Haiti

Louise Ivers: A higher purpose

Assistant professor dedicates work to Haitian poor

Louise Ivers works in Haiti for Partners In Health: "It's pretty much the best job in the world. It's a huge privilege to be in a relationship with a person where you're invited into. their darkest fears. You're in a position to put them at ease, to help them, to explain what's going on." Staff photo Rose Lincoln/Harvard News Office

Louise Ivers gently lifted the 7-month-old by his forearms, hoping he would pull himself up as a healthy child a third his age might.

But his head hung limply back, eyes wide, upper body slack.

At 7 months, when a healthy child would be sitting up on his own and thinking about crawling, this baby boy was unable to control his head, unable to pull himself from the sheets. Gently, she laid him back.

It was January 2008 and the baby - the youngest of four children - had been brought into the clinic Ivers heads at Boucan Carré, Haiti, after a period of vomiting and not eating well. He was skinny and malnourished, just the latest suffering child Ivers had seen on death's doorstep, in the clinic.

"I've had more children dying in my arms than most people have ever experienced in their whole lives," Ivers said. "One day, I had a little girl of about 8 die of malnutrition - an 8-year-old dying of starvation. I was thinking of the people I know in Ireland and the U.S., and most people don't know anyone whose child has died. Yet this is just everyday stuff. And we only see the half of it."

Ivers has been steadily seeing more and more of the health care picture around Boucan Carré in the five years she's been there. The number of patients coming to the clinic each day has grown dramatically from between 10 and 15 in early 2003 to as many as 300 a day in 2008. An assistant professor at Harvard Medical School and infectious disease specialist at Harvard-affiliated Brigham and Women's Hospital, Ivers works in a gradually expanding clinic through the nonprofit organization Partners In Health.

Established in the 1980s, Partners In Health has pioneered a model of health care among the world's poor that has revolutionized treatment of complex diseases such as AIDS and drug-resistant tuberculosis in impoverished settings. Founded by a group that included Maude and Lillian Presley Professor of Social Medicine Paul Farmer, Francois-Xavier Bagnoud Professor of Health and Human Rights and Professor of Social Medicine Jim Yong Kim, and Partners In Health President Ophelia Dahl in 1987, the organization now works in nine countries: Haiti, Peru, Russia, Lesotho, Malawi, Rwanda, Mexico, Guatemala, and the United States.

When Ivers arrived at the clinic in 2003, Partners In Health had just begun its collaboration with the Haitian government there. The organization had taken over a three-room clinic, staffed just by a nurse and chronically short of medicine. By early 2008, several new buildings had been constructed, including a clinic that contains examining rooms, a laboratory, a pharmacy, a small inpatient ward, and isolation rooms for TB patients.

Built on land donated to the government by a group of local residents, the facility remains isolated because of the region's horrendous roads, but has cell phone communication and Internet access via satellite. It also boasts a host of support services including 90 community health workers who visit patients at home daily, an agricultural operation, and housing assistance for homeless patients infected with HIV or TB.

The health care picture around Boucan Carré is similar to that in Haiti as a whole. With extreme poverty, malnourishment is rampant. With a lack of vaccinations, health education, and primary care, ailments barely given a second thought in the industrialized world take on life-threatening proportions. A lack of access to obstetrical care and operating facilities for pregnant women gives the nation a high rate of maternal death. The health picture is exacerbated by the high prevalence of AIDS, TB, and malaria.

Ivers' road to this remote community in one of the world's poorest nations has been a winding one. She grew up the middle of three children in Dublin, Ireland. At age 16, she was asked to select a course for her collegiate studies and chose to become the family's first doctor. It was a risky choice, since she didn't know any physicians other than her family doctor, but she says now she can't imagine doing anything else.

"It's pretty much the best job in the world," Ivers said. "It's a huge privilege to be in a relationship with a person where you're invited into some of their innermost secrets, their darkest fears. You're in a position to put them at ease, to help them, to explain what's going on. It's brought me here and allowed me to bring something to this project."

Ivers became interested in developing countries during medical school in Dublin, and one summer she worked at a rural clinic in Ghana. She's not sure how much good she was able to do during her three-month stint, but the experience was life-changing.

"I couldn't really believe kids were dying of measles and diarrhea, because we don't have that in Ireland," Ivers said.

After that, Ivers looked for a job that would combine her love of teaching and interacting with students with work in developing nations.

She came to the United States for a residency in internal medicine at Massachusetts General Hospital (MGH) and followed that up with an infectious disease fellowship at MGH and Brigham and Women's Hospital. In between, she worked in India and Vietnam and also spent time at the London School of Tropical Medicine.

It was while working at MGH that Ivers met Joia Mukherjee, who at the time was finishing her fellowship in infectious diseases. The two women hit it off and agreed to stay in touch.

Mukherjee, now an assistant professor at Harvard Medical School and physician with Brigham and Women's Hospital, went on to become the medical director of Partners In Health. In 2003 (when Ivers finished her own infectious disease fellowship), Mukherjee was looking for doctors to help the organization expand after receiving a large grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Ivers and Mukherjee agreed that Ivers would head to Peru, where a TB-centered program had been under way since 1994.

Just before Ivers left, however, Mukherjee called and asked if she might be interested in Haiti instead.

Ivers jumped at the chance, saying she was more interested in working on the whole suite of health problems linked to Haiti's extreme poverty than she was on Peru's more-focused program aimed at multi-drug-resistant TB.

In August 2003, just months after Partners In Health arrived at Boucan Carré, Ivers made her first trip there. She, Mukherjee, and Keith Joseph, the Partners In Health doctor stationed there, worked in the tiny clinic for two weeks. Ivers slept in the village priest's house and made numerous treks to the countryside to visit patients at home. Ivers laughs as she recalls wading a chest-deep stream at the end of one nine-hour hike, saying, "Maybe that was the job interview."

Whether it was a test or not, Ivers passed. For the next few months, she finished her infectious disease fellowship in Boston and familiarized herself with operations at Boucan Carré. Joseph, a pediatric tuberculosis specialist at Brigham and Women's Hospital, overlapped with her a few months and then moved on, eventually overseeing Partners In Health's expansion into Malawi.

Partners In Health co-founder Farmer said that Ivers stood out from the very first time they saw her in action in Haiti. To be successful in such a difficult environment, a doctor has to go far beyond the usual commitments of time and energy expended routinely in developed nations, where a physician may stay late to check on patients or provide additional care.

"Most doctors from the U.S. or Ireland have no idea that to be effective in a place like rural Haiti, you always have to go the extra mile," Farmer said. "Going the extra mile might involve, as Louise learned, wading across rivers to do home visits or transport a patient. It will certainly mean helping to build lab capacity and basic infrastructure, and training community health workers - not tasks we learned about in medical school, residency, or fellowship training. It will mean learning how to get your patients fed and, better yet, learning to keep people away from hunger."

Farmer said Ivers tackled all those tasks and more without a word of complaint.

"She's never said, 'Hey, this is not in my job description,' no matter how outlandish certain tasks would seem if presented to her at Harvard," Farmer said.

Ivers is fluent in Creole and compassionate with her patients. She's friendly with colleagues and energetic when confronting challenges. She has a deep knowledge of Partners In Health's complex operations and an abiding belief in its mission: provide the world's poor health care equal to modern standards, and address wherever possible the social problems that underlie their poor health.

Ivers' early days at Boucan Carré were sometimes hard. She lived in a shed - never intended for human habitation - attached to the local church. She recalls visits by cockroaches, rats, and even tarantulas. She remembers being stranded shoeless an hour's walk from the clinic when the four-wheel-drive vehicle she was riding in died in the middle of a river crossing. She recalls being embarrassed at how she hobbled painfully to the clinic across rocks that her shoeless patients traverse every day.

Even today, after constructing a new clinic with real sleeping quarters upstairs, Ivers will stop reflexively after putting on a pair of shoes she hasn't worn in a while, yanking them off and checking for spiders. In response to a question about how many hours a day she doesn't work, she responds hesitantly, as if thinking about it for the first time: "Only when I'm sleeping."

But Ivers resists any characterization of her own hardships as real suffering. After all, she says, she gets to go back to her apartment in Boston. Whatever she's going through, her patients have it worse, some of them much worse.

"Here, you can work in the clinic and go a full day without eating. So anytime I start to feel hungry, I think, 'These people feel like this every single day and they walk for six hours, carrying their children [to get to the clinic].' And so you rally and just sort of get on with it," Ivers said. "It's not that I'm interested in self-flagellation. I just really turn it around and [use it to remind me] why I'm here."

When asked why that is, Ivers responds: "When you have a skill like being a doctor, the idea of not using it to try and do something about the things that I see all the time is just unconscionable to me. I can't sleep at night because of the things that I see. . It's not even a question of what keeps me here. It's what keeps me there. Why do I go back to Boston ? I'm not really sure. My family's there, there's my connection to the University . but there's just so much work here to do."

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