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Fellowship Report (2004)



Fellow: Quy Ton

Fellowship Site: Lima, Peru; Boston, MA

Brief History of Organization (founding and salient steps):

Partners In Health (PIH) was founded in 1987, two years after the establishment of the Clinique Bon Sauveur in Haiti. PIH co-founders had been working in the area for years, and its presence has only grown since then. In the last 15 years, PIH has expanded its operations to 5 more countries and a number of new initiatives.

Since 1994, Partners In Health has been working with sister organization Socios En Salud (SES) in Lima, Peru, to train local community members in preventive care and treatment measures, to screen local residents for infectious diseases and other disorders, and to treat those in need. Three years ago, Socios En Salud became the hub of a multinational tuberculosis treatment project funded by the Bill & Melinda Gates Foundation through a grant to Harvard Medical School. In 2002 the project completed its expansion to all five districts of Lima. Over 800 patients are currently under treatment. Two hundred patients have completed treatment with a full cure.

Increasing numbers of patients required more infrastructure and staffing. The Socios staff grew considerably in 2002, now numbering 400 with volunteers. Larger-volume drug purchases and inventories necessitated the rental of a new storage warehouse. But more rapid diagnosis, and improved treatments have provided significant economies of scale, with a consistently high quality of outcome: the average cost of a two-year MDR TB regimen is down to $2,100 per patient, and is as low as $500 for patients whose disease is diagnosed and treated in a timely fashion. Program improvements are being studied and are spreading within the Peruvian Ministry of Health.

Based on the collaboration with Socios En Salud and the Ministry of Health, the government of Peru was awarded $26 million from the Global Fund to Fight AIDS, TB and Malaria earlier this year to continue expanding its care of patients with drug-resistant TB. This was a tremendous endorsement of the dedication and accomplishments of all the partners on this project. As Peru prepares to invest these resources in effective TB care, SES will continue working with the Ministry of Health and with physicians, nurses, and outreach workers throughout Peru who have been trained in the clinical and program methods first developed Haiti and then in the squatter settlements of Carabayllo. The continued support for this project provides hope to poor patients with drug-resistant TB in Peru and demonstrates that complex health interventions are possible in poor settings throughout the world.

Responsibilities/Duties/Tasks undertaken by the Fellow:

Clinicians and researchers at PIH and SES have been compiling increasing amounts of data on more than 1,500 patients receiving individualized MDR-TB therapy as part of a DOTS-Plus program that is expanding across the country. Last year, WHO’s Stop TB Working Group on MDR-TB concluded that identifying optimal standardized protocols to treat MDR-TB was a primary research priority. The data from Peru have already yielded a number of important publications addressing this priority.

I joined the research team at SES and PIH to contribute to the expanding literature on optimizing protocols to treat MDR-TB, particularly in resource-poor settings. I examined the role of adjuvant thoracic surgery among MDR-TB patients with bilateral disease. Patients with bilateral disease usually represent the sickest patients with MDR-TB, often those who were failing individualized chemotherapy regimens as evidenced by repeated positive sputum cultures. The decision to take these patients to surgery was based on the desperate clinical condition of patients and the clinical recognition by surgeons that chemotherapy alone would not be sufficient. Objective criteria for taking patients to surgery were lacking and risk factors for good or poor outcome after surgery needed to be identified to help clinicians better identify those patients with bilateral disease who would most benefit from surgery.

To help with this need, I conducted a historical cohort study by reviewing the charts of all MDR-TB patients receiving adjunctive surgery as part of the comprehensive DOTS-Plus treatment program in Lima, Peru. Included in the analysis were 41 patients with bilateral pulmonary lesions identified by pre-operative computerized tomography. Charts were reviewed thoroughly to identify patient demographics, clinical characteristics, surgical procedures and surgical outcomes to identify variables associated with poor treatment outcome. Data was collected via Access and univariate analysis was performed utilizing STATA software. A poster of the preliminary results of the study was presented at the 35th Union World Conference on Lung Health in Paris, France in late October. Currently, I am in the process of writing up the results of this study with the hope of submitting it for publication.

Conferences Attended:

Poster presented at the 35th Union World Conference on Lung Health in Paris, France from October 28 – November 1, 2004.

Other projects/works started or completed:

Worked with thoracic surgeons and assisted with surgical resection (lobectomy and segmentectomy) of a patient with MDR-TB.

How has your motivation for human rights work changed/altered or remained the same?

My motivation for human rights has increased due to this fellowship experience as my prior notions of what can help to increase the human right to health has expanded. I realized that research that highlights the effectiveness of interventions in resource poor areas can help show that these efforts are both effective and worthwhile.

After completion of your fellowship, how do you anticipate bringing your fellowship experience back home to your local community?

I hope to contribute to the expanding literature on optimizing protocols to treat MDR-TB, particularly in resource-poor settings by submitting the results with the hope of being published in a leading journal. After my time in Haiti, I hope to return to the University of Minnesota and share my experiences in Peru and Haiti by making presentations and displaying photos of my experiences at the school and at related health organizations.

Organizational Profile

Full Name of Organization: Partners in Health / Socios en Salud
Abbreviation and initials commonly used: PIH / SES
Organizational Address:
Partners In Health
641 Huntington Ave, 1st Floor
Boston, MA 02115
Telephone number: 617-432-5256
Fax number: 617-432-5300
Email address:
Names of Executive Director and Senior Staff:
Ophelia Dahl, President and Executive Director, PIH

Objectives of the Organization:

PIH coordinates innovative programs to combat AIDS and women's health problems in rural Haiti and urban Massachusetts, groundbreaking tuberculosis treatment projects in the prisons of Siberia and the shantytowns of Lima, and health policy initiatives on a global scale.

By establishing long-term relationships with sister organizations, PIH 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. In doing so, we draw on the resources of the world's elite medical and academic institutions, and on the lived experience of the world's poorest and sickest communities. Our staff of physicians, scholars, and activists tackles health crises deemed "unsolvable" and does whatever it takes to solve them.

The founders of PIH did not set out to establish an organization spanning three continents. We began in 1983 with a personal commitment to a few villages in rural Haiti, a country just 90 minutes from Miami by air. The principle that motivated us was simple: everyone, whether poor or affluent, deserves to benefit from the same high standard of medical care. Our first step was equally direct. We asked our Haitian colleagues what ailed them. The work that followed grew complex—not because our vision was complicated, but because the sources of their illness ran so deep.

The effectiveness of the community-based model developed by PIH in Haiti has been documented in many books and journal articles. We are now employing it in poor communities around the world, working with groups from the Peruvian and Haitian Ministries of Health, to the federal prison authority in Russia, to neighborhood activists in Boston.

At its root, though, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When a person in Peru, or Siberia, or rural Haiti falls ill, PIH uses all of the means at its disposal to make them well—from pressuring drug manufacturers, to lobbying policy makers, to providing medical care and social services. Whatever it takes. Just as we would do if a member of our own families—or we ourselves—were ill.

Domestic/International Programs:

Boston, MA: PIH headquarters, HIV Prevention and Access to Care and Treatment program (PACT), Program in Infectious Disease and Social Change (PIDSC)
Haiti: Zanmi Lasante, Clinique Bon Sauveur
Peru: Socios en Salud
Russia: Tomsk Oblast Project
Date of Information: November 2004
Information Supplied by: website, personal communication

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