Field Note March 04, 2020

“The World Needs to PIVOT, and Now We Know How to Start”


I’m walking deep in the rural countryside of Madagascar with three community health workers and their supervisor. They work with the non-governmental organization PIVOT, who is hosting my visit so that I can provide advice about how to adapt the program. Having started my work in community health in rural southern Mexico almost 15 years prior, I now try to lend what I’ve learned to such programs all over the globe, and make these trips as often as is useful to our colleagues. 

But now my hiking boots are full of mud and water – apparently they were better for corn and coffee fields than for rice paddies. We get to a particularly deep part and I look up, helpless. They pause to look back at me, and I can see the pity on their faces. Toky, a cheerful and robust community health worker in knee-high gumboots comes back and hunches in front of me so that I can hop on piggyback. Moments later, I’m across the stream, but not without a dose of pointing, laughing, and picture-taking. Malagasy social media is about to get a hilarious new meme, and I’m enthralled; I may have come to teach, but I’m reminded that partnerships are always about co-learning and humility.

PIVOT is a 501c3 that was started by US donors and leadership, but is now very squarely rooted in Malagasy soil, in Ifanadiana District, next to Ranomafana National Park. Madagascar is famous for being unique in the world, supporting flora, fauna and people found only in this place, but 90% of its original natural wonder is now already gone. Burned, logged, or producing rice for a growing population, you see in Madagascar the timeless question first asked at the dawn of agriculture and civilization: does the land belong to us, or do we belong to the land? We now live in a warming world, and everything is changing. In my time on the planet I’ve seen many examples that show we may be incapable of coming together to confront the problems that cross the lines we’ve drawn, be they national borders, distinctions of race, tribe, gender, class, age, or any of the many other axes of difference we’ve dreamed up. Pandemic viruses, however, remind us that we maintain these dividers at our peril; viruses jump our walls with ease, and only we stay trapped.

So, if we are going to preserve all that we’ve built, we need to pivot, and we need real, viable, ambitious examples of what works. The group I am visiting offers much to meet this need, and I hope it delights you that their name is PIVOT. 

In Ranomafana, you can see how a symbiosis between humans and the forest is possible; a UNESCO world heritage site adjacent, the town is booming, fueled by eco-tourism that is mostly for the Malagasy-with-means. I walk through the streets and see how wealth redistribution and environmental protection can follow the flow of delight: a middle-class visitor from the capital tells me with a tear in his eye, “This place is very, very, special. We must not lose it.”

The town is also booming because PIVOT provides high-quality health care with no user fees. Health is wealth, because young people who don’t die needlessly build things as they grow up, if given a chance. Abolishing user fees opens the gates so that all can enter the health system, and if the system can actually meet the demand, then patients will choose to enter over other, more personally expensive options. All over the world, a top cause of further impoverishment is catastrophic spending on healthcare; when the person you love is dying, it is deeply human to want to put out their fire with Champagne if it may save them. For us in the global north, that might be taking out a loan or maxing out a credit card; for the rural poor, after they’ve sold off their possessions and possibly even the roof over their head, the only substantial wealth available to them is the neighboring rainforest. How much illegal logging can be linked back to a worried parent, spouse, or sick child? The inhumane systems we have come to accept as the status quo force people, through their love, to make impossible choices like this every day.

Yet love can also build, and cherishing the details can be holy. You may have heard that there are more cellphones than latrines in the poor world. Well, PIVOT has one of the most ambitious digital health programs I’ve ever seen, utilizing data to inform action and decisions, such as an impressive geo-mapping of the rural paths we walked on my soggy hike. The community case management of childhood illnesses (iCCM – in which community health workers have a small kit of lifesaving medical interventions that they can provide in the most remote and rural places “where there is no doctor”) has rarely been effectively launched at scale. The reasons for this are many, but PIVOT has added a number of innovations that promise to position it as one of the most exciting and promising iCCM programs anywhere. Some of these are based on evidence coming out of programs launched by peer organization, such as implementing the proactive community case management which Mali-based NGO MUSO pioneered. Some are fresh and unseen anywhere else, such as the addition of Paracetamol (a.k.a. Tylenol) to the community health workers’ medicine kits. Why would the addition of a common, non-lifesaving medicine be of any use? Because parents like to see their children without fevers and pain, and for many symptom relief is the proof that a medicine worked. Every sleepless parent knows this: just a spoonful of Paracetamol helps the Artemether/Lumefantrine (antimalarials) go down. I hope that PIVOT’s example changes medicine kits everywhere in the world where such kits exist.

These details alone would make PIVOT an exciting program, in line with worldwide community health ambitions. Zooming out from these details, another picture comes into focus: PIVOT is finding success in all the right pieces of the puzzle, and putting together something very, very different. Some of this they learned from the organization I grew up in, Partners In Health (PIH), likely because some of their leaders have also worked at PIH, and our values are closely aligned. These include: partnership with the government, because public sectors are the best way to reach the poor equitably with “healthcare as a human right”; proper health systems extending care that you would want for yourself and your family; a happily motivated and qualified staff; enough stuff (i.e. the right equipment and a functioning supply chain) to do the toughest jobs; strong infrastructure to receive the increasing volume of patients accessing care, and even a nice space for care providers to see these patients; systems that make the engine hum; and social supports to address poverty and achieve equity of outcomes. 

If a clinical outcome is available anywhere, shouldn’t it be available everywhere? For example, if curable diseases are cured in Geneva, shouldn’t they be cured in Amboasary Village too? If your soul sings yes, well, then you’re unfortunately in the minority among global health “experts.” Don’t despair, however, because your people exist, and we are busy putting this aspiration into practice.

Blazing this trail is a group of effective leaders that deserve the accolades they have received. First, I was delighted to learn that over 50% of leadership roles at PIVOT are held by women, including 7 of 12 director-level and 21 of 40 manager/supervisor-level roles. The bravery of these leaders has launched this enterprise into necessary, but uncharted, territory. At a time when President Obama has reminded us that “if every nation on earth was run by women, you would see a significant improvement across the board on just about everything… living standards and outcomes,” I find myself nodding at his words as I observe the deeper truth of that idea in play out here. The mechanisms for this are many, but what I saw firsthand was the ability to deftly balance large clinical ambitions (“let’s go wide and deep in this community”) with that holy attention to critical details (“from whom are we buying our local goods, and are we spreading our disproportionate wealth fairly throughout this impoverished town that hosts us?”). 

Also quite impressive was the ability to weather all the slings and arrows inherent in this work: from endless meetings with government partners about contentious questions, to never-ending negotiations pushing against the dominant frameworks imposed by institutions in the global north. Radiating out from the top leadership is a latticework of similarly dedicated social justice warriors, all with their own dose of dedication and resolve. I have yet to meet someone here who yawns during a discussion about how to better reach the rural poor.

As I write this, COVID-19 is spreading rapidly. It is hard to say how long it will last or what will be the ultimate impact. In it, however, we are seeing just how vulnerable we all are, but also that we have no choice but to get through this together. For many in the global north, this is an awakening. But for our colleagues in the countries where PIH and PIVOT work, they have long known this truth: West Africans who saw Ebola, Mexicans in Chiapas who saw Zika, Haitians who see Cholera, Peruvians who see multidrug resistant tuberculosis, the Basotho who see some of the highest rates of HIV infection, and the list goes on. We have had many chances to make the necessary changes to confront such challenges with greater focus and agility, but we still haven’t done enough. In the face of this complexity, this is what we fight for every day to get us out of this seemingly endless cycle of disease and vulnerability: all lives have value, and we must validate those lives by assuring material benefits are available equitably, including education, health care, food, housing, peace, and justice. PIVOT has a mantra that says this well: care for the person, systems for the populations, innovation for the planet. 

When you look around today, do you feel that our modern civilization is on the right path? If so, feel free to ignore PIVOT’s example. But if you have even the slightest pang that change will be necessary, sleep well tonight knowing that an iterative yet irrefutable model exists in the deep countryside of Madagascar. And when you wake up renewed, please roll up your sleeves, put on your gumboots, and join us. We have a lot of work left to do.