) for diagnosis; chemotherapy; surgery; palliative care; and psychosocial support.

Due to cost constraints and an initial lack of a radiation therapy staff, the cancer center was not able to offer radiotherapy services when it opened. Clinicians tried to fill that gap by referring patients elsewhere, and providing them with financial support to access that care.

At the time, Rwanda was one of 28 African countries without a radiotherapy facility. So every month, Butaro clinicians selected 10 to 15 patients for referral to the cancer institute in Kampala, the nearest center with the capacity to provide radiotherapy services.

How Referral Saved a Mother, and a Family

PIH clinicians helped Françoise Umutesi get radiotherapy in Kampala, Uganda, in 2013. She's now a breast cancer survivor, and a grandmother.

Françoise Umutesi had a mastectomy in 2012, at Butaro District Hospital in northern Rwanda. She was one of the first patients at the hospital’s Cancer Center of Excellence, which opened that year.

Accompanied by a single oncology nurse, the patient group would make the 300-mile journey to Kampala by bus. On arrival, the nurse would show the patients to their hostel and the clinical facilities at the institute before delivering their documentation to staff. After completing radiation treatment—a six-week process, on average—the patient group would return to Rwanda.

Because treatment at the institute primarily was available to patients able to walk and move around independently, referrals were limited to those patients strong enough to undergo radiotherapy without a caretaker.

“And that was only about 20 percent of the patients who needed radiotherapy,” Shyirambere said.

Nevertheless, he added, the Butaro cancer center’s pioneering referral program has proven its worth.

The study assessed about 200 patients referred by the Butaro cancer center for radiotherapy in Uganda between July 2012 and June 2015. Follow-ups averaging about a year after their treatment showed that more than half of the patients had progressed successfully, with no evidence of recurrence.

The study was published in 2018 in the Journal of Global Oncology, and titled, “International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes.”

Shyirambere is a co-author on the study. He said that while the ultimate goal is to establish local radiotherapy capacity in countries across sub-Saharan Africa, achieving that goal will take time, which many patients don’t have. Until then, he said, efforts to provide short-term, bridging care can save thousands of lives.

Of course, implementing the referral program wasn’t without challenges—the biggest of which came in 2016, when the Kampala institute’s 20-year-old radiotherapy machine broke down and couldn’t be fixed.

The government of Rwanda pledged to open a radiotherapy service in Rwanda’s capital, Kigali. But that would take time, and clinicians at Butaro weren’t content to wait.

“We had to find another way to help our patients,” Shyirambere recalled.

He and colleagues quickly began searching for an alternative.

Within weeks, they’d negotiated a deal with one of Kenya’s best hospitals: a private facility in the capital, Nairobi, that agreed to provide radiotherapy services for patients from the Butaro cancer center at a deeply discounted price.

The cost of caring for one patient who receives radiation therapy in Nairobi was close to $10,000. Alex Coutinho, former executive director of Inshuti Mu Buzima, reflected on that cost in a letter from Nairobi in 2016, writing that, “very, very few Africans could access it.”

Coutinho described the Nairobi hospital’s state-of-the-art radiation therapy unit as having two linear accelerators, a brachytherapy unit, an MRI and CAT scan dedicated for staging and planning therapy, and a team of Kenyan clinicians managing the complex.

“This is what we want in Butaro or Kigali,” he wrote.

In the years since, the government of Rwanda has begun to put the pieces in place.

Rwanda’s first radiotherapy center opened last year, with the installation of two top-of-the-line linear accelerator machines at Rwanda Military Hospital in Kigali. The machines have now served many patients with cancer from Rwanda and the region, Shyirambere said.

The center has plans for continued growth, including development of brachytherapy, a radiation treatment that’s an essential component for several kinds of cancer, including cervical.

Shyirambere said the Butaro cancer center eventually will have its own radiotherapy capacity.

“But until then, we’re sending our patients to Kigali and a few selected cervical patients to Nairobi, until there is brachytherapy in Rwanda,” he said.

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Cancer Care a Vital Part of PIH Programs Around the World

mlawrence — Mon, 03 Feb 2020 20:12:21 +0000

Cancer Care a Vital Part of PIH Programs Around the World mlawrence Mon, 02/03/2020 - 15:12

Dr. George Talama (left) checks on patient Lawrence Kaufa, 83, at Neno District Hospital in October 2018. Kaufa lives more than two hours from the hospital and initially was seen by doctors at PIH-supported Dambe Health Center. Kaufa had difficulty swallowing for six months, leading Dambe staff, and then Talama, to suspect esophageal cancer. Talama referred Kaufa for an endoscopy, in just one part of the cancer care that PIH provides for thousands of patients around the world.

Zack DeClerck / PIH

Partners In Health supported the care of more than 4,000 cancer patients around the world in 2019. Nearly all of those people would otherwise have had no access to chemotherapy and other critical treatments, highlighting the essential, lifesaving need for cancer services in impoverished communities.

PIH’s largest cancer programs are in Haiti and Rwanda. In Rwanda’s northern mountains, PIH-supported Butaro District Hospital is home to the Butaro Cancer Center of Excellence, which opened in 2012, provides an array of cancer treatment, services and support, and sees 1,700 new patients every year.

At PIH-supported University Hospital in Mirebalais, Haiti, we’re training the next generation of doctors, nurses, and medical residents to care for patients with cancer. They perform CT scans, take biopsies of tumorous tissues, and much more.

But PIH’s cancer care extends far beyond those two flagship programs. PIH provides vital cancer screening and services in several of the 11 countries where we work. Here is a quick look at cancer care in three of those locations: the East Africa nation of Malawi, Mexico, and Navajo Nation in the southwestern U.S.

Malawi

Abwenzi Pa Za Umoyo, as PIH is known in Malawi, provides cervical cancer screening at 14 PIH-supported health facilities across Neno District, in partnership with Malawi’s Ministry of Health.

Nurse Judith Kanyema sorts medicines in preparation for a clinic and oncology care at Neno District Hospital. (Photo by Daniel Kaunga/PIH)

Dr. George Talama, primary health care clinical manager for PIH in Malawi, said cervical cancer screening is part of the integrated chronic care clinic at Neno District Hospital. People come to the clinic to receive care for a variety of conditions, ranging from diabetes and high blood pressure to HIV and TB, and staff have screened more than 25 percent of those clients for cervical cancer so far. Cervical cancer care at the hospital also includes treatment for pre-cancerous tissue, Talama said.

Additionally, PIH provides chemotherapy at the hospital for Kaposi sarcoma, a form of skin cancer associated with HIV. While chemotherapy for Kaposi is available across Malawi, patients from other parts of the country often come to Neno District for treatment because of the hospital’s strong success rate.

For patients in late stages of cancer, PIH provides palliative care, primarily at Neno District Hospital and Lisungwi Community Hospital. Staff from those hospitals also provide palliative care to patients at regional health centers and in visits to their homes.

Talama said PIH currently is supporting more than 30 cancer patients across the district, including 18 people with Kaposi sarcoma and five with cervical cancer.

Mexico

Breast cancer survivor Doña Suyi Escobar received support from PIH during her treatment, and now advises other cancer patients not to lose hope. (Photo courtesy of Compañeros En Salud)

Compañeros En Salud, as PIH is known in Mexico, helps cancer patients in the Sierra Madre mountains of Chiapas access an array of services. Our Right to Health Care program not only helps patients get referrals to the appropriate public hospital, but also provides social support to ensure they are able to actually receive that care. We cover the costs of food, lodging, transportation, and even insurance fees for patients, and help with clinical expenses including lab work, X-rays, ultrasounds and CT scans, as needed.

That support is reflected in the story of Doña Suyi Escobar, a wife and mother of three children who, about six years ago, found a lump in her right breast. When a biopsy at a regional health center confirmed she had breast cancer, a friend of her husband suggested they contact Compañeros En Salud. The PIH team helped Escobar’s family with lodging and transportation costs so they could access care, and supported her through radiation and chemotherapy.

Now recovered, Escobar said she advises other women to take care of themselves, perform self-exams to check for early signs of cancer, and most importantly, not to lose hope. Read Escobar’s story here.

Navajo Nation

Spanning 27,000 square miles and home to more than 300,000 people, the Navajo Nation is geographically the largest Native community in the United States. Community Outreach and Patient Empowerment, or COPE, is a Native-controlled nonprofit and sister organization of Partners In Health, and has been working on Navajo Nation since 2009.

Cancer is the leading cause of mortality for women on Navajo Nation, and the second-largest cause of mortality overall, but cancer screening rates are far lower than in other parts of the U.S.

The COPE Cancer Program works to improve patients’ outcomes through meaningful community engagement and education, with community-led initiatives including a Patient and Family Advisory Council, an annual Cancer Survivorship Conference, and the COPE Cancer Coalition.

COPE works with local stakeholders to develop and implement cancer education materials that are tailored for use in local communities, and to leverage technology to improve access to education and coordination of care.

Impacts include:

15 community members guide COPE programs and research, through the Patient and Family Advisory Council
92 outreach workers are trained in delivering the COPE-created, Navajo-specific Circle of Life cancer education curriculum
260 attendees learned and shared at COPE’s fifth annual, two-day Cancer Survivorship Conference
22 partners participate in COPE’s coalition to improve cancer outcomes on Navajo Nation
222 hours of engagement sessions with partners led to creation of a Community Action Plan

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Rwanda Oncology Doctor: Global Community Must "Reduce the Disparities in Cancer Care"

mlawrence — Fri, 31 Jan 2020 21:45:21 +0000

Rwanda Oncology Doctor: Global Community Must "Reduce the Disparities in Cancer Care" mlawrence Fri, 01/31/2020 - 16:45

Dr. Cyprien Shyirambere, oncology program director for Partners In Health in Rwanda, records medical information after seeing patients for follow-up visits at PIH-supported Butaro District Hospital. The hospital's Cancer Center of Excellence sees more than 1,700 new patients per year, and added new support facilities in August.

Cecille Joan Avila/PIH

Dr. Cyprien Shyirambere is the oncology program director for Inshuti Mu Buzima, as Partners In Health is known in Rwanda. He leads the bustling, vital Cancer Center of Excellence at PIH-supported Butaro District Hospital in the country's mountainous north. Many patients, family members, and caregivers travel to Butaro from across Rwanda or from surrounding countries such as Burundi and the Democratic Republic of Congo, where high-quality cancer care is scarce or nonexistent, to receive lifesaving treatment at the hospital. In recognition of World Cancer Day on Feb. 4, Dr. Shyirambere talked about what's new in Butaro, and how global action is needed to reduce vast disparities in cancer care around the world.

Q: Butaro District Hospital recently opened its Cancer Support Center, providing a place to stay during extended treatment for patients who live far away and their families. How is the Support Center working out so far? How is it affecting cancer care at Butaro District Hospital?

The 68-bed Butaro Oncology Support Center is open six to seven days a week, and accommodates cancer patients who come to Butaro as ambulatory chemotherapy patients, and outpatients. The average stay is two nights. Patients receive free meals, laundry, and nursing care, as well as counselling services by a qualified clinical psychologist, to help them cope with the disease. Since opening last August, the center has seen about 5,500 patient visits. With a nice view of the mountains in Burera District, it offers a dignifying environment and brings hope to our patients’ faces.

This center has improved the way we provide care to our patients, since it has decongested oncology wards and decreased burdens for patients, many of whom used to pass nights in the cold outside the hospital because they had nowhere to stay.

Q: Rwanda Military Hospital in Kigali now offers radiotherapy, which previously could not be accessed anywhere in Rwanda. Has that made a difference in treatment and referrals at Butaro District Hospital? What does it mean for cancer care in all of Rwanda?

The radiotherapy center at Rwanda Military Hospital has two state-of-the-art linear accelerator machines, which is a huge step towards cancer control in the country and the entire East African region. More than 50 percent of cancer patients need radiation therapy at some point of their treatment, either for curative intentions or as part of palliative care, to control symptoms and improve quality of life.

No country can achieve access to cancer care without planning for access to radiotherapy. More Rwandans and patients from neighboring countries now can access radiotherapy services, which previously was impossible for the majority of them.

Q: Has the hospital begun interacting with UGHE students? What has been happening, and are there plans for an expanded relationship in the future?

So far, the interactions between UGHE students, Inshuti Mu Buzima—as PIH is known in Rwanda—and Butaro District Hospital have been focused at the community level, to give students a sense of the social and economic determinants of health, and how community health workers are involved in the health care system.

There is a plan to expand the hospital to meet accreditation standards to become a teaching hospital for UGHE. In 2021, if all goes well, UGHE medical students will start doing clinical rotations in the hospital, and we hope our physicians will be involved in teaching those students.

The Butaro Cancer Support Center has been used by more than 5,500 patients since it opened last August. (Photo by Fabrice Nusenga / PIH)

Q: What’s new at the Butaro Cancer Center of Excellence? What challenges and successes have you seen lately?

New at the Butaro Cancer Center of Excellence:

Digitalization of data from our women’s cancer early detection program, in Open MRS (Open Medical Records System, an electronic, open-source medical record platform)
Pilot project to implement a patient navigator program, to reduce delays in care and abandonment of treatment, initially focusing on patients with Wilms’ tumor (a rare kidney cancer that primarily affects children)
Cultivating a culture of quality improvement, using quality improvement champions
Continuous medical education program for oncology clinicians, in collaboration with the Dana-Farber Cancer Institute’s Center for Global Cancer Medicine

Challenges:

Limited access to modern imaging technology, such as CT scans; limitations with pediatric oncology surgery and intensive care
Survival rates are still low, compared to high-income countries, and some drugs needed to improve that rate are still unaffordable
Limited space to accommodate growing numbers of cancer patients

Q: What else would you like to talk about on World Cancer Day, that I haven’t asked about?

On this World Cancer Day 2020, I stand with thousands of cancer patients around the world and their families. I salute efforts to address this growing burden and I urge the global community to reduce the disparities in cancer care, in order to achieve universal health coverage.

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UGHE Dean: Medical Education in Rwanda Part of "Bold Step" Needed to Curb Africa's Cancer Crisis

mlawrence — Fri, 31 Jan 2020 20:09:46 +0000

UGHE Dean: Medical Education in Rwanda Part of "Bold Step" Needed to Curb Africa's Cancer Crisis mlawrence Fri, 01/31/2020 - 15:09

Prof. Abebe Bekele (front, white shirt), dean of the University of Global Health Equity in Rwanda, stands on campus next to UGHE Vice Chancellor Dr. Agnes Binagwaho (to his left), with UGHE's first class of medical students. Bekele said UGHE is training its students to become not only experts in cancer diagnosis, but also advocates and drivers of social mobilization and policy support.

Photo courtesy of UGHE

There are nearly 1 million new cancer cases and more than 500,000 cancer-related deaths in Africa per year, and these totals are projected to double by 2040. Training the next generation of health leaders to counter this rise is of critical importance. Increasingly, we see a need for cancer education that explores both the prevention measures and social determinants of this highly treatable, but highly prevalent, disease. In recognition of World Cancer Day, we spoke to the University of Global Health Equity's founding Dean, Prof. Abebe Bekele, to spotlight his holistic approach to cancer education.

Q. This is the first academic year for students in UGHE’s new medical program. Those students arrived on campus last summer and will study for more than six years. They’ll have significant interaction with Butaro District Hospital, the Partners In Health-supported facility across the valley. What have the medical students seen of the hospital so far, and particularly its Cancer Center of Excellence?

UGHE’s MBBS program has an integrated curriculum. Students don’t spend the first two years just in classroom or the lab—they get exposure to clinics, health centers and health posts, right from the start. We call this progressive clinical immersion. Already, our students have visited the hospital twice, met the medical doctors, visited the health centers and spent time in the community. In January, they will start their basic sciences training, which consists of all the basic sciences in an integrated manner with clinical care. Students will spend time in the hospital, with patients and learning vital communication skills, alongside cancer diagnosis and treatment.

Q: How will students’ involvement with the hospital grow in years to come, through UGHE’s focus on progressive immersion within the curriculum?

Progressive clinical immersion is vital as it serves to blend and balance basic medical and clinical sciences. The first two years are focused mainly on basic medical sciences. That focus decreases as they progress, in a way that’s directly proportional to an increased focus on clinical sciences, with year three as the intersection. Why do we do this? It’s tied to the competencies: What kind of doctors are we trying to train, and what do we need them to do after graduation? These students will go on to diagnose and treat patients, conduct and understand research, serve as health system leaders, advocates of equity, and scholars. So we need to reverse-engineer the curriculum; defining the competencies first, then designing the curriculum, in a way that’s tailored to equip the students with the competencies.

Prof. Abebe Bekele, dean of the University of Global Health Equity in northern Rwanda, said prevention should be the starting point for slowing the rise of cancer cases across Africa.

Q. How does the integration of humanities in the curriculum contribute to students’ holistic approach to health delivery?

Humanities directly ties to clinical care within the cancer center. Our students learn about African history, the social determinants of health, political economy, gender and justice, and examples that relate to health, such as the identification of lymphoma in Uganda, Ebola, and the health impacts of the rubber industry in the Democratic Republic of the Congo. These examples directly tie to cancer care, looking first at the reasons behind the resurgence of cancer in Africa as a starting point.

Q: What makes the study of cancer, and cancer care, different from other medical areas of focus?

Data shows that cancer is on the rise in Africa. We need to prepare our doctors to first appropriately diagnose the diseases, then promptly refer these cases to proper therapy, and later, as they mature in their careers, consider specializing in cancer care to cater to these growing numbers. We should be looking at prevention as the starting point. Breast and cervical cancer are the two most common cancers affecting our population. Cervical cancer is preventable with appropriate vaccination, and both are treatable if diagnosed early.

Q: What are some examples of how UGHE students will study cancer, in the classroom or outside of it?

When our students enter their clinical years, they’ll spend significant time in the cancer ward: learning and contributing to quality improvement, data collection and research. In terms of research, our MGHD students complete research papers about cancer in the cancer hospital. This emphasis on research also is strongly supported by our faculty; the basic sciences team is developing a proposal in breast and colon cancer, something we hope will help students become more engaged in the subject.

Q: The WHO reports that cancer cases numbers could double by 2040 without strong counter-measures. How can UGHE play a role in addressing, and preparing for, Africa’s growing cancer crisis?

The most common cancers in Africa—breast and cervical—are preventable, or, if not, early diagnosis gives us a greater success in treating them. All of us have a role to play here: as physicians, nurses, public health experts, advocates, governments, policy makers and others. If we collaborate and contribute to prevention of those cancers, we can rapidly reduce the number of cases we see. Advocacy is important. UGHE trains its students to become experts in the diagnosis of cancers, as well as advocates and drivers of social mobilization and policy support for the government.

We also teach our students about equity in everything we do; it is the centerpiece of academics at UGHE. Women have better health-seeking behavior but they face enormous barriers to accessing care. They are restricted by finances, transport, access to hospitals, cultural taboos, responsibilities at home, gender-based biases and other factors.

Things are stuck at the moment, but not because of lack of awareness—we already know about and understand the mounting incidence of cancer in the continent. It is about who is going to take the bold step to address it.

We have not yet declared cancers as an emerging public health problem in the region. Now is the time to focus on cancer, now is the time to take action.

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A First—But Not Last—for Cancer Care in Sierra Leone

mbrownstein — Tue, 21 Jan 2020 17:11:07 +0000

A First—But Not Last—for Cancer Care in Sierra Leone mbrownstein Tue, 01/21/2020 - 12:11

Margaret, poised to be Koidu Government Hospital's first patient to survive choriocarcinoma, pictured at the PIH-supported facility in Kono, Sierra Leone.

(Photo by Emma Minor / PIH)

This time two years ago, Margaret had never heard of choriocarcinoma—cancer of the cervix and uterus. So when clinicians at Koidu Government Hospital (KGH), the Partners In Health-supported facility in Kono, Sierra Leone, diagnosed her with it in July 2018, she remembers feeling a wave of fearful confusion.

“I had no idea what was happening,” Margaret said. “None of my family or friends has had this sickness before. My mum thought I was going to die when they explained to her that it was cancer. When people in Sierra Leone have cancer, they rarely survive.”

Indeed, Margaret’s health was dire when she was readmitted at KGH in July 2018, five months after initially being treated at the hospital for a molar pregnancy (commonly a precursor to choriocarcinoma). Experiencing a fever and intense bleeding to the point of unconsciousness, Margaret was unable to walk, stand, or eat, and relied on the hospital’s blood bank and emergency blood donations from family members and KGH staff to stay alive.

“She bled two or three times a day. We needed to constantly replace her blood,” KGH midwife C.J. said. “Even maternal staff on the ward thought she might not make it.”

The entrance to KGH's blood bank, which was revitalized by PIH's investments in hospital infrastructure and which is located near the maternity ward, the hospital department that uses the most blood. (Photo by John Ra / PIH)

Clinicians had quickly discovered the cause of Margaret’s condition—a carcinoma, or cancerous growth, located in her cervix. After getting her bleeding under control, the KGH team turned to the larger problem: How could they treat this case, in a country where oncology care is nearly nonexistent?

“Very challenging” was how Dr. Marta Lado, chief medical officer for PIH-Sierra Leone, diplomatically described the current state of cancer care in Sierra Leone, where even basic health infrastructure is limited, at best. In partnership with the Ministry of Health, PIH is adding high-quality cancer care to its work strengthening Sierra Leone’s health care system, and is beginning to tackle the many challenges the country faces when it comes to oncology.

First of all, the diagnostic process is long and expensive, as samples and lab tests need to be sent to external private laboratories for analysis. If the result is cancer, a limited number of oncology drugs are available; Sierra Leone has no established national chemotherapy program. What’s more, most patients arrive at health facilities when their cancer is already advanced to a stage where palliative care is the only viable option, having held off going to see a doctor for fear of the cost of care and lack of access to nearby clinics or hospitals.

Another concern is that nurses and pharmacists don’t have formal training opportunities in cancer care, so many lack expertise in how to manipulate and administer oncology drugs. The country also has limited lab capabilities to properly diagnose cancer, and social support programs—which would help patients meet such needs as food, transportation, and housing—are rarely part of care.

All of these programs and resources are currently being planned for at KGH, which each month sees one or two patients arriving with any type of cancer—usually advanced stage lymphoma, leukemia, or, as in Margaret’s case, choriocarcinoma.

“At KGH, when we find a case that is an early stage and can benefit from treatment, we have been able to refer patients to PIH in Rwanda, or buy some chemo and administer it locally with the collaboration of a clinic in Freetown that has some trained and skilled staff,” Lado explained. “But honestly, these are very exceptional cases. We strongly believe that as we grow in our clinical care, we will start identifying more cancer cases in early stages; therefore, we need to start organizing the necessary care for them at KGH.”

(Photo by Emma Minor / PIH)

Margaret was one of these exceptional cases—and one who helped set in motion the expansion of cancer care at KGH.

PIH-Sierra Leone’s supply chain team managed to secure a shipment of Methotrexate, the drug that could cure Margaret, from India. She began inpatient chemotherapy in August 2018, and by December was discharged, needing to come back to the hospital every three to four weeks for her next round of treatment.

“Margaret looks great now and is a joy to have around the ward,” said Isata Dumbuya, KGH’s maternity manager, last summer. “She likes making everyone laugh and is always trying to help with things.”

After a year of care, in August 2019, Margaret completed her full course of treatment, with the next step involving quarterly blood tests to monitor her health. Now, she is poised to become the first woman to survive chroriocarcinoma at KGH.

She won’t be the last, however. Because her case made Methotrexate available, two other women with choriocarcinoma are currently receiving treatment.

More patients will follow, Lado said. “At KGH we are working really hard to increase the standard of care for our patients, including setting up a basic protocol for chemotherapy. We have already started with choriocarcinoma, and care for Kaposi Sarcoma and some types of lymphomas in children will be developed this year.”

A room in KGH's maternity ward, where Margaret received her care and now visits to lend support to current patients. (Photo by John Ra / PIH)

The aim too is to expand this care beyond KGH. “The government of Sierra Leone is extremely supportive with our programs and excited about all of our initiatives in Kono. Together, we are setting examples and role modelling, to give hope for a better health care system in the entire country,” Lado said.

At the center of this slow and steady progress at KGH and throughout Sierra Leone is Margaret. “She really has carved a path for others needing this care,” Dumbuya said.

Margaret herself may someday be providing it, as her experience as a patient has informed her future career goals. Determined to become a nurse, Margaret has returned to school with support from PIH, and on any given day can often be found in the KGH maternity ward offering moral support to patients.

“The doctors and nurses were encouraging, and my mum sees me now and she has good faith,” she said. “I want to get a job so I can be working and supporting my parents—I want to be a nurse. I like it at the ward; I want to be part of the KGH midwife team.”

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Celebrating Game-Changing Accomplishments at University Hospital in Haiti

yportillo — Tue, 14 Jan 2020 01:45:04 +0000

Celebrating Game-Changing Accomplishments at University Hospital in Haiti yportillo Mon, 01/13/2020 - 20:45

University Hospital in Mirebalais opened its doors on March 19, 2013, and quickly became a hub of care for the Central Plateau and a magnet for patients from across Haiti.

Photo by Cecille Joan Avila / Partners In Health

Nearly seven years have passed since University Hospital in Mirebalais opened its doors and began transforming health care for more than one million people across Haiti's Central Plateau. Since March 2013, thousands of patients have had access to specialized care provided by clinicians working with Zanmi Lasante, as Partners In Health is known locally.

University Hospital has also been home to a growing medical education program, which has graduated 123 residents from a variety of specialties, including emergency medicine, surgery, and pediatrics, to add to the growing health care workforce in Haiti.

For a deeper dive into University Hospital's many accomplishments, check out the below image, a bird’s eye view of the campus. Hover over various sections to learn more about how hospital staff save lives every day by providing high-quality care to all patients, regardless of their income.

A Safe Haven for Mothers and Babies

When University Hospital opened in 2013, staff frequently saw full-term pregnant women sleeping overnight on cement sidewalks waiting for labor to begin. Many of them lived far from care and wanted to be near the hospital as their due date approached. Mothers of babies in the neonatal intensive care unit also slept outside to be available for feedings. These everyday scenes were a testament to the mothers’ determination to receive high-quality care for themselves and their newborns. They also were the inspiration for Kay Manmito, the maternal waiting home PIH built on the grounds of University Hospital.

Kay Manmito, or “Mother’s Home” in Haitian Creole, hosts women with complicated pregnancies and mothers of premature and NICU infants, guaranteeing them a facility-based birth and providing them with free prenatal care, meals, psychosocial support, and health education. In 2019, Kay Manmito housed 378 women so that they could receive the lifesaving, dignified care they needed, from blood pressure monitoring to C-sections. These patients were among the 15 women, on average, who delivered each day in the neighboring hospital’s maternity ward. For expectant mothers like Natacha Jean Paul, whose risky pregnancy brought her to the facility, “the care found here is priceless.”

Training Haiti’s Next Generation of Clinicians

Brain drain has long stymied Haiti’s health care system. Doctors and nurses have historically had few options for specialized training within the country, and 80 percent of those who do train in Haiti leave within five years of graduation to practice abroad. The few clinicians with specialized training who remain in Haiti typically work in the capital of Port-au-Prince, far from where most patients—particularly the rural poor—can access care.

Medical education is integral to University Hospital, which was built as a teaching facility where Haitian clinicians could train in advanced specialties. Since opening, the hospital has begun offering residency programs in pediatrics, surgery, obstetrics and gynecology, neurology, nurse anesthesiology, and family, internal, and emergency medicine. To date, 123 clinicians have graduated from these programs, including the family medicine residency at PIH-supported St. Nicholas Hospital in St. Marc. Nearly 98 percent have chosen to work in Haiti and 60 percent with PIH-supported facilities, strengthening local health systems and caring for the most vulnerable patients.

Cancer Care for All

Cancer affects people around the world proportionately, yet access to treatment is disproportionate, as lifesaving chemotherapy and surgeries are often unavailable or inaccessible in poor countries. University Hospital’s oncology department is changing this reality. There, patients from across Haiti receive the diagnoses, specialized care, and psychosocial support they need to survive.

Last year, University Hospital provided cancer treatment to 652 patients, the majority of them women with breast cancer. Cita Cherie* is one such patient: She has been receiving palliative chemotherapy for an advanced stage of breast cancer since the hospital opened. “If it were not for the Mirebalais hospital, I would not be alive today,” Cherie says. “I get all my medication for free, and when I come to the hospital, the doctors take really good care of me. They welcome me and they really value me.”

*Name has been changed at patient’s request.

A Lifesaving Laboratory

The Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory, which PIH opened in 2016 across from University Hospital, has transformed health care for more than 1 million people. The 15,800-square-foot facility contains a clinical lab, a pathology lab, and Biosafety Level 2 and 3 laboratories, allowing staff to quickly and confidently diagnose and monitor infectious diseases and noncommunicable diseases like cancer. Highly trained technicians use advanced tools to improve the quality and timeliness of diagnostic services, meaning more patients receive better care in less time.

Rehab for the Body, Mind, and Spirit

The Center of Excellence in Rehab and Education is the first public facility of its kind in Haiti. Here, patients from all walks of life come for outpatient physical therapy sessions, and a select few remain for extended stays to recover from trauma. They are stroke survivors and amputees, accident victims and people living with various forms of disability. They come for physical transformation, and often leave with a mental and emotional lift as well.

Staff and patients interact in one of the most pleasant spaces on the University Hospital campus. The L-shaped facility fills with natural light and bright tile mosaics decorate the walls, some with Haitian proverbs worked into the design. One, appropriately, says: “Piti piti zwazo fè nich li,” or “Little by little the bird builds its nest.”

A Hub of Activity

University Hospital’s emergency department buzzes with activity. The suite of rooms rarely has an opening in its 16 beds, and two rows of chairs regularly fill with awaiting patients. Renovations are currently underway to expand the space to 36 beds and add on bathroom and shower facilities for patients on longer stays.

There are the typical emergencies, from broken bones and lacerations to heart attacks and motorcycle accidents. But there are just as many patients who come following acute episodes spurred from chronic illnesses, such as diabetes and heart failure.

The emergency department is often the first stop for University Hospital patients, who come from across the country at all times of day. They are greeted by seasoned clinicians and medical residents on rotation through the ward. So far, 16 emergency medicine residents have graduated from the program since its launch in 2013.

A Cut Above the Rest

University Hospital is home to six state-of-the-art operating rooms, tucked away in the heart of the facility. In 2018 alone, surgeons performed 1,666 lifesaving cesarean sections and more than 600 other women's health-related procedures, such as hysterectomies.

The operating theater hosts routine surgeries, such as appendectomies and the removal of tumors. It has also hosted teams of international surgeons who, in collaboration with PIH clinicians, have conducted cleft palate repairs and—most impressive of all—the separation of conjoined twins.

So far, 19 surgical residents have entered University Hospital’s medical education program, six of whom have graduated so far.

Always a Full House

In the pre-dawn hours, dozens of patients begin arriving at University Hospital’s main entrance to await their turn for high-quality care, at little or no cost. Last year, clinicians conducted nearly 182,290 outpatient visits and admitted close to 4,320 patients, many of whom had traveled hours to be seen by the facility’s top-notch doctors and nurses.

Once patients have registered and had their vitals taken, they sit in one of several waiting rooms for their name to be called. They come for consultations with maternal and mental health, dental services and radiology, oncology and chronic diseases. Those who are admitted may end up in a number of departments, such as labor and delivery, pediatrics, or isolation—should they be diagnosed with an infectious disease, such as multidrug-resistant tuberculosis.

Regardless of why they come, they will receive care within specialties that would otherwise be out of reach for the rural poor across Haiti.

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