Noncommunicable diseases (NCDs) lead to more deaths globally than all other causes combined—striking hardest among poor people.
Eighty percent of deaths from NCDs occur in low- and middle-income countries. Among those living on less than $1 a day, NCDs are often caused by malnutrition, infection, congenital abnormalities, and toxic environments—factors only exacerbated by poverty. Common NCDs include cancer, cardiovascular disease, diabetes, chronic respiratory diseases, high cholesterol, and rheumatic heart disease.
More staggering than the statistics are the disparities that exist in treatment and care among poor and wealthy countries. Almost 80 percent of the global cancer burden occurs in low- and middle-income nations, yet those countries represent only 5 percent of the global spending on cancer. Similarly, more than 80 percent of cardiovascular and diabetes deaths and almost 90 percent of deaths from chronic obstructive pulmonary disease also occur in low- and middle-income countries, according to the World Health Organization.
Addressing the inequalities in NCD treatment is a priority for PIH. In each of the countries where we work, PIH treats NCD patients by drawing on lessons learned from community-based initiatives to address HIV/AIDS and tuberculosis, allowing PIH to treat the diseases and address the economic factors that allow NCDs to wreak havoc in resource-poor nations. The effort to combat NCDs among the bottom billion will require services to prevent, treat, and manage illness, as well as strong advocacy to address the overwhelming burden of these diseases on the destitute sick.
Every year PIH provides free, comprehensive medical care to hundreds of thousands of children.
In 2012, about 6.6 million children died before reaching their fifth birthdays. To put it bluntly, every day 19,000 children every day are killed by conditions that could be prevented or cured with simple, affordable remedies—vaccinations, bed nets, food, clean drinking water, and antibiotics.
PIH strives to eliminate this unnecessary suffering and death by providing free comprehensive health care for children and their families and by working to ensure that children have access to the basic rights - vaccinations, health care, education - that are key to a healthy, productive life.
Each day, about 1,000 infants are born with HIV, the vast majority of whom reside in poor countries. Most of these infants could be protected from HIV infection through effective HIV testing and treatment for prevention of mother-to-child transmission of HIV (PMTCT). These interventions have nearly eliminated mother-to-child transmission in wealthy countries. In Haiti, PIH began offering PMTCT and HIV counseling to pregnant mothers in 1995, just one year after it became available in the United States.
PIH’s HIV Equity Initiative has provided antiretroviral therapy (ART) free of charge for thousands of Haitian children living with HIV since 2000. HIV care for children is fully integrated into other basic health services, also provided at no cost. In 2005, PIH began implementing this model first in Rwanda and later in Malawi and Lesotho.
With many other child-centered programs in the poor communities where PIH works, we offer children the same essential rights and services that have virtually eliminated deaths from common childhood ailments in rich countries.
Cholera is a waterborne illness spread by contaminated drinking water. In the absence of latrines or public sewage systems, the world’s poor often drink from the same river or stream used for defecation – infecting water supplies. People infected with cholera develop profuse, watery, high-volume diarrhea often within 12 to 24 hours of drinking contaminated water. Patients can go into shock and die if lost fluids are not replaced.
Cholera struck Haiti in October 2010, and it is clear that cholera will be in Haiti for the foreseeable future. The bacteria have contaminated the lakes, rivers and canals that millions of people use each day for drinking, cooking and bathing. More than 8,500 have been killed and hundreds of thousands infected.
Early in the epidemic, PIH/Zanmi Lasante put forth five steps essential to slowing the spread of cholera in Haiti:
1) Identify and treat everyone suffering from cholera
2) Make oral vaccines available
3) Improve Haiti’s water insecurity and sanitation
4) Strengthen Haiti’s health system
5) Harmonize global health policies in Haiti while also raising the bar on our goals
In April 2012, Partners In Health provided two-dose oral vaccinations to 45,000 people living in the country’s Artibonite region. Due to incredible efforts from PIH/ZL's network of community health workers and logistical staff, more than 90 percent were confirmed to have received the second dose—a very high completion rate. The Pan American Health Organization subsequently recommended expanding the use of the oral cholera vaccine in Haiti, and the World Health Organization endorsed a recommendation that a global stockpile of 2 million oral cholera doses be created to respond to outbreaks around the world—a major policy shift on the emergency use of cholera vaccines.
COMMUNITY HEALTH WORKERS
For more than two decades, PIH has hired and trained community health workers (CHWs) to help patients overcome obstacles to health care.
Transportation costs, social stigma, lack of information, discrimination, and time constraints are major barriers to medical care in poor communities. Even when treatment is free, these barriers prevent people from accessing necessary health care. CHWs help patients overcome obstacles to health care by accompanying patients through treatment, monitoring needs for food, housing, and safe water, leading education campaigns, and empowering community members to take charge of their own health.
As members of the communities they serve, CHWs establish relationships of trust with their patients, bridging the gap between the clinic and the community. CHWs help health care systems overcome personnel and financial shortages by providing high-quality, cost-effective services to community members in their homes, and by catching serious conditions at an early stage before they become more dangerous and expensive to treat.
Across PIH's sites, all patients beginning treatment for HIV/AIDS or tuberculosis (TB) are paired with a community health worker. Every day, these health workers visit patients in their homes to supervise treatment, ensuring they take their medications regularly and correctly. Over time, they teach their patients how to manage complex treatments, cope with side effects, and identify signs and symptoms of impending illness.
Despite the success of CHWs, too many developing countries lack the resources for strong public health systems. As a result, many of those who do make use of CHWs classify these positions as “health volunteers," denying essential workers fair payment and adequate training. International donors and many NGOs have followed suit. We believe there is no excuse for withholding payment for the highly skilled services of CHWs, who accompany patients through their greatest struggles and put themselves at daily risk of contracting deadly diseases. Payment directly benefits the health and welfare of the community by providing jobs to local people. PIH provides and advocates for professional treatment of CHWs—including fair payment, ongoing training, and provision of necessary supplies—so they may perform their vital work to the highest standards.
By accompanying patients day by day, CHWs develop a deep awareness of the effects of illness and poverty in their communities. This knowledge helps CHWs address broader barriers to health, including oppression, violence, and social and economic injustice.
In 1998, PIH launched its HIV Equity Initiative in rural Haiti. It was one of the first programs in the world to provide free, comprehensive HIV/AIDS treatment to the poor. The program's incredible success changed how the world approaches and funds diseases of the poor.
Since 1981, more than 60 million people have contracted HIV/AIDS, and more than 30 million have died from the disease. An estimated 33 million people are now living with HIV/AIDS—95 percent of them in developing countries and nearly two-thirds in sub-Saharan Africa, according to UNAIDS. HIV hits hardest among the poor and disenfranchised. It shatters families, impoverishes communities, and thwarts economic and social development of entire nations. More than 16 million children have been orphaned by AIDS, including more than 14 million in Africa alone. In sub-Saharan Africa, HIV has been shown to significantly reduce per capita economic growth, which contributes to the further impoverishment and illness of African communities.
HIV is transmitted through unprotected sexual intercourse, transfusion of contaminated blood, sharing of contaminated needles, and between a mother and her infant during pregnancy, childbirth, and breastfeeding. Young women are especially vulnerable to infection because they often have less access to adequate information and available medical treatments. In many countries, women’s subordination to men prevents women and girls from negotiating safe sex practices.
PIH adheres to four fundamental pillars when addressing HIV/AIDS in poor settings: providing treatment in the context of primary care, screening for and treating tuberculosis and sexually transmitted infections, and emphasizing women's health. PIH also provides housing, water, food, and psychosocial support to thousands of people living with HIV. To paraphrase a Haitian proverb, providing medicine alone is equivalent to asking someone to dry their hands in the dirt after washing them.
By providing social and economic support to people living with HIV, PIH addresses the root causes of poverty and disease, and not just the disease itself. PIH and other groups have proved that treatment can save lives while strengthening both HIV/AIDS prevention and primary care.
Partners In Health works to train care providers to treat mental disorders with safe, effective, and culturally sound programs that can be adapted for use around the world. Sometimes thought to be an affliction of wealthy countries, mental illness in fact causes great suffering and death in low-resource settings, including the places where PIH works.
The World Health Organization estimates that by 2030, depression alone will be the leading cause of disability around the world—outpacing heart disease, cancer, and HIV. In many poor places, the absence of care for mental and neurological disorders such as schizophrenia, bipolar disorder, major depression, and epilepsy has allowed stigma against people with these conditions to continue unchecked, discouraging people from seeking care and sometimes leading to inhumane treatment.
Although effective mental health treatments exist, much of the world lacks trained mental health care providers and comprehensive health care services that address mental health conditions in conjunction with other diseases. Treatment, including sound medical evaluations, social assistance, psychological support, and, in some instances, medication, can help people with mental illness make dignified recoveries that transform attitudes and fear.
At a growing number of sites, PIH works to deliver high-quality mental health care to people suffering from mental disorders. In Rwanda, PIH is collaborating with the Rwandan Ministry of Health to move mental health care away from locked inpatient facilities and into the rural communities where people live. PIH/Inshuti Mu Buzima provides clinical mentoring and technical support on training, quality improvement, and technologies to improve care, all with the goal of enabling local clinicians and non-specialists to deliver high-quality mental health care.
In Haiti, after the 2010 earthquake exacerbated the existing need for formal mental health care, PIH worked to implement a community-based model of mental health care. PIH and our sister organization, Zanmi Lasante (PIH/ZL), are now expanding services across the Central Plateau and lower Artibonite region through the support of Grand Challenges Canada and the Integrated Innovations in Global Mental Health program. Informed by the understanding that there is no health without mental health, the project in Haiti aims to create a model for community-based care that integrates seamlessly with PIH/ZL’s existing health care system.
At 35 million strong, nurses and midwives make up the large majority of the global health care workforce and deliver the bulk of all health care services.
But the distribution of nurses is far from equitable. According to the World Health Organization, five times more nurses work in high-income countries than in low-income ones, despite the higher burden of disease in poor countries. As a result, clinics and hospitals around the world are overwhelmed by patients and grossly understaffed. Nurses often shoulder this burden with low pay, few or poor educational opportunities, and inadequate resources to care for their patients.
At PIH sites, whether for a mother in labour in the mountains of Lesotho or a child suffering from cholera in Haiti, access to PIH’s qualified nurses and midwives—who comprise 84 percent of our clinical workforce—often means the difference between life and death. PIH promotes nursing as an integral part of delivering comprehensive, high-quality, and patient-centered care. At our sites around the world, we foster a culture of team-based care among nurses, physicians, and allied health professionals. This requires investing in nurses and midwives, improving the settings in which they work, and accompanying national Ministries of Health to do the same for nurses in the countries in which we work.
PIH’s nursing program aims to:
• Develop best practices of global nursing care in resource-limited settings by integrating service delivery, training, and research
• Strengthen nursing education and specialty expertise, which also provide professional development opportunities
• Identify and support nursing leaders to improve training and enhance patient care.
In Haiti and Rwanda, PIH’s nurse educators and mentors work alongside our nursing staff to improve patient care. These educators and mentors provide instruction but also an instant feedback loop and support system for staff nurses as they learn new skills and apply new knowledge.
In Haiti, some of our nurse educators focus on key specialties—such as maternal health, pediatrics, mental health, and surgery—which allows us to expand the capacity of our workforce and respond to more of our patients’ needs.
In Rwanda, PIH launched a program in 2010 called MESH—short for Mentoring and Enhanced Supervision at Health Centers—in collaboration with Rwanda’s Ministry of Health. The program connects experienced nurse mentors to staff nurses in rural health centers. Based on its initial success, the Rwandan government plans to expand the HIV portion of MESH throughout the country.
Surgical care plays an essential role in strengthening health systems in resource-poor settings around the world. Diseases that are treatable through surgery—such as cancer, trauma, infections, congenital anomalies, and complications from childbirth—account for 11 to 25 percent of the global burden of disease, according to the World Health Organization (WHO). However, 2 billion people around the world have no access to emergency or surgical care. The poorest third of the world receives less than 4 percent of the world’s available surgical services, while the richest third receives nearly 75 percent.
In Haiti’s Central Plateau, for example, there are only two orthopedic surgeons in an area that is home to more than 500,000 people and where a large proportion of emergency room visits are due to acute work-related injuries or trauma from traffic accidents or other sources.
Untreated surgical disease has an immense human, societal, and economic impact. For example, a disabled parent without access to safe surgical care may not be able to care for his or her family—a tragedy for the parent, the family, and society. As a result, the true economic impact of surgical disease that goes untreated can profoundly affect a country. In poor countries, surgical care remains limited despite its cost-effectiveness. With growing evidence of the need for safe surgical care and its positive economic benefits to a society, surgery can no longer be considered a privilege for the few.
Improving care delivery, education, training, and research within global surgery and anesthesia must be a key priority in global health. To that end, PIH is involved in the launch of The Lancet Commission on Global Surgery, a new initiative that aims to ensure all people have access to safe, high-quality, affordable surgical and anesthesia care. Officially launched in December 2013 with an introductory comment in The Lancet, implementers of surgical services and health and policy experts will team up to find the best strategies for providing surgical care with a focus on low- and middle-income health systems.
Surgical interventions in PIH’s sites include orthopedics, otolaryngology (ear, nose, and throat), plastics, pediatrics, urology, OB-GYN, and general surgery. At University Hospital in Mirebalais, Haiti, PIH now offers a surgical residency program to train the next generation of Haitian surgical professionals.
Building the skills of our local surgeons and research on how to improve surgery in resource-limited settings strengthens advocacy efforts for equity in surgical services. Advancing surgical services strengthens the entire team of nurses, anesthetists, surgical and sterilization technicians, and logisticians across the health system and leads to high-quality, equitable care.
Tuberculosis is a common—and in many cases lethal—infectious disease that offers a glaring example of global health care inequities. Drugs to fight TB have been in existence for 50 years, yet the disease continues to kill almost 4,000 people every day—nearly all of them in developing countries.
For more than two decades, PIH has treated and prevented tuberculosis (TB), multidrug-resistant TB (MDR-TB), and HIV/TB in some of the poorest and most vulnerable communities in the world. Our community-based approach to care has resulted in some of the highest cure rates and lowest treatment default rates ever recorded. These results prove that health problems once thought to be untreatable can be addressed effectively, even in poor and geographically remote settings. Our goal is to share the success of our approach on a broad scale.
The community-based approach utilizes community health workers who are trained and employed to serve as a vital link between their villages and medical facilities. They deliver drugs and treatment support to patients requiring complex drug regimens, and they provide TB drugs and antiretroviral therapy to patients co-infected with TB and HIV. They also monitor the health of their neighbors, perform active case finding, and refer sick patients to the hospital—often accompanying them there.
To increase the impact of our approach and avoid the creation of parallel systems, we partner with local governments and provide technical assistance to build up the public sector. Three of our original MDR-TB pilot projects have successfully been handed over to the national Ministries of Health, where they can be scaled up nationally and provide training and technical assistance to other countries in their regions.
In 2014, Partners In Health was awarded a groundbreaking grant from UNITAID to enroll 3200 patients into a treatment program involving new TB medicines across 17 countries. The project will devise a more user-friendly and effective treatment regimen and accelerate uptake of newly released MDR-TB medicines.
TB usually attacks the lungs, but it can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough or sneeze. Roughly one in 10 people living with the disease eventually develop an active case of TB, yet people who have HIV or are malnourished have a much higher risk of developing active TB. If left untreated, TB kills approximately 70 percent of people who develop active cases.
Treatment is difficult and requires long courses of multiple antibiotics—typically at least six months for drug-susceptible TB. Social contacts are also screened and treated if necessary. When people fail to complete the drug regimen for TB, the disease becomes resistant to treatment. It often develops into the more deadly MDR-TB.
A person falls ill with tuberculosis about every three seconds—the vast majority of whom live in poor countries. According to the WHO, 95 percent of all TB deaths occur in developing countries, resulting in about 10 million children who are orphaned due to TB deaths of one or both parents. People in the developing world are more likely to contract tuberculosis because their immune systems are more likely to be compromised due to HIV/AIDS. Today, TB is the leading cause of death for people infected with HIV/AIDS.
PIH works to improve the health of women across their lifetimes, including in pregnancy and childbirth. Pregnancy and childbirth should be occasions to celebrate life and hope. Yet for millions of women in the developing world, pregnancy and childbirth pose major risks of disability or death. Each year in Rwanda and Malawi, for example, one woman out of every 200 who deliver a baby will die in pregnancy or childbirth, as compared to one of 11,000 women in Canada.
Nearly all maternal deaths could be prevented with targeted interventions at the community, clinic, and hospital level. PIH strives to address these lethal inequalities by expanding access to innovative women's health services in the countries where we work. We provide access to basic health services proven to lower maternal death rates: family planning, comprehensive antenatal care, adequate nutrition, and medical care for childbirth and pregnancy. We also offer antiretroviral treatment for pregnant women living with HIV as a way to improve health and prevent mother-to-child transmission of the virus during childbirth.
Family planning is among the most effective tools for reducing maternal mortality. Women who receive education and contraceptive options are more likely to delay childbearing, have fewer children, and reduce their risk for obstetrical complications. Yet women in poor communities too often lack access to family planning tools. Clinics are too far away, fees for obtaining medical care are too high, and transportation costs are beyond their means. If family planning services were available to all women who want them, maternal mortality in poor countries could be dramatically reduced.
In Haiti, each of PIH’s clinics has a full-time nurse trained in sex education and reproductive health counseling. Staff in Haiti have been offering free condoms and contraception for more than 15 years. In 2003, we began training and mobilizing community health workers who specifically promote family planning and women’s health. These ajan fanm—women's health agents—travel throughout the countryside, teaching people about sexually transmitted infections, including HIV, and contraceptive methods. They also distribute condoms and oral contraceptives and refer pregnant women to clinics. This successful model is being replicated at PIH sites in Rwanda, Malawi, and Lesotho.
Each year in developing countries, 42 percent of all births occur without help from a skilled attendant, and 35 percent of pregnant women have no contact at all with health personnel before delivery, according to the United Nations Population Fund. Yet potentially fatal complications occur in 15 percent of all births. Because of this, it is critical that women deliver in or very near facilities capable of providing basic emergency obstetrical and newborn care. At PIH’s clinics in Haiti, high-quality obstetric care for pregnancy, childbirth, and emergency complications is available to all pregnant women. Each of PIH’s 12 facilities in Haiti is supported by six full-time obstetrician/gynecologists and 13 midwives who work across all sites. More work still needs to be done, however, as an estimated 70 percent of all deliveries in Haiti take place outside of health facilities.