The Burundian Paul Farmer is Seattle's latest global health hero

By any measure, the tiny east African nation of Burundi – one of the world’s five poorest – is a daunting assignment for a global health organization. Like neighboring Rwanda, the landlocked country of 10 million has witnessed its share of genocide and a 12-year civil war that left more than 300,000 casualties.

Yet for a small but growing network of Puget Sound area physicians and global health experts, Burundi also stands as a hopeful sign of change. Joined by Harvard’s Dr. Paul Farmer, founder of Partners in Health, Seattle physicians Sachita Shah, Kris Sherwood and Joseph Alsberge donate their time and medical expertise to the residents of Kigutu through the nonprofit organization, Village Health Works. Connections between Seattle and Kigutu date back to Village Health Work's very beginning. While the majority of Village Health Works employees are Burundian, the organization also employs a powerful network of advisors in global health, technology, women's health, development and agriculture — 12 out of 25 are based in Seattle.

More than 20 years ago, Village Health Work’s founder, Deogratias [“Deo”] Niyizonkiza, fled from a horrific massacre in the rural hospital in Mutaho in northern Burundi where he was a third-year medical student. Niyizonkiza’s harrowing odyssey, recounted in Tracy Kidder’s bestselling book, "Strength in What Remains," planted the seeds for what is today one of the remarkable success stories in community development and global health.

Following his daring escape from Burundi in 1994, Niyizonkiza landed in New York City, graduated from Columbia University and attended the Harvard School of Public Health. There he met Farmer and began working at the PIH in neighboring Rwanda. After further studies at Dartmouth Medical School, Niyizonkiza returned to Burundi to realize his dream of establishing a rural clinic in his native village of Kigutu in southwestern Burundi in 2007.

“Village Health Works was an idea in my mind for a long time,” he said during a visit to Seattle last week. “When I came to the United States, I left Burundi, but it never left my mind. One of those memories was mothers dying in childbirth.” Another was a rural community suffering from malnutrition, few roads, crumbling infrastructure and a lack of access to basic agricultural necessities or healthcare.

By all accounts, Burundi’s health statistics are numbing. The war-ravaged nation has fewer than 300 physicians. Waterborne diseases and lack of sanitation account for one in five deaths and more than 54 percent of children under five suffer from severe malnutrition. The average life expectancy is 50 years. Burundi also has one of the highest rates of child mortality in the world — 180 out of every 1,000 children under the age of five don't make it. Most of those deaths are due to infection, primarily diarrheal disease, pneumonia and malaria.

Equally paramount is the legacy of armed conflict between Hutu and Tutsi tribes from 1993 to 2005 and a generation still reeling from the trauma of bloodshed and decades of lingering mistrust.

In the middle of all this is Village Health Works. Since opening its doors in 2007, the clinic has treated more than 70,000 patients. In 2012 alone, Village Health Works saw huge advances: it treated 22% more patients than the year before, saw a 228% percent increase in the rate of voluntary HIV testing and a 221% rise in prenatal consultations.

Dr. Sachita Shah, who practices at the University of Washington’s Harborview Emergency Center, coordinates ultrasound training for doctors at Village Health Works. Shah got involved with the project after meeting the clinic’s first Burundian physician at a Partners in Health ultrasound training she conducted in Rwanda. She attributes the success of Village Health Works to its holistic approach to community development and health.

“It’s impossible to improve the health structure of a people without somehow addressing the challenges of poverty, food security, shelter and education as well,” she said. Community involvement with the clinic is the linchpin of that philosophy. “I’ve worked with several nongovernmental organizations over the years, and one of the most striking and unique things about VHW is how invested the Kigutu community is in making it successful.”

Right from the start, the people of Kigutu donated 10 hectares of land, cleared the brush and built a road to bring in supplies for the clinic. “Despite being severely impoverished, they believed in the mission of VHW and what it would bring to their area,” said Justin Hanseth, who grew up on Bainbridge Island and cofounded Village Health Work’s food security project.

Native Burundians remain an integral part of the clinics operations. The clinic now has a staff of five Burundian doctors, 17 nurses, three lab technicians, and more than 107 community health workers in its catchment area.

“We are working in one of the poorest countries on the planet that has gone through hell on earth,” Niyizonkiza said. “The community, Hutus and Tutsis, got together, made bricks, made the road that links all paved roads and built the clinic. We are all victims. When I approached the community about our vision for the clinic, they got it. We have found a way to forget about the past and heal the wounds. We’re not just building a clinic – we’re building peace.”

Hanseth traveled from Bainbridge Island to Burundi in 2008 to lay the groundwork for the clinic’s food security program. Trained in permaculture design at the Bullock’s Permaculture Homestead on Orcas Island, the Seattle University alumnus specializes in sustainable agriculture and incorporating appropriate technology and regenerative design in food production.

“Burundi had been war-torn and deforested over the past several decades, and innovations in agriculture were several decades behind,” he said. “Before I arrived, I could find almost no information about the bioregion, much less the specific site. No temperature ranges, no precipitation averages, no soil composition data, no analogous projects in the area to learn from. So step one was to make friends quickly, and learn everything I could through local knowledge.”

Hanseth and his Bainbridge Island High School classmate, Joseph Alsberge, who later studied at Cornell Medical School, interviewed several hundred households to determine their nutritional needs. “There wasn’t a lot of data. Our first task was identifying which fruits, vegetables, and grains would grow best in the rainy and dry seasons.”

The project eventually developed a 125 square meter demonstration garden and 75 square meter plant nursery. “Deo wanted all things agricultural to be right next to Triage, so every community member who came through the site would see how important nutrition is to one’s health,” Hanseth said. “He also wanted people to see first-hand the volume and diversity of foods that could be grown in Kigutu.
 We used regenerative systems as often as possible in the work we did. We enhanced soil fertility, grew animal fodder, grew seeds and produced food on site.”

In the five years since Hanseth and Alsberge launched the food security program, Village Health Works has expanded its nursery, created a three-acre production garden, begun breeding livestock, established a seed bank, developed agriculture education curriculum and interwoven the food security program with the clinic’s nutrition ward.  

“We also initiated an outreach system to aid patients in replicating their own food systems by supporting over 400 household gardens throughout our catchment area and agricultural and livestock cooperatives," Hanseth said. "VHW now has 62 co-ops with an average of 25 families each.” A sign of the project’s efficacy, not a single case of childhood malnutrition has been reported within one-and-a-half kilometers of the clinic in the last two years.

Alsberge, a 2007 graduate of Portland’s Lewis and Clark College, helped start the HIV and malnutrition program for children, coordinated community health workers and helped set up the clinic pharmacy, often traveling to Rwanda to obtain materiel for the nutrition and HIV program. “I wasn’t prepared to see that kind of poverty before,” he said. “I’ve traveled in Ecuador and Central America, but Burundi was my first time in sub-Saharan Africa. The poverty was mind-blowing. There was no electricity, water, or anything in the beginning.  We just camped out in tents.”

Niyizonkiza’s former Dartmouth Medical School classmate, Seattle physician Dr. Kris Sherwood, travelled to Burundi with him in 2006 when the clinic was first being built. The civil war had ended several months before. “The clinic was a long-time dream of Deo’s. Most of the planning was done by community members."

“They did a great job of learning from Partners in Health,” Sherwood said. “The people at VHW are the most amazing and dedicated physicians and nurses. The community is extremely dedicated to improving the health of all of the clients, and it is invested in not only the medical programs, but also poverty eradication, economic development, nutrition and sustainable agriculture.”

Future plans for Village Health Works call for the building of a teaching hospital, a women’s health pavilion and a surgery center. “We want medical services to serve patients and train local health professionals in a dignified environment,” Niyizonkiza said.  “We want a strong infrastructure so we can train others and inspire others beyond Burundi.”

Global health leaders in Seattle like Dr. David Fleming, director and health officer at Seattle King County Public Health and former director of Global Health Strategies at the Bill and Melinda Gates Foundation, view the clinic as a powerful example of community-driven health care. “The VHW concept is spot-on – recognizing that health is determined by a lot more than what happens in a clinic, and working in a cross-sector way along multiple fronts to improve community conditions.”

“This is one of those concepts that has great relevance here in Seattle,” said Fleming, who is involved in the Global to Local Healthcare Initiative, a collaborative partnership that delivers healthcare services for underserved communities in south King County.

Rising from the ashes of the civil war, the clinic already has bequeathed the residents of Kigutu with a palpable sense of pride and hope. “It has given them an appreciation and true perception of themselves, others and the world in a community with a bloody, horrific past that had dehumanized them,” Niyizonkiza explained.  

“This is a perfect way of building peace and prosperity in countries with a history like that of Burundi – from the bottom up and by engaging the community.”