Partners In Health Articles 'Everyone in Freetown Knows Cholera': Door-to-Door With Vaccine Teams in Sierra Leone The teams wound down dirt paths, high-stepped through muddy slums, and climbed stairs cemented into lush hillsides. Never mind the lack of road signs and house numbers—they knew where they were going. They lived nearby.

How di body?” one would ask a neighbor.

Body fine,” the person would reply.

A team member in rubber gloves then would reach into a soft-sided cooler, tear the top off a tiny vial of milky solution, and let the person shoot it like a liqueur. Another would make notes in a log book. The third would hand over a paper record. And the fourth would mark the lintel of the front door: “OCVR217,” meaning Oral Cholera Vaccine Round 2, 2017. The large chalk letters felt portentous. Evil, in the form of cholera, should now pass over this house.

A de go!” or “Bye!” team members would say and walk on to the next home. And the next.

Marked door
A vaccination team member marks a home in Freetown to show that the family completed the first of two doses. (Photo by Jon Lascher / Partners In Health)

Such was the scene in Freetown, Sierra Leone, in early October, when roughly 2,000 teams, 8,000 people total, fanned out to complete the largest cholera vaccination campaign since a vaccine was invented in 1885. Consultants are assembling a final report, but preliminary national data suggest strong results. Thanks in part to Partners In Health’s support, as many as 90 percent of half a million people took both doses, thus protecting themselves against the “kaka vomits,” as cholera is sometimes referred to locally.

“This was a huge success,” says Dr. Dennis Marke, program manager at the Ministry of Health and Sanitation’s Expanded Program for Immunization.

Seen alongside similar campaigns—recently carried out by UNICEF in Bangladesh, and Doctors Without Borders in Zambia—the record-setting goal of distributing 1,036,300 vials of the vaccine in Freetown not only saved thousands from severe, life-threatening diarrhea and dehydration. It also testified to the dramatic strides made by Sierra Leone’s Ministry of Health and PIH in fighting a disease that still threatens some 2 billion people worldwide.

The need for a vaccination campaign in Freetown was clear. Seen from afar, the capital is one of the most beautiful in Africa. Green mountains decline into a colorful downtown, which pushes up against white-sand beaches. But up close, the city, population 1 million, is a mess. A five-story high mountain of trash marks the center of downtown.

Superlatives tend to ring especially hollow in the summer. During August’s heavy rains, landslides broke loose up high and buried houses, primarily in the Regent and Juba neighborhoods. Down low, runoff swept through Congo Cross, Kroo Bay, and other decades-old shantytowns near White Man’s Bay. Health clinics were inundated with water up to the knees. Bridges collapsed. Houses, such as they were, washed away, wooden planks and scraps of metal flushed into the sea.  

“Within an hour, it was a flood,” said Serla Matukomaron, who was asleep on the floor of her shack by the ocean at the time. “Everyone was shouting, everyone was busy.”


Top: A view of the capital from up high. Bottom: A shantytown on the edge of the dump at the center of the city. (Photos by Jon Lascher / Partners In Health)

“A handicapped man couldn’t walk,” recalled her neighbor, “so someone came and carried him.”

Matukomaron, a fisherman’s daughter and mother of two, felt the rising water while she slept on the elevated floor of her shack. She awoke at 3 a.m. and gathered her children.

“The water came higher than their heads,” she said. She got her children to safety by floating them through the slum’s dark, labyrinthine alleyways in a plastic washing tub.

When the rains finally abated in late August, the damage was clearly more than other rainy seasons. Reuters declared the deluge one of the deadliest recent natural disasters on the continent. The landslides and flooding displaced an estimated 6,000, killed 1,141 (including family members of PIH staff), and left the capital—never the most sanitary city—with pools of water contaminated by toppled outhouses, broken pipes, and blankets of trash.  

Marke kept his eyes on the horizon. While the military tried to figure out what to do with bodies after morgues ran out of space, he pulled together a small group of nonprofits and began formulating a plan. PIH-Sierra Leone Executive Director Jon Lascher, who helped pioneer the launching of cholera vaccination campaigns during emergencies, met with Dr. Marke each morning for a week.

PIH Deputy Policy and Partnership Director Dr. Bailor Barrie chose to defer beginning a PhD program in the U.S. to help Dr. Marke, whom he first met as a medical intern in 2003.

“We all agreed that cholera was next,” says Barrie.

Just beginning to formulate a plan was progress. Five years earlier, Marke might have simply thrown up his hands. Few residents of Freetown were likely to buy the vaccine for themselves. The vaccine’s $3 price is a week’s rent for roughly half the population. And his immunization department would have been largely powerless to get its hands on a significant amount. As recently as 2012, the World Health Organization considered a cholera vaccine too expensive to recommend.

But this wasn’t five years ago. Two big steps had been taken since.

A vaccination team member shoulders a cooler of the temperature-sensitive medicine. (Photo by Jon Lascher / Partners In Health)

First, PIH had helped make sure cholera vaccine was available to the world. In Haiti in 2012, PIH and the Haitian Ministry of Health refused to accept that poor people didn’t deserve a $3 vaccine, and had bought and delivered their own cholera vaccines. The program, run by two PIH physicians and Lascher, proved an overwhelming success. Ninety percent of patients received both doses. The World Health Organization promptly changed its position and stockpiled the vaccine.

Second, Marke now had the infrastructure to deliver the vaccine. With limited resources, he had built a thorough, albeit fragile, web of refrigeration throughout the country over the last few years. At the government’s central warehouse one day in October, a logistician opened the latch on a thick door, pushed aside a clear plastic curtain, and showed off the network’s centerpiece: a cavernous new walk-in refrigerator nicknamed France, for its country of origin. It could keep a full battery of vaccines between 2 and 8 degrees Celsius, whether stored on the bottom shelf near the door or near the cooling fan in the back, and whether the national power grid suffered one of its daily outages or not. From France, virtually any drugs could travel to solar-powered refrigerators, double-insulated coolers, and more throughout Sierra Leone—without spoiling.

Dr. Marke
The Ministry of Health and Sanitation's Dr. Dennis Marke, right, an immunization expert, inspects an early shipment of the vaccine. (Photo by Jon Lascher / Partners In Health)

All of which is to say, when cholera became a clear threat, and Marke asked about ordering the vaccine in late August, representatives in Geneva replied with hearty encouragement.

All they had to do was hand out the vaccines.

Marke, Barrie, Lascher, representatives from the World Health Organization, and other colleagues divided the city into areas, evaluated which were most threatened by cholera, and alerted staff at those 19 local health centers that drugs were on their way. Each health center would use its vehicle to pick up the medicine at the central warehouse. (Marke’s team can afford only one vehicle.) Then health care workers, trained on how best to distribute the vaccine, would walk the drugs to homes and schools. Along with sharing what they knew about delivering temperature-sensitive cholera vaccines to poor people in the tropics, Lascher and Barrie offered to loan out two dozen PIH case managers, one manager to ensure that the drugs were accounted for and in good condition at each facility in the city.

On Sept. 7, the first 518,150 vials of cholera vaccine arrived from Korea. The vials were packed in lipstick-sized boxes that were inside larger, cardboard boxes; surrounded by cold packs; nested inside Styrofoam boxes; and stacked inside bigger boxes.

The central warehouse soon looked like a cardboard explosion. Incinerators and refrigerators were double-checked. The drugs were distributed to the respective health centers, only to be shuffled again later, when population census info proved inaccurate. And a week later, on Sept. 15, 2,000 teams of health care workers fanned out into the city to administer the first dose.

“Seeing Dr. Marke pull all this together in a short time makes me really admire him,” said Barrie. “Even though it was a new vaccine, the acceptance rate was very high.”

Indeed. Three weeks later, a small team approached elderly sisters who did not necessarily look like they wanted to drink a mysterious liquid offered by 20-somethings in matching white vests.


Top: Two vaccination team members take a break after a long morning. Bottom: A team member opens one of the 1,036,300 vials of the medicine that were distributed. (Photos by Jon Lascher / Partners In Health)

The sisters sat on their patio, finishing each other’s thoughts while staring out at the bog water that had overflowed into their neighborhood weeks earlier and, as in other areas of the city, refused to drain away.

“Ten years ago, this place was bushy,” said Princess Hawa Goba, nodding toward a submerged field.

“Now the house is like an island,” said Phebean Brown-Coker.

Others had it worse, they knew. In Lumbley, dogs were rumored to be digging up body parts.

“Some people have nowhere to go,” lamented Hawa Goba.

The team stopped to chat. Had the sisters been offered two doses, they wanted to know?


Had they been warned of the possible side effects, like abdominal discomfort?


Had they chosen to take it?

Brown-Coker and Hawa Goba looked at each other in bafflement, turned their heads toward the pair, and expressed their astonishment in unison.

“Of course,” they said.

Brown-Coker put a finer point on her answer. “It’s a vaccine,” she said.

Some did refuse.

“I vomited after the first dose, I don’t want to take a second,” said a mother, while supervising her teenage son’s bagging of charcoal, which he would sell on the street.

Her doctor had purportedly advised as much, but she couldn’t remember his name. Or when she visited. Or what his rationale was. In any case, she wasn’t going to take it. “I going to sleep,” she said, rising and heading inside.

But like the sisters, the overwhelming majority were more than happy to take it.

“Everyone in Freetown knows cholera,” said Barrie.

Isha Sankoh, a 60-year-old vendor and grandmother, certainly does. After her first husband was killed in Sierra Leone’s civil war and her second husband turned out to be “too mean,” she moved with her five children to low-lying Kroo Bay, in hopes of growing her business selling charcoal, palm oil, and soda pop.

Isha Sankoh
Freetown resident and cholera-survivor Isha Sankoh at home in October. (Photo by Jon Lascher / Partners In Health)

“Every year, I would lose property during the flood, leave and live with neighbors, then go back,” she said.

During the rainy season five years ago, she fell horribly ill and quickly became too weak to walk. Friends carried her to the health center in the slum, and watched over her kids and grandkids while she recuperated.

“I had cholera almost to the death,” she said.

After being discharged, she moved her family to this one-room shack on higher ground. “I plan to change my life,” she said. “I plan to move from here to a better house.”

Had she taken the vaccine?

Of course, she said.

So the team continued on.

Fri, 17 Nov 2017 11:53:32 -0500
Sheila's Story: Reflections for World Diabetes Day Chimwemwe Chipenge easily remembers the date of the diagnosis that saved her daughter’s life: June 31, 2014.

That was the day Chimwemwe told clinicians with Abwenzi Pa Za Umoyo, as Partners In Health (PIH) is known in Malawi, that her young daughter, Sheila, “was getting smaller, losing loads of weight,” and experiencing dizziness, headaches and frequent urination. The clinicians diagnosed Sheila, now 14, with type 1 diabetes.

Sheila had been losing weight and not feeling well for weeks, but she had tested negative for malaria and other routine infections. While diabetes was a shock, and new to the Chipenge family, they were relieved to finally learn what had been causing Sheila’s symptoms. In the months that followed, Chimwemwe and Sheila learned that type 1 diabetes often affects young children, and that Sheila would need insulin twice a day. They also learned that, unlike malaria or other curable infections, type 1 diabetes was an ongoing, incurable condition that would require regular attention.  

In the years since, though, the Chipenge family has discovered that through steady access to care and a supportive community, Sheila is able to thrive.

Her story is an inspiration as the international community recognizes World Diabetes Day—an important moment to advocate and raise awareness for diabetes globally. Staff at PIH organizations around the world, from Malawi to Navajo Nation, are marking the occasion with many diabetes-related events, including patient education sessions in Haiti and a screening campaign in Rwanda.

The care that Sheila receives is part of PIH’s integrated chronic care clinic, a model developed in partnership with Malawi’s Ministry of Health. The model’s goal is to increase access to care for people with non-communicable diseases in rural areas.

PIH’s integrated care model began as an HIV program. Clinicians now are building on that success to offer community-level care and screening for several chronic diseases—such as HIV, type 1 diabetes, rheumatic heart disease, and cervical cancer—under one umbrella. Providing integrated care enables PIH to reach many more patients like Sheila, and to link them to health services and social support. 

That support often starts at home. Over the past three years, Chimwemwe has played a critical role in managing her daughter’s condition. She gives Sheila her insulin injections twice a day, at 6 a.m. and 6 p.m., and cooks healthy, hearty food, such as brown bread and whole-grain porridge, to support the injections.

Chimwemwe also is ready to recognize and respond when Sheila’s blood sugar drops unexpectedly.

When Sheila “gets a fever and sweats a lot, I know that she is dizzy,” Chimwemwe said. “So, I take a little sugar and give it to her.”

Although managing Sheila’s type 1 diabetes is a challenging new reality for her and her family, they continue to receive significant help from the community. Health workers from Neno District Hospital have coached Sheila on how to manage her diabetes at home. PIH helps operate the local hospital in rural southwestern Malawi, where the Chipenge family lives. A community health worker checks in regularly with Sheila and her mother, monitors Sheila’s health, and accompanies Sheila when she needs to visit the clinic.

PIH’s integrated chronic care clinic is a unique program in Malawi and an important model for the region. The clinic shows how complex, non-communicable diseases can be effectively managed in rural settings by investing in strong health systems and providing regular access to screening services, patient education, follow-up care, and life-saving medicines.

Over the next three years and beyond, PIH will continue supporting local communities and patients like Sheila while working with Malawi’s Ministry of Health to strengthen and expand services at district hospitals.  

For her part, Sheila is focused on things close to home—like being a teenager and growing up. She’s now in eighth grade and enjoys spending time with her friends after school.

Sheila said she plans to study hard, so one day she can become a nurse and “save sick people’s lives,” as the PIH team in Malawi helped save hers.

Tue, 14 Nov 2017 12:17:52 -0500
Lovenyou's Transformation in Haiti The Partners In Health truck kicked up gray dust as it rolled to a stop, just down the hill from the two-room shack where 17-month-old Lovenyou Pierre lived with seven of his relatives. Lovenyou’s mother, Jodanie Louis, emerged from the modest home, and he followed close behind.

Lovenyou tightly gripped his 25-year-old mother’s worn jeans and stared at the visitors with bright, liquid brown eyes. His short curls were a light rust color. He wore a blue T-shirt that said “Tough Guy,” and had nothing on his bottom except a fine layer of dust. He had been sick for the past several days with diarrhea—possibly the result of drinking unclean water collected from the nearby river. The closest pump was a “bon ti marche,” or good little walk, of about an hour.

Lovenyou’s tummy troubles weren’t why staff with Zanmi Lasante, as PIH is known in Haiti, were visiting. They had come to follow up on Lovenyou's visit, four months earlier, to the malnutrition clinic in Boucan Carré, where he was diagnosed with severe malnutrition. He was just past his first birthday and weighed 17 pounds—well below the normal growth curve for boys his age, according to the World Health Organization—and measured a below-average 29 ½ inches.

Roughly 1 in 5 children are starving in Haiti, and 1 in 3 are stunted because they don’t have enough to eat. In an average month in 2016, 127 patients received care and nutritional supplements at the malnutrition clinic in Boucan Carré. That’s just a fraction of the total number of starving children PIH helped last year; altogether, staff enrolled 9,000 children as new patients in the 12 clinics and hospitals PIH supports across the country.

Shortly after that first visit to the Boucan Carré clinic, Lovenyou took a turn for the worse. He spiked a fever, had diarrhea, wasn’t eating, and—scariest of all—kept losing consciousness. Panicked, Louis scrounged for the money to pay a driver to take her and Lovenyou to University Hospital in Mirebalais, a 30-minute motorcycle drive from their home.

PIH staff admitted Lovenyou immediately, hooked him up to an IV, and performed a battery of tests to ensure the toddler wasn’t suffering something in addition to starvation. (Some children’s cases become infinitely more complicated when staff discover they also test positive for HIV or tuberculosis.) Tests showed nothing alarming, but did confirm he was dehydrated and in dire need of additional nutrients.

Eight days later, Lovenyou was healthy enough to return home. Louis began taking him regularly to the clinic in Boucan Carré. When she couldn’t afford the motorcycle ride, they walked. By foot, and while carrying a sick child, it took her nearly two hours, one way. Once there, PIH nurses weighed Lovenyou and provided him with a supply of Nourimanba, the nutrient-rich peanut paste PIH produces and distributes to its malnutrition clinics.

Louis religiously fed Nourimanba to Lovenyou three times a day, and his appetite returned. She talked about the experience in a shy, quiet tone, while her son squirmed in her arms. He eventually wiggled free and shimmied to the ground to play with other children.

Lovenyou is Louis’s third child; she has two by another man, who’s no longer in the picture. Lovenyou’s father worked as a mason in the capital of Port-au-Prince and was not home often.

(left) Djenika Decat (Right) Luis
Djenika Decat (left), Lovenyou's older sister. Jodanie Louis (right), Lovenyou's mother. (Photos by Cecille Joan Avila / Partners In Health)

Louis did what she could to make a living. She took out a small loan from Fonkoze, a nonprofit with an office bordering PIH’s clinic in Boucan Carré. With 3,000 gourdes, about U.S. $50, she bought bouillon cubes, candies, cookies, spaghetti, and school supplies to sell on market days in neighboring communities. She repaid the loan, bit by bit, every 15 days. With the profits, she bought food and paid school fees.

Toward the end of the visit, Louis’s older sister, Magdala, appeared from inside their home and welcomed the visitors inside. Sunlight filtered between the wood slats of the walls and under the zinc roofing. Cups, jars, and cooking supplies covered a table across from the doorway. Clothing hung from exposed beams above. Near darkness cloaked the back room, where a single bed filled half the space. An elderly woman lay on a mat on the dirt floor. She was Magdala and Jodanie’s mother, and she clearly was not well.

She had been sick with a fever and headache for five days. Ms. Esther Mahotiere, the nutrition program coordinator, and Ms. Asmine Pierre, lead nurse of the malnutrition clinic in Boucan Carré, knelt down to speak with her. They asked about her symptoms, what medicines she had taken, if any, and encouraged her to go to the clinic.

Back outside, a heavy truck rumbled by on the dirt road below, its bed laden with bananas and hitchhikers. Lovenyou found a stick and chased neighbors through the tall grass bordering their yard. He laughed, deep dimples indenting his cheeks, and ran faster than his little legs could carry him until he wiped out on the ground nearby.

Louis, a slender woman with thick cords of hair, shook her head and smiled. It was the look of a tired mother whose child had been a bit naughty. And it carried a hint of relief.

Lovenyou still had a ways to go to recover, but in the past four months, he had gained 2 ½ pounds and half an inch in height. His condition had improved from severely to moderately malnourished, and he was now visiting the clinic every 15 days, instead of every eight.

Back in the PIH truck headed home, Mahotiere looked relieved.

When they act rascally, she said, it’s a good sign. That means they’re healthy.

(Photo by Cecille Joan Avila / Partners In Health)


Wed, 08 Nov 2017 10:17:05 -0500
Wall Street Journal: Dr. Gary Gottlieb and Money Well-Spent A recent Wall Street Journal interview with Partners In Health CEO Dr. Gary Gottlieb offers a candid perspective on the challenges of implementing and funding global health. Dr. Gottlieb, the former president and CEO of Partners Healthcare and a psychiatrist by training, has led PIH since 2015. Below he speaks to the organization’s “laserlike” focus on investments in maternal mortality, community-based health care delivery, and the use of hard data to drive decision-making up and down the board.

Fri, 03 Nov 2017 14:57:14 -0400
Hospital Attendant Saw Decades of Neno Health History Over seven decades in Malawi’s Neno District, Rosemary Mapemba not only has witnessed transformative changes in health care and quality of life, but also has been a daughter, a mother, a grandmother, a Partners In Health patient, a much-loved PIH hospital attendant, and, now, finally, a retiree.

The last of those things is the only one that makes her sad.

“The government said I’m too old,” the 68-year-old Mapemba said with a rueful smile in October, via Skype, referring to national employment regulations. “I need to work again.”

Mapemba’s desire to continue working is all the more impressive when you consider her commute. She was a hospital attendant at Neno from 2008 through 2016, working for Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi. She walked to and from work every day, up and down the mountains between her home—in a village named George 2—and the Neno hospital, about five miles away. The trip took her at least two hours each way. That meant she spent four hours walking every workday, for nine years. Through rugged country. Usually alone.

But it didn’t mean she showed up late.

“She was often the first one at the office, at 7:30 a.m.,” said Stephen Po-Chedley, a volunteer medical informatics advisor at Neno from 2013 to 2014. “We would shuffle around every morning to get out of Rosemary’s way, because she took great pride and was stubbornly persistent in her work, and wanted to make sure everything was cleaned every day.”

Mapemba’s work went well beyond cleaning—she made sure patients had basic needs, kept hospital offices supplied with materials, helped the information technology team handle requests, and more. Her diligence and sunny personality made Mapemba a favorite not only among Neno staff, but also within the larger communities around the hospital and George 2. Mapemba said simply, “I made a lot of friends.” But that doesn’t tell the story of someone whose retirement drew such a broad response—several current and former co-workers were eager to talk about her—and who is a living history of health care in the region.

Mapemba was born on Sept. 28, 1949, in the Nanzanga area of Neno District. She spent much of her childhood in Zambia and suffered full-body burns there, she said, in a fire that killed hundreds and hospitalized her for more than a year. Mapemba returned to Malawi and Neno District in 1964, shortly after the country’s first president, Hastings Kamuzu Banda, had come to power.

Health services for Neno District were based in a police station back then, Mapemba said, before a more formal health center was established in 1978. She recalled how people in the Neno area often would go into forested areas to find plants they used as natural medicines, such as tree roots that functioned “the same as quinine” and were used to treat malaria.

Mapemba said people who were very sick eventually were able to go to Mwanza District Hospital, about 30 miles south, but transportation remained scarce with just one ambulance.

“In those days, health care wasn’t good,” Mapemba said. “Even if you went to the hospital, the providers were not available.”

She said the availability of medicines also was hit or miss—“Sometimes you could find it, and sometimes not”—and did not improve after Malawi’s first multiparty presidential elections in 1994.

Rosemary Mapemba's daily walk to Neno District Hospital
Rosemary Mapemba, 68, walked this rural, mountainous route to and from work at Neno District Hospital for nine years. She said the roughly 5-mile trip took 2 hours each way. 

Mapemba has witnessed generations of change in health care. She gave birth to two of her four children, for example, at hospitals in Blantyre, Malawi’s second-largest city. She delivered her third child at a Red Cross building in Neno District, and her fourth at the regional health center. Two of her 15 grandchildren, though, were born in the new maternity ward at Neno District Hospital.

And earlier this year, one of her grandchildren received malaria treatment known as artemether-lumefantrine, at Neno.

Mapemba said the years have brought broad changes to the community, including a market and more streetlights, along with Neno District Hospital itself. PIH opened the hospital with Malawi’s Ministry of Health in 2007.

“Now, the hospital is good and the doctors treat us well,” she said.

Mapemba experienced that treatment firsthand, after she became so sick in 2006 that nobody would bring her to see doctors.

“They were all waiting for me to die,” she said.

Mapemba’s daughter eventually brought her to PIH’s health facility in Neno, where APZU’s first executive director, Dr. Keith Joseph, and his team diagnosed Mapemba with HIV. They started her on antiretroviral therapy, and suspected she was battling tuberculosis, as well. The timing was fortunate—PIH began working in Neno in 2006, the same year she fell ill.

There were no x-ray facilities in Neno yet, though, so Joseph accompanied Mapemba to Mwanza District Hospital, where she was diagnosed with TB and began treatment for that, too.

Mapemba said she also was struggling with hypertension at that time, but began recovering on all fronts in 2007. About a year later, she started her job as a hospital attendant—helping people at Neno, rather than the other way around.

Po-Chedley said Mapemba didn’t speak much about the hurdles she had faced in her life.

I was aware of some of her health challenges and we discussed them, but she never really framed them as grand challenges. I think she was modest in that sense; you knew she worked hard because you could see it, not because Rosemary told you,” Po-Chedley said. “Rosemary had pride in working with APZU, and I hope she knows how important she was to the incredible work PIH does in Malawi.”

Po-Chedley added that Mapemba, “was a constant, positive, persistent, and hard-working source of inspiration.” She routinely called him “achimwene,” or brother. Mapemba often called long-term expatriates at Neno achimwene or “achimwale,” which means sister. Po-Chedley said that even though she speaks English, Mapemba tried to teach her foreign co-workers a little Chichewa every day.

Beth Dunbar, former director of monitoring and evaluation for APZU, said the same, noting that Mapemba would greet her every morning with, “Mwadzuka bwanji abwenzi?,” which translates to, “How did you wake, friend?”

“I’m sad that she’s retiring; she’s always a happy presence,” Dunbar said in October, sitting next to Mapemba on the Skype call.

Mapemba was reserved and spoke quietly on the Skype, belying the gregarious nature that’s evident in co-workers’ stories, and in photos of her with family and friends. But she smiled widely when Dunbar turned to her and gave a compliment that undoubtedly is felt by many.

“You took good care of us,” Dunbar said.

Fri, 27 Oct 2017 11:04:42 -0400
Refugee Camp Eye-Opening for UGHE Students Orderly lines of homes and shelters stretch far down crowded, uniform roads at Mahama Refugee Camp in southeastern Rwanda, where more than 55,000 people have arrived since 2015 after fleeing political unrest and violence in Burundi.

The turmoil has displaced more than 400,000 Burundians across Rwanda, Tanzania, Uganda, and the Democratic Republic of the Congo, according to the United Nations High Commissioner for Refugees. The U.N. agency oversees Mahama, in conjunction with the government of Rwanda’s Ministry of Disaster Management and Refugee Affairs.

Dr. Agnes Binagwaho and about 20 students from the University of Global Health Equity (UGHE) visited Mahama on a hot day in mid-September. UGHE is a Partners In Health (PIH) initiative, with several sites in Rwanda. Binagwaho is the university’s co-founder and vice chancellor, senior lecturer in global health and social medicine at Harvard Medical School, and former Rwanda Minister of Health.

She said raw emotions from people’s displacement were starkly evident at the camp.

“This is a crisis of recently traumatized people, and it’s still ongoing,” Binagwaho said. “Even if we are happy that they have a house, that they have access to basic sanitation and basic care, it is row upon row of people who are suffering, and you can feel it.”

Dr. Agnes
 Dr. Agnes Binagwaho (center) chats with UNHCR Field Officer Victoria Copa Camara (left) as the University of Global Health Equity MGHD Class of 2019 visits Mahama Refugee Camp. (Photo by Danny Kamanzi / UGHE)

For students in UGHE’s new cohort, the visit to Mahama was a powerful introduction to global health equity, and inequity, during their first week of class. The visit was part of students’ intensive opening to the semester. The week also included a visit to a malnutrition treatment site—and homes of families with children in a malnutrition program—near PIH-supported Rwinkwavu Hospital, a few hours northwest of Mahama.

“The field visits are part of an overall active learning principle, getting students engaged in communities around them,” said Kamille Beye, teaching and learning manager at UGHE. “I think the (Mahama) visit helped expose the students to things that are going on in their own country…I think it opened their minds to a wider view.”

Mahama spans about 120 acres near the Akagera River, which borders Tanzania and is part of the upper headwaters of the Nile. A U.N. guide and camp director met the university group early on the day of the visit and brought them around Mahama 1 and Mahama 2, the camp’s two halves. The group saw sites including a clinical laboratory, a food distribution center, a water filtration area, and an entrepreneurship center for women and girls.

PIH co-founder Ophelia Dahl joined the visit. She praised the forward-looking vision of UGHE and Inshuti Mu Buzima, as PIH is known in Rwanda.

“It was good to meet with colleagues and new master’s students, to meet the people who will implement, on a grand scale, the details of global health equity,” Dahl said.

Mahama is proving to be a potential model for delivering equity in a setting with very limited resources.

All of the children at the camp have access to education, and there are two health centers, which Binagwaho said provide a level of care that’s comparable to what can be found across Rwanda. The Ministry of Health is also training displaced Burundians at Mahama to be community health workers, so displaced people can have links to care through people they know and trust.

“If you want the lives of refugees to be protected… you create social capital, you create trust, and you create safety,” Binagwaho said. “This camp is something new, because community health doesn’t exist (in refugee camps) elsewhere. This is a good practice that should be replicated.”

Class of 2019 student Dr. Charles Nkurunziza, a resident in obstetrics and gynecology at the University of Rwanda’s College of Medicine and Health Sciences, said conditions at Mahama were better than he expected.

“What I saw, it’s not what I thought it would be,” he said. “The health centers are really amazing.”

Andre Ndayambaje expressed a similar view. Ndayambaje, also a new student, lives in Kigali and has a bachelor’s degree in nursing sciences and midwifery, from the University of Rwanda. He’s worked for 11 years at Kigali’s King Faisal Hospital, as a midwifery nurse in the neonatal intensive care unit.

UGHE students continue their full-time jobs while earning graduate degrees in global health delivery. The university opened in 2015—the same year as Mahama, coincidentally—and held its first graduation last May. Seventeen students have received a master’s of science degree so far.

       Students and staff of UGHE listen as camp personnel give an overview of Mahama Refugee Camp. (Photo by Danny Kamanzi / UGHE)     

Ndayambaje has just begun pursuing his MGHD, as the master's in global health delivery is known. He said many of the practices at Mahama help create stable communities—by providing broad access to food, water, shelter, health services and education—and could be implemented outside the camp’s borders.

“They are not solely for refugees,” Ndayambaje said of the camp’s services and infrastructure. “They can be done even for local systems.”

Mahama also faces significant challenges, amid its successes. A September report by the U.N. refugee commission said the Burundian upheaval has created “one of the least-funded refugee crises in the world.” At Mahama, the commission added, space is nearing capacity and expansion efforts are underway, while more displaced people continue to arrive every day.

Beye said UGHE hopes “to build an ongoing relationship with the camp, and possibly other camps, as well,” to help students shape their roles as future global health delivery leaders and have ongoing impacts in the region.

One of UGHE’s first students already is doing just that.

Binagwaho said Dr. Angeline Mumararungu, a health program manager for Gardens for Health International and a member of UGHE’s first cohort, visits Mahama weekly to oversee and support several nutrition-related programs. Mumararungu has helped integrate health, gardening and nutritional education, along with related counseling for more than 400 displaced Burundian families. She trains people at Mahama to provide health and nutrition education, as well.

Binagwaho said Mumararungu’s work reflects UGHE’s vision.

“We want more of our students to go and provide services to the most vulnerable,” Binagwaho said. “The more our students are spread across the world to serve vulnerable populations, the more we will be able to change the world.”

Fri, 20 Oct 2017 11:32:40 -0400
Joint Statement on STREAM Stage One MDR-TB Clinical Trial Results Partners In Health (PIH), Interactive Research and Development (IRD) and the Zero TB Initiative (ZTBI) welcome the release of the interim results from the STREAM Stage 1 clinical trial. This is the first clinical trial of a new treatment regimen for multidrug-resistant tuberculosis (MDR-TB), and we congratulate the investigators for successfully conducting it. Unfortunately, we have noticed much confusion about the results of this clinical trial, both in the lay press and in the countries in which we work.

As organizations supporting MDR-TB treatment programs in multiple countries, we are carefully reviewing the results of this trial and considering how they should influence recommendations to national TB programs, clinicians and our patients.

The STREAM Stage 1 trial was designed to answer a specific research question. The answer is clear: the trial was not able to establish non-inferiority (equivalency) of the 9-month shortened regimen compared to the 20-month conventional MDR-TB regimen.

It is important to note that study participants in the conventional 20-month regimen arm were treated according to the 2011 WHO guidelines, which did not recommend the use of newer TB drugs. If later WHO guidelines had been used, there may have been an even bigger gap between the 9-month shortened regimen and the conventional 20-month regimen.

Also seen in the interim results of the STREAM trial was a similarly high rate of certain adverse events, such as ototoxicity and hepatotoxicity, among patients receiving the 9-month shorter regimen compared to the 20-month conventional regimen. National TB programs should ensure that patients receiving the 9-month shortened regimen are closely monitored for potential adverse events.

Despite the lack of evidence for non-inferiority, there may be countries that decide to implement the 9-month shorter regimen for reasons of cost or feasibility. They should make this decision carefully based on drug resistance surveillance and other epidemiological data. For this reason, we look forward to more detailed analysis of the STREAM Stage 1 data that may indicate what subsets of patients are more likely to have favorable outcomes or have less adverse events. This will help national TB programs determine which patient populations should be targeted for scale up of the 9-month shortened regimen and populations where the longer regimen will be preferred.

We commend the investigators in the successful execution of STREAM Stage 1, and believe that this rich dataset will help to inform future clinical trials of new TB regimens. Although Stage 1 was unsuccessful in showing non-inferiority of the 9-month shortened regimen, the findings of Stage 2, which is testing two novel regimens at the same trial sites, are eagerly awaited. Finally, we call on the WHO to rapidly convene an expert group to revise and clarify its current recommendations for implementation of the 9-month shortened regimen under programmatic conditions.

Wed, 18 Oct 2017 15:36:14 -0400
Revisiting Lunie, a Malnutrition Patient in Haiti Lunie Lozama was the picture of a mischievous toddler. Shy yet curious, she hid behind her mother’s legs and played peek-a-boo with visitors to her home in rural Lascahobas, Haiti. Her round cheeks were dimpled, and her shiny black hair twisted into neat pony tails crowning her head. She wore a faded purple onesie with “Mom’s Beach Bum” across the front. Her mother smiled as she said that her daughter wasn’t afraid to fight her three older siblings.

Lunie wasn’t always that way. In April 2016, one month after turning 2, she arrived at the Partners In Health clinic in Lascahobas and was diagnosed as severely malnourished. She weighed 23 pounds and measured 31 inches—at least five pounds lighter and three inches shorter than what the Centers of Disease Control and Prevention recommend for average girls her age.

Lascahobas is among the busiest malnutrition clinics supported by Zanmi Lasante, as PIH is known locally. Nurses tended to an average of 250 patients per month, and started a total of 1,076 new children on malnutrition care last year. At all of its 12 facilities across the lower Artibonite and Central Plateau regions, PIH enrolled more than 9,000 new cases of starving children in its malnutrition program in 2016 alone.

Lunie's mother, Gertha Morette, feeds her daughter therapeutic food during their first malnutrition visit in April 2016. (Photo by Cecille Joan Avila / Partners In Health)

Those numbers fail to paint a full picture of the tragedy in Haiti, where roughly 1 in 5 children are starving, and 1 in 3 are stunted because they don’t have enough to eat.

Last year, Lunie counted among them. Her mother, Gertha Morette, brought her to the Lascahobas clinic for the first time that April. The lethargic little girl had a fever and diarrhea, wasn’t eating, and her feet were so swollen that it was painful for her to walk. Morette, pregnant at the time with her fifth child, perched Lunie on her lap and patiently fed her a packet of therapeutic food. Staff instructed them to come back every eight days so Lunie could be weighed, and to pick up a fresh supply of Nourimanba, the nutrient-enriched peanut paste PIH manufactures for malnourished children.

Getting to the clinic was easier said than done for Morette. She and her husband live with their children in a two-room, wood-slat house that straddles the top of a cliff a good 20-minute ride by motorcycle from Lascahobas. Goats are more frequent sights than vehicles along the dirt road leading to their home.

Morette paid a neighbor to take her and Lunie by motorcycle each time they had an appointment, holding Lunie on her lap while riding behind the driver and using precious money that now couldn’t go toward other household expenses. (Nearly 60 percent of Haitians live below the national poverty line of $2.41 per day, according to the World Bank, and 24 percent live on roughly half that.) Morette’s time away meant she needed to find help caring for her other children, and that she couldn’t sell produce at the market or tend her crops.

But the sacrifice paid off. Within two months, Lunie’s condition had improved from severely to moderately malnourished. Her feet shrunk to normal size, enabling her to walk without pain. She started gaining weight and shooting up in height. And she regained her appetite, eating more of what her family grew in their garden, and not just Nourimanba three times a day. Nurses told them they could start visiting every 15 days, instead of every eight.

They followed the new regimen as best they could. By mid-November, Lunie had gained more than three pounds and added another inch in height, and her mid-upper arm circumference—a commonly used indicator of malnutrition—had gone from 4 ½ inches to 6 inches.

Her body wasn’t the only thing changing. Lunie began acting much more like the stereotypical terrible 2-year-old. The toddler delivered a healthy helping of attitude, for example, on the November morning when Ms. Colin Alourdes, head nurse of the Lascahobas clinic, and Ms. Esther Mahotiere, PIH’s nutrition program coordinator in Haiti, visited her and her family. Lunie shelled green beans into a silver bowl, wedged in between Morette’s legs, as she warily watched her visitors. She barely roamed from her mother’s side, marking her territory.

Green beans are among the vegetables Lunie's family grows nearby. (Photo by Cecille Joan Avila / Partners In Health)
home visit
Ms. Colin Alourdes (left), head nurse of the malnutrition clinic in Lascahobas, is proud of Lunie's progress, from unable to walk to an into-everything toddler. (Photo by Cecille Joan Avila / Partners In Health)

A small cry came from inside their dirt-floored home. Morette stood up from her chair and led visitors inside, to where her 3-month-old daughter, Neleida, lay on the family’s sole bed. She scooped up the curly-headed infant and walked back outside.

In more ways than one, Morette had her hands full, yet the proud mother seemed calm and confident. She wanted to give back something to the nurses, whom she felt had saved her daughter’s life, and said she would recommend the clinic to any friends who feared their children might be malnourished.

There was another good reason for Morette to be at ease that morning. At the Lascahobas malnutrition clinic on the previous day, she had received wonderful news: Lunie no longer needed to return.



Fri, 13 Oct 2017 14:58:08 -0400
PIH, Partners Break Ground on Cancer Support Center in Rwanda Partners In Health, the Government of Rwanda and other collaborators broke ground in September on an innovative, two-story building that will be able to house more than 70 cancer patients, loved ones and caregivers on the Butaro District Hospital campus, providing stability and community during extended treatment. 

Crews are laying foundations and framework for the Butaro Cancer Support Center, which will provide housing, a cafeteria and meeting spaces for patients and caregivers. Doctors at the adjacent Butaro Cancer Center of Excellence treat hundreds of children and adults every year. Many of those patients travel to Butaro from across Rwanda or from surrounding countries, where high-quality cancer care can be scarce or non-existent.

The support center’s design features open-air galleries and roofed, exterior walkways lined with arches, creating shared spaces where patients, attendants and clinicians can gather. Architectural firm MASS Design integrated a patients’ needs assessment and surveys of patients, attendants and clinicians into design decisions, which focus on dignity and wellness during the entirety of patients’ cancer treatment.

The support center’s Sept. 15 groundbreaking featured leaders of PIH and Inshuti Mu Buzima—as PIH is known in Rwanda—along with Rwanda government officials and representatives of several partners and local communities. The center's construction is sponsored by the Massachusetts-based law firm of Faber, Daeufer & Itrato and supported by the generous gifts of individual donors.

Rendering by Mass Design 


Wed, 11 Oct 2017 16:57:11 -0400
PIH Releases How-to Guides for Mentoring, Quality Improvement Program MESH-QI Implementation Guide” online, through the Knowledge Center link on its website. Also posted there is a comprehensive “Costing Toolkit,” which provides a budgetary roadmap for a broad range of services and needs across a health system.    Dr. Jean Claude Mugunga, senior manager of monitoring, evaluation and quality for PIH, and author of the Costing Toolkit, said examples of costing work that’s integrated into HSS principles are uncommon.   “As a result, many policymakers and stakeholders are not fully aware of the flow of resources within the health system and where resource gaps may occur,” Dr. Mugunga said.   The guide offers step-by-step approaches to effective cost analysis, anticipating many of the information gaps that can limit analytic capacity.   Even with notable gains from MESH-QI programs so far, the need for more training programs and collaborative learning remains significant.   A PIH report in 2015 said Rwanda, for example, still had just less than 1 nurse—0.7, to be exact—per 1,000 residents. The report called that rate, “one of the most severe shortages of nurses in the world.”   The World Health Organization recommends that a country have at least 2.3 health care providers—including physicians, nurses and midwives—per 1,000 people. Adding physicians and midwives to Rwanda’s data brings the country’s rate to just 0.84 care providers per 1,000 people, according to the report.   Implementing MESH-QI can address staffing challenges in a variety of areas. PIH sites have applied MESH-QI to treatment practices for HIV, non-communicable diseases, mental health, maternal and child health, and more—and the model is expanding well beyond Rwanda.     “We definitely have a MESH program here,” said Dr. Emily Wroe, clinical director for Abwenzi Pa Za Umoyo, as PIH is known in Malawi. “It’s been up and running in a really significant way on malaria for a long time.”   Wroe said APZU’s use of MESH-QI includes mentoring and training programs to improve treatment of malnutrition and maternal health, with mental health applications planned for the near future.   “It’s become a tool that we’re using in a lot of different programs,” Wroe said.   Another example of MESH-QI principles in action is the All Babies Count program, which Inshuti Mu Buzima began with the Rwanda Ministry of Health in 2013. The program focuses on improving health care for mothers and infants before, during and after delivery.   After pilot efforts proved effective from 2013-15, PIH and Rwanda’s health ministry now are scaling the program nationally, with a goal of supporting 76 new health facilities, training more than 300 health care providers and serving a population of more than 1.8 million—all with the goal of reducing newborn mortality by at least a third by 2019, according to a PIH summer newsletter.    “We organize learning collaboratives that include clinicians such as doctors, nurses and midwives, as well as non-clinical staff such as data managers and administrative personnel, and also government officials,” the newsletter states, describing the program. “These learning collaboratives create a community to review recent data, develop quality improvement projects focused on improving key indicators, and share successes and challenges.”   Dr. Alishya Mayfield, senior clinical adviser on strategy for PIH, said All Babies Count “is an innovative use of the MESH model, which strengthens clinical care for mothers and infants by improving mentorship of nurses, and by giving clinicians more ownership of quality improvement initiatives in the health care facilities in which they work.”   Authors and supporters of the new MESH implementation and costing guides hope such innovative uses and expansions continue. The guides were created with support from MESH-QI mentors, clinicians, and technical advisors; district hospital leadership in Rwanda; and the Doris Duke Charitable Foundation’s African Health Initiative.   “Toolkits such as these allow an opportunity to replicate best practices without excessive cost,” said Jennifer Goldsmith, director of administration for the Division of Global Health Equity at Brigham and Women’s Hospital, and lead editor of the toolkits. “PIH can facilitate programs at our own sites and share our learning with partners with a level of detail and guidance that differs from past publications. This approach will allow our learning to endure and our approach to expand, improving care delivery where it is most needed.”
  MESH-QI download icon       Costing Toolkit download icon   ]]>
Tue, 10 Oct 2017 11:18:58 -0400
Visiting Djouvensky, a Malnutrition Patient in Haiti The Partners In Health pickup bumped along a rutted road, passing more cows than vehicles on a late morning last November. The driver parked in the shade of a lone tree, and 29-year-old Yonide Arelul and two PIH nurses stepped out of the cab and into the blinding sun.

It was the literal end of the road—for vehicles, anyway—so the women trekked carefully down a rocky slope, crossed a stream, and continued hiking the rough-hewn path through the lush hillside beyond.

One of Arelul’s children was enrolled in PIH’s malnutrition program at the clinic in Boucan Carré, Haiti, where Ms. Asmine Pierre is lead nurse, and Ms. Esther Mahotierre supervises as the nutrition program coordinator. The staff with Zanmi Lasante, as PIH is known in Haiti, wanted to check on the boy’s progress, but had no idea where the family lived. So Arelul walked to the clinic that morning, then mounted the pickup alongside the nurses for the first leg of the trip, and led them the rest of the way on foot.

Roughly 1 in 5 children are starving in Haiti.

Arelul, and many rural Haitians like her, overcome barriers like these every day to access health care. When PIH clinicians see them arrive at a clinic, they know the patients are in desperate need of help.

Roughly 1 in 5 children are starving in Haiti, and 1 in 3 are stunted because they don’t have enough to eat. Arelul’s son, Djouvensky Maxime, was one of the 127 patients, on average, who visited the malnutrition clinic in Boucan Carré every month last year to receive a food supplement and nursing care. That’s just a fraction of the total number of starving children PIH helps. Altogether, 9,000 such children were new patients at PIH-supported clinics and hospitals across the country in 2016.

Arriving home

The sun felt piercingly hot. Pierre held a manila folder above her head in self-defense as she and Mahotiere trailed behind Arelul. Papaya trees and sugar cane seemed to bow in the heat. A farmer and his horse ambled past, laden with burlap sacks of homemade charcoal. Farther up the path, a group of schoolchildren in checkered shirts and neatly tied hair ribbons chattered on their way home for lunch.

Twenty minutes in, Arelul veered off the path. She crossed her family’s compound, seeking the shade of the banana-leaf awning attached to her two-room home. Her mother was bathing Djouvensky in the dirt courtyard. He stood in a pink plastic tub, his short-cropped hair catching drops of water poured over his head with an empty container of Nourimanba, a nutrient-rich peanut paste PIH manufactures for malnourished children. Once dried and dressed, he tucked himself into his mother’s lap and soon fell asleep.

Djouvensky’s twin brother, Djouven, stood nearby like a sentinel—curious about the visitors, yet protective of his brother. The 23-month-old boys were nearly the same size and are Arelul’s babies. She has five children altogether. Her 9-year-old daughter was studying in Mirebalais, and a pair of 4-year-old twin boys played in the shade nearby.

Arelul adjusted Djouvensky so that his head rested on her shoulder. He was her “sick” child, the one who nearly died from malnutrition.

Arelul and children at home.
Arelul holds a sleeping Djouvensky while she gives a tour of her home, followed by her 4-year-old twin sons, Ali (from left) and Alex. (Photo by Cecille Joan Avila / Partners In Health)

Some children graduate from the malnutrition program within several months by gaining enough weight and height to place them back on a normal growth curve. Others don’t complete the program the first time around. Last year alone, of the nearly 8,000 children enrolled in PIH’s severe malnutrition program, 50 percent dropped out. Their families live far from the nearest clinic and can’t afford transportation. Sometimes one parent is caring for multiple children at home, and can’t slip away for appointments. Other times, families have nothing to feed their children beyond Nourimanba, which is meant to supplement—not replace—a child’s normal diet.

Arelul faces these challenges, and others, in getting Djouvensky the care he needs. Her husband works in Port-au-Prince as a welder and comes home once a month. She relies on her parents for help, but they—like many of their neighbors—are subsistence farmers and spend long hours tending their crops and livestock. So most days, she alone cooks, cleans, and cares for her children, and tends her own fields.

Daily life is a blur for mothers like Arelul, who don’t have the luxury of choosing what is best for their children. They often get by on good enough.

A rough beginning

With her last pregnancy, Arelul didn’t have time for regular prenatal visits. She was nearly full-term when she went into labor. Her family ran for the local birth attendant so that she could deliver at home, like two-thirds of women in Haiti, and she gave birth to a healthy son. But something wasn’t right. Her placenta wasn’t descending, and she was still in an immense amount of pain. The birth attendant recommended she go to the nearest clinic. For that, she would need a minor miracle, and some strong backs.

A crew of men were rounded up. Together they lifted the mattress on which Arelul labored and hoofed it, double time, to Boucan Carré. Normally, the walk takes about an hour; that day, it took 30 minutes. Doctors examined the distraught mother and provided her with surprising news: there was another baby. She gave birth to her second son minutes later.

He had nearly fallen below both growth curves and needed immediate medical attention.

Djounvensky was the smaller of the two. He wasn’t growing like his brother and always seemed sick. Arelul took him to the Boucan Carré clinic, where he was referred to the malnutrition program. Nurses diagnosed him as severely malnourished and started him on treatment. But he just didn’t seem to be getting better, which made his mother wonder if the sacrifices she’d been making to get him there were worthwhile. She decided to stop attending the weekly clinic visits.

Instead, the family took Djouvensky to a cousin, a local traditional healer. They were thinking he wasn’t “doctor sick,” but possibly under the influence of darker forces. The cousin provided them with treatment, but encouraged them to return to the clinic. They did. That cycle repeated again as the boy’s parents became increasingly frustrated. The toddler still couldn’t walk or talk and was lethargic, while his twin brother ran around, chatted, and made mischief. Her husband was ready to give up on Djouvensky.

For Arelul, that was not an option. She arrived at the clinic a third time with Djouvensky last November. Just shy of 2 years old, he weighed 22 pounds and measured 31 inches. According to World Health Organization growth standards, he should have been 27 pounds and 35 inches—in other words, he had nearly fallen below both growth curves and needed immediate medical attention.

The turning point

Djouvensky sits on the lap of Ms. Asmine Pierre, lead nurse of the malnutrition clinic in Boucan Carré. (Photo by Cecille Joan Avila / Partners In Health)

Pierre and her team placed Djouvensky on Nourimanba and scheduled him to return to the clinic every eight days so they could replenish his stock of peanut paste and weigh him. Arelul stuck with the program this time, spoon-feeding him Nourimanba three times a day and attending all his appointments. Sometimes she took the family’s horse and rode with Djouvensky to the clinic. On market days, when her mother needed the animal to haul corn, potatoes, and rice, Arelul hired a motorcycle driver to take them. If all else failed, she carried Djouvensky on her back.

Her diligence paid off. Djouvensky began to walk. He played more with his twin. He even said his first word, “Mama.”

Pierre, who was sitting near Arelul in the shade during the home visit nearly a year ago, paged through Djouvensky’s file and confirmed that his condition had improved from severely to moderately malnourished over just a couple of weeks. It was a small adjustment in language, but a huge difference in the boy’s daily life—and future potential.

In that moment, though, Djouvensky had no idea he was the center of attention. He was just waking up from deep sleep. He stuck his thumb in his mouth, walked over to Pierre, and snuggled on her lap. Shy and quiet, he stared at visitors with saucer-like brown eyes. His skin shone. His cheeks looked full. He had many weeks left of treatment, but finally, things were turning in his favor.

Arelul stood to escort Pierre and Mahotiere back to the main path. The sun was still punishing as the nurses retraced their steps to the pickup. At the base of the last hill, they paused beside a front-loader parked by a stream. Someday, the machine would be used to carve the rest of the gravel road, connecting rural residents more quickly to health care in the town clinic.

But that was far in the future. Pierre and Mahotiere had many more home visits to make.

walking back
Arelul walks Ms. Esther Mahotiere (left), the nutrition program coordinator, and Pierre to the edge of her family compound. (Photo by Cecille Joan Avila / Partners In Health)


Wed, 04 Oct 2017 10:17:55 -0400
Delivering Hope in Lesotho Matumisang Khasipe—a mother, wife, and nurse midwife for Partners In Health—says she loves her job at Nkau Health Center in Lesotho.

“I’ve been working for PIH for two years,” she said. “And there’s nothing better than patients telling you they’re happy.”

Nkau is about a two-hour drive southeast of Lesotho’s capital, Maseru. People often travel long distances through the mountainous region, on foot or horseback, to get care there. The clinic serves a population of about 15,000 and can see up to 30 childbirths in busy months, according to staff with Bo-Mphato Litsebeletsong Tsa Bophelo, as PIH is known in Lesotho.

Providing that amount of care could be a tall order in a country with one of the highest maternal mortality rates in the world.

But Khasipe and all of Nkau’s staff have set the bar high for maternal and infant health. They emphasize facility-based deliveries—which are much safer than childbirths at home—and conduct referrals to district hospitals for complicated pregnancies and emergencies, in order to prevent as many maternal deaths as possible.

Or, ideally, to reduce that number to zero.

“There shouldn’t be any maternal deaths,” said Khasipe, one of two PIH-supported midwives and three general nurses at the clinic.

Matumisang Khasipe in Nkau, Lesotho. (Photo by Terry Holzman / Partners In Health)

Nkau is one of seven remote health centers across Lesotho that are involved in PIH’s Rural Health Initiative. The initiative began in 2006 as an effort to support HIV care in the most rugged, remote areas of the small country, which is entirely surrounded by South Africa.

The initiative has since expanded, adding services focusing on maternal health, children’s health, and tuberculosis. One example is the Maternal Mortality Reduction Program, which began in 2009. In that year, just 5 percent of the region’s childbirths took place at a health care facility. By 2015, the facility-based delivery rate averaged 90 percent across the region served by the Nkau, Bobete and Nohana health centers.

Safe childbirths are just a part of the personal care that Khasipe and her colleagues help deliver at Nkau, every day.

In addition to new sets of tiny infant clothes and onesies emblazoned with “Partners In Health, Baby!” for example, newborns get immunizations and other postnatal services, free of charge.

Clinic staff encourage new mothers to stimulate their babies by playing and talking with them, holding them and singing to them. Village health workers travel widely to visit new and expecting mothers in their homes.

“Among other duties, village health workers go door-to-door to identify pregnant women in early stages and accompany them to facilities for their first prenatal care,” said Joalane Mabathoana, PIH’s manager of maternal and child health services in Lesotho.

Health workers also advise pregnant women who live far from the clinic to come and stay in maternal waiting homes until their babies are safely born. They receive consistent prenatal care, including ultrasounds, and doctors can more easily identify medical complications as women approach their due dates.

Mabathoana said women often begin staying at a waiting home about two weeks before their due dates. If emergencies arise, Nkau staff can help transport women to facilities with more resources.

Mothers at Waiting Home
Nearly all of the expectant mothers in the maternal waiting home at Nkau Health Center in Lesotho, on this day in March 2016, were paired with maternal health assistants, a vital part of ensuring safe deliveries for mothers and newborns. (Photo by Rebecca E. Rollins / Partners In Health)

Khasipe said such transports sometimes involve help from the local community.

“People respect what happens here,” Khasipe said. “There’s a nearby businessman who lets us borrow his car to bring women in labor” to the closest hospital, if an additional vehicle is needed in an emergency.

Khasipe’s commitment to quality health care for everyone, regardless of their financial means, runs parallel with PIH’s mission—and with her personal story. When Khasipe was 18, her first baby died. She was devastated.

The experience motivated her to go to nursing school.

“I took the chance to be a nurse in search of answers to why my baby died,” she said.

At the National Health Training College in Maseru, Khasipe studied general nursing and midwifery, and got firsthand experience in providing care.

“But I was traumatized,” she said. “I thought I could save all babies, like no one had saved mine.”

Khasipe and her colleagues have saved plenty of lives since. She’s been regularly promoted for her skills and commitment to her patients. And in 2012, she got another, more personal reward: She gave birth to twins. Her husband was away at the time, working in a mine. He now helps raise and support the family by farming. He lives with the children on their land while Khasipe spends most of her time in Nkau.

“I talk to him almost every day,” she said. “It’s hard to be apart. He’s my best friend.”

Khasipe reflected on the significant changes she’s seen at Nkau over just the past two years, and said the facility is continually expanding its role in the community.

“We save many lives,” she said, “both young and old.”

Tue, 03 Oct 2017 15:08:31 -0400
Cholera Vaccine Saving Lives in Sierra Leone After torrential rains flooded Freetown, Sierra Leone, in August, raising fears of a cholera epidemic, government employees supported by Partners In Health will fan out from health centers around the capital October 5 to deliver the second and final dose of a vaccine that will protect roughly half a million residents from the deadly diarrheal disease.

Discussions about a vaccination campaign began as soon as floods washed through coastal slums, contaminating drinking water with bacteria-infested sewage. PIH Sierra Leone Executive Director Jon Lascher, a cholera campaign expert, and PIH Deputy Policy and Partnership Director Dr. Bailor Barrie, a Sierra Leonean physician with strong relationships in the government, joined emergency coordination meetings.

Things progressed quickly. Barrie worked hand-in-hand with Dr. Dennis Marke, Sierra Leone’s Programme Manager for the Expanded Programme on Immunization, to help deliver drugs from an international stockpile of essential medicines. PIH also bolstered the government’s plan by adding three dozen supervisors for the effort, everywhere from the warehouse that received the drugs to the health centers that sent employees out into neighborhoods. As a result, nearly all of the proposed population of 518,000 received a first dose of oral vaccine—an impressive number given that campaigns elsewhere, in less urgent times, often reach a far smaller proportion of targeted patients.

Hopes are high for the final dose. By all accounts, the government’s emergency vaccination campaign, supported by Partners In Health, has been swift, smart, and thorough.

“Having the vaccine accessed and delivered so rapidly in Sierra Leone adds some much-needed relief for people often last picked to receive the benefits of modern medicine,” said Lascher.

Check out the full story, which will include PIH’s paradigm-shifting cholera vaccination work in Haiti, when it appears in early November.

Fri, 29 Sep 2017 09:43:38 -0400
Staff Safe After Latest Mexico Quake, Doctors Give Aid Near Epicenter Partners In Health staff reported no significant damage or injuries at the 10 rural clinics and maternal waiting home that PIH supports in Mexico, following the country’s second major earthquake in two weeks.

The 7.1-magnitude earthquake struck roughly 100 miles outside Mexico City early Tuesday afternoon, killing more than 200 people and causing dozens of buildings to collapse.

Partners In Health is known as Compañeros En Salud in Mexico. Staff reported feeling light tremors in their region of rural Chiapas, some 500 miles to the southeast of the quake’s epicenter in Puebla.

All PIH doctors and staff checked in safe and sound. No damage was reported at PIH’s 10 rural clinics or the maternal waiting home in Jaltenango, where PIH is headquartered. But many staff and clinicians have friends and family living in the affected region, including Mexico City, Morelos, and Puebla.

Dr. Hugo Flores, executive director of PIH in Mexico, and Dr. Jimena Maza, director of primary care, spent most of Tuesday afternoon and Wednesday morning contacting the offices of collaborators to check on their safety. PIH works locally with colleagues from Advent International, Johnson & Johnson, Promotora Social, the MacArthur Foundation, and the National School of Nursing and Obstetrics.

“We have tracked down all of them, and they and their families are fine,” Flores reported.

Doctors who completed their social service year through PIH in Chiapas were in touch with current staff to transmit emergency information. At least three of the clinicians plan to volunteer in medical relief efforts in and around Mexico City, including Drs. Aníbal Gutiérrez Torres, Luciano Torres Sánchez, and René Delgadillo González.

“Doctors are now seeing patients at the hospitals,” González reported by voice message, while sirens whined in the background. “The question now is the people who are outside and in need of medical attention, because the hospitals here are usually full.”

González, who has volunteered in the past for Red Cross in Mexico, said medical brigades were forming to provide emergency aid throughout the capital and encouraged anyone with time and ability to lend a hand. The arrival of earthquake victims adds pressure on the already overburdened emergency rooms dealing with normal demand, including patients arriving in labor or from car accidents, gunshot wounds, heart attacks, and falls.

“So we are covering both fronts,” he said. “We’re working in ambulances, emergency rooms, and the Red Cross Hospital.”

Tuesday’s powerful earthquake struck less than two weeks after an 8.1-magnitude quake struck off the southwest coast of Mexico, killing 90 people and destroying thousands of homes. PIH clinicians and staff and the facilities in which they work were located far enough away that all remained unharmed.

Photo by René Delgadillo González
Photo by René Delgadillo González


Wed, 20 Sep 2017 13:10:20 -0400
What to Read: Recommendations from PIH Staff  

Born a Crime

Trevor Noah

In his uplifting memoir, comedian, social critic, and “The Daily Show” host Trevor Noah recounts his extraordinary experiences growing up biracial and under apartheid in South Africa. He never quite fit in, but he used his “outsider” perspective to his advantage. A speaker of English, Afrikaans, Xhosa, Zulu, Tsonga, Tswana, German, and Spanish, Noah bounced from group to group and won acceptance from all of them.

Although his story is often tragic, the comedian’s writing leaves me laughing.

—Ryan Jiha, finance grant manager, Partners In Health


The Black Jacobins

C.L.R James

“The Black Jacobins” is a history of the Haitian Revolution of 1791–1804, and of the role of Touissant L' Ouverture, a former slave who led the uprising and later became governor of Saint Domingue (before Napoleon ousted him in 1803).

James is an odd historian. He wrote the book in 1938 and his writing is anything but dispassionate, so the book comes across as not very objective or academic. But I found it refreshing that James made his political views clear, and he effectively captures the horrors of slavery and the hypocrisy of the French.

One of the most interesting and puzzling parts of the story for me is how L'Ouverture—with no military training or experience—emerged as a brilliant military strategist. We tend to think people can only do what they have been trained to do, and I feel this creates passivity that stunts creativity. While we have recently seen what can happen when someone with no preparation for leadership becomes a national leader, and I don’t want to encourage people to follow his lead, I think the idea that we need technocrats to move fields forward is an error that can be easy to make.

—Megan Murray, professor of global health and social medicine, Harvard Medical School


Harry Hole Series

Jo Nesbø

Nesbø is a Norwegian writer known for his crime novels and their main character, Harry Hole, who is kind of a mess but “gets the job done.” There tends to be grisly murders of very nice people and lots and lots (and lots) of coffee drinking (in between benders).

—Sidney Atwood, programmer and analyst, Division of Global Health Equity, Brigham and Women’s Hospital


Forty Million Dollar Slaves

William C. Rhoden

Rhoden’s book is disturbing and uncomfortable. It draws parallels between slavery and today’s black athletes playing for white-owned sports teams. He goes back to the beginning of sports in America to show the plight of black athletes, from jockeys to boxers, under white control.

It gave me a broader view of today’s athletes. I look at Colin Kaepernick, the former 49ers quarterback who protested racial injustice by refusing to stand at games during the national anthem, and it’s apparent to me that Kaepernick understands that he and his peers are not really playing for themselves.

While riveting, it was saddening and made me feel we haven’t come very far. But if nothing else, it’s a must-read for its historical background, which shows how important a role African-Americans played in starting sports in America.

—Mary Cooper, accounts payable accountant, Partners In Health


All the King’s Men

Robert Penn Warren

This summer I reread Robert Penn Warren’s “All the King’s Men,” which won the Pulitzer Prize in 1947. The novel is loosely based on the story of Huey Long, a populist politician in Louisiana in the 1930s, but it’s really a story about how people compromise or uphold their values. After 70 years, it seems incredibly current, demonstrating the power a politician can wield over people who feel they are unappreciated and not getting a fair deal. It captures how narrators can be unreliable and how seemingly hardened people can still be damaged or change completely. It’s totally captivating.

—Jennifer Goldsmith, director of administration, Division of Global Health Equity, Brigham and Women’s Hospital



Hermann Hesse

If I were pleasure-reading, I would pick up my tattered copy of Siddhartha and read it for the fifth time. The novel, set in ancient India, is about a young man who journeys to discover the meaning of life. As he wanders, he tries to find enlightenment through practices ranging from spiritual idealism to materialism. It’s a highly accessible book that’s short in length but profound in impact and has always been my go-to when I have felt stuck in life or need some inspiration. It’s also rather poetic—where else have you heard of lips resembling ‘freshly cut figs?’

—Jerome Galea, research associate, Department of Global Health and Social Medicine, Harvard Medical School


Moving Kings

Joshua Cohen

L.A. Times’ critic Mark Athitakis called it brilliant. The New Yorker’s James Woods ultimately found it unsatisfying. Whatever your take on this short novel published in July, Cohen’s maximalist writing style definitely makes other contemporary fiction look timid by comparison. (E.g. One character wears “a vintage polyblend suit pullulating with pleats.”) And the story, about a young Israeli soldier attempting to start afresh in modern-day New York City, never panders to a reader’s desire for easy truths. Indeed, it made me squirm, snort with laughter, and deeply appreciate the traumas that can hide behind familiar faces.

—Eric Hansen, senior writer, Partners In Health


Buzz Aldrin, What Happened to You in All the Confusion?

Johan Harstad

For a book that I imagine no one’s read, I’d recommend a novel called Buzz Aldrin, What Happened to You in All the Confusion? by a Norwegian author named Johan Harstad. It’s about a guy who has a bit of a mental breakdown and ends up recovering in the Faroe Islands. The narrator’s voice is quirky and unique, and the descriptions of the Faroe Islands have kept me wanting to visit for years. I found it at the library accidentally, but the story has stayed with me.

—Lewis Seton, senior grants administrator, Division of Global Health Equity, Brigham and Women’s Hospital


Cash In, Cash Out

Hannes van Rensburg

This is Hannes van Rensburg’s personal story about starting a mobile banking business in South Africa in 1999. The entrepreneur poured his blood, sweat, and tears into the company, Fundamo, and is brutally honest about his struggles, doubts, failures, and lucky breaks. He describes choosing between his personal and professional goals and how his morals guided his business decisions. 

It is still too early to understand how mobile banking will change the lives of the poorest citizens, but van Rensburg offers exciting possibilities: He believes that the mobile banking economy goes hand in hand with poverty alleviation. It’s a book that challenged me to consider how banking fits with human rights and our work at PIH.

—Mike Johnson, MEQ senior analyst, Partners In Health


Inside Out and Back Again

Thanhha Lai

Lai’s story is about a 10-year-old Vietnamese refugee girl who fled Saigon with her family to resettle in Alabama. It’s based on Lai’s own experience leaving the city at the end of the Vietnam War. She writes in verse and tells the story through the young girl’s eyes. It won adult and children’s literary awards and is a New York Times bestseller. I read it as part of a mommy-daughter book club I just joined. It’s timely, considering the current political climate in the U.S. and Trump’s position toward immigration. A quick and lovely read.

—Leslie Friday, senior writer, Partners In Health

Wed, 20 Sep 2017 12:17:33 -0400
Doctors See Daily Success at Butaro Cancer Center Five years after opening, the Butaro Cancer Center of Excellence is achieving extraordinary successes in rural northern Rwanda, amid daunting challenges.

Doctors at the Partners In Health-supported facility are treating about 1,700 patients every year, young and old, on the campus of the public Butaro District Hospital. The campus lies amid lush, green hills in a remote region not far from the Ugandan border. 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.

Antoinette Habinshuti is deputy executive director of Inshuti Mu Buzima, as PIH is known in Rwanda. She said the care provided at Butaro is incredible, especially given the cancer center’s location and limited resources.

“This is a place where you wouldn’t easily find a pediatric ward for cancer patients,” she said.

Some of Butaro’s greatest successes can be found in its youngest visitors—children who come to the cancer center with slim hopes buoyed by fighting spirits, often with cancer that is in late stages because of treatment delays or misdiagnoses elsewhere.

In recognition of Childhood Cancer Awareness Month, which continues through September, we spoke with Dr. Cyprien Shyirambere, Dr. Grace E. Dugan, and other current or former members of Butaro’s pediatric oncology team. With optimism and energy known only to doctors who see positive steps toward recovery happen daily, they described what it takes, and what is needed, to treat the hundreds of children who have come to the cancer center since it opened in 2012.

“A normal day in the pediatric oncology ward at Butaro would have about 15 patients to see,” said Shyirambere, associate director of the oncology program and one of the center’s two pediatricians, along with Dr. Alexis Manirakiza. “Among them are 10 who need chemotherapy and maybe four other patients who were admitted because they are sick, very sick and on oxygen.”

Shyirambere said his day usually starts around 7 a.m., making rounds through the ward to see if any children have immediate needs. If all is well, he’ll start preparing chemotherapy regimens for the day. That process can take several hours, Shyirambere said, adding that the crafting of chemo regimens is part of an ongoing collaboration with Dana-Farber Cancer Institute in Boston.

Shyirambere’s afternoons at Butaro can include administering chemo, conducting bone marrow biopsies for new patients, and, of course, just spending time with the children he’s treating.

“It’s a busy day for a doctor and a few nurses,” he said.

Patients in the pediatric ward last spring included Frank Mugisha, 6. In March, Frank completed 30 months of treatment for acute lymphoblastic leukemia, and was shown in PIH photos smiling in a doorway and spending time at Butaro with his aunt. Butaro staff will continue monitoring him for the next five years.

© Partners In Health
Dr. Alexis Manirakiza (left), one of the ward's two pediatric oncologists, listens to a question from clinical officer Dr. Grace Dugan. At right is Dr. Jean Pierre Bucyanayandi, a pediatric resident.

Dugan, who’s been a clinical officer in Butaro’s pediatric cancer ward for about a year, said relapse is a constant concern.

“It takes a long period of follow-up to be sure you’ve really cured someone,” she said.

Also in Butaro last March was Blandine Umurisa, 12, who was completing more than two years of treatment for acute lymphoblastic leukemia. Her treatment had included three rounds of chemotherapy. PIH photos of Blandine show her working on math homework a day after chemo, and walking through the ward with her arm around Shyirambere’s waist, and his arm over her shoulder. Although she had finished her cancer treatment, doctors diagnosed Blandine with pulmonary tuberculosis in November 2016. Her treatment for TB was ongoing last spring.

Dugan said Blandine was from the Democratic Republic of Congo, and living in a refugee camp in Rwanda. Blandine visited Butaro for a routine follow-up Sept. 18, Dugan added, and her cancer still was in remission.

The names of both children have been changed for privacy.

Their stories are among hundreds.

The 20 or so beds in the cancer center’s pediatric ward are nearly always full, because of rapidly rising demands for cancer care and the hospital’s already high-volume general pediatric ward.

Dugan spoke frankly about the challenges of operating the only full-service cancer care facility within hundreds of miles.

“There are times when every second bed has two kids in it,” she said.

Monitoring all of those patients around the clock requires staffing levels that the cancer center doesn’t always have.

In an August conference call from Butaro, Shyirambere quickly cited a desire for an “adequate number of nurses,” when asked his greatest need. But he also was quick to praise the nurses he has on his team.

“They work extra hours, to make sure every child with cancer receives care before they go home,” often working well into the evening, he said. “I really appreciate the hard work of our nurses.”

Habinshuti, IMB’s deputy executive director, said increasing recognition of the work at Butaro—and increasing numbers of people seeking care—can create difficult decisions for doctors.

“I think the challenge we have now is being victims of our own success,” she said. “Cancer treatment requires a lot of resources, but it’s going well so far.”

© Partners In Health
Inside the pediatric ward at the Butaro Cancer Center of Excellence, a PIH-supported facility at Butaro District Hospital in rural northern Rwanda. Children in the ward often mix in schoolwork, activities, and playtime between treatment and checkups. 

A shortage of health care workers is a global problem, and particularly severe in Africa and southeastern Asia. A 2015 report by the World Health Organization estimated a global shortage of 17.4 million health care workers, including nearly 2.6 million doctors and more than 9 million nurses and midwives. The document estimated there were 43 million active global health workers worldwide in 2015. 

Butaro’s staff often is boosted with support from Dana-Farber and PIH.

Jen Haley, for example, is a former Dana-Farber cancer nurse who worked at Butaro as an oncology nurse educator from September to December 2016, through a PIH program.

Haley said she helped nurses at Butaro learn to watch for symptoms at various treatment levels, improve the overall quality of treatment, and educate patients’ families and caregivers about cancer and related care.

Haley said she also stressed “the importance of letting them be kids,” amid the rigors of extended treatment. She and Dugan hosted Movie Fridays, for example, showing children’s movies on laptops—Haley said “Madagascar” was a favorite. Young patients at Butaro also were fans of pop music, Haley added, and liked to grab her smartphone to sing and dance along.

“I think that was where I kind of got my mental health from, just going in and playing music with the kids,” Haley said. “Kids are so resilient. One minute you’re giving them a shot and the next minute they’re running up and giving you a hug.”

Butaro’s staff has to be equally resilient, amid limited resources.

They don’t have a CAT scanner, an intensive care unit, or enough nurses. Stocks sometimes run out of needed medicines, and radiotherapy machines are a distant hope.

Dugan said working at Butaro has showed her that those things should be staples, not wished-for items.

“Cancer treatment is not a luxury. This is not an optional extra for a health system in a poor country. It’s very much at the core of what should be provided,” she said in August, days before returning to Rwanda after a visit to the U.S.

Shyirambere said he draws strength from successes. Treating children with cancer can be incredibly emotional, he said, but the reward is seeing young patients come back for positive follow-ups, return to school, and resume healthy childhoods.

“You feel like your day has been excellent,” he said.

Check out this photo gallery to see more images from Butaro's pediatric cancer ward.

Mon, 18 Sep 2017 10:57:39 -0400
Staff Share Stories After Quake in Mexico One week after a monstrous 8.1-magnitude earthquake struck off the southwest coast of Mexico, Partners In Health staff said all 10 clinics they serve in rural Chiapas remained structurally sound, and that doctors, nurses, and community health workers escaped shaken, but unharmed.

Stories of individual challenges—including a woman who gave birth during the quake—poured in over the past week.

Clinicians continued providing services through the past week, while other staff assessed damage in the region of the Sierra Madre served by Compañeros En Salud, as PIH is known locally. Aftershocks rocked the region for days after the quake struck, just before midnight Sept. 7. The National Seismological Service in Mexico recorded more than 2,055 throughout the country, some registering as high as magnitude 6.1.

"The CES team and the communities where we work escaped the worst of the earthquake,” said Dr. Hugo Flores, executive director of PIH in Mexico. “And yet, while these emergencies serve as sharp reminders of the fragility of human life and that of marginalized communities, I could not emphasize enough how the impoverished people of this world live in a constant state of catastrophe.

“More than the occasional natural disaster, these communities are faced with adversity every day as they struggle to find the means to survive.”

This reality became all the more evident in recent days as PIH staff checked on colleagues, friends, and community members throughout Chiapas. Logistics coordinator Moíses Mazariegos discovered at least a dozen mudslides blocking the serpentine routes he travels regularly from Jaltenango to the various clinics. Local residents cleared most of the roads by hand, despite treacherous conditions caused by the rainy season.

Earthquake damage
Earthquake damage left a home inhabitable in Reforma. Photo by Dr. Assad Daniel Saad Manzanera / Partners In Health

In Reforma, 10 families evacuated their homes due to damage caused by the earthquake, according to Dr. Assad Daniel Saad Manzanera, a PIH doctor fulfilling his social service year there. It was unclear Friday morning how many families in other communities faced a similar situation.

Electricity is generally spotty in Laguna del Cofre, another community that PIH serves. Some residents reported that power cut off shortly before the earthquake and remained out until Wednesday. Crews have since knocked out power again to repair damage caused by the quake.

Power in Jaltenango, the base of PIH operations in Chiapas, also cut out during the quake, leaving the city’s hospital in the dark. A PIH patient from Salvador Urbina was in active labor when the lights went out in the delivery room, according to Dr. Mariana Montaño, the maternal health program coordinator. Working together, Ministry of Health clinicians and Miriam Torres, a PIH obstetrics nurse, remained by the woman’s side—risking their own safety as the building shook—and successfully delivered her baby.

“I want to congratulate our maternal clinic staff for continuing to deliver care in the middle of the crisis,” says Dr. Valeria Macías, director of secondary and tertiary care. “Without them, the life of the mother giving birth during the earthquake would have been at risk.”

Hundreds of miles away in the state capital of Tuxtla-Gutiérrez, the children’s hospital cancelled all of the week’s appointments as a cautionary measure as aftershocks continued. PIH visits this and other hospitals regularly to accompany young patients seeking specialized care. Staff scrambled in recent days to reschedule appointments for four such patients, all of whom are in stable condition.

As staff recounted the hurdles they overcame this past week, they knew the situation could have been much worse. In the neighboring state of Oaxaca, 76 people died and 11,000 homes were destroyed as a result of the powerful quake, according to The Washington Post.

The next big natural disaster in Chiapas might not be as forgiving. So PIH staff are reviewing contingency plans, evaluating ways to improve security across sites, establishing clear evacuation routes, and prepping emergency kits as precautionary measures. They don’t want to regret the disasters they could have prevented, especially when—for some of their poorest patients—every day is an unnatural disaster.

“No matter what they do, they know that something can come out of nowhere and change their present and planned future in a single instant,” said Dr. Rodrigo Bazúa, coordinator of community programs, referring to the poor communities PIH serves. “We need to acknowledge that this difference in perspectives is the product of persistent neglect throughout history. We have to start building resilient systems for everyone.”

Fri, 15 Sep 2017 10:20:00 -0400
Helping Teens in Peru Manage HIV: A Q&A with Dr. Molly Franke A Partners In Health collaborator in Peru is examining why many teenagers are struggling to consistently take their HIV medication, and working with team members to improve care and support for the vulnerable, often-overlooked patient group. 

Dr. Molly Franke, a Harvard Medical School epidemiologist and longtime collaborator with Socios En Salud—as Partners In Health is known in Peru—turned her attention to adolescents living with HIV at the request of a colleague at National Children’s Hospital in Lima. About 130 adolescents receive HIV care and treatment at the facility, but many of them struggle to routinely take their medication. In the most severe cases, adolescents stay in the hospital until they show steady improvement. Franke and the SES team set out to find out why these young adults were struggling and what she and her colleagues could do about it.

There’s great potential for very positive results: The development and increasing availability of antiretroviral therapy in recent decades means HIV is no longer a death sentence. But taking daily medication is crucial for enabling patients—of any age—to live full lives. 

The teen-focused project at National Children’s Hospital is still in its early stages, but Franke and PIH are making quick progress. They’ve piloted a support group for affected teens and have submitted a paper for publication in a medical journal. They’re also applying for grants to develop and study interventions to improve teens’ health. 

We spoke with Franke about her research, the obstacles that teens living with HIV face, and the steps PIH is taking to keep them connected to care.


We don’t hear much about adolescent HIV in Peru. Why not?

HIV isn't as prevalent in Peru as it is in other countries in the world. We often hear about HIV in Africa, where the prevalence and overall numbers are much higher. But really, everyone is very far behind in addressing the needs of adolescents with HIV. It’s only relatively recently that large numbers of children who were infected with HIV at birth have survived into adolescence. 

Whether we are talking about medication adherence, HIV diagnosis disclosure, HIV education, or sexual and reproductive health, there is a dire lack of interventions that have been designed specifically for adolescents and proven to be effective. It’s alarming because we’re seeing rates of death and non-adherence rise during adolescence, and this likely reflects the gap in health services for this group.

Adolescents living with HIV are not different from other adolescents in that they often begin to explore romantic and sexual relationships. Many health providers and caregivers feel unequipped to discuss sexual and reproductive health with this group, and health providers often have competing demands for their time. The consequence of this is that these conversations never happen and the adolescents don’t have the tools they need to make informed, confident decisions that will keep themselves and their partners healthy.


How do pre-teens fare?

Our own data, from a group of about 30 adolescents in Lima, suggests that most children were doing relatively well from 10 to 12 years of age. They reported taking their medications and generally did not report experimenting with sex, drugs, or alcohol. Beginning around age 13, adherence rates started to decline, and they began to report sexual activity and experimentation with drugs and alcohol. This, of course, is exactly what you would expect to see in adolescents, regardless of HIV status, in many places in the world. The take-home message is that interventions need to be in place to address these issues well before the age at which we begin to see these behaviors.


How did your research begin?

It was really at the request of a collaborator, an extremely committed pediatrician who provides HIV care to all of the children and adolescents living with HIV who receive their care at the National Children's Hospital in Peru. She approached the SES team for support in providing an adherence intervention for adolescents she treats. She was nearly at the end of her rope because the only recourse she has for kids that are not taking their meds is to hospitalize them, until they get back on track. Of course, this is not a long-term solution.


What obstacles do the teens face?

On top of the daily struggles that go along with the adolescent life phase and confronting an HIV diagnosis, many are living in poverty and don't have strong support at home. Among adolescents receiving care at the National Children’s Hospital in Lima, 25 percent are orphans of both parents and about 20 percent live in a group home environment.


What has the PIH team in Peru done so far to help these teens?

We are very much in the early stages of addressing this problem and so our initial approach has involved talking to HIV providers, guardians or caregivers, and adolescents, to understand their needs.

We piloted a peer-support intervention for adolescents living with HIV who, according to their physician, were struggling to maintain optimal adherence to their HIV meds. We work with a fantastic psychologist who trained women living with HIV to serve as facilitators of these groups. The goal was to give the adolescents a space to speak their minds and to take advantage of their peer group to help think through some of the challenges they were encountering. Overall, the adolescents really enjoyed the groups and we would love to find a way to keep them going. The groups also helped us understand what the adolescents were thinking about, what they are worried about, and what they would like to see in a future intervention.


What have you found so far?

Our first analyses have focused on factors that facilitate or interfere with good adherence to HIV medications, considering the perspectives of caregivers, health providers, and the adolescents. We started there because this information is, of course, critical to developing and tailoring interventions to this group. We found that barriers included a lack of caregiver support and supervision, pill fatigue, side effects from antiretroviral drugs, and a lack of information or misinformation about medications. Having strong support from a caregiver facilitated good adherence.


What interventions are being put in place to help these teens?

The two things we are aiming for right now include an accompaniment intervention to support adolescents with suboptimal adherence and an accompaniment intervention to help adolescents bridge the transition to adult care. For the adherence support intervention, we’d like to evaluate the traditional in-person accompaniment model as well as alternatives, such as accompaniment via mobile messaging, which might be more appealing to teens. For the transition intervention, the idea would be to provide accompaniment support through the precarious period during which they switch from the warm, nurturing environment of the pediatric clinic to adult health facilities and adult providers. The idea would be to match them to a peer-supporter who can accompany them to their initial clinic visits, help them enroll in health insurance, etc.


How did you start working in HIV?

In college, I began working at a summer camp in New York for children who were infected with or affected by HIV. This was 1998, so not long after the more potent and lifesaving combination antiretroviral regimens became standard in the United States.

I grew up in a small town that was not very diverse, and I had no idea of the extent to which HIV was disproportionately affecting the African-American community. It was a jolt to my admittedly naïve view of the world to find that nearly all the campers were either African-American or Latino. My first summer I worked with the oldest girls, who were 13, so not that far from my own age. After a week of spending 24 hours a day with the kids, the injustice felt personal, and I knew that I needed to find a way to contribute to fight against HIV and health inequality. For a while, I thought this would be through social work, but when I saw the ways in which researchers at Partners In Health were using data to move the needle on multidrug-resistant tuberculosis and access to antiretroviral treatment, I became convinced of epidemiology as my weapon of choice. 

The good news is that, 20 years later, most of my former campers are healthy and have families of their own. Many adolescents’ concerns in Peru mirror those of adolescents living with HIV in the U.S. They want answers to questions like, What does my future look like? Can I have a romantic partner? Can I have children? Is everything going to be OK? Many have a hard time envisioning their future. I would love for them to know that their future doesn't have to be any different than the future of their peers.

Wed, 13 Sep 2017 15:48:56 -0400
Massive Earthquake Spares PIH Sites in Mexico A magnitude 8.1 earthquake struck off the southern coast of Mexico late Thursday night, with tremors felt hundreds of miles away in the capital Mexico City and into neighboring Guatemala. The epicenter was closest to the state of Chiapas, where Partners In Health collaborates with the Mexican government to provide health care in 10 rural clinics throughout the Sierra Madre.

PIH leaders in Chiapas surveyed communities early Friday to check on clinicians and staff. Doctors at all 10 clinics had been contacted by Friday afternoon, and all responses were positive. Some clinicians heard reports of minor damage to residents’ homes or roofs, but no one had come to PIH clinics for emergency care as of late Friday.

One clinician in Soledad said the powerful quake created a crack along an interior wall in the clinic there. Another doctor, in the remote community of Monterrey, reported a mudslide on a nearby mountain, but hadn’t heard of any resulting injuries. Other staff based in Jaltenango saw piles of rubble dotting the streets.

Chiapas Earthquake 2017 Clinics

Aftershocks continue to rock the region, and PIH staff worried that the situation could take a turn for the worse.

“We are concerned for those living in very poor, inaccessible mountainous regions, where landslides have historically wiped out entire communities,” wrote staff with Compaňeros En Salud, as PIH is known in Mexico. “We are in the rainy season, and another strong earthquake may cause major disasters in the area. Because most people live more than two hours away from the nearest hospital and the unpaved roads often become impassable, a huge effort to open channels of transportation and communication would be required to provide adequate medical care.”

The PIH team continues to collaborate with the local government by providing medical supplies and helping prepare a contingency plan if evacuation is necessary from the hospital in Jaltenango or nearby clinics.

It was unclear late Friday how many people had been injured or killed in Chiapas or other states closest to the quake’s epicenter, nor how much damage it had caused to roads and buildings.

The New York Times reported Friday afternoon that dozens had been killed in what is being called Mexico’s biggest quake in decades.

Fri, 08 Sep 2017 15:57:52 -0400
PIH Preps for Worst as Irma Soaks Haiti As Hurricane Irma churns through the Caribbean north of Hispaniola, Partners In Health staff in Haiti watch the skies preparing for the worst, while hoping for the best.

Rain has been falling over the Central Plateau since the predawn hours, according to Dr. Paul Farmer, a Partners In Health co-founder and chief strategist, who’s weathering the storm there. Farmer spoke at noon today with PIH leadership in Haiti, whom he said sounded confident about staff preparations and optimistic that the country might escape a direct blow from the Category 5 storm.

Irma’s path through the Caribbean has been erratic so far, having leveled much of the island of St. Martin and largely spared Puerto Rico, for example.

Farmer said the biggest concern for Zanmi Lasante, as PIH is known locally, is how aging infrastructure will weather the potential 180 mile-per-hour winds and torrential rains. Clinics and hospitals in Hinche, Belladère, and St. Marc are at least 80 years old, he said, and not built to withstand such fierce tropical storms. St. Marc, which lies at sea level on the west coast, is expected to see storm surges over the course of the day.

PIH hospital staff are primarily concerned about a spike in cholera cases, trauma from road accidents, and tetanus caused by cuts from flying debris. University Hospital in Mirebalais will serve as a reference for all severe cases throughout the country and is currently staffed to handle mass casualties of up to 40 people at once.

Staff morale is good, Farmer said. For better or worse, they have gained valuable experience after enduring numerous hurricanes, earthquakes, and other disasters in Haiti over the past decade.

“I don’t think it’s an exaggeration to say that Zanmi Lasante is the strongest institution, medical or otherwise, in Central and Artibonite, Haiti,” Farmer said. “We have the biggest staff, the most resources, and the most allies in the United States and elsewhere.

The next 12 hours will test the team’s strength as it continues to prepare for Hurricane Irma’s worst.

Thu, 07 Sep 2017 16:00:08 -0400
PIH Braces for Hurricane Irma Nearly a year after Hurricane Matthew battered Haiti’s southern coast, the Caribbean nation is preparing for another blow, this time from Hurricane Irma. The Category 5 storm could make landfall across a northern swath of Hispaniola, hitting the Dominican Republic and Haiti as early as Thursday morning, according to the National Hurricane Center. Meteorologists predict winds of up to 180 miles per hour and torrential rains.

Several public hospitals and clinics supported by Zanmi Lasante, as Partners In Health is known in Haiti, lie in the storm’s predicted path. At sea level on the west coast, Hôpital St. Nicolas in St. Marc is expected to receive the worst blow from heavy rainfall and flooding.

Other facilities near the Artibonite River, such as those in Belladère, Cerca-La-Source, and Boucan Carré, could suffer from flashfloods and mudslides, said Sheila Davis, PIH’s chief clinical officer. University Hospital staff in Mirebalais spent most of Tuesday covering exposed walls with plastic, filling sandbags, fueling vehicles, and storing extra water in preparation.

“The team there is taking preparedness very seriously,” said Dr. Paul Farmer, a PIH co-founder and senior strategist, who spoke today from Haiti.

“City officials and the community of Mirebalais are looking toward that hospital as the primary site for not just a clinical response, but helping to organize a broader response.”

University Hospital is the largest physical structure in the region and could serve as a shelter during and after the storm. “The hospital itself is secure and built to withstand a major earthquake,” he added.

Irma follows less than two weeks after Category 4 Hurricane Harvey slammed into Houston, Texas, dropping a record 52 inches of rain, and less than a year after Category 4 Hurricane Matthew killed 1,000 people and left 1.4 million in need of urgent aid in Haiti.

Experts have labeled Irma a Category 5 hurricane, the most severe form, and expect it to be extremely violent and deadly. Most rural Haitians live in houses built from mud, stones, sticks, and corrugated metal. Many are subsistence farmers who rely on their crops, livestock, and fruit trees for food and extra income.

“A Category 5 storm, if close enough to Haiti, will take off roofs … and wash people away if they’re anywhere near someplace that might flood,” said Farmer, who has weathered numerous severe storms in Haiti and will again this week.

“People learned the hard way through previous storms to get on top of their buildings if they’re made of cement,” he said. “But that’s not possible if there’s heavy wind.”

Farmer added that despite the fears of a potentially devastating storm, the strong preparation he has seen in central Haiti reflects decades of work in the country to improve health systems and resources—and the resilience of people who have endured significant disasters in recent years.

“There’s not only the fact that there’s more national preparedness, and there are more places like University Hospital that are built for this…but there’s also the indomitable spirit of the Haitians, and I don’t think it’s corny to say it,” said Farmer. “We have motivated, well-trained, and decently supplied staff who reach from the Dominican border to the coast of St. Marc, and that just wasn’t here 30 years ago.”

Flooding outside of St. Marc following Hurricane Ike in 2008.
A flooded neighborhood in St. Marc following Hurricane Ike in 2008.
(Photo by Evan Lyon / Partners In Health)


Wed, 06 Sep 2017 12:50:07 -0400
From Earthquake to Epidemic: A Q&A with Dr. Patrick Ulysse After a decade of working for Partners In Health in Haiti, in early 2015 Dr. Patrick Ulysse moved to Maryland County, Liberia to help his colleagues and the national government fight the growing Ebola epidemic. The regional director then stayed on to strengthen the health care system in the remote southeastern region, where a ferry brings supplies roughly once a month and one university, PIH-supported Tubman University, trains nurses. “I remember when I first started in Haiti in 2006, I said, ‘I’ll go to PIH for one or two years, then I’ll go for my master’s in public health and continue on,’” he recalls. “But I just fell in love with the mission, the values, of PIH.”

Earlier this week, we chatted with him about his love for those values, the transition between continents, and his thoughts for the future of Maryland County.


Q: How would you describe Liberia, and Maryland County specifically?

You can look at Liberia two ways. On the one hand, it is still a poor country, still has a lot of challenges around its health indicators. To make it simple: About 1 in 28 women die of maternal causes.

At the same time, you have a generation of young people who want to learn, want to know. And when you work with them, you can see hope. They are open to learn, they are ready to make a change.

Maryland County is a beautiful place. When I say a beautiful place, I mean a beautiful place. The beach. The palm trees. The forest. I’m from the Caribbean, but I would pay for a vacation in Maryland County.

Dr. Regan Marsh and Dr. Patrick Ulysse (right) in Harper, Liberia
Dr. Ulysse (right) and Dr. Marsh (left) unwind on a beach in Harper, Liberia. (Photo by Rebecca E. Rollins / Partners In Health)


Q: How are the challenges in Haiti different from those in Liberia?  

One of the big difference is HR. In Haiti, we have a lot of human resources available—training, schools, all those things—which are not available in Liberia.

But I’ve been working for PIH for so long, being in Liberia is sort of like déjà vu. I see the challenges and know that if we do what we need to do, we’ll be where we need to be.


Q: What are the central challenges in Maryland County?

Supply chain at the county level is challenging (especially regarding road transportation and management), however, we are working together with the county health team to improve the situation. So is the lack of human resources available in the country and county. But maternal death is still on the top of the list. We still have a lot to do, but we are making progress. And even small improvements have a big impact.

For example, if I train all the midwives in Maryland County, if I give them all a refresher, this has a big impact on the quality of care they can provide for pregnant women (they call them “big belly” women). And how much does it cost to do a training? It’s small compared to the impact.


Q: What’s the team like?

The team is great. We have a lot of folks who worked for PIH before as part of the leadership, so it’s easy to make decisions and move forward with the same vision. We also have newer staff that have came on board in Liberia, so PIH's values are only proliferating. After that, the partnership we are building with the Ministry of Health—it’s great.

We have a director of policy and partnerships working inside the Ministry of Health and we share all our outcomes weekly. That’s why more than 20 percent of our funding is from partnerships established directly in Liberia.

We are accompanying the Ministry to run the new ward for patients with drug-resistant tuberculosis, which will open in Maryland County soon and will be the first such ward outside of the capital. And that was the decision of the Minister of Health, who said, given PIH’s years of experience working on MDR-TB, we were in the best position to partner with them. Since February, we've supported the county health team in opening a new HIV clinic in Pleebo Health Center, which has enrolled 65 newly diagnosed patients. (Approximately four patients test positive every week.) And after eight months of the community health program, the rate of tuberculosis patients who default has dropped from 77 percent to 12 percent.

Dr. Patrick Ulysse, Dr. Maxo Luma, and Nurse Viola Karanja.
From left to right: Dr. Ulysse, Nurse Viola Karanja, and Dr. Maxo Luma, who manage clinical programs with PIH Liberia, stand near the discharge gate of a decommissioned Ebola treatment unit in Sierra Leone. (Photo by Jon Lascher / Partners In Health)


Q: You’ve worked at, or in concert with, other development, emergency aid, and health organizations. What sets PIH apart?

PIH is different because we don’t accept ‘no.’ We always try to figure out a way to save a patient’s life. The drugs aren’t available? We try to get them. A service isn’t available? The patient is transferred.

PIH is also exceptional because, thinking of Haiti, we built a generation of physicians—physicians who, when they see a patient, they don’t just see a disease or pain, but the patient’s living situation, the patient’s social challenges, the patient’s emotional health. PIH trains you to see the patient in his entirety, and to value that entirety.

Wed, 30 Aug 2017 16:33:46 -0400
PIH Director: “Staggering” Losses in Sierra Leone Flooding Partners In Health’s top official in Sierra Leone described “staggering” losses Tuesday among PIH family and friends in Freetown, where rescue work was ongoing after devastating floods and mudslides killed hundreds a day earlier.

Just before dawn Monday, while most of the city slept or prepared for work, uncommonly heavy rainfall caused hillsides to give way in southern neighborhoods of Freetown, the nation’s capital. Mud roared down unstable slopes, killed at least 300 people, and left at least 1,000 homeless. Rescuers were continuing to search through debris into Tuesday evening.

Numerous family members of PIH staff are among the dead.

“There have been staggering losses among some of our staff members,” said Jon Lascher, executive director at PIH Sierra Leone.

One PIH employee lost eight members of his family, Lascher said. Another lost five. A third lost his sister.

“And the list goes on,” Lascher said in a Skype conversation Tuesday.

His comments reflect the massive tragedy in Freetown, where many residents lost entire families and homes. Reuters called the mudslides one of the deadliest natural disasters in Africa in recent years.

© Partners In Health

Sierra Leone’s Ministry of Health, army, and more were leading the response from a downtown command center, using logistics and communications systems originally set up for the Ebola epidemic. Lascher and Sierra Leone native Dr. Bailor Barrie, medical director at PIH’s Wellbody Clinic, were involved and assessing how PIH could help.

They said the response’s first priority was managing the overwhelming number of bodies arriving at morgues. Finding shelter for people who lost their homes also was a high priority. Lascher said many of the displaced were camped at National Stadium, a roofless soccer stadium.

PIH has also been focused on taking care of its staff.

“We spent much of yesterday trying to provide support to those we know who lost family members and homes,” Lascher said. “Early today, I went to visit one of our staff members whose house was destroyed and what I noticed in the mud were pots and pans and clothes and stuffed animals—everything that people owned, washed away.”

While the larger response takes shape, PIH also is helping arrange funerals and counselling.

“I think the next few days, as more people are recovered, is going to be a difficult time,” Lascher said. “You hear sirens from ambulances passing much more frequently than normal, and you know those ambulances are unlikely to be carrying the sick.”

© Partners In Health
Rescue and recovery workers, wearing coveralls reminiscent of those needed by Ebola burial teams as recently as last year, cross Freetown on Wilkinson Road near Congo Cross on Tuesday.


Wed, 16 Aug 2017 10:30:52 -0400
Fodei Daboh: A Sierra Leonean Healing His Town One Stone’s response wasn’t exactly a surprise. In up-country Sierra Leone, in the central chiefdoms of Kono District, the man with the rapper-inspired nickname was a known member of a young gang that tried, a bit too aggressively, to wash cars on the red-dirt avenues outside the gaping diamond mines. “He was a rude guy,” recalls Fodei Daboh.

Still, no one expected One Stone* to explode quite like he did. After being diagnosed with HIV, One Stone left the clinic, threw away the free anti-retroviral medicine, and gathered up his posse. They surrounded the house of a local health worker and shouted obscenities at her loud and long, as if she was somehow responsible for his illness.

Daboh, Partners In Health’s community health worker manager in Sierra Leone, took over. Since 2010, he has worked with PIH and its precursor in Kono, Wellbody Alliance. He currently manages a large staff, including 101 community health workers who support and advise patients during treatment and accompany them to the facility when they need care. One of those community health workers was the woman One Stone had yelled at.

“He’s just such a boss,” says Mara Kardas-Nelson, director of community based programs at PIH Sierra Leone. “You walk through the back streets of Koidu on a Saturday morning and everyone greets him. He stops to say ‘What’s up,’ ask how a person’s health is, ask about their goats, make little business deals. He knows everyone, is an integral part of the community.” And by all accounts, he goes the extra mile to make sure patients get what they need. He wasn’t a fan of One Stone’s bad behavior, but he also wasn’t about to let the man kill himself.

After asking around a bit, Daboh found the car washers and sat down with One Stone. “They were having beers, so I went to the bar and bought two bottles of beer and came back and gave him one,” Daboh recalls.

It seemed to ease tensions, and provided an entré into the clique. Every few days for more than a month, he hung out with One Stone, often buying him a beer but never bringing up his HIV diagnosis.

“Then, one day, I spent the whole day with him,” says Daboh. “And I realized, he has really, really accepted me.”

Daboh finally entreated One Stone to get help: “I said, ‘One Stone, you are my brother. Before you die young, before it’s too late, I want to take you to a hospital.’” It worked. The slow accumulation of trust allowed them to take the first steps toward treatment together. Today, a year later, One Stone is not only healthy, but a friend to PIH and Daboh.

© Partners In Health
PIH community health worker Mohamed Lamin Jarrah (center), one of over 100 staff members reporting to Daboh, walks with an HIV patient (left) in Koidu city, Sierra Leone, in September 2016. (Photo by Jon Lascher / Partners In Health)

Only some of the 800 HIV and tuberculosis patients that Daboh’s team of community health workers support are as demanding, but the anecdote is illustrative nonetheless. Every health worker strives to meet the unique needs of each patient. And Daboh—personally, expertly—has invested similar time, energy, and sympathy toward hundreds of patients, from a baby abandoned at the clinic to a grandmother who needs help going to the bathroom.

“Daboh understands how to communicate with his community,” says Storm Portner, who co-managed the program with Daboh and is now a medical student. “He understands what people are going through better than I ever could.”

That empathy wasn’t easily won. Daboh was born in Sierra Leone’s Bo District in 1972 and dreamed of being a lawyer. Beginning in 1990, he moved from school to school to stay ahead of the spreading civil war, ultimately fleeing Freetown when the violence finally caught up to him there. In neighboring Monrovia, Liberia, his sister, gainfully employed, paid his university tuition fees until that country’s civil war engulfed them, and he went from budding law student to homeless man in a bullet-riddled city. “It was not easy,” he says.

Allen Peal, the son of the Liberian ambassador to America, who had seen Daboh around and liked him, gave him a chance to manage a one-truck shipping enterprise. Daboh quickly proved his worth and was invited to work as a clerk on a rubber plantation, where he again excelled. Some four years later, he supervised 1,000 rubber harvesters.

© Partners In Health
A Liberian rubber estate not unlike the one where Daboh worked as a supervisor. (Photo by Rebecca E. Rollins / Partners In Health)

With an aging mother in need of care, he returned to Kono, Sierra Leone, in 2004, and used his savings to set up a small mining operation. It wasn’t a bad bet. Kono was then one of the most valuable and productive diamond mining regions in the world. Alas, his 10 employees found no diamonds, and he ran out of money. He looked for work for two years, without success.

“I became a street guy again,” says Daboh. “People started pointing fingers. ‘A rich man can become a painter,’ that is the saying.”

In 2007, things started to look up when a former headmaster offered him a job as a teacher, but the sunny forecast didn’t last. “I started getting sick—continuous, continuous, on and off, on and off,” he says. Weight loss. Fatigue. A chronic headache. He persisted as a teacher, but with hospitals and clinics in the area offering few, shoddy, or no advanced tests for illnesses like HIV or TB, Daboh treated himself with whatever medicine seemed right. He was 37 years old. He had been rich and homeless, safe and caught in crossfire, and healthy and perilously sick. And he had yet to give up. 

He also proved a natural leader. Convinced his symptoms spelled HIV, he joined a nationwide support group called NETHIPS, the Network of HIV Positives in Sierra Leone. He learned about the disease, became a district coordinator, and supported the organization’s expansion, helping them win a grant from a partnership with the World Health Organization.

When Wellbody Alliance, which is now a part of PIH, began the community health worker program in Kono in 2010, it immediately hired him as a community health worker. And that’s when he secured for himself yet another chance at a stable, long life. “On the day of the TB training,” recalls Daboh, “the guy knew how to teach so well, after he had explained the signs and symptoms, I stood up and said, 'I know my problem.'” With help, he managed to finally get a TB test, which confirmed that yes, he had had TB all along.

Daboh is cured now, and his community health worker program is seen as a model for the nation, with government officials, including the Minister of Health, visiting the district. The program supports patients across Kono, which has a population of just over half a million people, and sports impressive results: patients attached to a community health worker are 50 percent more likely to stay in care and demonstrate higher CD4 rates, a measure of immune response.

“At the beginning, maybe a person says things just to get the job of community health worker,” says Daboh. “But as time goes—one month, two month—you see that person’s attitude starts improving and every day you see their commitment increasing. Because the more a person comes across patients, the more they will get committed.”

Of course the increasing commitment might not have to do with patients. It could be that people become more and more committed to helping the sick and vulnerable the more time they spend with Daboh.

*Name has been changed.

Fri, 11 Aug 2017 12:35:21 -0400
CASITA Program Helps At-Risk Children Excel in Peru Life in a house with three children under 5 is, to say the least, chaotic. Analy Cipriano spends most days cooking, cleaning, doing laundry, and keeping a watchful eye on her babies in the cramped slums of Carabayllo, north of Lima, Peru. Money is tight, and spare time practically non-existent.

Yet when staff from Socios En Salud, as Partners In Health is known locally, came by with formula for her infant daughter, Ashley Minaya, and mentioned a free child development group, Cipriano was interested. Although nearly 6 months old, her baby still couldn’t sit up without support and seemed lethargic. The young mother decided to give it a try.

Every Wednesday for three months, Cipriano brought Ashley to the nearby health post in Punchauca, where PIH staff led early childhood education sessions for her and seven other mothers and their children. They sang songs, played games, read books, and practiced activities that encouraged age-appropriate language and motor skills. Each week, they were given tasks to practice at home and report on later in class.

Our children are able to learn more than we know.

Cipriano saw Ashley excel with the extra attention. Her baby learned to sit and started crawling. She was more animated and began saying little words here and there. She understood and followed instructions around the house. And she played by herself with toys they’d learn to make from recycled materials.

“I didn’t see my other kids do the same,” Cipriano said, crediting the PIH sessions for the difference. “Our children are able to learn more than we know.”

Cipriano’s experience wasn’t unique. Among the 180 families enrolled from 2013 to 2016 in PIH’s pilot program, called Proyecto CASITA, 85 percent of children at risk for developmental delays showed marked improvement, said Maribel Muňoz, leader of Proyecto CASITA. This was true regardless of whether families participated in individual, home-based interventions or group sessions like the one Cipriano and her daughter attended.

The results proved so strong, in fact, that PIH earned a grant from Grand Challenges Canada to vastly expand the program to reach 3,000 children between the ages of 6 months to 24 months in and around Carabayllo. The work will be accomplished over a three-year span, which started in May 2016, with the help of partners in the municipality of Carabayllo, the Ministry of Health, and the Korean International Cooperation Agency.

To meet the expansion’s ambitious goals for recruiting more families, PIH trained an additional 30 community health workers. The workers have diligently knocked on doors throughout the district to identify young children at risk of developmental delays.

CASITA participants, Miguelito and his mother, Mariela
Mariela holds her son, Miguelito, who has developmental delays related to microcephaly. The two participate weekly in Project CASITA sessions.
Photo by William Castro Rodríguez / Partners In Health

Sadly, they don’t have trouble finding candidates.

Carabayllo’s extreme poverty means families often face tough choices and live under constant stress. Malnutrition, domestic violence, teen pregnancy, and chronic illness are among their many daily challenges. PIH found, for example, that at least 70 percent of women enrolled in the CASITA pilot suffered some form of depression or stress, often related to spousal abuse. Such environments are toxic for children who, like sponges, soak up and internalize household tension.

Those families who qualify for CASITA are invited to attend three months of group sessions, hosted in community centers or any one of nine health posts or clinics throughout the district. Community health workers run the sessions and divvy up activities so that caregivers practice skills related to their children’s specific developmental delays.

Activities are both fun and focused. To hone fine motor skills, families make a game of picking up lentils from the floor. To strengthen tiny abs and backs, they sit supported while grabbing for toys just out of reach. And to practice speech, they read books and repeat words together.

Victoriano Meza and his son, Jake, play during a CASITA session.
Victoriano Meza and his son, Jake, practice fine motor skills during a CASITA session. Photo by Jorge Flores / Partners In Health

Beyond group sessions, PIH provides support to families through food baskets, mental health services, and assistance in applying for national identification cards, which give them access to a range of services—including subsidized health care—provided by the government.

Muňoz is encouraged by the progress these select Carabayllo children have made over a short span of time. “They are breaking down paradigms in our country,” she said, by growing up well-fed, well-educated, and in healthy home environments. “These children can be reference points for future kids. We are betting that what we do today isn’t for today. You have to see it as an investment in the future.”

Mothers and their children celebrate graduation from the CASITA program.
Mothers and their children celebrate graduation from the CASITA program outside PIH's offices in Lima. Photo by Jorge Flores / Partners In Health


Fri, 28 Jul 2017 09:44:28 -0400
Iconic Hospital in Malawi to Expand One of the first patients Dr. Emily Wroe met in Malawi, the slender nation bordered by Tanzania to the north and Mozambique to the south, was a pregnant mother with severe rheumatic heart disease. “Normally a patient in her condition can’t climb a flight of stairs,” says the Partners In Health clinical director for the country. “This woman, Nimiya, she walked seven hours to the clinic.”

Soon Wroe and fellow PIH staff will be able to help more women fiercely determined to get better. With donors’ support, PIH and the Ministry of Health will break ground on an outpatient clinic at Neno District Hospital this fall. The new single-story building will sit next to the main facility and will include smartly designed check-in areas, consultation spaces, and exam and treatment rooms. Thousands of sick people, who now sometimes face long queues, will be diagnosed and started on treatment for a variety of illnesses—in a single visit. “It’s so exciting to be able to match health service and infrastructure design, and meet such a tremendous community need,” says Wroe. “It makes care much more accessible.”

The new clinic adds to services that Ministry of Health clinician Grant Gonani already calls “awesome.” In 2007, the government of Malawi invited Partners In Health to work in Neno, a rugged district of hills, maize and potato fields, and weak health care. Most pressingly, local farmers, earning less than $1 per day, were suffering some of the worst rates of HIV on the continent. Roughly 1 in 7 adults in the district were infected.

PIH dove in head-first. Staff constructed health centers; hired and trained hundreds of people in the community as health workers; and built Neno District Hospital as the centerpiece of a revitalized health system. HIV survival rates in the district skyrocketed, becoming the highest in the country, with 90 percent of patients alive one year after starting treatment. The hospital grew busy, despite the fact that for many, the easiest route to it still involves a long walk and fording a river.

The outpatient clinic is a logical next step. People with more routine health needs, and those needing emergency care, will be treated at the facility. They will check in, have their medical records pulled, get tested for common conditions such as HIV and hypertension, be offered family planning, and be treated for everything that’s troubling them—be it HIV or epilepsy, hypertension or diabetes—as they would in the United States, for example.

Astoundingly, the clinic will also be seen as pioneering. Research suggests that Neno District is one of those rare places where patients can have most of their chronic health conditions taken care of in a single visit. In most health care facilities in sub-Saharan Africa, if you come for HIV treatment, for example, you must return later for a diabetes exam.

To doctors who treat women who’ve walked for hours to make an appointment, that, of course, doesn’t sit well. “We’re doing ‘innovative’ stuff,” says Wroe, of the new outpatient clinic, “but actually, most of it is bloody obvious.”

Tue, 25 Jul 2017 10:57:59 -0400
PIH Hosts First Cross-Site Lab Training It was a logistical and technical feat that had never been pulled off in Partners In Health’s 30-year history. Eleven staff members from eight PIH sites around the world arrived in Toulouse, France, for a week’s worth of training on everything from standard operating procedures to complex diagnostic exams for tuberculosis, HIV, and chronic myeloid leukemia.

PIH Director of Labs Daniel Orozco saw the week’s sessions as an opportunity for technicians to meet face-to-face, share their expertise and strengthen lab skills, and create a network of support they can use in the future to troubleshoot particularly tough cases.

The training, which was co-funded by the TB Care II project and made possible through the United States Agency for International Development, was split into two focus areas: basic laboratory procedures and an intensive course on GeneXpert—a rapid molecular test created by Cepheid Inc., headquartered in Toulouse, that is used to diagnose and monitor the treatment of a range of diseases.

PIH supports more than 20 laboratories across eight sites. Some are home to more basic diagnostic capacity; others are designed to specifically focus on a single disease, such as TB. While a handful of laboratories, such as those in Sierra Leone, opened in 2015, others have been around for decades, such as those in Haiti. Laboratory expertise and technology equally vary across sites, depending on whether staff are catering to a small clinic or a large referral hospital.

Orozco, a microbiologist by training, and his team designed the March training so that the first two days focused on lab practices and strategies. They discussed the importance of standardizing procedures across sites, the logistics behind purchasing and distributing supplies, and which tests should be available at each level of the health care system—from local clinics on up to specialty hospitals.


Claudine Nolte (clockwise, from left), quality management officer at University Hospital in Haiti, Moise Michel, a biomedical engineer at University Hospital, Roger Calderon, lab manager in Peru, and Zhanel Zhantuarova, a lab quality officer in Kazakhstan, practice basic maintenance on the GeneXpert, an instrument used to diagnose and monitor a variety of diseases at PIH laboratories.

The following three days were a deep dive on GeneXpert, at least one of which is available at each attendee’s sites. Staff practiced pipetting samples and running tests through the instrument for diseases such as TB, HIV, and chronic myeloid leukemia. They learned how to interpret results and error messages. And they worked on troubleshooting problems and general instrument maintenance.

“The information that I got here is of high value, because I’ll be able to use it when I get home,” said Mokenyakenya Matoko, laboratory head at PIH Lesotho, where TB infection rates are among the highest in the world. “Understanding how to best use this instrument is really going to benefit our patients.”

GeneXpert, a cube-shaped instrument the size of a home office printer, has revolutionized the whole diagnostic experience for patients living in poor countries, like the ones where PIH works. Patients wait hours, not weeks, to discover whether they have TB. If they do, they also learn whether their strain is multidrug-resistant—and particularly difficult to treat. Such rapid, accurate information allows clinicians to get patients on the correct medications and avoid further transmission.

With a week’s work behind them, lab staff were energized to share what they’d learned. “I will train my colleagues, and I will share everything that we have seen with them,” said Robert Gakumba, who heads the lab at Rwinkwavu Hospital in Rwanda.

Several people said their perspective had shifted after hearing the challenges faced by other PIH colleagues. Yearning for the latest diagnostic equipment was not the same thing as struggling to maintain a reliable source of electricity. They appreciated the opportunity to swap stories and advice, and vowed to stay in touch. Since the training, Orozco and his team built a database to track GeneXpert operations to ensure trainees continue to communicate.

“I’m really happy to have had the opportunity to share our experiences,” said Roger Calderon, lab director at PIH in Peru.

Matoko agreed. “We need each other in terms of sharing documents, experiences, and technologies,” he said. “This was really helpful; I’m looking forward to the next one.”

And so is the Boston-based lab team, which continues to ramp up the program by adding more GeneXpert machines to sites, providing software updates, and finding funds to expand the menu of tests available.  

Mon, 10 Jul 2017 14:09:37 -0400
Harvard Study: Vitamin A Helps Protect Against TB Tuberculosis is the most deadly infectious disease in the world, killing 1.8 million people in 2015 alone, yet little is known about why exposure to the airborne disease sickens some people and not others.

Harvard researchers think diet may be key to TB transmission. According to an article published in Clinical Infectious Diseases in May, people with low levels of vitamin A were at least 10 times more likely to develop TB after exposure to the disease than those with higher levels. Increasing consumption of vitamin A—found in carrots, sweet potatoes, dairy, meat, and supplements—could be a powerful tool in disease prevention.

Dr. Megan Murray, the Ronda Stryker and William Johnston Professor of Global Health at Harvard Medical School, and her team of investigators discovered this link as part of an epidemiological study of TB among people living in Carabayllo and surrounding districts north of Lima, Peru. Staff from Socios En Salud, as Partners In Health is known locally, were essential for recruitment, patient follow-through, and blood sample collection and analysis of the 12,000 participants over five years.

We spoke with Murray, PIH’s director of research, about the surprise findings, why adolescents with low vitamin A levels are particularly at risk, and what the vitamin A link means for TB prevention.

How did your team arrive at this discovery?*

Households in Carabayllo were recruited when somebody developed TB, so we knew that we were looking at a population that was relatively high risk. Among the 12,000 household contacts, about half had given a blood sample. We checked to see if people had undiagnosed TB at the time that we drew their blood. Then we followed people for infection, and then for disease. With TB, those are different. Lots of people were already infected. About half of the people who weren’t, became infected within the next 12 months—probably because of exposure. About 2 percent of the people developed active TB. We took those cases and matched them to people who were just like them in terms of age, gender, and other factors, but who hadn’t developed TB. Then we compared their vitamin A levels, and they were really different.

Were you surprised by that difference?

We were just stunned. We were actually interested in vitamin D. People had been speculating for many years that low vitamin D is associated with TB risk, based on a seasonal pattern. The argument is that the disease starts to progress in the summer and takes five or six months to manifest. We were following that up, but then we had some data from a previous study that Dr. Molly Franke, an assistant professor at Harvard Medical School, had done in kids that showed that fruits and vegetables, in a case-controlled study, were protective against TB. We thought, ‘Well, let’s throw in some fruits and vegetables that seem to be associated with various vitamins.’

We were just stunned.

It turns out that vitamin A is only minimally associated with fruits and vegetables; it’s actually more in dairy and meat. When we got this result—that contacts with low levels of vitamin A were at greater risk for developing active TB, we were like, “Whoa, that can’t be right.” We looked for every possible reason why it might not be right, but we do think it is right.

The 10-fold factor is striking. Can you put that in context?

It’s huge. The strongest risk factor that we know is between smoking and lung cancer. That’s a 20-fold risk. It’s not a great example, because it’s so extreme that it’s way out of the normal ballpark. When you think about something like smoking and heart disease, you know it’s a very strong link. A ton of the heart disease in the world is caused by smoking. But it only doubles the risk. As epidemiologists and public health people, we’re interested in odds that are as low as 1.1, which is a 10 percent increased risk. We’re talking here about 10 times or 20 times the risk.

Vitamin A-deficient adolescents had up to 20 times the risk of developing TB. Any idea why?

We know that TB rates are higher in that age group than in any other age group. As kids move into puberty, from 10 to 20 years old, they’re at enormously high risk. We don’t really know why that is.

Adolescent health is not something that is well studied, especially around immunity. We do know that there’s some infectious diseases that are much worse in adolescence. Because of the growth spurt, they have very different metabolic demands and processes.

Vitamin A deficiency is prevalent among 30 percent of the population in low- to middle-income countries. Why is this?

I’m assuming it’s because of diet. If you think about it, it’s in dairy, meat, and fish. These aren’t very common in our diet. And the poorer the country, the less vitamin A you’re going to get.

To support these recent findings, your team is now helping design a study to test vitamin A supplementation among guinea pigs exposed to TB. How far along are you, and do you see anything promising?

Our collaborators at the University of Colorado—Fort Collins set up a nice guinea pig model in diabetes. They can make guinea pigs diabetic and then see what happens with TB. One of the questions we’ve been asking is, ‘What effect do drugs routinely used for diabetes have on TB?’ They’re on to some very interesting stuff suggesting that some of the anti-diabetes drugs could be useful in controlling TB, regardless of whether you’re diabetic or not.

When we learned this about vitamin A, I asked them if they could set up a similar project. They designed it, and we are waiting minute-by-minute for NIH funding. We’ll be ready the minute they say, “Go!”

So how long will it be before we test a vitamin A intervention in humans?

We can try it today, because this is something we know is good for people. We don’t need animal results to proceed with a trial here. We know that people who are vitamin A deficient should be given vitamin A, regardless of their TB risk. The trial that we’re envisioning is really about whether people at risk for TB should be screened for vitamin A. If they were low, we would treat it.

What do you hope will come about as a result of this publication?

I’ve had people say, ‘Why bother with a clinical trial? Let’s just give everyone vitamin A.’ I agree with that to some degree. In the U.S., we don’t recommend people who are not vitamin A deficient to take it. People take enormous doses of vitamins, and they can actually take too much vitamin A. To get people on board and to have TB programs start thinking this is a good approach, having some evidence that it’s useful is going to be good.

The poorer the country, the less vitamin A you’re going to get.

If you live in the U.S. and somebody in the household has TB, you get screened by the public health department. They come and do a skin test for TB and, if you have it, you get six to nine months of a preventive drug. We’d like to do that in lower resource settings. But some countries say, ‘Our TB burden is just too high. We can’t give half our population these drugs.’

The nice thing about vitamin A is that it’s good for other things besides TB. There’s a lot of interesting research going on right now on the relationship of vitamin A and general immunity.

*This interview has been edited and condensed.

Tue, 27 Jun 2017 15:34:28 -0400
Mortarboards Away! Liberia Graduates Next-Level Nurses In far southeast Liberia on May 31, families packed into grand, high-ceilinged St. Theresa Cathedral. “No matter what comes my way, no matter how I cry,” a gospel choir led the crowd in singing, “one thing I know that is definitely in my heart, my tomorrow must be greater than today.” A speech from the dais echoed the themes of persistence and optimism, urging the guests of honor to continue to “go to bed smarter than you woke up.” Soon after, Tubman University, a Partners In Health-supported public university, graduated the first class in a groundbreaking nursing program.

When the 15 students enrolled two years earlier, they had already earned Associate Degrees in Nursing and passed the national board exams. Some had been caring for patients in hospitals, health centers, or clinics for a decade. With the launch of the Tubman University program, they had returned to learn even more skills, participating in the first RN-to-BSN program anywhere in the country outside of the capital Monrovia. They attended classes every weekday, studying subjects such as nursing theory, and conducted research on effective nurse-patient communication, for example. Now they’re ready to become nurse leaders, managers, and teachers, or pursue master’s degrees in rare-but-essential specialties like pediatrics.

Minnie Horace, a PIH nurse clinical lead and one of the program instructors, points to a tangible feeling of momentum. In 2015, PIH helped Tubman’s first class pass its RN exams. Since then, PIH has helped modernize nearby J.J. Dossen Hospital and expand Pleebo Health Center. The RN-to-BSN program is just the latest to stoke enthusiasm about the future of health care in Maryland County.

Of course even the graduates who have pledged to serve the county will be tempted to leave, travel 18 hours north, and find work in Monrovia, where pay can be better. Sixty percent of all trained health staff in Maryland County are paid by donor organizations or, astonishingly, volunteer in hopes of one day earning a salary. So the graduation is both cause for huge celebration, and a reminder that much work remains for any organization hoping to keep up with the dogged, unrelenting progress of local nurses and students.

Mon, 26 Jun 2017 16:18:34 -0400
Urgent: Contact U.S. Senators About Health Care Bill The Better Care Reconciliation Act violates our right to health, and with the secret way it was crafted, it also violates our right to a fair deliberative process. As the Senate takes up debate, we remain committed to fighting for the right to health care for all.

There are so many ways that this bill violates PIH's core principles of making a preferential option for the poor. The bill threatens to:

1. Gut Medicare
2. Give tax cuts for the wealthy
3. Eliminate government subsidies for insurance
4. Remove protections for those with a pre-existing conditions
5. Defund Planned Parenthood

We must defeat this bill.  Use the suggested script below and call the senators listed at the bottom of this page. Thank you!

First, speak with the front desk person, “Hello, my name is ____________________ I am an American citizen (or a citizen of the state of the senator you are calling)."

If you are asked where you are from you can say either “I am not comfortable giving my address” or “I am an American citizen and this bill affects all of us.”

"I vote, I am involved in organizing. I am calling to register that I am AGAINST both the AHCA and the Senate’s bill to repeal and replace ACA.  I (or a loved one) have _____________a medical condition that requires on going care and medications. What I (or a loved one) need to stay healthy is UNDER THREAT because the  proposed senate bill (Better Care Reconciliation Act- BCRA) will cut subsidies for insurance, will result in far higher premiums for insurance, and will not protect me (or my loved one) because of this “pre-existing condition.” I believe that all of these cuts and restrictions are  being put in place to provide tax cuts for extremely wealthy people. This is unjust and violates the social contract of our society.  Also, I am enraged by the fact that this bill was crafted without any public hearings and done in secret. This violates our rights to a free and open process."

"I would like to speak to the health aid of Senator ___________________ to register my opinion on this terribly dangerous and deeply unfair bill."

IF THE HEALTH AID ANSWERS, repeat the personal story above.

"Thank you for your time, I appreciate the ability to register my strong opposition to this Senate’s bill to repeal the ACA and replace it with something that will result in tens of thousands of deaths and loss of health insurance coverage for more than 23 million people."


ARIZONA: Sen. Jeff Flake (R)
Legislative Assistant Helen Heiden • • 202 224 4521

ARKANSAS: Sen. Thomas Cotton (R)
Abigail Welborn, Legislative Assistant • • 202-224-2353

ALASKA: Sen. Murkowski, (R)
HELP Cmte Legislative Aide • 202 224 6665
Legislative Director • 202 224 6665

COLORADO: Sen. Cory Gardner (R)
Legislative Director Curtis Swager • • 202-224-5941
Ali Toal, Legislative Assistant • • 202-224-5941

LOUISIANA: Sen. Bill Cassidy (R)
Senior Health Policy Adviser Matt Gallivan * • 202-224-5824
Research Analyst Davis Mills • • 202-224-5824

MAINE: Sen. Susan Collins (R)
Legislative Assistant Elizabeth Allen • • 202 224 2523

OHIO: Sen. Rob Portman (R)
Legislative Assistant Sarah Schmidt • • 202-224-3353

NEVADA: Sen Dean Heller (R)
Legislative Assistant Rachel Green • • 202 224 6244

WEST VIRGINIA: Sen. Shelley Moore Capito (R)
Legislative Assistant Dana Richter • • 202-224-6472
Legislative Correspondent Mike Fischer • • (202) 228-1395



ARIZONA: Sen. John McCain (R)
Legislative Assistant David Benne • • 202-224-2235

ALABAMA: Sen. Luther Strange (R)
Legislative Correspondent Maria Olson • • 202-224-4124

ALABAMA: Sen. Richard Shelby (R)
Legislative Assistant Clay Armentrout • • 202-224-4124

FLORIDA: Sen. Marco Rubio (R)
Legislative Assistant Ansley Rhyne • • 202-224-3041

NORTH CAROLINA: Sen. Richard Burr (R)
Health Policy Director Angela Wiles • • 202-224-3154

PENNSYLVANIA: Sen. Patrick Toomey (R)
Legislative Assistant Theo Merkel • • 202-224-4254

WISCONSIN: Sen. Ronald Johnson (R)
Legislative Director Sean Riley • • 202-224-5323

TEXAS: Sen. Ted Cruz (R)
Legislative Counsel Joel Heimbach • • 202-224-5922

UTAH: Sen. Michael Lee (R)
Legislative Director Christy Woodruff • • 202-224-5444
Legislative Assistant Andy Reuss & Leslie Ford • •  202-224-5444

NEBRASKA: Sen. Ben Sasse (R)
Legislative Assistant Jessica Smith • • 202-224-4224

SOUTH CAROLINA: Sen. Lindsey Graham (R)
Legislative Aide Nick Myers • • 202-224-5972

IOWA: Sen. Chuck Grassley (R)
Director of Health Policy Karen Summar • • 202-224-3744

IOWA: Sen. Joni Ernst (R)
Legislative Assistant Andrea Hechavarria • • 202-224-3254

ARKANSAS: Sen. John Boozman (R)
Legislative Assistant Jennifer Humphrey • • 202-224-4843

TENNESSEE: Sen. Robert Corker (R)
Health Care Policy Adviser Arne Owens • • 202-224-3344

TENNESSEE: Sen. Lamar Alexander (R)
Chief of Staff David Cleary • • 202-224-4944
Director of Operations Misty Marshall • •  202-224-4944




Mon, 26 Jun 2017 11:12:57 -0400
Community Health Worker Program Expands in Chiapas Dr. Rodrigo Bazúa didn’t have to think long to come up with examples of how new community health workers were making a difference throughout rural Chiapas, Mexico. There was Aracely in Letrero who, he believes, prevented a maternal death by convincing her neighbor to give birth at the hospital in Jaltenango. Then there’s Maribel in Plan de la Libertad, who helped get a patient’s diabetes and hypertension under control. And the list went on.

The women are among 33 new community health workers, or acompaňantes, recruited and trained over the past year to work in Letrero, Monterrey, Salvador Urbina, and Capitán. The expansion means that all 10 communities supported by Compaňeros En Salud, as Partners In Health is known locally, now have workers to support patients suffering from chronic illnesses, such as diabetes, hypertension, and depression. A select few focus on improving nutrition and maternal health.

“The relationships patients have with their doctor is short,” says Bazúa, a community programs coordinator for PIH in Mexico. “Control of chronic diseases is for the long term. It really depends on a strong relationship with the community health worker.”

PIH’s acompaňantes serve as bridges between the local clinic and the surrounding community. They are trusted neighbors who have been carefully recruited, trained, and supported by supervisors and local clinicians. They visit patients in their homes, interact with their families, and come to understand patients’ physical, emotional, and social situations—all of which come into play in maintaining good health. They become their patients’ strongest advocates and, quite often, their good friends.

“The tasks that community health workers contribute are tasks that doctors simply cannot do,” says Daniel Palazuelos, chief strategist for PIH in Mexico. “It’s not that these tasks are too complex or un-learnable, but community health workers have something doctors do not have: time, and a position in the community that can build a fundamentally different therapeutic relationship.”

Bazúa and Dr. Mariana Montaño, who shared the position of community programs coordinator up until March 2017, led the most recent expansion. After carefully examining the acompaňante program, they focused on elements that weren’t working perfectly, and coupled their analysis with a community health worker survey. The overarching lessons were that, before PIH recruited more workers, it needed to give supervisors fewer patients and provide them with better training and support.  

The tasks that community health workers contribute are tasks that doctors simply cannot do.

The doctors designed a supervisor curriculum that focused on leadership, professionalism, and conflict resolution. The idea wasn’t to shame supervisors, but to understand what difficulties they faced and discuss how to overcome those obstacles.

Last spring, they began testing their new approach. Monterrey, one of the most remote villages from PIH’s base in Jaltenango, began recruiting and training new community health workers in April. Three months later, it was Salvador Urbina, then Letrero in September, and finally Capitán in January.

Staff spoke with pasantes, or first-year doctors supported by PIH, in each community to assess how many patients could use a community health worker. Typically, these patients suffer from diabetes, hypertension, alcohol abuse, depression, epilepsy, or schizophrenia. Nearly all need social support. But PIH also included on the list malnourished children and pregnant women, especially those considered at risk—such as teenagers or women with histories of complicated pregnancies.

Once they knew how many community health workers they had to recruit, the pasante and PIH staff hosted meetings in each village to explain the program. Attendees, mostly women, asked questions and decided whether it was a good idea for their community. Staff then interviewed volunteer candidates and made their final selections.

The recruits completed a four-week training, half of which focused on chronic disease and the other half on mental health. Veteran community health workers helped conduct these trainings, another PIH first, and were on hand to answer questions. “This has been an enriching experience for both sides,” says Montaño. “It represents a unique opportunity for social connection.”

Dr. Fátima Rodríguez (center), coordinator of PIH’s mental health program in Mexico, leads a training for new community health workers Vilga Vázquez (seated, from left), Celmira López, and Ernestina López in Capitán, Mexico. Photo by Mary Schaad / Partners In Health

Once training was complete, pasantes paired workers with patients. The relationships are far from obligatory; patients have the final say about whether they need, and want, such assistance. Usually, they do. Still, PIH staff say, it can be awkward convincing an octogenarian, who may have known a community health worker from the time she was in diapers, to entrust her health and well-being to someone without a medical degree. Over time and repeated visits, trust builds between the two.

Workers visit new patients once a week for six months to ensure they are taking their medication and have their sugar levels or blood pressure under control. That frequency changes over time, depending on the patient’s health. Meanwhile, PIH staff closely supervise the recruits, dropping by the community for several days each month to provide guidance and “follow them like a shadow,” Bazúa says. Program staff also conduct monthly trainings to continue the workers’ education and provide a forum to troubleshoot difficult cases.

Bazúa and Montaño say it has been difficult to determine whether workers provide “successful” home visits. They are now developing ways to measure that qualitatively and collect data on basic services provided with each visit. Whatever they discover will help inform how PIH can further improve and expand the program.


Wed, 14 Jun 2017 13:38:41 -0400
This Week: CNN's Dr. Sanjay Gupta Interviews Dr. Paul Farmer We’re pleased to announce that Partners In Health will be featured this week in a special CNN multimedia series called “Champions for Change.”

CNN Chief Medical Correspondent Dr. Sanjay Gupta visited Haiti last month to interview Dr. Paul Farmer and profile the work of our staff at University Hospital in Mirebalais. The CNN team spent three days in Haiti, documenting the impact of our efforts in the country’s central region.

In an online essay about the man who inspired him, Gupta writes, “My personal attitudes toward charity and altruism, in part, have been shaped by wanting to live up to the ideals Farmer has shown me, because if pure altruism really does exist in humans, it probably looks a lot like him.”

"Champions for Change” will feature other individuals and organizations, but the segments featuring Dr. Farmer and PIH will air on CNN and CNNgo at these dates and times:

• Wednesday, June 14: 8 a.m. EST
• Thursday, June 15: 9 p.m. EST
• Saturday, June 17: 3 p.m. EST
• Saturday, June 17: 9 p.m. EST (a one-hour show featuring highlights from the series)

Watch the full segment from CNN below: 


Wed, 14 Jun 2017 12:05:45 -0400
Three Clinicians Bring Pioneering Mental Health Services to Liberia A village healer warned that if she crossed the river, then bad things would happen, but in Regina’s* youth there was no need to worry. She grew up, helped around the house, and married. She visited her husband’s parents on the far bank, but Regina’s family performed the right rituals and no misfortune befell her. Then, one day, Regina again climbed into a canoe and floated across the turgid brown water of the Cavalla. This time the rituals didn’t help.

When nurse and Partners In Health Mental Health Coordinator Garmai Cyrus visited the Buah District of southeast Liberia last year, Regina had been hallucinating for two decades, picking through trash and sleeping in the streets. Her family blamed the river.

Cyrus patiently earned their and Regina’s trust and, months after she first arrived, was able to diagnose Regina with schizophrenia. Much to the relief of all, an anti-psychotic medication proved effective. Regina now lives at home with her family. She’s clean, well-dressed, and easy to chat with. “You wouldn’t believe her transformation,” says Cyrus.

Such are the small miracles that PIH’s three-person mental health team helps perform in Liberia. Across 5,000 sparsely populated square miles of the southeast, Program Manager Bethuel Nyachieng’a, Coordinator Willis “Archie” Yansine, and Cyrus meet mentally ill people where they are, both geographically and spiritually, and do their best to help.

It’s a big job. The three have mentored and offered refresher courses for government mental health clinicians, the majority of whom received a few weeks of training years ago. They have publicized mental health issues, including via radio programs, and established ways to refer patients to specialists. And with their government colleagues, they have treated and followed-up with roughly 1,000 people suffering conditions including epilepsy, psychosis, and depression. “Building mental health in the southeast is very hard,” says Yansine. “It’s just now that people are getting to know about mental health.”

But with each accurate diagnosis, the PIHers are changing that. In one region last year, 166 patients had been diagnosed with epilepsy—ten times as many cases as substance abuse, which is typically far more common. “Everyone was ‘epilepsy, epilepsy, epilepsy,’” recalls Cyrus.

Partly from his previous work in Somalia and Kenya, Nyachieng’a knew that epilepsy’s seizures, tremors, and other symptoms can easily be confused with other conditions. So before changing any treatments, he and local clinicians took another, more thorough pass at diagnosis. The correct number suffering epilepsy proved to be 46, while the others suffered from depression, psychosis, and other ailments. Once accurately diagnosed, patients were placed on more effective treatments.

The team also makes uncommon improvements by venturing beyond hospital grounds. In Harper, one of the major cities in the southeast, Nyachieng’a performed a survey of homeless people, including two former child soldiers who lived on the streets and carried toy guns. All in all, some 43 faced mental health challenges. Nyachieng’a helped stabilize their lives by bringing them rice, reuniting them with their families, or putting them in the care of a nearby Catholic church. Then he treated or followed-up on virtually all of them.

“In the areas you need to reach by canoe, the big challenge is that patients are not seen as patients; they’re seen as possessed by demons,” says Nyachieng’a. But here, too, the team has turned challenges into opportunities. Yansine, for example, joined forces with herbalists and traditional healers. He met them, shared some basic information, and offered to provide the healers with the medical expertise and medication needed for them to expel the demons. “We developed a rapport,” he says. “Now they will call me about the aggressive patients and I will do an assessment and give them the treatment.”

All of this and more have made a big difference in whole communities, but it’s only from faraway that you’d call the changes something as impersonal as “progress.”

Cyrus, for example, grew close with Regina, and found herself learning some very real, very non-allegorical details about Regina’s life before she “ran crazy,” as her family said. Regina lost two children during birth. Her husband abandoned her. And when she crossed the river that portentous day in the 1990s, it wasn’t to taunt fate or the village healer. Regina was fleeing civil war for a refugee camp in Ivory Coast. Mid-stream, a nearby boat capsized, killing friends and relatives. Whatever mythic powers might or might not have been at play, Regina experienced a lot of psychological trauma and had no experts to turn to.

“It’s hard for me to express the feelings,” says Cyrus, “but I am so grateful to be able to work with Regina and other patients.”

*Name has been changed.

Tue, 30 May 2017 15:24:39 -0400
After Hurricane Matthew: PIH's Impact in the South Six months ago, Hurricane Matthew plowed across the southern tip of Haiti, leveling houses, sweeping away crops and livestock, and killing approximately 100 people in early October last year.

Many residents have since rebuilt homes from scattered debris and replanted fields in the wake of the powerful Category 4 storm. Yet 175,000 people remain without reliable housing and at least 1.5 million—or nearly 40 percent of the population living in the southwest peninsula—lack regular access to food, according to the United Nations Office for the Coordination of Humanitarian Affairs.

It has been a trying time, and Zanmi Lasante, as Partners In Health is known locally, has been in the hardest-hit southern states since the beginning. At the Ministry of Health’s request, PIH collaborated with officials in Sud and Grand d’Anse departments to support Immaculate Conception Hospital in Les Cayes, the sole public referral hospital for 1.5 million people. Staff also shored up cholera treatment centers and supported the government’s cholera vaccination campaign, which reached nearly 800,000 people.

Immaculate Conception Hospital was pummeled by the hurricane’s torrential rains and 145 mph winds. PIH hired contractors to repair damaged roofs across much of the hospital, including the maternity and pediatric wards. Plumbing and electrical structures were repaired. A new generator was installed to ensure near round-the-clock power, and a chlorine machine is now in place to help decontaminate the wards and maintain sanitation. The internal medicine ward, emergency room, and post-op area are now being renovated and may be ready by July.

Before the hurricane, the hospital contained only a quarter of the supplies it needed. PIH stocked the facility with essential medicines and helped develop a three-month reserve of supplies to meet future demand. Staff also ensured a nearby warehouse received the medical supplies necessary to back up other public clinics in the region.

In February, medical residents from University Hospital in Mirebalais provided emergency preparedness training to clinicians at the Les Cayes hospital, paying particular attention to how to triage patients and deliver urgent care.

These basic steps had a major impact. Immaculate Conception Hospital served 25,200 patients from last October through this March, an average of 4,200 patients each month—a huge accomplishment for a hospital that was flooded, dilapidated, and understaffed at the time of the hurricane.

Flooding at Immaculate Conception Hospital in Les Cayes. Photo by Rebecca E. Rollins / Partners In Health

A building near Immaculate Concpetion Hospital that was badly damaged by Hurricane Matthew. Photo by Aliesha J. Porcena / Partners In Health

PIH anticipated a spike in cholera cases following the hurricane and, unfortunately, its fears were confirmed. Staff prepared the cholera treatment center near Immaculate Conception Hospital and 10 PIH-supported centers in the Central Plateau and lower Artibonite by renovating water, sanitation, and electrical systems and buying necessary equipment, such as ambulances to transport the sickest patients to and from the centers. More staff was hired. And 380 community health workers began a six-month training to identify symptoms of the deadly diarrheal disease and help patients get access to care.

Many storm survivors carry a heavy mental and emotional burden after losing their homes, livelihoods, and friends and family members. PIH collaborated with other nonprofits, such as Handicap International and International Medical Corps, to recruit three social workers and four psychologists, who provided counseling to clinicians and community members. Twenty community health workers were also trained to identify symptoms of mental illness and given materials so they could support and refer neighbors to Immaculate Conception Hospital. 

The preparation paid off. PIH treated 1,682 patients at cholera treatment centers between October 2016 and March 2017. Meanwhile, the organization worked with the Haitian Ministry of Health to help vaccinate nearly 800,000 Haitians against cholera in the south, 60,000 of whom received their dose at Immaculate Conception Hospital.

PIH has been wrapping up efforts in the south following its six-month commitment, and staff are now returning to Port-au-Prince and Mirebalais. But they are connecting with local partners, such as St. Boniface Haiti Foundation in nearby Fond-des-Blancs, to ensure the Les Cayes hospital will continue to be supported during the long recovery ahead. 

Thu, 11 May 2017 09:52:41 -0400
New Birth Waiting Homes to Welcome Expectant Mothers in Sierra Leone Others are bigger. Elsewhere they’re more plentiful. But it’s tough to beat the understated dignity of the new birth waiting homes that Partners In Health opened in eastern Sierra Leone last week.

The three white houses sit on a hill at the quiet edge of the city of Koidu. Four beds in each bright, airy building will welcome a total of 12 expectant mothers at a time. Shaded porches will provide a place to rest. At the back is a small examination room where nurses can perform daily checkups. In a covered outdoor kitchen nearby, a cook will prepare breakfast, lunch, and dinner. While other waiting homes ask mothers to pay their own way or work off the cost of meals and accommodations by washing dishes, the PIH waiting home offers everything for free. Best of all, the home sits just a stone’s throw from Wellbody Clinic, where there hasn’t been a single maternal death in two years.

In Sierra Leone, half of all women give birth at home, and many die or lose children after suffering complications that could have been addressed at a well-equipped health clinic staffed by trained personnel. The national maternal mortality rate, 1,100 per 100,000, is one of the highest in the world. The hope is that women will come to the homes ahead of their due dates, when nothing is an emergency, and then give birth in the clinic. During the soft opening this spring and summer, the home will welcome patients from the three nearby areas with the highest maternal mortality, per the advice of local health officials. They’ll then reach out to more distant regions and welcome any mother likely to have a tricky birth.

There’s no guarantee the community will take up the offer. Birth waiting homes have been around since at least the 1970s, and there have been plenty of misfires. In Ghana, an early attempt at a waiting home in an abandoned ward of a hospital attracted just one mother, and she stayed only for a night. (Feedback cited the “desolate” setting.) Mozambique’s early homes lacked local political support and failed to take off. In Indonesia, expectant mothers were asked to pay dearly for small, thatched-roof huts attached to the houses of male strangers. Needless to say, the women declined.

Waiting homes are improving on the whole, however, and are en route to being everywhere from Cuba to Mongolia. A free maternal waiting home in Malawi virtually eliminated maternal mortality in the area. At an expansive complex in Zimbabwe, up to 100 women are checked in at any time. They say the days are a rare respite from domestic responsibilities and often sing, especially while relaxing together at night.

The home in Sierra Leone is still a ways from being that established. But clinic staff have reason to be optimistic. PIH’s commitment to offer not just adequate but great health care has resulted in a half dozen successful waiting homes around the world—in Mexico, Malawi, and Lesotho. And in Sierra Leone, though the home itself is low-key and dignified, the team's PR approach is direct. They recently appeared for an hour on a talk show on the local public radio station, FM 90.2. After answering caller questions, they concluded with, “Let us encourage the women in our lives to come stay at the birth waiting home to have a safe birth!”

Fri, 05 May 2017 16:27:06 -0400
Working in Global Health: Katie Kralievits I grew up with a close connection to Haiti. My maternal grandparents lived in Port-au-Prince for many years, and several of my family members were born there. In the late 1950s—in part due to political instability—my family fled Haiti for Miami, Florida, but continued to speak Haitian Creole and maintain close contact with their friends back in Port-au-Prince. This influence continued for decades, and I was raised to have a deep appreciation for the Haitian people and culture. I learned about Partners In Health while in graduate school and, prior to joining the organization, supported it mainly because of its work in Haiti.

As an undergraduate at the University of Notre Dame, I didn’t have a clear academic focus. I intended to major in chemistry and decided, at the mature age of 17, to pursue medical school. However, in my first two years of college, I realized I much preferred calculus and Spanish to chemistry, and switched my major to mathematics, while still considering a career in medicine.

To buttress potential medical school applications, I shadowed physicians, worked in a research lab, and conducted literature reviews for a physician in Miami, but I wasn’t invested in any one topic, nor was I particularly committed to pursuing medicine. During my senior year, I was fortunate to secure a clinical research job in Miami, but with graduation less than a month away, I was told that the position’s funding was eliminated. Plan A went out the window. While I was stressed to be jobless, I was also relieved since I knew my interests lay elsewhere.

I turned to my advisor, who suggested a Master of Science in Global Health degree at Notre Dame. After learning more about the program and the potential opportunities it offered, I applied and was admitted.

Within weeks of starting, I realized how little I knew about global health. The program provided an excellent introduction to this emerging field, while allowing me to discover career opportunities that suited my interests and strengths. Over the course of the year, I conducted a thesis research project, which culminated with two months of “field experience” in Peru. While I had traveled abroad many times before—mostly to Greece, where my father is from, and around Europe—this was the first time I’d worked and lived in a low-resource setting. And while my research project seemed elementary at the time—and even more so a few years later—it gave me the opportunity to gain work experience abroad.

The greatest benefit of the academic program was the opportunity to connect with and learn from leaders in the field, including representatives from the World Health Organization, the U.S. Centers for Disease Control, Catholic Relief Services, and others. During the semester, I met Dr. John Meara, who was then chairing the Lancet Commission on Global Surgery. He spoke about the Program in Global Surgery and Social Change at Harvard Medical School and the Lancet Commission’s goal of improving access to surgical care in low-resource settings. His research, which was heavily quantitative, was interesting to me, and I asked if I could help. Dr. Meara started sending me introductory papers on the topic, and I was assigned a small project to work on for the Commission.

I was grateful for even a chance to work for an organization I admired so much.

Finding a job in global health after graduation was next to impossible. That year, I applied to at least 30 entry- to mid-level jobs. I was finally offered a one-year research associate position with a widely-recognized Catholic international aid organization in Lusaka, Zambia. I was nervous, yet excited, and figured this would be another good opportunity to gain additional field experience.

In summer 2014, I moved to Lusaka, where I received a warm welcome from my Zambian and American colleagues alike. After a few months, however, I had accomplished very little. I quickly realized the challenges of working for a massive U.S.-based organization—each decision required half a dozen steps to receive approval from headquarters. Most importantly, I felt disconnected from the work we were doing. Patients and recipients of our services were termed “beneficiaries,” and there was minimal regard for their opinions on how we could better serve them and their communities.

Similarly, being an expat in this part of Africa was often uncomfortable. While I can’t complain about my accommodations nor about the friendships I made, unapologetic segregation in the workplace was the norm. I distinctly remember the organization’s leadership urging me to “be careful” when spending time with my Zambian friends, who were far more accomplished young professionals than me. 

During my tenure in Zambia, a catastrophe was wreaking havoc on the other side of the continent: the Ebola epidemic. Though thousands of miles away, I closely followed its development, and it was during this time that I rediscovered PIH’s work. I was impressed by its rapid response to this emergency and its prioritization of patient care. When reading the website one evening, I stumbled on the employment page and saw a posting for a research assistant. I was thrilled, as it was the only posting for which I was qualified on paper. I submitted my application that night and waited—for four months.

When I received a phone interview, I was grateful for even a chance to work for an organization I admired so much. Though a fraction of the size of my then employer, I knew PIH’s work was different. The organization seeks to provide quality health care to those living in abject poverty. Rather than reaching the most patients for the least amount of resources—a priority, I quickly learned, for many organizations—its goal is to raise the standard of services for those without access to health care.

I left Zambia a few months before my term was complete and have been working with PIH for two years. Every day I am inspired by the work being done by my colleagues in Boston and in the 10 countries where we work.

My job as a research assistant is multifaceted, and I have the privilege of working with an incredibly collaborative team. On any given day, we coordinate and support the research for Dr. Farmer’s writing commitments, from articles to op-eds to textbook chapters, and prepare materials for events, including lectures and classes. This provides me with the opportunity to learn from and work with Dr. Farmer and his academic colleagues, who are leading experts in their fields.

This role has also taught me the meaning of accompaniment, one of PIH’s core values. I often travel with Dr. Farmer and experience firsthand the complexities and daily demands of his life as a physician, professor, and public figure. Though the hours can be unpredictable, I am always in awe of Dr. Farmer’s ability to juggle dozens of commitments, while never failing to maintain constant follow-up on his patients—whether in Haiti or Rwanda or Boston—his students, and his colleagues from around the world.

I also have the chance to meet young and enthusiastic students interested in pursuing a career in global health. I often receive similar questions, and I continue to offer the same advice:

  1. Do something that interests you. As an undergraduate and graduate student, I wasn’t particularly interested in going to medical school. And that’s okay. Global health is about much more than providing medical care abroad—something I didn’t understand before I pursued my master’s degree and worked in Peru and Zambia, and now with PIH. There is room for everyone interested in this work, so I encourage students to pursue their interests and direct them toward a career of serving others.
  2. Get “field experience.” I say this in quotes, because the field can mean rural Africa or a marginalized neighborhood in one’s own hometown. It’s imperative to spend time understanding the experiences—and suffering—of others to better serve those in most need.
  3. Aim low. This may seem like bad advice, but when I was applying for jobs as a graduate student, I was looking for opportunities for which I was totally unqualified. I often hear young (and often inexperienced) students express concern about pursuing an entry-level job, or one with administrative duties. After encouraging them to get involved in any way possible, I gently remind them that if they are committed to this work, no task is too small.

In my two years with PIH, I’ve learned just that: No task is too small. And that’s because the mission of the organization continues to motivate me every day and in every aspect of my role. 

Thu, 04 May 2017 10:15:26 -0400
Medical Aid and Food to Thousands of Peru Flood Victims One month has passed since devastating floods and mudslides swept Peru’s coastline and communities north of the capital of Lima, killing 113 people and destroying the homes of an estimated 700,000 people.

The powerful rainy season storms, sparked by an El Niño in the neighboring Pacific Ocean, cut power and access to clean drinking water in the region. Roads and bridges crumbled, leaving remote farming villages isolated for days.

Volunteers and staff from Socios En Salud, as Partners In Health is known locally, responded immediately to the disaster. Every day since March 20, 50 medical brigades over the past month pushed throughout the Carabayllo District, PIH’s headquarters north of Lima, and beyond to deliver emergency aid and medication to more than 3,200 people, distribute 500-plus baskets of food, and tend to the mental health needs of nearly 200 patients.

Each new day was an opportunity to make a difference for those most in need—for people like *Jazmín, *Carlos, and Celeste.

Like many residents of Santa Rosa del Huaico, Jazmín just wanted to cross the swollen Huaycoloro River, which had wiped away her family’s home days earlier. Following her family and friends, the 6-year-old tried to pick a path along mounds of bags and trash that had accumulated midstream, but she slipped and fell. Her hands sunk deep into the muck, and a shard of broken glass sliced her left wrist.

Luckily, a PIH medical brigade had been established nearby. Her mother took her to one of the pop-up tents, where a volunteer doctor cleaned her wound, stitched her back together, and bandaged her wrist. All the while, Jazmín smiled and bravely sat through the ordeal. She never cried or complained, just chatted calmly with her doctor.                                                                                     

*Jazmín hugs Carmen Contreras, director of intervention programs in Peru, after receiving care at a medical tent. (Photo courtesy of Socios En Salud)

Miles away in Chocas, *Carlos was coming to terms with his own loss. The mudslides destroyed his home, including important documents and all the clothing he wasn’t wearing. He and his family were left without electricity or running water.

The floods seemed an unfair blow to Carlos, who had already suffered for three years with a debilitating injury. A terrible accident had left part of the 40-year-old’s left leg and foot paralyzed, and it was difficult for him to get around before the storms. Now it was nearly impossible.

In early April, a PIH medical brigade found Carlos outside his makeshift home erected from a tarp and a bedsheet. Staff taught him physical therapy exercises and massage techniques to improve his range of motion. His recuperation is slow, but steady, and he receives visits from volunteers who provide him counseling as he faces the long road ahead.

*Carlos (center) sits outside his makeshift home while PIH staff and volunteers examine his left leg. (Photo courtesy of Socios En Salud)

A week into the flooding, a PIH medical brigade visited the village of Las Brisas, where the Chillón River had swallowed more than 150 families’ homes. Flor Pérez, 19, and her 1-month-old baby, Celeste, were among those who had seen their houses swept away in the rushing waters.

Dr. Leonid Lecca, executive director of PIH in Peru, visited the mother and her infant, who had been born prematurely and underweight, in a neighbor’s home. He noticed that the baby was badly dehydrated and had a swollen abdomen. Staff escorted the family to a nearby health center. And Daniela Puma, a nurse working with PIH, began visiting the family regularly to ensure they had diapers and other medical supplies.

Two weeks after that first visit, Celeste was healthy and stable. A recent checkup even revealed she’s well within the average range of length and weight for an infant her age.

Flor Pérez (left) smiles at her newborn daughter, Celeste, who has recovered from dehydration and gained weight. (Photo by William Castro Rodriguez / Socios En Salud)

*Names have been changed to protect privacy.

Thu, 27 Apr 2017 12:18:11 -0400
Study Brings Relief to Rwandans with Hepatitis C Dr. Shumbusho gazes intently at her patients from behind narrow glasses, her gray wisps of hair pulled back into a bun, and listens to them describe the challenges of their deteriorating health. They have come to Rwanda Military Hospital from across the country, seeking answers about hepatitis C, an illness that causes ongoing damage to their livers.

Some didn't know they had the disease until recently. Others did but haven’t been able to do anything about it, because treatment has long been difficult to access. Hepatitis C drugs are expensive, don’t always work, and come with severe side effects. But if the disease is left untreated, up to 20 percent of these individuals will develop liver cirrhosis. Up to five percent of them will die of liver cirrhosis or liver cancer.

The good news is that the latest hepatitis C drug, approved in 2014, is almost 100 percent effective and carries only typical side effects you’d see on any drug label. The bad news is it was originally priced at more than $1,000 per pill, which is taken every day for 12 weeks.

Paying this price isn’t an option for Shumbusho’s patients, whose annual income is less than $700 a year. But in this hospital, there are closets full of the medication because these patients are part of a clinical study Shumbusho and her colleagues are leading to understand who contracts hepatitis C and how they respond to treatment.

“The true burden and impact of hepatitis C in sub-Saharan Africa has never been quantified,” explains Dr. Neil Gupta, a former chief medical officer for Partners In Health in Rwanda and a principal investigator of the study. Nobody really knows how many people have the disease in Rwanda, especially in rural areas, he says, but the government estimates as many as 55,000 have advanced hepatitis C. Why the prevalence is so high and how people contract it is unclear.

That’s why Rwanda Military Hospital, the University of Rwanda, the Rwanda Biomedical Center, Stanford University, Brigham and Women’s Hospital, and Partners In Health established the study, which will identify and treat 300 participants over two years. Most of them are subsistence farmers and rural residents who otherwise would have no way of being treated.

Shumbusho has seen patients every day since February. They arrive—many of them after very long journeys—get their bloodwork done, and receive the medication. Then fatigue shifts to relief. For many, it’s the first time they’ve received treatment for an illness that has plagued them for decades.

Their gratitude spurs Shumbusho on. “It’s very motivating.”

Study Coordinator Alphonsine Imanishimwe counsels a new patient through her first dose of medication. Photo by Neil Gupta / Partners In Health

Patients come back every month for three months so Shumbusho can monitor their progress. She’ll keep track of their weight, hear how they’re coping with the daily medication, monitor any side effects, and log these details for the study.

By late 2017, Shumbusho, Gupta, and their colleagues will not only have a sense of why the disease is so prevalent and among whom, but they’ll also provide recommendations for improving treatment policies around it, such as how many blood tests patients should receive and how often they should see their doctors.

Rwanda Military Hospital will be further set up to handle hepatitis C in the future. It will have a pharmacy stocked with drugs, clinicians trained in the specifics of the disease, and a new machine for diagnosing hepatitis C.

And they’ll have hard evidence that treatment with the right drugs is a surefire solution. Gupta hopes the study will get more attention on the topic and stimulate research. “We need more work like this,” he says.

Most importantly, the study will cure hundreds of very sick people. For Gupta, access to treatment is the main goal. “The drugs are extremely effective and are not reaching the majority of people who need them,” he says. “Our ultimate objective would be to use this experience to demonstrate and advocate for access to this treatment for millions of others in resource-poor settings globally."

Gupta and other authors recently published a baseline study for hepatitis C treatment in Rwanda.

J.M.V. Halleluia is a laboratory technician working on the study. Photo by Aaron Levenson / Partners In Health


Thu, 27 Apr 2017 09:22:14 -0400
Stevenson's Story: Starvation in Central Haiti He felt impossibly light. At 6-months-old, Stevenson Louis should have been a pudgy, smiling, playful infant. He should have been sitting on his own, or close to it. Instead, he was as weightless as a newborn cradled in my arms. His dark chocolate eyes stared up at me vacantly, his face expressionless and somber. I wanted nothing more than to make him smile. But I doubt he’s done that much in his short, difficult life.

His mother, Manise Darius, handed me Stevenson as soon as she walked into the malnutrition clinic in Boucan Carré, Haiti. We’d met the day before during a home visit. Still, I’m not sure why the 26-year-old mother entrusted me with her son. Maybe her arms needed a break following the long walk from her house to the clinic. Or maybe she’d read my mind and knew how much I missed holding my own son, whom I’d left—fat and happy—back in Boston only days before.

The view behind Darius's home. Photo by Cecille Joan Avila / Partners In Health

I traveled to Haiti in November to report on the malnutrition program run by Zanmi Lasante, as Partners In Health is known in Haiti. As part of the trip, I and several PIH colleagues made home visits to families enrolled in the program, observed care at two malnutrition clinics, and had a tour of the Nourimanba production facility, where PIH produces a nutrient-rich peanut paste fed to malnourished children at 12 health facilities throughout the Central Plateau and lower Artibonite.

On our first reporting day, we visited three families in and around Boucan Carré. Darius was the second mother we met, and by far the worst off. Although her 2-year-old daughter, Ferlanda Louis, was the only one of her children enrolled in the malnutrition program, it was clear Stevenson would benefit as well. Ms. Esther Mahotiere, a nutrition program coordinator, and Ms. Asmine Pierre, lead nurse of the clinic’s malnutrition program, encouraged her to come to the clinic to have them checked out.

Esther Mahotiere, the nutrition program coordinator, stirs a tub of Nourimanba before feeding a patient at the malnutrition clinic in Boucan Carré. Photo by Cecille Joan Avila / Partners In Health

That was easier said than done. Darius lived several miles outside of Boucan Carré, had three other children at home, and her husband was rarely home because he—like many men in the area—worked hours away in Port-au-Prince. She didn’t have enough money to feed her family on a daily basis, much less pay for a motorcycle ride into town.

So when Darius arrived in the clinic that Tuesday morning with little Ferlanda hugging her right leg and Stevenson on her left hip, I couldn’t help but smile. She’d made it. She’d come. She was trying, despite all the odds stacked against her.

Assessing starvation



Mahotiere (above image) measures the height of a boy visiting the malnutrition clinic. Darius (below image) holds Stevenson while a nurse gauges his upper arm circumference, which helps determine the degree to which he is malnourished. Photo by Cecille Joan Avila / Partners In Health

After handing me Stevenson, Darius and her daughter found a spot on the wooden benches inside the packed clinic. Ferlanda had on the same purple and green princess gown she’d worn the day before and was slowly nibbling the periphery of a wafer cookie. It was one of the treats packed into the bag of food we delivered to her family’s home less than 24 hours ago. Darius handed another package of wafers to the toddler sitting beside them. The boy clutched it in his hand, content just holding the rare treasure.

It was barely 9:30 a.m., and the air already hung heavy and stale in the clinic. Mahotiere, Pierre, and two nursing students tended to the flow of women and men who’d come with children in various stages of starvation. That’s a harsh word—starvation. But there’s really no substitute that can adequately describe what happens to a fragile, growing body when it receives one meal a day—if even that—over an extended period of time.

When children don’t get enough to eat, they fail to gain weight and height at a proper pace. Their hair becomes brittle and turns a coppery hue. They’re more likely to get sick and have a harder time healing. Severe acutely malnourished children may develop a condition called marasmus, in which an overall nutritional deficiency causes them to waste away and look more like human skeletons than rough-and-tumble toddlers. They could also develop kwashiorkor when deprived of protein. Their hands, feet, face, and even scrotum can become painfully swollen. Their bellies distend like overinflated balloons.

Roughly 1 in 5 children are starving in Haiti, and twice as many are stunted.

These are the physical signs of starvation, but there are also mental repercussions that are equally alarming. Children’s brains fail to develop at a proper pace, making it more difficult for them to learn and concentrate. All of these factors combine to set children severely behind their peers—potentially for the rest of their lives.

It was the first visit for some children visiting the Boucan Carré clinic that day. For others, it was one in a series of weekly or bimonthly visits, all depending on whether they were severely or moderately malnourished. Nurses measured the children’s height, weight, and upper arm circumference—which provide clues to the degree an infant or toddler is malnourished—and jotted the numbers down in their charts. Then each child and guardian sat down with a nurse for an individual consultation and were sent off with a fresh supply of Nourimanba.

Roughly 1 in 5 children are starving in Haiti, and twice as many are stunted. Not all of them receive the care they need, but some do make it to PIH clinics and get enrolled in a malnutrition program. In Boucan Carré, an average of 127 patients visited the clinic every month and nearly 700 patients enrolled last year alone. That was just a fraction of the 9,000 children suffering from malnutrition whom PIH helped at its clinics and hospitals across the country in 2016.

Mahotiere tries to grab Stevenson’s attention, while Ferlanda nods off to sleep behind him in front of the family’s two-room home. Photo by Cecille Joan Avila / Partners In Health


Patient by patient

I’d been holding Stevenson for half an hour when I realized I’d have to let him go to do my job. I tried one last time to make him smile by tweaking his cheeks, then swaying side-to-side as if he were my tiny dance partner. His face remained unchanged, his eyes still locked with mine. Other mothers watched and smiled softly to themselves. Reluctantly, I handed him—slender and warm—back to his mother.

Mahotiere, a kind and no-nonsense nurse, sat at a wooden desk behind a wall of manila folders. She searched through the pile, called out a name, and waited for the child and guardian to take a seat on the plastic chair beside her.

Jelciné Marie Lourde and her 18-month-old son, Ocléne Davensky, took their turn. In the two months since he was enrolled, Ocléne had gained 4 pounds and weighed nearly 18 pounds. According to the Centers for Disease Control, an average boy his age should be 27 pounds, yet the fact that he was gaining weight was a positive sign.

As she chatted with the boy’s mother, Mahotiere opened a jar of Nourimanba, dipped in a wooden tongue depressor, gave the thick slurry a swirl, and scooped a small dollop out for Ocléne to taste. Clearly, he was a fan. His mouth opened wide to accept the peanut paste.

Youseline Benjamin sat down next. She seemed older than the rest, but it was hard to judge ages when, uniformly, every child looked younger than what their chart read. She, shockingly, was 11. She had been enrolled on August 30, 2016, weighing just 38 pounds. Other girls her age should be at least twice that size. It hit me that my 8-year-old daughter, who is average for her age, weighs 60 pounds.

Youseline Benjamin, 11, sits for her consultation with Mahotiere. Photo by Cecille Joan Avila / Partners In Health

Since enrolling in the malnutrition program, Youseline has gained 9 pounds. Her only complaint that morning was of a mild rash on her belly. Mahotiere examined her and jotted down a prescription to fill at the nearby pharmacy.

A slight stir rose in the room around a mother perched on the front bench. She was holding her daughter gingerly over her lap. The toddler’s shirt slid up to reveal what looked like white and yellow scales where there should have been brown skin. Pierre asked the mother what had happened, and learned that the little girl had fallen backward into an open fire. By the look of the girl’s skin, the accident had happened days—if not weeks—ago. The nurse sent mother and daughter to urgent care with instructions to have clinicians tend to the severe burn.  

Meanwhile, Claudia Louis and her 2-year-old son, Kendy Michel, took a seat alongside Mahotiere. Kendy had just been enrolled the week before, but he had already developed a taste for Nourimanba. The nurse checked his temperature and gave him a sample of the peanut paste.

Kendy couldn’t get enough. His jaw unhinged as wide as a baby bird’s with each helping. Then, while his mother gathered up their things, he continued shoveling the paste into his mouth from one of two tubs they took home. He cried pitifully when his mother finally closed the jar, shushing him apologetically as she scooped him into her arms.

Kendy Michel, 2, sits on his mother’s lap and shovels Nourimanba into his mouth. Photo by Cecille Joan Avila / Partners In Health

My colleagues and I couldn’t get enough of Kendy. He attacked his tub of Nourimanba with such zeal that it was hard not to love him. He stood out from the other children, who sat lethargic and moon-eyed as they waited their turn in the crowded clinic. Each child made me think of my own three back home. I realized that the first thing I wanted to do when I returned was to cook a meal for my children, watch them clean their plates, then repeat the process endlessly.

Starting again

Sitting at a desk beside Mahotiere’s, Pierre started new files for Ferlanda and Stevenson as the children perched on their mother’s legs. Because Ferlanda had missed two appointments in a row, she was categorized as having “abandoned” the program. Darius explained that she had intended to come, but that Stevenson had been sick. She had no one else to rely on, so they had to stay home.


Ferlanda (above image) gets her turn on the scale. Darius (center, below image) balances Ferlanda and Stevenson on her lap while Asmine Pierre (left), lead nurse of the clinic’s malnutrition program, feeds the children Nourimanba. Photo by Cecille Joan Avila / Partners In Health

Most children graduate from the malnutrition program after completing three months of appointments and Nourimanba supplements. They gain weight and grow inches taller. They begin reaching major development milestones, such as sitting, crawling, walking, and talking. In other words, they begin to do what children their age are supposed to do.

Some don’t reach these milestones the first time around. Their mothers, like Darius, are peasant farmers who raise their own food and sell what they can in the market. Sometimes crops fail. Droughts strike. Floods wipe out fields. And husbands fail to send home what they’ve earned at jobs miles away in the city. That means there is very little money for anything, and families must make painful choices between food or transportation, clothes or medicine.

Outside her home, Darius holds a handful of the low-quality rice, typically used as chicken feed, that she buys and prepares for her children. Photo by Cecille Joan Avila / Partners In Health

So when parents or guardians don’t arrive for appointments at the malnutrition clinic, their absence is never mistaken for lack of love or compassion. They know their children are starving. Quite often, they are too.

PIH’s malnutrition staff understand this intimately. When families eventually return to the clinic, they don’t browbeat parents or guardians. They simply grab another intake form and start the process over. Again. And again. And again. For as many times as it takes to pull that child out of starvation and place them on the path to a healthy future.

I watched Pierre as she measured Stevenson’s upper arm, his dark eyes following solemnly her every move. I took in his brittle, rust-colored hair that Darius had tied into a neat sumo ponytail. I glanced at his spindly arms and legs that hung limply from a white onesie. And I wondered if he would make it. I couldn’t bear the thought of him not.

Pierre offered Ferlanda a taste of Nourimanba, which she licked delightfully from her lips. Then it was Stevenson’s turn. His delicate mouth opened and closed over the wooden tongue depressor. Then the faintest of smiles lit his face.

Darius holds Stevenson in the doorway of their home, made from mud, sticks, and corrugated metal. Photo by Cecille Joan Avila / Partners In Health


Wed, 19 Apr 2017 11:31:46 -0400
TOGETHER, WE STAY Infrastructure Manager Steve Mtewa watched as people streamed into Dambe Health Center on its opening day in Neno, Malawi, last year. He knows what people in his rural community face when they’re sick. Getting ill is possibly the worst challenge because reaching clinics is time-consuming and costly.

We treated 108 people that day, among them five patients with such severe hypertension they were at risk of stroke, four with suspected tuberculosis, and 47 who tested positive for malaria — and it wasn’t even malaria season.

This center will serve 30,000 people in and around Dambe; the staff at other facilities we built and renovated around the world this year will care for hundreds of thousands more. By investing in infrastructure, mobilizing equipment and medicine, and providing clinical expertise, we are prepared to respond to immediate and long-term crises.

New maternity waiting homes in Malawi, Haiti, Lesotho, and Mexico provide safe, clean places expectant mothers can stay before and after delivering their babies. When it comes to delivery, women have access to trained midwives and, if complications arise, they are referred to a nearby facility for lifesaving procedures.

We worked with the Ministry of Health to improve infrastructure and care at the National Tuberculosis Hospital in Monrovia. We also began improvements to Pleebo Health Clinic and a nearby referral facility, J.J. Dossen Memorial Hospital.

In Haiti, we opened the Stephen Robert and Pilar Crespi Robert Regional Laboratory, which sits next to University Hospital. The proximity means that oncology patients who previously waited three months to receive a diagnosis can now get one in three weeks.

In Rwanda, we began construction on a 250-acre campus for the University of Global Heath Equity. When complete, classrooms, administrative buildings, a library, and dorms will drape a picturesque hill in northern Burera District. Thousands of students and health professionals from around the world will learn not only how to treat patients, but how to build health systems — eventually enabling them to run the provision of health care in their home countries.

That is the goal that drives our work. Whether a new waiting home, refurbished hospital, or cutting-edge university, these investments are symbols of our long-term commitment to the communities we serve.


We Go. We Make House Calls. We Build Health Systems. We Stay.

See Partners In Health's full 2016 Annual Report.

Tue, 11 Apr 2017 10:30:00 -0400