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Harvard Public Health Review/Summer 2002


Partners in Peru

Liliana Teves's ten-year-old son had never known his mother without the bloody cough and night sweats that came with her tuberculosis. Although she was a patient in Peru's national TB program, one of the best in the world, her disease was unresponsive to drugs; it progressed relentlessly. Just last year, Teves weighed only 73 pounds and was too weak to get out of bed. "These patients were termed 'hopeless.' They didn't even have access to palliative treatment. They were just sent home to die," says Dr. Mercedes Becerra, SD'99, an epidemiologist with Partners In Health, a Boston-based non-profit health organization. "The international health community had decided that multidrug-resistant tuberculosis was not cost-effective to treat. In Peru, like most poor countries, it was a death sentence."

Partners In Health (PIH) was founded in 1987 by Harvard Medical School's Paul Farmer and Jim Yong Kim, among others, to tackle the health crises of the world's poorest and sickest communities--problems typically regarded as insoluble. Not surprisingly, its mission has drawn a number of Harvard School of Public Health graduates into its fold. In 1995, PIH initiated a treatment program for multidrug-resistant tuberculosis (MDR-TB) in a vast, impoverished district of Lima, Peru, called Carabayllo. It wouldn't be long before a few dedicated alumni made their way to its dusty shantytowns. "We've had very good success in this region, curing 90 percent of all patients," says Carole Mitnick, SD'00, a PIH epidemiologist who began working in Lima while still at the School. She and her colleagues attribute their exceptional results to the way PIH treats all aspects of the disease, supplying housing, employment, food, moral support, in addition to superior care. The group also has a unique structure that contributes to its ability to achieve both clinical success and policy impact.

"It's clear that multidisciplinary collaborations are simply the most effective ways to achieve the extraordinary health outcomes we seek," says Mitnick. A visit to the PIH "casa" in central Lima shows a snapshot of the team. On a night last March, four of the Boston-based staff, frequent visitors to Lima, gather around the folding metal table in the main room. The clock says 1 a.m., and the doors to the dormitory-style rooms--bunk beds and a closet--are open to help dispel the heat of the day. The discussion is lively and charged with an electricity that promises to keep this group awake far into the morning. They personify the breadth of PIH's structure: epidemiologists, clinicians, and an anthropologist. Their conversation leaps: strategy for pushing through drug acquisition policy at an upcoming summit; protocols for an epidemiologic study; smoothing over the finer points of a complex medical procedure for a young MD.

"The makeup of the team at PIH gives us the ability to think critically about how social inequalities affect the health of the poor," says Dr. Arachu Castro, MPH'98, an anthropologist with PIH. "And with our multidisciplinary approach, we act at many different levels, from providing direct care to patients to developing public health projects, to training students and professionals, and to shaping international health policy." The Gates Foundation awarded PIH a multimillion dollar grant to expand and document the Peru MDR-TB program by 2005, making it a replicable standard worldwide. Castro explains the public health element of this success: "The operational research component of the social scientists is critical--understanding how workers in different communities operate, how directly observed therapy can build infrastructure in very poor rural or poor urban settings." Dr. Michael Rich, MPH'00, a clinician, adds, "We wouldn't have gotten the Gates money if we hadn't documented our work from an epidem-iologic point of view. People around the world are saying, 'Show me the data; show me it's cost effective.' The data prove the 'untreatable' patients are treatable, that this program can work."

PIH's policy success goes far beyond the Gates grant. "It wouldn't be an overstatement to say that PIH had a role in the WHO decision to change the standardized Category 2 regimen for TB. Our arguments, based on research in Peru and several settings in the former Soviet Union, showed how bad things were," says Mitnick, speaking of a turnaround in global policy that many regard as a milestone in TB care. "We're a small organization but our multidisciplinary structure gives us an incredible ability to effect policy change." PIH also played a role in the formation of the Green Light Committee, which was formed to acquire second-line TB drugs--critical for the treatment of MDR-TB--at a fraction of their market price.

Castro points to the breadth of training of the PIH individuals themselves as another key to the team's effectiveness. In addition to her master's in public health from the School, she holds PhDs in anthropology and sociology. In one project, she coordinates PIH's work with the Pan American Health Organization, providing a foundation for health policy in infectious disease. "My combined training in anthropology and public health is an immeasurable help in this work," she says. Rich is another dual degree holder. He was a doctor at a community health clinic in Lynn, Mass., and ran a TB program in Uzbekistan with Médecins Sans Frontières before coming to the School in 1999 for his MPH. "Public health training helped me understand that while the priority is to treat the patient, I can learn from the patient to help save a larger group. It's helped me make a larger use of my abilities."

On a broader scale PIH has been a model for collaboration, not competition, between medicine and public health. A recent affiliation between PIH and Harvard Medical School has forged unexpected bonds with the School of Public Health as well. A flood of epidemiologists and doctors from both schools train and work together around the world on PIH projects, and formal and informal partnerships abound. Some PIH staff--like Dr. Ed Nardell, former head of the Massachusetts State Laboratory Institute--hold joint appointments on both faculties. "Our objective is to provide one standard level of care to all people, to change the fundamental way health care is delivered to the poor," says Mitnick. "The poor have been systematically exploited and systemically disadvantaged; consequently, they deserve First-World-quality health care. This requires that we all work together."

As for Liliana Teves, her dirt-floored shack outside Lima is gone and her MDR-TB is on the way to a cure, thanks to efforts of all those who work for PIH. She lives in a well-ventilated apartment near the Hospital Nacional Sergio E. Bernales. She still needs to rest after doing even the most basic chores and some days vomits frequently from the side effects of the medications. But her family is clothed and well fed, and she is cared for daily by a community health worker. Her husband works for PIH as the gardener at its offices, and smiles easily now, while their kids laugh and play soccer in the dusty street outside. "Now I have support, and PIH is raising my spirit a lot," Teves says. "That's something I needed. And through that, my life is improving."

P. Alex Graham

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