Partners In Health (PIH)

Our mission is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, Partners In Health strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. We draw on the resources of the world's leading medical and academic institutions and on the lived experience of the world's poorest and sickest communities. At its root, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When our patients are ill and have no access to care, our team of health professi...
Oct 25, 2013

PIH Haiti Earthquake Recovery - Oct.2013 Update

Photo credit: Michelle Morse/PIH
Photo credit: Michelle Morse/PIH

Young Haitian Doctors Begin Medical Residencies at University Hospital

On April 28, Dr. Paul Farmer stood before a microphone in a large conference room in Haiti's University Hospital.

Several days before, bomb blasts at the marathon in Boston, Massachusetts, had killed three people, but not a single person who made it to a hospital died. In that grim emergency, teaching hospitals made a difference, Farmer told the crowd.

“I love working at a great Boston teaching hospital, Brigham and Women’s. I love being able to train the next generation of physicians and nurses. And I want Haiti to have something like it, too,” Farmer said.

This month, University Hospital in Mirebalais, Haiti, took a significant step toward becoming the teaching hospital envisioned after Haiti’s 2010 earthquake, which devastated the country’s already-fragile medical infrastructure. On Oct. 1, the hospital’s first medical residents—all young Haitian doctors—began hands-on training in pediatrics, general surgery, and internal medicine.

The application process was intensive and merit-based: 238 people applied and took an entrance exam. Of those, 45 were interviewed, and 14 were selected. Class members hail from all over Haiti. Some studied at Haiti’s state medical school or private schools in Port-au-Prince; others went to the Dominican Republic. Some just graduated from medical school and completed their social service year; others have been practicing for a few years. By coincidence, the class is evenly split between men and women.

Dr. Jean-Louis Willy Fils, 29, from the northern city of Cap-Haïtien, has wanted to be a doctor for as long as he can remember. He describes surgery as his “true vocation,” so to be selected for a University Hospital residency was more than he hoped for.

“One year ago, I couldn't have even imagined learning surgery in a hospital with an international standard of quality, for the good reason that such a hospital didn't exist in the country yet,” Fils said. “That's the proof that great things can be done in Haiti.”

Over the next several years, these 14 doctors will receive instruction from Haitian and foreign physicians—some of whom are faculty at the same teaching hospital where Farmer trained and now teaches. The curriculum for their training was developed through special working groups and designed to follow the Accreditation Council for Graduate Medical Education International’s (ACGME-I) standards.

After completing orientation this month, residents will begin caring for patients as well as rotating in departments such as emergency medicine, TB/HIV clinic, and oncology. Each day, they will spend an hour in special education sessions for residents, and once or twice per week they will be on call throughout the night. They will also conduct research to improve the quality of care. The ACGME-I guidelines require they work no more than 80 hours a week, but they’ll probably come close.

"The residency program at University Hospital represents the most serious attempt, to my knowledge and during my lifetime, to systematically create a critical mass of Haitian physician specialists that will have the opportunity to be fully useful to all Haitians," said Dr. Pierre Paul, PIH senior advisor. He added that he and his physician colleagues have traditionally questioned the poor outcomes of Haiti's health sector, but now feel questioned themselves about their responsibility to improve health care in Haiti. "University Hospital and its new residency program stand as formidable evidence of the efforts that young Haitian health professionals are making to restore, in a sustainable way, hope and dignity in the future of health in Haiti."

As new classes of residents begin each fall, the number of physician trainees will double and triple. And the programs will expand to include other health professionals, such as nurse anesthetists and other nurse specialists, as well as more medical specialties—such as emergency medicine—which would be the first such training program in the country.

In addition to hands-on training, the curriculum includes lessons on social medicine and the root causes of disease, such as poverty, which have been part of PIH’s work since its early days in Haiti. The programs are designed to train and retain a new generation of doctors to the poor who work outside of Port-au-Prince, the traditional mecca for medical training.

“We envision a workforce of doctors, nurses, and other health professionals who are driven by medical excellence and committed to high-quality care for all Haitians,” said Michelle Morse, PIH deputy chief medical officer for Haiti. “The start of these residencies brings Haiti one step closer to this vision.”

Too little training, too few doctors

The American Medical Association describes the training for doctors in the United States as “lengthy.”

Four years of college. Four years at medical school. Up to seven years in a residency program and three years in a fellowship for specialists, who make up 95 percent of American doctors.

Add it up, and many doctors have had more than a decade of medical training. Much of it takes place through hands-on coaching from senior physicians in teaching hospitals with all the latest diagnostics and treatments.

In Haiti, one reason for needless sickness and death is the lack of trained professionals to provide health care. There are only 25 physicians per 100,000 Haitians. The United States has more than tenfold that number: 280 doctors for every 100,000 Americans.

In Haiti, half of doctors are generalists who have completed medical school and a social service year but no specialty training. Each year, about 450 graduating doctors compete for only about 150 residency positions.

Those residencies allow Haitian doctors to become specialists in fields such as internal medicine and pediatrics, but even those additional years of training are wanting. Most residencies are based in hospitals that are ill-equipped and under-staffed, with limited supervision by experienced doctors. Attending physicians are underpaid, leading many to spend their time in private practice, instead of teaching physician trainees.

PIH conducted a survey of Haitian residency programs to better understand the country's medical education needs. The survey found that 55 percent of residents don’t have Internet access at the hospitals where they work, and 80 percent of the programs do not have an exit exam for residents.

“These residencies are operating in hospitals that are severely short on resources, from staff to equipment,” Morse said. “University Hospital has electronic medical records, an emergency department, a CT scanner—it allows us to have a whole new level of quality care and training at a hospital with the appropriate resources.”

Double brain drain

The lack of opportunities leads many young Haitian doctors to seek training and employment in other countries, causing a brain drain in the health workforce. A staggering 80 percent of all physicians trained in Haiti leave within five years of graduation to practice abroad. Of the doctors who stay in Haiti, most practice in Port-au-Prince, which makes it difficult for rural people to access care. The medical education programs at University Hospital aim to slow or even reverse that double brain drain—from rural to Port-au-Prince or abroad—by encouraging talented young doctors to train in Haiti and stay there to practice medicine.

Dr. Ketly Altenor, 27, hopes to return to St. Marc, Haiti, to practice medicine. Growing up there, Altenor lost her father at 12 years old, and her mother supported the family as a street vendor. Despite her family’s poverty, Altenor excelled in school and earned a competitive spot at the state medical school. She graduated with the support of a scholarship from the nonprofit Haitian Education and Leadership Program, which provided housing, a stipend, and mentorship. She was accepted into the pediatrics residency at University Hospital after graduating from medical school.

“After my training I intend to return to work in my hometown, where there aren’t enough pediatricians,” Altenor said. “I will try to extend pediatric care to remote areas of the Artibonite region. I want to work in social medicine and really help people.”

Though University Hospital’s medical residencies are just starting, other training activities have occurred since the hospital opened. Since Farmer delivered his talk, or “grand rounds,” to inaugurate medical education at University Hospital, staff have participated in daily continuing education sessions to improve care, from training on using ultrasound to sessions to help faculty become better teachers.

As Farmer said, “University Hospital was built to be a teaching hospital because the hypothesis, here, is that the quality of medical care will be improved whenever training and research—the ‘feedback loops’ that allow us to learn—occur in tandem with compassionate care.”

Oct 9, 2013

Help PIH Respond to Cholera - Oct. 2013 Update

Photo: Jon Lascher/Partners In Health
Photo: Jon Lascher/Partners In Health

Research on PIH Cholera Vaccination Project Released in Journal

Posted on October 09, 2013

Research reporting the results of Partners In Health’s cholera vaccination project in Haiti was released today in a special section of The American Journal of Tropical Medicine and Hygiene.

The journal’s October issue, released just before the third anniversary of the cholera outbreak on Oct. 19, 2010, features a variety of public health research on cholera in Haiti.

As part of the special section, PIH Senior Health and Policy Advisor Dr. Louise Ivers and colleagues discuss the results of PIH’s rural cholera vaccination campaign in early 2012. The demonstration project was executed in collaboration with Haiti’s Ministry of Health and sought to vaccinate two vulnerable communities in the Artibonite region and build support for using the vaccine more broadly.

“Vaccines should not be viewed as a silver bullet that can subdue cholera in Haiti,” Ivers said. “But wider use of them, such as in campaigns targeting particularly vulnerable populations, can play a meaningful role in protecting people from illness and death.”

The journal article explains the project’s design and successful results. A total of 45,417 people in two communities received at least one dose of the two-dose vaccine, representing 77 to 93 percent of the targeted population. Even more, 91 percent of people who received the first dose also received the second, an excellent completion rate.

Another article reports the results of a similarly successful campaign in Port-au-Prince, conducted by the nonprofit health care organization GHESKIO.

These projects proved that delivering the vaccine in the midst of an epidemic was possible in Haiti. The evidence contributed to the World Health Organization’s recommendation in 2012 to expand access to the vaccine in Haiti and the Dominican Republic.

Ivers said that community involvement was critical to the project’s success. In advance of the vaccination, community health workers conducted a census of the community and registered people to receive the vaccine. PIH and our Haitian sister organization, Zanmi Lasante, also worked with community leaders to ensure support of the campaign. Ivers said it wasn’t hard to convince community members to be vaccinated because they knew the danger through personal experience.

“We interviewed people in focus groups before the vaccination campaign and they had very emotional stories to tell about their experience with cholera,” Ivers said. “So it was not a far-off, distant issue, but a real and immediate threat.”

Sep 11, 2013

Maternal Mortality Reduction - Sept. 2013 Update

Photo credit: bec rollins
Photo credit: bec rollins

Patient Profile: Risking Death to Give Life

When Parters In Health/Lesotho (PIH/L) staff found Matsepiso (pictured above), she had barely survived 36 hours of obstructed labor at home without a skilled health care provider. Her pelvis was broken, her baby was dead, and she had developed an obstetric fistula—an abnormal opening—which not only prevented her from moving, but also caused her partner to reject her. Matsepiso was alone, and her life was ruined at age 19.

What Matsepiso needed was a proper hospital with surgeons, an operating theater and anesthesia, antibiotics and a blood bank, but there was no such thing anywhere near her village.  After complicated negotiations with hospitals closer to Lesotho, PIH/L was able to arrange for free treatment in an Ethiopian hospital (an 8 hour trip by plane), where she remained for treatment for one year.

Matsepiso returned to her village and has since given birth to a healthy baby.  Furthermore, she joined our team of community health workers, working with PIH/L to provide high-quality maternal care to prevent such injuries from happening again. 

We cannot afford to medevac every woman who needs it, but we equally can’t afford for mothers to die in delivery, orphaning their other children to be raised—or not—by someone else.   This is why Partners In Health works to improve the system that failed Matsepiso, by make it safer for women to give birth in the first place: by offering family planning services and comprehensive pre- and postnatal care, by getting women to clinics to deliver their babies, and by providing access to emergency obstetrical care so when a narrow young woman like Metsepiso is in difficulty, a doctor can intervene, save her life and save her child.

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