Web of care

Lake Peligre fills the valley floor, its dark blue waters a relief to the eye after hours winding through central Haiti’s hot, treeless hills on the dusty, potholed road that passes for National Route 3.

Fishermen in traditional dugout canoes paddle across the lake’s surface, a placid scene viewed from Route 3’s perch high on one side of the valley’s steep walls. The lake is screened from the road by a row of tiny, two-room shacks, their occupants sitting outside, watching as passing traffic dodges pedestrians, dogs, and livestock.

Peaceful today, the lake’s look is deceiving. Its creation in the 1950s led to decades of misery for the farming families that once made their living on the valley floor. But it has also led to a revolution in health care for the world’s poor in places as far flung as Peruvian shantytowns, remote Lesotho mountain communities, and Russian prison cells.

Threads connect these far-flung places to an Episcopal priest who saw his church drowned along with his flock’s farms and to an idealistic Harvard Medical School student who stumbled onto the displaced farmers’ shacks in the nearby hills at a place called Cange.

They lead in a broadening web to other idealistic students, to professors and global bureaucrats. They lead to the halls of power, to the World Health Organization, to Harvard-affiliated Brigham and Women’s Hospital, the Harvard School of Public Health, Harvard Medical School, and to a rapidly globalizing nonprofit called Partners In Health.

The threads eventually lead back to the poor, lying today in clinics in some of the world’s most inaccessible places, where a bedside physician wields a thermometer or stethoscope or syringe, or just kneels and watches.

The Episcopal priest is Father Fritz Lafontant, today in his 80s and happy to tell the story of how in 1983 he met an idealistic student named Paul Farmer, who in turn met two other young idealists named Jim Yong Kim and Ophelia Dahl. Together, they began work among the Haitian poor that today has the world sitting up and taking notice.

Farmer is the Maude and Lillian Presley Professor of Social Medicine at Harvard Medical School (HMS). Kim is professor of social medicine at HMS and Francois-Xavier Bagnoud Professor of Health and Human Rights at the Harvard School of Public Health (HSPH). Dahl is the president of Partners In Health (PIH). The organization, a private nonprofit, attests to its close ties to Harvard, listing as its “partners” Harvard Medical School’s Department of Social Medicine, the Harvard School of Public Health’s Francois-Xavier Bagnoud Center for Health and Human Rights, and the Division of Social Medicine and Health Inequalities at Harvard-affiliated Brigham and Women’s Hospital.

Its partners also include affiliated organizations and ministries of health in countries where it operates: Haiti, Peru, Lesotho, Rwanda, Malawi, Russia, the United States, Guatemala, and Mexico. In addition, whether as patients, community health workers, nurses, drivers, technicians, doctors, or top Partners In Health administrators, the people of those nations are active participants in improving their homelands’ health situation.

Fernet Leandre, director of HIV and TB for Partners In Health’s Haitian partner organization, Zanmi Lasante, worked at government-run clinics in his Haitian homeland as a social service resident before coming to Zanmi Lasante in 1996. During that time, which he called “deeply painful,” he was routinely frustrated by a lack of the drugs and equipment needed to help patients. At Zanmi Lasante, he said, he has the tools to do his job.

“I couldn’t really provide any care,” Leandre said. “When I came to Cange, it was exactly what I was waiting for. It was like a dream come true for a young physician like me.”

When Farmer first arrived at Cange in 1983 he found an impoverished community with no health facility. People lived in extreme poverty and suffered from a variety of ailments. They had little food and no clean water.

“The families here were in terrible, terrible shape. The land was no good, they had no houses, no water,” Lafontant said.

In the years since, the hospital at Cange has become a major medical center whose effectiveness and story of transformation prompted one prominent international health official to say that for an infectious disease doctor, a visit to Cange is similar to that of a pilgrim to a sacred site.

On arrival at Cange, after hours traversing rutted, potholed dirt roads, one pulls through high green gates into a lower dirt parking lot and a welcoming sign: “Bienvenue au Complex Socio-Educatif de Cange.”

The main buildings are above you and away to the left, wrapping around the small, steep hill on which the campus sits. Though a warehouse and a school border the parking lot, most of the buildings, including the main hospital, are hidden by the terrain and the thick trees that cover the site.

One of Farmer’s – and Partners In Health’s – beliefs is that creating a beautiful, restful place is as important for the sick poor as it is for the sick rich. Everywhere Partners In Health establishes itself, tree plantings and flower beds follow. David Walton, an instructor in medicine at Harvard Medical School, infectious disease specialist at Brigham and Women’s Hospital, and longtime physician with Partners In Health, said creating a beautiful campus requires some effort, though not much cost. Expending the effort shows respect for their patients and gives them dignity despite the poverty in which many live their daily lives.

The result is that Cange seems to the first-time visitor as much botanical garden as hospital. The towering trees are particularly noticeable, given the deforested hillsides one has to traverse along Route 3 to get there. If one climbs the fieldstone-walled road winding up the hillside, one quickly arrives at a small pond full of colorful fish. The spot, shaded by the trees overhead, is peaceful and a common resting place for newly arrived patients nervously waiting to see the doctor.

The hospital itself provides a full range of services, with operating rooms, an emergency room, separate maternity and tuberculosis wards, and dental and eye clinics. It serves as the referral hospital for a network of nine health clinics run in partnership with the Haiti government that reach across Haiti’s Central Department, one of the poorest regions of one of the world’s poorest countries. It also serves as the flagship for Partners In Health’s operations around the world, a hopeful example of the changes that 20 years of unwavering commitment and toil can bring.

Joia Mukherjee, assistant professor of medicine at Harvard Medical School and Partners In Health’s medical director, said she once brought a group of residents from Brigham and Women’s Hospital to the area. The group walked six hours to visit a community that had never been served by doctors. They saw the starvation and extreme poverty in which the local people lived and wound up vaccinating 300 and seeing another 700 with various ailments. The next day, she said, they came to Cange to attend mass at Father Lafontant’s Episcopal Church.

“I brought the residents here and they just started weeping,” Mukherjee said, “because they saw what 20 years of engagement can do.”

Though it got its start in Haiti, Partners In Health’s work expands beyond that island nation. Since the mid-1990s, the organization has worked in the United States, running programs based on the Haitian model of community-based care for the sickest and most marginalized HIV patients in Boston. At about the same time, it tackled a job that international health experts said was hopeless: treating multi-drug-resistant tuberculosis among Peru’s urban poor. Later that decade, Zanmi Lasante in Haiti turned to treatment of those infected with HIV, the virus that causes AIDS. The prevailing wisdom at the time was that AIDS couldn’t be treated in poor countries because the drugs were too expensive and too complicated to administer without robust health care systems like those typically seen in the industrialized world.

But with a relentless belief that people will stop saying “It can’t be done” if someone proves that it can, Farmer, Kim, and the small army of people following their lead have again and again shown that decent health care can be brought to the world’s poor.

“We push the limits of the possible, set it up, and put it in place,” Kim said. “We don’t have the argument [about whether it’s possible] until we’ve tried it. And once we’ve tried it, the argument changes.”

Partners In Health operates in the nations it serves through a network of clinics and an army of community health workers who extend the clinics’ reach into the countryside. Together, they offer a comprehensive continuum of care that has not only been hailed for its effectiveness and replicated in nine countries, but which is forming the foundation for a new academic discipline in global health delivery at Harvard, spearheaded by Kim.

The model treats not only the medical conditions patients present, but also attacks their underlying causes – whose roots often lie in poverty. Farmer said it’s been described as a “whatever it takes” approach, a description of which he approves.

The can-do approach means taking steps that would be foreign to physicians in major urban hospitals. It means hours-long treks over mountain pathways to check on a patient. It means not just giving a nourishing treatment for malnutrition, but planting the peanuts to make it, and roasting them yourself. It means not just advising HIV-positive mothers to use formula to feed their babies and to be sure they use clean water to mix the formula, but also casting large concrete containers to filter impurities from the water supply. It means being able to communicate with both a nation’s president and its poorest residents. It means missing meals, missing sleep, endless travel, and tireless dedication.

That can-do approach is tested daily by the conditions in which the organization works. Along the road to the clinic at Boucan Carré in Haiti, for example, rainy season floods have led to the deaths of two women from complications of their pregnancies and destroyed a Land Rover crossing with supplies. Partners In Health is pressing the Haiti government to build a bridge to provide a safe crossing, but the amount appropriated is not enough for the job, leaving Partners In Health – which has already commissioned a study of bridge feasibility – searching for a solution.

“It’s burdensome enough to know that you’re going to have to build the operating room,” Farmer said, discussing the situation’s frustrations. “You want to take care of people? You have to build the operating room and find the electricity and do the supply chain and make sure you have sutures and an autoclave to sterilize things. So all that work has to get done . and then you have to build a bridge?”

Despite the organization’s whatever-it-takes flexibility, at its heart lies a unwavering belief: that people living in the Third World shouldn’t get second-class care. In other words, women needing a Caesarean section shouldn’t die on a riverbank simply because there’s no way across. The organization strives to provide care that is up to modern medical standards despite the challenges that come with working in places where communication, transportation, electricity, and even water are sometimes lacking.

The patients know that and come flooding.

At site after site, PIH physicians tell a similar story. When they arrive to take over operations of an existing clinic, it typically sees just a few patients a day. Meanwhile, in the surrounding countryside, the sick and dying suffer at home. They stay home because they can’t afford the fees charged to see a doctor or nurse, more fees for medical supplies, such as sutures to close a wound, and another round of fees for antibiotics and other medicines. To top it off, there may be no medicine to be had and no doctors to be seen. With clinic staffing unreliable, the patient could make the exhausting and painful journey there, only to be without care and far from home. Better to stay in bed, surrounded by loved ones.

One of the first changes Partners In Health makes is reliability. Clinics are always open and there is always a doctor available. The clinics use modern inventory control techniques to ensure needed supplies and medicines are available. And, though they often charge a nominal fee to those who can afford it – 60 cents at the clinic in Lascahobas, Haiti – they don’t turn anyone away for lack of money.

The patients respond. Traffic typically increases dramatically within a year, tenfold or more, as word spreads that reliable care is available. Physical expansion of the facility often follows.

Jines Sophonie brought his 19-month-old son, Jean, to the clinic at Lascahobas in January after he fell into a cooking fire and suffered burns across much of his small body. Sophonie said they made the 30-minute ride on a motorcycle from distant Savonet. When asked why he made the trip to Lascahobas, Sophonie said simply, “There’s nowhere else.”

Nearby sat 2-year-old Davelnor Mirales, whose mother carried him as she hiked three hours over Haiti’s hills to reach the small clinic. Mirales was suffering from kwashiorkor, a starvation-related condition characterized by a swollen stomach and legs, stunted growth, and skin and hair abnormalities.

The doctors at Lascahobas started Davelnor on a diet of milk until his body could handle a more nutrient-packed food called Nourimanba, manufactured by Partners In Health, Haiti, from locally grown peanuts, milk powder, vitamins, and oil. Assistant Professor of Medicine Louise Ivers, who divides her time between her work in Haiti with Partners In Health and Brigham and Women’s Hospital in Boston, said that the Nourimanba has produced dramatic results compared with more traditional treatments for malnutrition, reducing swelling from kwashiorkor in as little as a week.

The most recent phase in Partners In Health’s history has been one of expansion. In 2002, the organization received a large grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria that fueled dramatic expansion of its HIV program in Haiti.

Three years later, a request from the government of Rwanda and funding from the Clinton Foundation’s HIV/AIDS Initiative put Partners In Health on the front lines of the global AIDS epidemic, fighting the disease where the epidemic burns hottest: sub-Saharan Africa. Invitations from other governments followed.

The organization and its suite of wraparound services aim to improve treatment and prevention of infection with HIV, the virus that causes AIDS. Partners In Health’s “four pillars” of AIDS care are prevention and treatment of HIV itself in the context of improved primary health care, which encourages people to visit clinics and agree to be tested for HIV; detection and treatment of tuberculosis – since tuberculosis is often associated with AIDS and is the leading cause of death among people infected by HIV; detection and treatment of sexually transmitted infections; and an emphasis on improving women’s health. Women’s health is an important component of HIV/TB care because it allows early diagnosis of HIV in newborns, allows doctors to monitor mother-infant transmission, and is an important focus in nations where childbirth remains a leading cause of death. A housing program for needy families living with AIDS and an emphasis on food security provide important additional support.

Since antiretroviral drugs need to be taken daily, a critical part of Partners In Health’s program lies in a corps of community health workers who conduct daily rounds and visit patients in their homes. During these visits, the workers not only ensure the patients take their medicines, they also monitor their general condition, their living situation, and the health of others in the household, providing an important route for early intervention.

Cenatus-Pierre Gaston, who discovered he was infected with HIV more than three years ago after seeking treatment for tuberculosis, said Partners In Health’s Haitian arm, Zanmi Lasante, saved his life, allowing him to marry and to work to help others stricken with the disease.

“I gathered my courage and said, ‘My life isn’t over,’” Gaston said. “If Zanmi Lasante wasn’t there, these bones wouldn’t be here anymore. I’d already be dead for three years and six months.”

Because of the nature of HIV treatment, Kim said work on the disease provides an opportunity to transform health care around the globe. An incurable ailment that can be controlled with an ongoing regimen of powerful drugs, HIV can only be effectively treated through established health care systems. In nations that have none, Partners In Health is building them as it goes, one clinic at a time.

“We’ve always had just outrageously huge ambitions to treat the poor,” Kim said. “The most common thing in the world is to set low goals for people who are powerless.”