Louise Ivers: ‘I can’t sleep at night because of the things that I see.’

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Assistant professor dedicates work to Haitian poor

Louise Ivers gently lifted the 7-month-old by his forearms, hoping he would pull himself up as a healthy child a third his age might.

But his head hung limply back, eyes wide, upper body slack.

At 7 months, when a healthy child would be sitting up on his own and
thinking about crawling, this baby boy was unable to control his head,
unable to pull himself from the sheets. Gently, she laid him back.

It was January 2008 and the baby — the youngest of four children —
had been brought into the clinic Ivers heads at Boucan Carré, Haiti,
after a period of vomiting and not eating well. He was skinny and malnourished, just the latest suffering child Ivers had seen on death’s doorstep, in the clinic.

“I’ve had more children dying in my arms than most people have ever
experienced in their whole lives,” Ivers said. “One day, I had a little
girl of about 8 die of malnutrition — an 8-year-old dying of
starvation. I was thinking of the people I know in Ireland and the
U.S., and most people don’t know anyone whose child has died. Yet this
is just everyday stuff. And we only see the half of it.”

Ivers has been steadily seeing more and more of the health care
picture around Boucan Carré in the five years she’s been there. The
number of patients coming to the clinic each day has grown dramatically
from between 10 and 15 in early 2003 to as many as 300 a day in 2008.
An assistant professor at Harvard Medical School and infectious disease specialist at Harvard-affiliated Brigham and Women’s Hospital, Ivers works in a gradually expanding clinic through the nonprofit organization Partners In Health.

Established in the 1980s, Partners In Health has pioneered a model of
health care among the world’s poor that has revolutionized treatment of
complex diseases such as AIDS and drug-resistant tuberculosis in impoverished settings. Founded by a group that included Maude and Lillian Presley Professor of Social Medicine Paul Farmer, Francois-Xavier Bagnoud Professor of Health and Human Rights and Professor of Social Medicine Jim Yong Kim,
and Partners In Health President Ophelia Dahl in 1987, the organization
now works in nine countries: Haiti, Peru, Russia, Lesotho, Malawi,
Rwanda, Mexico, Guatemala, and the United States.

When Ivers arrived at the clinic in 2003, Partners In Health had
just begun its collaboration with the Haitian government there. The
organization had taken over a three-room clinic, staffed just by a
nurse and chronically short of medicine. By early 2008, several new
buildings had been constructed, including a clinic that contains
examining rooms, a laboratory, a pharmacy, a small inpatient ward, and
isolation rooms for TB patients.

Built on land donated to the government by a group of local residents,
the facility remains isolated because of the region’s horrendous roads,
but has cell phone communication and Internet access via satellite. It
also boasts a host of support services including 90 community health
workers who visit patients at home daily, an agricultural operation,
and housing assistance for homeless patients infected with HIV or TB.

The health care picture around Boucan Carré is similar to that in
Haiti as a whole. With extreme poverty, malnourishment is rampant. With
a lack of vaccinations, health education, and primary care, ailments
barely given a second thought in the industrialized world take on
life-threatening proportions. A lack of access to obstetrical care and
operating facilities for pregnant women gives the nation a high rate of
maternal death. The health picture is exacerbated by the high
prevalence of AIDS, TB, and malaria.

Ivers’ road to this remote community in one of the world’s poorest
nations has been a winding one. She grew up the middle of three
children in Dublin, Ireland. At age 16, she was asked to select a
course for her collegiate studies and chose to become the family’s
first doctor. It was a risky choice, since she didn’t know any
physicians other than her family doctor, but she says now she can’t
imagine doing anything else.

“It’s pretty much the best job in the world,” Ivers said. “It’s a
huge privilege to be in a relationship with a person where you’re
invited into some of their innermost secrets, their darkest fears.
You’re in a position to put them at ease, to help them, to explain
what’s going on. It’s brought me here and allowed me to bring something
to this project.”

Ivers became interested in developing countries during medical
school in Dublin, and one summer she worked at a rural clinic in Ghana.
She’s not sure how much good she was able to do during her three-month
stint, but the experience was life-changing.

“I couldn’t really believe kids were dying of measles and diarrhea, because we don’t have that in Ireland,” Ivers said.

After that, Ivers looked for a job that would combine her love of
teaching and interacting with students with work in developing nations.

She came to the United States for a residency in internal medicine at Massachusetts General Hospital
(MGH) and followed that up with an infectious disease fellowship at MGH
and Brigham and Women’s Hospital. In between, she worked in India and
Vietnam and also spent time at the London School of Tropical Medicine.

It was while working at MGH that Ivers met Joia Mukherjee, who at the time was finishing her fellowship in infectious diseases. The two women hit it off and agreed to stay in touch.

Mukherjee, now an assistant professor at Harvard Medical School and
physician with Brigham and Women’s Hospital, went on to become the
medical director of Partners In Health. In 2003 (when Ivers finished
her own infectious disease fellowship), Mukherjee was looking for
doctors to help the organization expand after receiving a large grant
from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Ivers and Mukherjee agreed that Ivers would head to Peru, where a TB-centered program had been under way since 1994.

Just before Ivers left, however, Mukherjee called and asked if she might be interested in Haiti instead.

Ivers jumped at the chance, saying she was more interested in working
on the whole suite of health problems linked to Haiti’s extreme poverty
than she was on Peru’s more-focused program aimed at
multi-drug-resistant TB.

In August 2003, just months after Partners In Health arrived at
Boucan Carré, Ivers made her first trip there. She, Mukherjee, and
Keith Joseph, the Partners In Health doctor stationed there, worked in
the tiny clinic for two weeks. Ivers slept in the village priest’s
house and made numerous treks to the countryside to visit patients at
home. Ivers laughs as she recalls wading a chest-deep stream at the end
of one nine-hour hike, saying, “Maybe that was the job interview.”

Whether it was a test or not, Ivers passed. For the next few months,
she finished her infectious disease fellowship in Boston and
familiarized herself with operations at Boucan Carré. Joseph, a
pediatric tuberculosis specialist at Brigham and Women’s Hospital,
overlapped with her a few months and then moved on, eventually
overseeing Partners In Health’s expansion into Malawi.

Partners In Health co-founder Farmer said that Ivers stood out from
the very first time they saw her in action in Haiti. To be successful
in such a difficult environment, a doctor has to go far beyond the
usual commitments of time and energy expended routinely in developed
nations, where a physician may stay late to check on patients or
provide additional care.

“Most doctors from the U.S. or Ireland have no idea that to be
effective in a place like rural Haiti, you always have to go the extra
mile,” Farmer said. “Going the extra mile might involve, as Louise
learned, wading across rivers to do home visits or transport a patient.
It will certainly mean helping to build lab capacity and basic
infrastructure, and training community health workers — not tasks we
learned about in medical school, residency, or fellowship training. It
will mean learning how to get your patients fed and, better yet,
learning to keep people away from hunger.”

Farmer said Ivers tackled all those tasks and more without a word of complaint.

“She’s never said, ‘Hey, this is not in my job description,’ no
matter how outlandish certain tasks would seem if presented to her at
Harvard,” Farmer said.

Ivers is fluent in Creole and compassionate with her patients. She’s
friendly with colleagues and energetic when confronting challenges. She
has a deep knowledge of Partners In Health’s complex operations and an
abiding belief in its mission: provide the world’s poor health care
equal to modern standards, and address wherever possible the social
problems that underlie their poor health.

Ivers’ early days at Boucan Carré were sometimes hard. She lived in
a shed — never intended for human habitation — attached to the local
church. She recalls visits by cockroaches, rats, and even tarantulas.
She remembers being stranded shoeless an hour’s walk from the clinic
when the four-wheel-drive vehicle she was riding in died in the middle
of a river crossing. She recalls being embarrassed at how she hobbled
painfully to the clinic across rocks that her shoeless patients
traverse every day.

Even today, after constructing a new clinic with real sleeping
quarters upstairs, Ivers will stop reflexively after putting on a pair
of shoes she hasn’t worn in a while, yanking them off and checking for
spiders. In response to a question about how many hours a day she
doesn’t work, she responds hesitantly, as if thinking about it for the
first time: “Only when I’m sleeping.”

But Ivers resists any characterization of her own hardships as real
suffering. After all, she says, she gets to go back to her apartment in
Boston. Whatever she’s going through, her patients have it worse, some
of them much worse.

“Here, you can work in the clinic and go a full day without eating.
So anytime I start to feel hungry, I think, ‘These people feel like
this every single day and they walk for six hours, carrying their
children [to get to the clinic].’ And so you rally and just sort of get
on with it,” Ivers said. “It’s not that I’m interested in
self-flagellation. I just really turn it around and [use it to remind
me] why I’m here.”

When asked why that is, Ivers responds: “When you have a skill like
being a doctor, the idea of not using it to try and do something about
the things that I see all the time is just unconscionable to me. I
can’t sleep at night because of the things that I see. … It’s not even
a question of what keeps me here. It’s what keeps me there. Why do I go
back to Boston? I’m not really sure. My family’s there, there’s my
connection to the University … but there’s just so much work here to