partners in health

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Cancer Haves And Have-Nots: Care And Treatment In 2 Different Worlds

By Michael J. Misialek, M.D.
Guest Contributor

Imagine feeling a lump on your body, visiting a doctor, and then waiting seven months (if you’re lucky) to find out whether it is cancer.

This has been the reality for the vast majority of patients in two of the world’s most impoverished nations, Rwanda and Haiti — both emerging from different but unthinkably grim histories of structural violence.

But since 2012, more patients are getting the care that everyone deserves, no matter what country they live in. A medical partnership between several Boston-based hospitals has radically reduced turnaround time for cancer diagnosis, and shrunk the number of people who fall through the cracks.

It is difficult to quantify the exact numbers here, since record keeping in the past has been poor. One data point: In Rwanda, where these interventions are in place, far fewer patients are lost to follow-up after they’ve been treated compared to patients in other poor countries, according to Dr. Larry Shulman, senior vice president for medical affairs at Dana-Farber Cancer Institute, and leader of the medical partnership.

As a pathologist at of one of these partner institutions — Newton-Wellesley Hospital — I can’t help but think about the patient behind the slides under the microscope. Here’s one: Tushime, an 11-year-old Rwandan girl, who had a large tumor protruding from her jaw.

The tissue sample from Tushime’s tumor arrived in Boston in a suitcase carried by an employee of Partners in Health, the global nonprofit. Like all other specimens, hers was processed into a slide by the pathology department of Brigham and Women’s Hospital and read by Harvard faculty.

Tushime’s tumor turned out to be a rhabdomyosarcoma, a common childhood sarcoma. After 48 weeks of chemotherapy and surgery in Rwanda, she is now healthy and free of disease. Doctors there used standard chemotherapy for a cost of about $300 (which was covered by Partners in Health, Dana Farber and the Rwandan government). They relied on age-old, tried and true chemotherapy drugs; in comparison, the newer chemotherapy agents in the U.S. often cost several thousands of dollars.

Even though access to care has improved dramatically in the developing world there is so much work to be done. There are patients who still present with tumors at an advanced stage, many being neglected for months or even years because of barriers to care. There’s often a lack of access to facilities for both diagnosis and treatment, and funding for cancer care is limited. As a result, ordinary diagnoses become extraordinary.

This is an image of a less aggressive (low grade) breast cancer, something that is fairly common among patients in the U.S. You can see the well formed tubules and glands of cancer, but fewer tumor cells growing in a more organized fashion -- only about 30 percent of the image is tumor. (Courtesy of Michael J. Misialek)

This is an image of a less aggressive (low grade) breast cancer, something that is fairly common among patients in the U.S. You can see the well formed tubules and glands of cancer, but fewer tumor cells growing in a more organized fashion — only about 30 percent of the image is tumor. (Courtesy of Michael J. Misialek)

This is an image of an aggressive (high grade) breast cancer not uncommonly diagnosed among patients in countries where access to medical care is limited, such as Haiti. You can see a solid mass of cancer -- the photo is 100 percent tumor. (Courtesy of Michael J. Misialek)

This is an image of an aggressive (high grade) breast cancer not uncommonly diagnosed among patients in countries where access to medical care is limited, such as Haiti. You can see a solid mass of cancer — the photo is 100 percent tumor. (Courtesy of Michael J. Misialek)

Under my microscope, I’ve seen some of the most aggressive appearing tumors from patients in these countries. What are typically rare cancers here in the U.S., such as sarcomas or unusual variants of breast cancers, are all too common in developing nations. Continue reading

Partners In Health: In Ebola-Stricken Nations, People Are Dying — But From Other Illnesses Too

In this Tuesday, Oct. 21, 2014 file photo, a man suffering from the Ebola virus lies on the floor outside a house in Port Loko Community, situated on the outskirts of Freetown, in Sierra Leone. (Michael Duff/AP)

In this Tuesday, Oct. 21, 2014 file photo, a man suffering from the Ebola virus lies on the floor outside a house in Port Loko Community, situated on the outskirts of Freetown, in Sierra Leone. (Michael Duff/AP)

Among the groups on the forefront in the international effort to address the Ebola crisis in West Africa is Boston-based Partners in Health (PIH). The group is promising to keep staff and volunteers in Liberia and Sierra Leone for several more years to fight Ebola and address other public health concerns in those countries.

Helping to lead the PIH initiative is chief nursing officer Sheila Davis, who returned to Boston earlier this month and remains largely confined to her home in Roslindale.

She joins Morning Edition Wednesday to talk about how the ongoing crisis reveals how vital public health infrastructures are.

Interview Highlights

Sheila Davis: Many times more people are dying, not because of Ebola, but because of this weakened health system. So even the facilities that have been open to provide care for other things — such as malaria, safe child birth — those in most counties are closed. So more people are dying, because they’re not being able to get health care for other, non-Ebola reasons.

A lot of the attention to both countries has been just treating the acute Ebola. But, if we don’t work at the same time to build up this system, we’re going to see these acute outbreaks or hotspots for quite a long time.

On whether PIH had any idea how serious the Ebola outbreak would become: 

SD: I don’t think we did. The first cases we heard about in probably March, April or May. Like all of the other previous Ebola outbreaks, the thought was it would show up and it would be quickly gone and a few hundred cases would be there worldwide, and we would stop hearing about it very quickly.

And then, during the summer, when we were hearing more and more about cases being found in Liberia, Sierra Leone, Guinea, we had two smaller nonprofits that we worked with in those areas, and we had been in contact with them. And they, as well as the governments of Liberia and Sierra Leone, asked us to come in and help.

Continue reading

Related:

Gottlieb Leaving Partners HealthCare For Partners In Health

Partners CEO Dr. Gary Gottlieb

Partners CEO Dr. Gary Gottlieb

The CEO at Partners HealthCare, the state’s largest private employer, plans to step down.

Dr. Gary Gottlieb agreed Friday to become the CEO at Partners in Health, a global health organization whose latest project is an Ebola response effort in West Africa.

Gottlieb is scheduled to make the transition on July 1, 2015. His decision comes amid acourt review of Partners’ controversial expansion plans and questions about Gottlieb’s ability to manage political dynamics outside the hospital network.

His supporters point out that Gottlieb has just begun his second five-year contract, and they say Partners board members urged Gottlieb to stay. But some current and former Partners leaders say dissatisfaction with Gottlieb’s leadership has been building for months and that the Partners in Health job offers Gottlieb a graceful way out.

He will take a dramatic pay cut, from more than $2 million a year to $200,000 a year at Partners in Health.

Gottlieb serves on the board at Partners in Health, has visited the group’s projects in Haiti and Rwanda, and calls it the most important global health initiative in the world.

“This is a singular opportunity to lead that organization at a time when it is clear that improving sustainable health care throughout the world is critical to all of us,” Gottlieb said.

Gottlieb says he began thinking seriously about moving to Partners in Health this summer, and decided to make the change earlier in the fall after hearing Partners in Health co-founder Paul Farmer describe what was happening in West Africa.

“With Ebola, maternal deaths had increased because there was no place for people to deliver babies,” said Gottlieb. “Malaria deaths had increased because there was no way to provide the appropriate care for what is a more ordinary terrible disease. The notion that building sustainable health care was essential for real social justice and real change had become even more obvious.” Continue reading

Boston-Based Partners In Health Leaps Into Ebola Crisis

Members of Partners in Health work with representatives from Liberia and Sierra Leone via conference call to help combat the Ebola outbreak. (Jesse Costa/WBUR)

Members of Partners in Health work with representatives from Liberia and Sierra Leone via conference call to help combat the Ebola outbreak. (Jesse Costa/WBUR)

An advance team from Boston-based Partners In Health heads for Ebola-stricken Liberia Monday. Four doctors, including co-founder Paul Farmer, and two operations staff will lay the groundwork for an ambitious two- to three-year project that will require well over 100 volunteer doctors, nurses, lab techs and public health workers. The budget for just the first year is $35 million.

“We are at a dangerous moment with Ebola,” said Farmer as he prepared for the trip. “Even though this is a huge jump for PIH, I am confident we will succeed.”

PIH will work with two established groups, Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone, to strengthen existing public health clinics and train several hundred new community health workers. In addition, PIH will open two 50-bed Ebola treatment centers in rural areas of each country.

The plan began to take shape last week, as the World Health Organization reported a near doubling of Ebola cases in Liberia and an estimate from Columbia University projects 30,000 cases by mid-October if conditions in the country deteriorate.

“There’s more doctors on a single floor of the Brigham than in the entire country of Liberia.”

– PIH's Paul Farmer

In the colorful offices of PIH, decorated with art from countries where the group works, some staffers are flashing back to 2010 and the weeks following Haiti’s earthquake. Ebola is creating another humanitarian crisis, one that is unfolding right before their eyes.

The call for volunteers went up on PIH’s website five days ago. More than 100 people responded within 24 hours, but it will take some time to determine if the skills of applicants fit the needs of these rural Ebola treatment and isolation units. PIH is trying to screen potential recruits quickly. It plans to send a first round to a training run by the Centers for Disease Control next week and open the centers by mid-October or early November.

“To do this right, we will depend on people who are willing to fight against this terrible crisis,” said Joia Mukherjee, chief medical officer at PIH. “The reason we will need a lot of non-Liberians, non-Sierra Leoneans — these countries simply do not have enough doctors and nurses.”

“There’s more doctors on a single floor of the Brigham than in the entire country of Liberia,” added Farmer, who is also chief of the Division of Global Health Equity at Brigham and Women’s Hospital.

He hopes to tap the medical wealth of Boston for the Ebola project, but the PIH board has demanded that a plan to treat and evacuate sick volunteers is in place before the operation begins. Farmer and Mukherjee are talking to the U.S. Department of Defense and other possible partners about transportation and care options.

A fourth doctor in Sierra Leone died Saturday, bringing the total number of health care worker deaths in Liberia, Sierra Leone and Guinea from Ebola to 150. Continue reading

Jim Kim: World Bank President, Astronaut Rapper

I’ll admit it, I’m a biased, pro-Jim Kim groupie.

Ever since I sat in on a Harvard class with Kim and Paul Farmer in which they recounted stories about treating people with drug resistant tuberculosis in Peru and in Russian prisons, the historical factors driving HIV/AIDS in Haiti in those early years, the gritty mechanics of health care delivery and the deep connections between poverty and disease, I’ve been awed by their incredible dedication to the idea that health is a human right. It’s impossible not to be.

So it’s pretty cool that Kim was elected Monday as the World Bank’s next president.

But Kim does have a lighter side: See him as a rapping astronaut here on YouTube.

Here’s more on his global health accomplishments from the folks at Partners In Health, the international health non-profit Kim co-founded 25 years ago:

“I can think of no one better able than Jim to help families, communities, and entire nations break out of poverty, which is the mandate of the World Bank,” said PIH co-founder and Harvard University Professor, Dr. Paul Farmer.

As a physician and medical anthropologist, Dr. Kim’s mission to serve the poor has led him from Haiti to Peru to Lesotho and beyond for nearly three decades. He and Paul Farmer met as medical students at Harvard and joined with Ophelia Dahl, Thomas J. White, and Todd McCormack in 1987 to found Partners In Health. Continue reading

Case Studies, Now Online, Grapple With Global Health Dilemmas

For anyone interested in global health, fixing big problems in poor countries or just getting a sense of how the folks at Harvard Business School think, check out these newly accessible, free (for students and educators, at least) case studies that deal with thorny health care delivery dilemmas in poor regions of Rwanda, India, Haiti and throughout Africa.

The 21 studies range in scope and geography, for instance, Multi-Drug Resistant Tuberculosis Treatment in Peru (a classic) to Botswana’s Program for Preventing Mother-to-Child HIV Transmission.

The case study model was pioneered at Harvard Business School to help students simulate a decision-maker role in examining various issues in the financial and corporate world. But a few years ago, the renowned doctors and medical anthropologists who launched the non-profit Partners in Health — Paul Farmer and Jim Kim, now president of Dartmouth — began to apply the case study method to public health problems in poor countries in collaboration with Harvard Business School’s Michael Porter.

Medical and other students needed some kind of out-of-classroom experience dealing with health issues among the poor, the thinking went, and short of getting on a plane, the cases provided detailed, real-life problems — and in some cases, solutions. And though some of the studies might appear dry — perhaps you’re not fired up about Building Local Capacity for Health Commodity Manufacturing: A to Z Textile Mills Ltd. — I’ve had the privilege of sitting in on classes with all three of these guys and I can say it’s truly inspiring and intellectually gripping. Never, ever dry. (In fact, the A-Z Textile case study is the amazing story of a local Arusha, Tanzania maker of insecticide-treated bednets to prevent malaria and the misaligned incentives that brought them, sadly, down).

All 21 cases were developed jointly by the Global Health Delivery Project, a collaboration between Harvard’s medical and business schools, the Brigham & Women’s Hospital and Partners In Health.

Paul Farmer On The Haiti Earthquake

A young Haitian girl with cholera symptoms

The world gave a collective gasp of horror 18 months ago when word came of the devastating earthquake in Haiti. Now Paul Farmer, the doctor whose name is synonymous with bringing better health care to Haiti, has written a book on the aftermath, “Haiti After The Earthquake.” It’s described as “Paul Farmer’s written account of the earthquake, the root causes of the devastation it wrought, and the relief and recovery efforts of Haitians and those who came to their assistance.”

He’s scheduled to talk about it on “Fresh Air,” aired on WBUR today at 1 p.m., and his Boston-based organization, Partners In Health, just sent word that the staff would be running a five-week summer reading and discussion series on the book, here.

Dr. Evan Lyon of Partners In Health writes:

In the book, Paul and co-contributors—among whom I feel privileged to count myself—reflect not only on the lives saved and lost, on the challenges encountered and overcome, but also on the century of underdevelopment and internecine politics that have plagued Haiti. Continue reading

Cholera In Haiti: Cases Stabilize But Conditions Remain Desperate

A young Haitian girl with cholera symptoms

In a conference call with reporters today, Parters In Health Haiti Chief of Mission, Dr. Louise Ivers said while the number of cholera cases appears to have leveled off, the conditions in the capital, Port-au-Prince remain dire. For instance, she said, people still lack access to clean water, and unsanitary conditions are rampant. “People are in desperate situations,” she said, with up to 1.2-1.5 million people living on the streets in camps in the capital, displaced after January’s massive earthquake. Dr. Ivers confirmed the total number of cholera patients is over 3,000, with 253 deaths. Five cases have been confirmed in Port-au-Prince.

At PIH’s medical facilities, she said, there has been, on average, a steady population of 400 patients a day requiring hospitalization. But, she added, “the number (of patients) has been about the same for the past few days. “There hasn’t been a dramatic increase or decrease,” she said, and the organization is “seeing slightly less severe cases; more people are going to hospital for services when they are more ambulatory.”

She said PIH is working with community health workers, the Haitian Ministry of Health and Doctors Without Borders to conduct a widespread community education and mobilization effort to get the message out about hand-washing and using clean water and toilet facilities. The groups are also distributing water purification packets and oral rehydration salts. But with “no plan to truck in clean water,” there is still the potential for the epidemic to worsen, she said.

She said the Ministry of Health has a three-part plan to deal with sick patients. It will:

— Set up a post where people have have quick, easy access to oral hydration solution
–Establish a center for intravenous hydration
–Send patients with more severe diarrea and dehydration symptoms to treatment centers

When asked what the chances are that the epidemic could hit Port-au-Prince and spiral out of control, Dr. Ivers said it is still possible that the epidemic could be contained. “I don’t think it’s inevitable there will be a more widespread outbreak in the capital,” she said. “But I think it is inevitable there will be more cases.”

Still, with so many transient families living in the densely packed camps, with limited access to soap, clean water and proper toilets, at this point, public health officials tell NPR, they are preparing for the worst.

Cholera Outbreak In Haiti: An Update From Partners In Health

A Haitian child suffers from cholera symptoms

Boston-based Parters In Health Haiti Chief of Mission Dr. Louise Ivers and PIH Chief Medical Officer Dr. Joia Mukherjee will be on a conference call today at 3 pm to discuss the cholera epidemic that has broken out in the Lower Artibonite region of Haiti, where the organization operates three hospitals in partnership with the Haitian Ministry of Health. PIH is now mobilizing in the camps in Port au Prince, where five cases of cholera have been confirmed so far.

CommonHealth will post an update following the conference call this afternoon.

PIH reports: “As of Sunday more than 3,000 cases and over 250 deaths had been reported. Hôpital Saint Nicolas in St. Marc, which PIH operates in partnership with the Haitian Ministry of Health hospitalized 300 patients on Sunday. Every day hospital patient management improves. PIH and its partners have rushed clinical reinforcements and supplies to the region and have mounted a massive community education and mobilization campaign. Community health workers are fanning out throughout the area to distribute oral rehydration salts and soap and to warn people of the need to drink only clean or purified water and wash their hands frequently—the two keys to preventing further spread of the disease.”