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					  Panel on International Collaborations: 
   Perspectives from Haiti:1979-2008


                Jean William Pape MD
                     Professor of Medicine
   Division of International Medicine and Infectious Diseases
     Weill Cornell Medical College New York, NY, USA
    Director, Les Centres GHESKIO, Port-au-Prince, Haiti



Inaugural Meeting of the University Consortium for Global Heath 
  University of California, San Francisco, September 7-9, 2008 
      Health Challenges in Haiti

l Highest infantile and maternal mortality rate
l Highest prevalence of HIV outside of Africa
l Highest prevalence of TB in the western 
  hemisphere
l MDs/10,000 inhabitants, ratio = 2.5
l 4 medical schools:
  – 400 graduates/year + some from Cuba; 
  – 65% leave the country within 5 years of graduation   
l Annual health expenditure/person:  $US 8.0
   Mortality in infants with diarrhea in Haiti


State University Hospital
                                 National infantile mortality
    Haitian Study Group on Opportunistic Infections
    and Kaposi’s Sarcoma (GHESKIO) May 2, 1982
l Mission
     – Services, Training, Operational Research
          l   In Diarrheal diseases, HIV/AIDS, other STIs, TB, 
l Collaboration with 
     – US universities: Cornell, Vanderbilt, University of Virginia, Harvard
     – French Institutions: Institut Pasteur, Fondation Merieux, Universite d’ Amiens
     – Local institutions: Ministry of Health, Haitian Medical Society and > 120 
         public and private institutions 
l    Support 
     –   Care: USAID; GFATM; PEPFAR;UN agencies; 
     –   Research: NIH;ANRS 
     –   Training: Fogarty; USAID; 
     –   FHAME: Local private foundation dedicated to GHESKIO
What is necessary for a successful collaboration?
1) Must focus on a defined project with specific and measurable 
   outcomes
2) True collaboration: clear advantages for both parties on day 1
3) Credible: based on the credibility of the entities involved 
4) Long term investment: no hit and run deal: Necessary to show results 
   of the intervention: 10-20 years
5) Comprehensive: Holistic approach ideally involving 3 aspects:  
   research , training and patient care
6) Be relevant: must address what is identified in the country as a public 
   health problem
7) Oriented towards capacity building: human resources, training, 
   equipment, infrastructure
8) Must rest on strong ethical standards
9) Must have support of the Ministry of Health and reliable institutions 
   and communities
10) Long term success: depend on ability to retain key staff , create role 
   models and a new generation of well-trained , dedicated staff 
  What often inhibits collaboration?

l Types of partners involved: credibility is essential 
l Undelivered and broken promises: must be direct 
  and straight about expectations
l Insufficient support from foreign site
l  Government interference: Avoid politics at all 
  costs
l Fight among international partners
Benefits by GHESKIO/Haiti of international
               collaboration
l   Research: focused on major public heath issues: infectious diarrhea, HIV/AIDS, 
    TB, STI with development of integrated model for prevention and care 
l   Patient Care:
     – National center for diarrheal diseases, HIV/AIDS,TB, STI, Malaria
     – Only lab with capacity to do :
        l TB culture and sensitivity and species differentiation
        l PCR tests for HIV, TB 
        l HIV resistance testing
        l Malaria resistance testing

l   Training: National Training center 
     – Multiplication of training by Cornell Fogarty fellows
     – Creation of first in country MPH program with focus on Global Health  
l   National Impact
     – National reduction of mortality associated with infantile diarrhea
     – HIV:
        l National decrease in the prevalence of HIV 
        l Massive scale-up of prevention and care 

     – National reduction of STIs with national plan to eradicate congenital syphilis
     GHESKIO Formal Training in 2007
    (HIV counseling, TB, OIs, HAART, PMTCT)
                               92 - 95   96 - 99   2000 - 2002   2003   2004   2005      2006   2007   TOTAL



Laboratory Technicians          137       220         233        128    111     60        98     51     1038


Social Workers                  385       301          41         84     60     29        44     31     975


Nurses                          409       501         771        300    342     534      239    132     3228


Physicians                      629       906         293        116    101     132      143    101     2421


Pharmacists                                                              7      12        20     9       48
                                 -         -           -
Others (*)                      140       173                    219     13     58        99     4      706


Community Activities             26       571        10227       2000   3600   2260      3992   2736   25,412
CAB (*)
TOTAL                           1726      2672       11565       2847   4234   3085      4635   3064   33,828



     * College students, Youth association, Press workers, Teachers, Community Leaders
  National Expansion services for Prevention and Care of
   HIV/AIDS/TB/Malaria (MOH/GHESKIO network)  
43 HIV sites supervised by GHESKIO



  - PEPFAR
  - FM


11 Malaria sites




               GHESKIO Centers




       Multidisciplinary mobile teams essential for supervision, monitoring
       and continued on the job training
             National HIV Seroprevalence studies
                    in Haiti (1993 – 2006)
  National HIV and syphilis                     National HIV seroprevalence: DHS 
  Seroprevalence 1993-2003*                                 (2005-2006)**




*Pregnant women at 1st prenatal visit           * *5250 women and 4855 men
New Focus of Global Heath at GHESKIO
l   Eradication of congenital syphilis, MDRTB, HIV/TB interaction, 
    dengue, nutrition, women health issues (cancer) 
l   Create new training programs addressing the country’s needs:
    – In-country MPH program focused on GH issues: nutrition, health systems, 
      health inequities, implementation science
    – Work with local medical schools to:
       l Develop new curriculum based on the needs of the country and 

       l Create other category of personnel: nurse practitioner




l   Use HIV/AIDS support to improve overall heath system

l   Work to empower communities to be involved:
    – Increase hospital deliveries, 
    – HIV: ART adhere, early care, combined HIV/TB approach 
    – Create model of services delivery in slums
                    The first GHESKIO Generation




Marie Eugenie Beaulieu MT, Head of the lab 1979-present   Yonie Cadot, Head Nurse1979-present




 Dr Rose Irene Verdier
                             Dr Reynold Grand Pierre        Dr Marie-Marcelle Deschamps
   Head Clinics 1984-         Head of Expansion of
        present               services1988-present          Assistant Director 1983-present
         Clinical Trial Team


                                             Dr Patrice Sévère, Coordinator        Dr Paul Léger, Clinical Data 
                                                          CTU                              Coordinator




Dr Francine Noël,       Dr Jean Juste,            Alexandra Apollon, MT        Dr Cynthia Riviere,     MacArthur Charles 
Head, Pediatrics                                       Laboratory                                     MD, PhD, Laboratory
                      Coordinator, CIPRA                                       Coordinator ACTG
               Important Collaborators

 Peter F Wright,             Warren D Johnson Jr,                  Alain Mérieux,
   Vanderbilt                      Cornell                   Fondation Rodolphe Mérieux




  Other  collaborators           Other  collaborators               Other collaborators
David Haas, Janet Nicotera   Daniel Fitzgerald, Roy Gulick      Emilio Brignoli, Guy Vernet
GHESKIO Institute of Infectious Diseases
   and Reproductive Health (IMIS)

                       
      Vision and plans for trans-national scale-up:
 Trans-Caribbean HIV/AIDS Initiative (TCHARI) Founders

Jean William Pape MD, Professor of Medicine, Weill Medical College of 
Cornell University, NY , USA, and Director, GHESKIO Centres, Haiti, Chair
Brendan Bain MD, Professor of Medicine, The University of the West Indies, Jamaica
Courtenay Bartholomew MD, Professor of Medicine, 
Medical Research Foundation of Trinidad and Tobago
Antonio de Moya PhD, Presidential Council on AIDS (COPRESIDA), 
Dominican Republic
Ms. Linda Jackson, Office of AIDS Research, National Institutes of Health
Yasuhiro Yamamura PhD, Professor, Ponce School of Medicine, Puerto Rico
Carmen D. Zorrilla MD, Professor of Obstetrics and Gynecology, 
University of Puerto Rico School of Medicine, Puerto Rico
Stewart Smith, TCHARI Regional Coordinator 
                     Summary
l Much has been done in Haiti to control major 
  diseases in the most difficult conditions
l International collaboration has been essential  
l Success can be defined by:
  – Initial staff who remain involved and 
  – Capacity to attract new ones
l Much needs to be done and the UCGH can be an 
  important partner: What works in Haiti can work 
  anywhere else

				
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