Since the 1994 genocide in Rwanda, which claimed up to 1 million lives, “the country has become a spectacular public health success story and could provide a model for the rest of Africa,” the Times’ Don McNeil reports.

Consider these statistics cited in the news story:

In 1994, 78 percent of the population lived below the poverty line; now 45 percent do. The gross domestic product has more than trebled. Almost 99 percent of primary-school-age children go to school.

With help from Western donors, the number of people getting treatment for AIDS rose to 108,000 from near zero a decade earlier.

Many doctors fled Rwanda before the genocide, and many were killed. Even now, the country has only about 625 doctors in public hospitals for a population of almost 11 million. But it also has more than 8,000 nurses, and a new corps of 45,000 health care workers, elected by their own villages, to do primary care for malaria, pneumonia, diarrhea, family planning, prenatal care and childhood shots.

Largely because of these workers, the country has high rates of success in curing tuberculosis and keeping people with AIDS on antiretroviral drugs.

Nearly 98 percent of all Rwandans have health insurance. Annual premiums are small and subsidized by donors, and subscribers pay 10 percent co-pays. But many aspects of preventive care, like mosquito nets and immunizations, are free. The country has a national system of computerized medical records and uses cellphone text messaging to get reports from village health workers.

Since 2000, the maternal mortality ratio has fallen by 60 percent; the likelihood that a child would die by age 5 has dropped by 70 percent.

What jumps out for me is the 45,000 community health workers delivering primary care. Perhaps some lessons here for the rest of us as well?

A trio of superstar health innovators have a message for the broken U.S health care system: broaden the definition of health to include basic life necessities, bring care to where people live and study how it’s done in poor countries where you can’t always rely on expensive tests and drugs to make people better.

The persuasive new report on “re-aligning health with care” is written by Harvard doctors Paul Farmer (co-founder of the medical nonprofit Partners in Health) and Heidi Behforouz (executive director of the Prevention And Access To Care And Treatment [PACT] program) and Rebecca Onie, CEO of the nonprofit Health Leads. In it, they argue that with some rethinking, the U.S. can deliver better care at a lower price.

They lay out the central problem here:

The health care system is in crisis, driven chiefly by escalating costs, suboptimal health outcomes, scarce primary care resources, and rising poverty. At the same time…a growing number of health providers around the globe have learned to deliver high-quality health care at low cost. Now we need to align our resources in the United States to bring this knowledge fully to bear in saving dollars and lives.

Sounds great, but how to do it? The key, they write in the Summer 2012 edition of the Stanford Social Innovation Review is to change the way we view the “product” of health care, the places it’s delivered and the providers who dole out patient care.

Health Includes Basic Needs

The authors cite a 2007 study at Johns Hopkins Medical Center in which 98 percent of pediatric residents said that referring well-child patients for help with basic needs could improve the children’s health. “But how many of those residents routinely screened their patients for food sufficiency? Only 11 percent.” The moral: Health care is much bigger than just prescribing medicine. This is the founding principle of Rebecca Onie’s Health Leads, a group that recruits student volunteers to support doctors prescribing food, heat and other basics to low-income patients.

In Brazil, they deal with this problem through a program that routinely sends low-income children home after hospitalizations with resources to make sure they have access to nutrition, sanitation and psychological support, the paper notes.

But in the U.S., the current system provides few incentives to connect patients with basic needs. For example, the authors write that Medicaid reimbursements are specifically forbidden when it comes to getting patients plugged in to social services, or helping them obtain food stamps or energy assistance.

Health Workers In The Community

Paul Farmer is an authority on radically rethinking where care is provided. In Haiti’s Central Plateau, with just one doctor for every 50,000 people, Farmer helped pioneer the concept of paying community health workers, or accompagnateurs, to visit the homes of patients to make sure they take their medicines, but also attend to other critical needs, like transportation, shoddy housing and emotional support. Based on this model, the PACT program was launched in Boston to serve the sickest and most vulnerable HIV-positive and chronically ill patients in the city. That model, in turn, has expanded to help other poor, chronically sick patients who live in “the shadow of Harvard’s finest hospitals.”

Beyond The M.D.

By expanding the ranks of community health workers, the authors note, doctors, nurses, social workers and other professionals can “practice to the top of their license” and spend more time doing what they’re trained to do. This “task-shifting” also saves money and reduces inefficiencies.

The paper concludes:

It is by no means a new discovery that poverty and poor health are linked or that health resources are more likely to be used if they are offered conveniently to the recipient, or that a goal as complex and ambitious as “health” can be effectively pursued only with a multidisciplinary team of workers.

…

But what’s new is this: The U.S. health care system has reached a tipping point. Reform is in the air with primary care especially positioned for transformation.

…

“Health” is a bold, expansive aspiration. Let’s make sure what we call “health care” is broad enough to get the job done.

Dr. Paul Farmer’s speciality, among others, is his clarity when articulating a moral imperative.

Here he is on the opinion page of yesterday’s New York Times making the case to keep The Global Fund for Aids, Tuberculosis and Malaria (which has itself been injured recently by financial troubles of various kinds) alive.

Farmer, of course, is a Harvard infectious disease doctor and a cofounder of Partners In Health, the global health nonprofit, which has received support from The Global Fund in several countries. Farmer cites four reasons why The Fund matters, including its spillover benefits to other health and development areas, and its substantive investments in local health systems. Here’s more:

Third, the Global Fund proves how much multilateral organizations can accomplish. While the usual players — the G-8, say — bear the greatest financial burden, I would urge some of the recipient countries to consider themselves partners of and contributors to the fund. In today’s global economy, countries like India, Russia and China play meaningful roles as donors and as recipients of grants. Gabriel Jaramillo, a Brazilian banker who last week was named the fund’s general manager, will surely strengthen these links and reinvigorate its leadership. The Global Fund is a truly multilateral organization, and stronger for it.

Fourth, a recession is a lousy excuse to starve one of the best (and only) instruments we have for helping people who live on a few dollars a day. Most marginalized populations around the globe have always faced economic contraction; “financial crisis” has been ongoing for them since the day they were born. It would be a great mistake to allow one of the world’s most effective global health institutions to fail because we need to get our own fiscal house in order.

Along with Pepfar, the Global Fund has, without question, helped turn the corner on AIDS. It has also helped realize substantial gains against TB and malaria that must be maintained. We need to summon the funding and political will, now, to protect the hard-fought progress of the past decade.

That’s the subject line in a letter being sent to more than 184,000 supporters later today from the global health nonprofit Partners In Health.

The letter begins this way:

We’ve never done this before.

We’ve never asked you to contact your Members of Congress, but the situation is dire. Today is World AIDS Day and the poor we serve need your help.

PIH, along with other international health organizations and donors, has made enormous gains against HIV/AIDS over the past decade. These gains led to 6.6 million people receiving HIV/AIDS treatment. But today we’re at significant risk of seeing our progress stall or even stop.

Just last week, leadership of the Global Fund to Fight AIDS, TB, and Malaria (GFATM) — the most effective and transparent global health funding mechanism in the world to date — announced that they are canceling the next round of grant applications. The reason: major donors haven’t kept their financial promises to the poor.

The letter goes on to explain that Congress will vote this month on the 2012 contribution to the Global Fund, as well as the President’s Emergency Plan for AIDS Relief (PEPFAR). PIH is asking friends and supporters to urge Congress to allocate at least $6 billion for HIV/AIDS and PEPFAR with $1 billion for the Global Fund in this year’s State & Foreign Operations Appropriations Bill. (For more details, and a sample letter to Congress drafted by PIH, click here.)

Partners In Health co-founder, Dr. Paul Farmer, who will speak today on this topic at the Harvard School of Public Health World AIDS Day symposium, detailed the urgency of funding these programs in an op-ed last month in The Washington Post. “Ten million people — many of them young and most of them poor — will die around the world this year from diseases for which safe, effective and affordable treatments exist,” Farmer writes. “In Haiti, these are known as “stupid deaths.” What’s more, inadequate health services predominate precisely where the burden of disease is heaviest, keeping a billion souls from leading full lives in good health.”

At the same time, the AP is reporting that President Obama will announce new steps to combat AIDS. The story says:

Senior Obama administration officials said Obama will set a goal of getting antiretroviral drugs to 2 million more people around the world by the end of 2013. In addition, the U.S. will aim to get the drugs to 1.5 million HIV-positive pregnant women to prevent them from passing the virus to their children.

The new global goals build on the work of the President’s Emergency Plan for AIDS Relief, which focuses on prevention, treatment and support programs in 15 countries hard-hit by the AIDS epidemic, 12 of them in Africa. Bush launched the $15 billion plan in 2003, and in 2008, Congress tripled the budget to $48 billion over five years.

Despite Obama’s more ambitious goals, the plan’s budget is not expected to increase.

Yesterday, Dr. Paul Farmer, co-founder of the group that has been working in Haiti for 25 years, spoke to reporters about the need to greatly intensify efforts to stop the epidemic, and mount a more comprehensive response, including vaccinating about 100,000 Haitians with a cholera vaccine that is “safe, proven, effective.”

(The cholera vaccine, never before used in Haiti, will be rolled out beginning in January, PIH says.)

Here’s a bit of what Farmer said on the call (transcribed by PIH) which you can listen to here.

On the Need for a More Integrated Approach:

“What we’re calling for, a year into the epidemic, is a prompt integration of these prevention and care and treatment measures, including: chlorinated water at the household or village level, hand washing and hygiene measures, building up systems that haven’t previously had them, improved case-finding, treating with oral rehydration salts and finally integration of oral cholera vaccine.”

On Stopping the Water Insecurity:

“Some years ago, PIH and many sister organizations began talking about the right to water. We did so because those of us who are clinicians, we can sit in our clinics and work in our hospitals and wait for people to come in sick with complications of water-borne diseases, or we can work with public authorities and appropriate NGO partners and others to build real water security in Haiti. We’ve been sounding that drum for some years now.”

On AID Agencies Are Leaving Haiti:

“There’s been this steady erosion of support, people coming in and leaving, it’s been ADD of humanitarian work, it’s just so short term. But we’re not there for the short term, our partners are Haitian, we work with the Ministry of Health, our organization is really fundamentally a Haitian organization. And we, unable to retreat to some other activity or some other place in the world, are now probably putting in a half million dollars a month into cholera.”

On the Increased Production of Cholera Vaccine:

“This entire debate should sound familiar… [because there were] the same discussions around HIV. The failure of imagination regarding price and this fetishized cost — that it had to cost $10,000 per patient per year [for HIV], which was absurd at the time, because it’s not as if these drugs or the vaccines were made out of platinum… they could easily be manufactured, and the same plunge in prices with the increased demand, we expect to see that with cholera vaccine, and that of course will help us to have a global vaccine stock pile”

The 21 studies range in scope and geography, for instance, Multi-Drug Resistant Tuberculosis Treatment in Peru (a classic) to Botswana’s Program for Preventing Mother-to-Child HIV Transmission.

The case study model was pioneered at Harvard Business School to help students simulate a decision-maker role in examining various issues in the financial and corporate world. But a few years ago, the renowned doctors and medical anthropologists who launched the non-profit Partners in Health — Paul Farmer and Jim Kim, now president of Dartmouth — began to apply the case study method to public health problems in poor countries in collaboration with Harvard Business School’s Michael Porter.

Medical and other students needed some kind of out-of-classroom experience dealing with health issues among the poor, the thinking went, and short of getting on a plane, the cases provided detailed, real-life problems — and in some cases, solutions. And though some of the studies might appear dry — perhaps you’re not fired up about Building Local Capacity for Health Commodity Manufacturing: A to Z Textile Mills Ltd. — I’ve had the privilege of sitting in on classes with all three of these guys and I can say it’s truly inspiring and intellectually gripping. Never, ever dry. (In fact, the A-Z Textile case study is the amazing story of a local Arusha, Tanzania maker of insecticide-treated bednets to prevent malaria and the misaligned incentives that brought them, sadly, down).

All 21 cases were developed jointly by the Global Health Delivery Project, a collaboration between Harvard’s medical and business schools, the Brigham & Women’s Hospital and Partners In Health.

He’s scheduled to talk about it on “Fresh Air,” aired on WBUR today at 1 p.m., and his Boston-based organization, Partners In Health, just sent word that the staff would be running a five-week summer reading and discussion series on the book, here.

Dr. Evan Lyon of Partners In Health writes:

In the book, Paul and co-contributors—among whom I feel privileged to count myself—reflect not only on the lives saved and lost, on the challenges encountered and overcome, but also on the century of underdevelopment and internecine politics that have plagued Haiti.

When Paul decides to put pen to paper, you can be certain that he won’t be satisfied with offering a cursory recounting of events. Haiti After the Earthquake stays true to his anthropological lens, rooted in decades of experience in Haiti.

And:

It is my fervent hope that this book will do more than bear witness to the suffering the earthquake caused. Rather, I hope it will educate readers about the historical context in which it occurred and the true scope of what remains to be done.

Haiti is still in desperate need. Cholera continues to afflict the country. Aid remains undelivered, promises unfulfilled. Sign up now to read Haiti After the Earthquake with PIH. Reflect with us on what progress has been made, and discuss how we can best accompany Haiti as it builds back better.

Farmer speaks of the term broadly in his address, but its origins are close to his heart: decades ago, in Haiti, he helped mobilize a cadre of community health workers, or “accompagnateurs” to help treat and care for the sick and dying in their own neighborhoods and towns. This model of using local health workers as a central component of any medical support team has been replicated in communities around the world: in Rwanda and Peru, for instance, and more recently in the poorest neighborhoods around Boston. In Haiti alone, Partners In Health trains and employs over 2,000 Haitians as accompagnateurs, and these health workers were critical during last year’s devastating earthquake and subsequent cholera outbreak.

“All that I have to offer you today turns about the notion of accompaniment,” [Farmer] said to the audience. “It is an elastic term, but here it means sticking to a task until it is deemed completed by the person that you are accompanying.”

Farmer acknowledged that the concept could initially appear unrelated to government, but said that it has far-reaching implications. He asked graduates to consider the potential increase in the effectiveness of humanitarian aid that is executed according to the notion of accompaniment.

“Many of you here will be soon leading foreign contractors and NGOs—if you are not already—and you will need to help these organizations find a way to accompany our developing partners and intended beneficiaries away from deprivation and suffering,” he said.

“Just because we can’t tangibly measure the value of accompaniment, doesn’t mean that we can’t use it in the service of the common good,” Farmer added.

These health workers, part nagging mom, part medical fixer, part guide through daunting insurance and social service bureacracies, do what ever it takes to connect patients to better health: they help with transportation and child care, advise on mental health problems and promote asthma and diabetes management. They can feel like a close aunt, or sister, talking to a new mom about post-partum depression, for instance, and when necessary, a health worker might even pick up a sponge, to help a patient learn how to clean the house.

The goal of the program, Network Health Alliance, is clear: better care for the patient and lower cost to the system by reducing expensive emergency room visits and hospitalizations and enveloping people more fully into a primary care setting.

In an odd twist, the concept of community health workers originated in poor countries like Haiti, as part of a more integrated health system promoted by the renowned doctor, Paul Farmer:

Here in Massachusetts, this wealthy medical mecca of high-tech hospitals, community health workers are part of an experiment to use low-tech lessons learned in the poorest of countries, Haiti. As the state, and the nation, begin to revamp broken parts of the health care system, the need for these health workers, who fill a critical gap by supporting families in their homes, is clearer than ever before, says Partners In Health co-founder Paul Farmer, the doctor famed for developing a cadre of such workers in Haiti. “There has been more discussion about the need for innovation in this arena this year than ever before,” he said. We are finally acknowledging that “it is very expensive to give bad medical care to poor people in a rich country.”

If you want to learn more, read Atul Gawande’s excellent story on “Hot Spotters” in The New Yorker, and Tina Rosenbeg’s piece in The New York Times about a program that uses health workers to support AIDS patients in New York City.

And listen to Radio Boston, which is planning to air a segment on community health workers Tuesday at 3.

Speaking in advance of a conference on the topic next week at Harvard Medical School, Farmer, joined by other global health experts, said that diseases shouldn’t be treated in isolated silos, but rather through integrated health systems that can tackle a range of disorders — not simply diseases traditionally identified with the poor.

“For example,” Farmer said, “a good cardiac surgery program would improve the quality of surgical care in general. Not just for one disease… Better operating rooms, better supply chains, better trained surgeons…Let’s use these vertical programs to strengthen health systems in general…If you look at cervical cancer, if you have a good vaccination program, that you use to vaccinate for polio, to prevent polio, measles, or tetanus, it is a delivery system for the cervical cancer vaccine, Gardasil. And so we’re trying to use this principle also to drive forward our advocacy work as well as to why it’s important to take on these neglected NCDS.”

Dr. Gene Bukhman, Director of the Program in Global Non-communicable Disease and Social Change at Harvard Medical School, suggested the moral imperative to treat and prevent these types of illnesses: “Until recently, it’s been perceived that these disease are very difficult to tackle in the poorest countries. The needs are enormous. There’s an enormous burden of highly prevalent conditions like HIV, diarrheal disease, children continue to die at a high rate before age 5, women die in childbirth, and there’s been a question about how possible in the midst of that it is to address this collection of diseases, which are more complex perhaps, and less prevalent individually, but for which there are amazing interventions. Because of the focus (this year) on NCDs globally, this is an opportunity to gather together and focus the world’s attention on how it’s possible, now more than any other time in human history to be able to reach the poorest people in the world who have these conditions and who deserve interventions for prevention and treatment and palliation as a human right.”

The conference on March 2-3 is hosted by Harvard Medical School, Partners In Health, the Brigham and Women’s Hospital, the Harvard School of Public Health, the Harvard Global Equity Initiative, the Global Task Force on Expanded Access to Cancer Care & Control in Developing Countries, and the NCD Alliance. The meeting will bring together experts about conditions such as rheumatic heart disease, Burkitt’s lymphoma, malnutrition-associated diabetes, and the respiratory impact of household fuels.