The story of Partners In Health is the story of ordinary people with an extraordinary ambition: to make health care accessible for all.
What began in 1983 as a rural clinic in Haiti has grown into a global movement. PIH’s work has reached 10 countries, and five founders have paved the way for a staff of now 16,000. One patient and one clinic have become countless lives saved throughout 222 health facilities around the world. And a seemingly impossible mission has become proof that modern medical care can, and should, exist in the world’s poorest places.
This is the story of PIH—its founding and its future — and the movement we are all a part of.
Comments have been edited for clarity and brevity.
In 1983, Ophelia Dahl and Paul Farmer, not yet a medical student, met doing volunteer work in Haiti. They were invited by Pere Lafontante and his wife, Yolande, to work in Cange, a community of internally displaced peasant farmers. There they founded Zanmi Lasante — Partners In Health in Haitian Creole — along with friends Todd McCormack, Jim Yong Kim, and Tom White. Zanmi Lasante began providing health care in the impoverished village through a small community clinic. In 1987, in order to fund Zanmi Lasante’s work revitalizing the clinic and caring for patients, the group founded the Boston-based nonprofit, Partners In Health.
Dr. Paul Farmer, co-founder and chief strategist: In Mirebalais, which happened to be where I met Ophelia, there was only one doctor. I worked as his assistant, writing down names and checking vital signs. There was no staff, no basic things we needed, and no systems. The doctor told me, there’s got to be better ways to do this. And I thought, we should shut this down and start something else. Cange was in part a reaction to that first year living in Mirebalais and this fee-for-service, shambolic clinic with one brilliant, but unsupported, doctor.
Ophelia Dahl, co-founder and chair of the board: If you had gone to Cange in 1983, you did not have to be a social scientist to say, this is terrible. There is no option for health care, not enough food, no housing or school, nothing. Our reaction to that was relatively simple: We can do better than this.
Farmer: That really was worked out in the process of moving between places with affluence and scarcity. It’s really that juxtaposition. I’m in between Harvard and Haiti, going back and forth to Cange, and what it looks like to me is: we got stuff, staff, space, and systems; and they don’t.
Dahl: I remember going to visit Paul in Port-au-Prince, standing on the balcony with him there and looking down and having this overwhelming sense of complexity, sort of the idea that we could be so — it’s not arrogant, but that we thought we could make a difference. And Paul said very clearly, ‘We are going to Cange, where we already know people, and where we have each other. Let’s just see what we can do.’
Farmer: I didn’t have a well-thought-out plan — I was 23. We were idiots, right? But some understandings either came with us or came out of that year about how to do global health work. One thing we got right; we listened to people. We did surveys, we interviewed them. You learn a lot.
Todd McCormack, co-founder: I met Paul the first day of my freshman year at Duke. Before his trip to Haiti, he informed me casually that for 10 cents, he could plant a tree. He never explicitly asked me to give him money, though his message was clear: 20 trees in Haiti was a better choice than buying another $2 beer. Even before there was Partners In Health, I knew if I gave Paul a dime, it would get to Haiti and a tree would get in the ground. Looking back, it’s a great metaphor for the roots we wanted to plant — to let partners know we are going to stand by them and stay put no matter what might happen.
Dr. Fernet Leandre, chief programs officer for Zanmi Lasante: Before arriving at Cange, I did my social service year in northwest Haiti in a rural commune called Anse à Foleur. As a junior physician, freshly graduated, you were dumped somewhere where you have to do everything with nothing. And quickly I got frustrated and depressed every day because people were dying not because of lack of knowledge, but because of the lack of means at this public facility. I was looking for a place to practice where people could have access to at least a basic standard of health care. This is how I ended up in Cange.
Dahl: As soon as you put up even a tiny sign saying come and get your care here, everybody swarmed. Those were some of my earliest memories, being confronted very starkly with these terrible conditions and realizing, even as a 19-year-old with no skills, that something could be done. Which is not to say I could suddenly become an expert, but just making common cause and deciding that I would bring the fruits of my own privilege to a place where there was not enough.
McCormack: As Paul says, if you’re a doctor, and you’ve taken an oath to treat the sick, it’s not that complicated to ask, ‘Well, who are the sickest people?’
Leandre: We were only three physicians over there at that time. But there was a good lab, a functioning X-ray, and we could treat tuberculosis, HIV, and the other curable, preventable diseases in kids and adults. I would say what struck me was that people were desperately looking for care and came from far away, traveled for days, and sometimes spent the night at the facility to have full access to health services. I remember we used to see more than 500 patients a day in Cange.
Dahl: We knew that it wasn’t enough to build a one story building, but that didn’t stop us from having bigger ambitions, which is why we built all of our medical buildings with rebar sticking out. I think that that rebar philosophy, that we are never finished building and growing, is something that has stayed with us as we’ve become bigger, more professionalized, and established.
Inspired by the organization’s success delivering health care in Haiti, Father Jack Roussin invited his friends, PIH Co-founders Farmer and Kim, to start working in Peru in 1994, and the government of Russia invited PIH to do the same in 1998. Both Peru and Russia faced deadly epidemics of tuberculosis and multidrug-resistant tuberculosis (MDR-TB), a more severe form of the airborne disease. PIH began treating patients in Carabayllo, an impoverished slum of Lima, and in prisons and communities throughout Tomsk, Siberia.
Farmer: In 2000, we got word from the Gates Foundation that we were going to receive a significant grant to fight MDR-TB in Lima. Later, they allowed us to use it in Russia as well.
Dr. Jaime Bayona, former executive director of PIH in Peru: The cost of treating a patient with that diagnosis in New York City was $250,000. But even in Carabayllo, we never let treatment cost become an obstacle. The efforts of PIH staff to fundraise and provide all the necessary support for treatment was a lesson in pragmatic solidarity that I will never forget.
Dr. Sonya Shin, executive director for PIH in Navajo Nation: I went to clinics throughout Carabayllo asking about patients who might have MDR-TB and then went to seek out those patients in their homes. Some patients had already passed away, a few were skeptical that things would be different. Most were eager for treatment and grateful not to be forgotten. The early days had a tone of innocence and ambition. There was a sense of urgency and joy — joy in working together and the bonds of friendship.
Dr. Joia Mukherjee, chief medical officer: I started in Peru. The level of care and compassion and day-to-day support was really humbling. It taught me that whether a team member is a driver, cook, community health worker, physician — everybody contributes to a patient’s story and healing. One of our drivers back in the early days actually carried patients with MDR-TB out of their homes with a nebulizer machine trying to get them to breathe properly. This driver was at great personal risk, when many of the medical professionals in Peru wouldn’t even come near a patient like that.
Farmer: In Tomsk prisons in 1998, 24 percent of people on therapy for TB and MDR-TB were dying. This is a horrific situation for the former Soviet Union, where everything had collapsed. We were there saying, ‘We’re here to help get the staff, stuff, space, and systems necessary to combat this epidemic. It’s not about the political situation between the Russians and the Americans. It’s about people sick with this disease inside a prison.’
Dahl: That became the MO of PIH: We will go to the remotest places.
Zanmi Lasante was expanding in Haiti while PIH was expanding globally. Staff began treating HIV in Cange — setting new precedents for global HIV care — while revitalizing health facilities and providing care throughout Haiti’s Central Plateau and lower Artibonite.
Mukherjee: I came of age as an HIV activist, and I think to be in Cange, treating people who no one thought could be treated, and seeing them get as much better as my American patients had, was an absolutely thrilling experience.
Leandre: We received this big grant from the Global Fund, and began scaling up what we had been doing in Cange to other surrounding facilities like Thomonde, Boucan Carré, and Lascahobas. We started the new sites with young people who have been trained in our philosophy in Cange.
Loune Viaud, executive director of Zanmi Lasante: My fondest memories are the car meetings when on the road to our clinics, patients’ home, and the countless hours strategizing in those early days to accomplish what others always said was impossible. To do whatever it took to get people healthy so that they could lead normal, productive lives.
Mukherjee: What we are taught in medicine in the United States is a very biomedical model, that your responsibility ends in making the diagnosis and prescribing the right care. If it ends there, poor people will die. People in difficult social situations will die.
Dahl: Boucan Carré was on the other side of this river called, Fonlanfe, the like, “Depths of Hell.” It was almost a stream most of the time, and then in rainy season it became raging. It trapped people on the other side, particularly women in childbirth, and we could not get them across safely. There was no bridge, and building a bridge was a complicated thing. It required big institutions, governments, the department of transportation, engineers. But we said, ‘It doesn’t matter how many years its takes us, we are going to get this done.’ It took six years to put in a permanent bridge, and it was really an extraordinary effort of partnership. One of the things that sticks with me is our organizational drive to do everything that’s necessary to get people care. If you believe in access, that means getting a bridge built.
In 2003, Pulitzer Prize-winning author Tracy Kidder published Mountains Beyond Mountains, a book tracing the origins of PIH and the lives of its founders. The book introduced PIH to new audiences, strengthening the movement for global health equity.
Farmer: I met Tracy Kidder in Haiti in 1994. He was on assignment for The New Yorker writing about the American intervention in Haiti that year.
Tracy Kidder, author of Mountains Beyond Mountains: This guy was clearly interesting. What was he doing forsaking Harvard medicine and a cushy life in Brookline for this part of Haiti? After we first met, I didn’t see him again for six years. I think, in the back of my mind, I avoided getting back in touch for fear that it would disturb my peace of mind. You know, we get addicted to our comforts, and we like to imagine that we’ve earned them. That idea falls apart the minute you start to ask yourself, ‘What would my privileges look like if I had been born in Haiti, to a peasant family?’ At some point, I started hearing about him again, and I thought I should get back in touch. He was quite welcoming and invited me to travel with him for a month.
Farmer: He was a great student. Not so great as a traveling companion if you’re late for an airplane, which I always was.
Kidder: Ha! He was really quite nice to travel with, except that he did love to get to an airplane just before the gates closed. We went to Haiti, South Carolina, Haiti, Miami, Paris, and Moscow, and then back. What he called a ‘light month of travel’— just astonishing to me. I wrote a profile for The New Yorker. Then it was a question of waiting to see if Paul would give me access to go on.
Farmer: This conversation went on for years. If you’re really committed to the mission, you’re protective of it. I wouldn’t want any of my deficiencies to lessen the appeal of this mission, which is not about any individual. But we decided we’d give it a try. He was clearly willing to go on record with an in-depth piece saying, ‘This is what these folks are up against’ — particularly the patients and the people he met. He went to Russia. He went to Lima. He went everywhere with me.
Kidder: I didn’t set out to do a good deed. I just happened on what seemed like a really good story, and I tried to tell it as well as I could. There are a lot of things I saw and hoped to depict — resilience, courage, exposing the truth of the misery of the world, historical reasons for it. I think what most storytellers hope to do is to have you feel those things all over again, through the story that you’re telling.
Dahl: It’s a complicated story to tell, and I think Tracy did us an enormous service by doing that, by telling it as a story. Paul is extraordinary, don’t get me wrong, but there was a part of it that said this was not just one person’s quest. This was an enormous team of people that got together and realized they wanted to address the terrible conditions their fellow humans were living in. We knew in order to do it, it would be a long game and we would stick together through thick and thin.
McCormack: I always enjoy my time with Paul in Haiti. However, now Paul’s own work in Haiti is far less compelling than seeing the system he envisioned and helped build function independently from him. Given that Paul is such a compelling person, it’s easy to miss this important fact in the PIH story. Few leaders create structures that no longer depend on their leadership.
Mukherjee: I’m very humbled by the young people I meet who got interested through Mountains Beyond Mountains. They understand that the work is not about a person or an organization, but about justice or injustice. This is a generational phenomenon of young people saying we want a better world, a more feasible world, a safer world, a healthier world.
Dahl: We saw how many people were very interested in this story and in this work. That book was published 16 years ago, and I think what we had achieved then feels small compared to what we have achieved since then.
Mukherjee: The book ends in Bon Sauveur, a charity clinic in Cange, where there was great work going on. Since the book was published, we made a strategic decision to support the public provision of care. That’s when we became even more radical.
Throughout the early 2000s, more and more governments invited PIH into their countries. We’ve partnered with these governments to deliver and improve health care in poor, remote communities, and provide technical expertise on how to scale up these improvements nationally.
Farmer: It was never going to be just about Haiti. We wanted to go to places where there were zero hospitals and zero doctors.
Mukherjee: In partnership with governments, we support somewhere in the neighborhood of 222 public facilities around the world. I think it’s made our work incredibly complicated. It would be way easier to have 222 Canges — private clinics run solely by PIH — but it’s not the right thing to do to address injustice and achieve the right to health.
McCormack: How do you try to build a health system that outlives Paul Farmer, Ophelia Dahl, or Jim Kim? The ambition I am most proud of is that we never tried to make this about how we can only get more resources for just PIH. Our playbook for success is open source code. By sharing our model with partners and fighting for policy change to reflect best practices, PIH’s impact extends well beyond our own patients and the work of our team.
Bayona: Working on public health problems in direct partnership with governments is a way of guaranteeing sustainability. In 2000, the majority of funding for MDR-TB treatment in Peru was from abroad. In 2010, due to PIH’s successful intervention in controlling MDR-TB in the country, the Peruvian government adopted lessons learned and decided to take on 100 percent of the cost for fighting MDR-TB, so that the national budget went from $3.5 million in 1996 to more than $30 million in 2010.
Leandre: I remember when I started in Rwinkwavu in Rwanda. There was no functioning hospital. There was at most a health post or a dispensary. Nothing was working. Now, Rwinkwavu is a big hospital, staffed by Rwandans among whom some— at the beginning — were trained by our staff from Haiti.
Mukherjee: We have areas in Haiti, Malawi, and Lesotho where we have achieved universal coverage of HIV. That means everyone knows their status, and everyone who is HIV positive is on treatment.
Kidder: That’s been the most important thing to me about PIH so far. The proofs that it’s offered the world, that these things can be done. And this comes out of a context where a lot of people were saying it couldn’t be done. You couldn’t treat MDR-TB. You shouldn’t even try to bring AIDS care to Africa. What PIH has done is shown that it was nonsense — it wasn’t true.
In 2010, we once again tested the limits of what’s possible in global health care. When a 7.0-magnitude earthquake devastated Haiti, we responded by building a 300-bed teaching hospital in a community two hours north of the capital of Port-au-Prince. University Hospital in Mirebalais — where Paul Farmer once assisted the area’s only doctor — opened in 2013, offering high-quality, specialized health care to everyone and residency programs to the country’s next generation of clinicians.
Dr. David Walton, former chief operating officer of University Hospital: On the day of the earthquake, I got a call from my mom saying, ‘Where are you?’ and I said, ‘I’m in Boston.’ She said, ‘Oh,’ because she never knows where I am. And she said, ‘Your brother said there was an earthquake in Haiti.’ I said, ‘There are no earthquakes in Haiti.’ And then, you know, things changed from there.
Mukherjee: After the earthquake, there were really difficult times, but incredible spirit. We had teams from Ireland, the United States, Canada, Switzerland, Israel, and of course Haiti. It was a remarkable kind of international solidarity for Haiti, which we hoped would last forever.
McCormack: PIH is not a disaster relief organization, but because people did a little research on who is doing great work in Haiti, a lot of people gave to us after the earthquake. I think they knew we wouldn’t just try and deal with the immediate bandaid that needed to be put on so many wounds, but also work with the government and build back systems better.
Farmer: The teaching hospitals of Haiti were all just destroyed. Building University Hospital was clearly a priority for the Haitian people. So when someone would say, ‘Well, it’s not a ranking priority to have a teaching hospital after the earthquake,’ someone had to say, ‘Are you kidding? If it’s not a ranking priority now, when will it ever be?’
Walton: It’s three years of a complete blur. One hundred and twenty-hour weeks for three years straight. There are so many stories, so much craziness. We started construction, and cholera broke out about two kilometers from our construction site. There was election violence during the hospital construction. There were innumerable challenges. Despite that, we did all kinds of things that were never done before. Was it hard? Of course it was hard. But we continued to say, ‘We’re going to do it.’ The same page of the same playbook PIH used for years around MDR-TB and HIV.
Viaud: We have been part of a process that has saved millions of lives, that has assisted individuals and families to lead productive lives, even in the face of HIV/AIDS or TB. Children have been born who would have otherwise died. We have figured out ways to train generations of Haitians in medical sciences in the most impoverished areas of Haiti.
Walton: It makes me proud every time I think that University Hospital is there, and that PIH has leveraged it in the way that it has. We’ve capitalized on the infrastructure by doing incredible things around teaching and training. The majority of residency graduates who train at University Hospital are going to stay in the country. I’m convinced that most of them are staying because they were trained in that facility, and they see what is possible. And that is, I think, an extraordinary gift.
PIH currently works in Haiti, Peru, Mexico, Rwanda, Malawi, Lesotho, the Navajo Nation, Kazakhstan, Liberia, and Sierra Leone. From a small clinic in Cange to these 10 countries around the world, PIH’s scope has expanded, but our core belief has remained the same: Health care is a human right.
Mukherjee: The great thing about my first 20 years at PIH is that we won these massive battles to provide care for HIV, tuberculosis, child health, maternal health. Now we need to take that a step farther. And the step farther is universal health coverage — that everyone should have a right to basic health care, secondary health care, surgery, real things that save lives.
McCormack: A family is a great metaphor for PIH. In fact, it is even explicitly referenced in the PIH mission statement to help us think about how to respond to the challenges we face. Of course, we value planning and fiscal responsibility, but we also need to respond to those who are sick, “just as we would do if a member of our own families were ill.” That is much easier to say than to put in action, but it is what differentiates PIH and makes us do things that at the outset don’t seem “cost effective.”
Shin: I believe the health care profession can truly be transformed if the next generation of leaders and health care providers is trained in a way that incorporates the moral imperative to achieve health equity, and equipped with the tools and knowledge to address inequality at a systems level.
Dahl: It’s really about creating a pipeline of human beings and investing in them and training them as we were invested in and trained. When you think about how much it costs to train someone, it is paltry compared to the catalytic effect of that investment.
Mukherjee: We need a much bigger team. It can’t be the work of a handful of people. It can’t be a few Americans or a few Haitians. It’s gotta be a massive number of people, internationally of every walk of life. There’s so much space for people to be involved in this movement to provide health as a human right. Social justice is a team sport.
Leandre: The goal is to fill the gap in the health system by training the new generations of specialists to address the global burden of disease. The new burden of disease that I see PIH focusing on is mental health and noncommunicable diseases. But we won’t forget our backbone as an institution, which is community-based health care with a focus on well-trained community health workers.
Dahl: We should continue making sure that we are as ambitious as we were in 1985, that we are still pushing the boundaries and making sure that there is enthusiasm for global health.
Walton: We have a lot to do that can be more transformative in the places we’re already working. University Hospital is amazing and precedent-setting, but what we’re doing there is not rocket science. There should be a University Hospital in every single region in Haiti. There are five Mirebalais-like hospitals within a stone’s throw of my own house in Boston.
McCormack: This is a central challenge for this generation; the growing gap between the well-to-do and the poor. People think poverty is a given, and it’s not. People will look back at us 200 years from now and say, ‘How did we let 4 million people die from infectious diseases that rich people have been free from for decades?’ We should be charitable and support our schools and our civic and religious institutions, but this work for me is more of a moral imperative. We have to be on the right side of history and all get engaged with this issue. For me, PIH provides a proven conduit for that engagement.
Mukherjee: I will never forget a man I saw two years ago in Liberia who died of a broken leg. He was a father of five. He got into a minor motorcycle accident, broke his leg, and died because he had no access to simple orthopedic care. He had an open fracture, a very small piece of the bone coming out of the skin, but he died of gangrene. That should be considered unconscionable in the 21st century.
Farmer: Some people feel we’re trying to do too much or move too fast. But it’s not true to say we’re trying to do too much for the poor. No one’s tried to do too much for the poor, the destitute, the sick.
Kidder: I sometimes wonder why the world appears to be ruled by violence, chaos, idiocy. Ever since I happened on to PIH, I’ve taken comfort that there are effective counterforces out there. As Paul might put it, there’s no data to suggest they’re going to win this contest, but that doesn’t matter. What matters is that they’re there. And they are effective and admirable. And for some reason, that’s enough.
