A Year In Review, 2020
Below is a snapshot of our 2020: stories of lives saved, history made, health systems strengthened, and hope restored—representing how together, we continue to make Sierra Leone, and our world, more just, healthy, and joyful.
Rising to the Occasion
Dr. Marta Lado, our then-Chief Medical Officer leading care at Sierra Leone’s main COVID-19 referral hospital, walks arm-in-arm with a patient in the isolation ward.
This spring, as COVID-19 grew into a historic pandemic, the unknowns loomed for health workers across Sierra Leone. When would the virus arrive? What effects would preventative measures like lockdowns have on impoverished communities? When COVID-19 cases inevitably arose, how fast would the virus spread, and with what effects on patients?
Most urgently: How could health facilities best prepare?
In Kono, a rural district in eastern Sierra Leone, Partners In Health immediately began providing COVID-19 training to community health workers, clinicians, cleaners, and other staff at PIH-supported Wellbody Clinic and Koidu Government Hospital (KGH), ensuring every frontline health worker was up-to-date on what we then knew about the virus’ clinical features, spread, prevention, and treatment.
No one knew when COVID-19 would reach Sierra Leone or how quickly it would spread. Amid these unknowns, however, our staff’s responsibility as caregivers remained the same as ever. As internal medicine specialist Dr. Marta Patiño told a group of KGH staff during one training:
“Care. Kindness. Information. Patience. Empathy, empathy, empathy.”
Past, present, and future, these words define our work and our mission: to make sure every person, in Sierra Leone and beyond, has access to the health care we would want, expect, and demand for our own family.
This year, these values underpinned not only our fight against COVID-19, but all of our vital work that continued—from working with community leaders to connect patients to care, to opening a critical care ward for premature newborns, to bringing noncommunicable disease care directly into patients’ homes.
We’re thrilled to share with you some of this work, made possible by your generous partnership, relentless optimism, and commitment to equity.
Letter from the Executive Director:
Dear friends,
For many around the world, 2020 was a year of struggle unprecedented in scale. In Sierra Leone such challenges are anything but new—an unjust reality PIH Sierra Leone’s team knows all too well.
Our 500+ member team not only supported a pandemic response in Kono and nationally, they worked tirelessly to ensure all of our commitments were preserved. Despite the pandemic, our routine work not only continued, it grew. We served more patients than ever before, and our courageous frontline health workers adapted, putting into place new protections and implementing lessons learned the hard way—by fighting Ebola.
As you will see in this annual report, our team continues to inspire awe at how much they can accomplish in the face of seemingly unthinkable challenges and scarcity.
In 2020, we also announced our bold initiative to radically reduce maternal mortality. I am thrilled to report that our target to break ground on the Maternal Center of Excellence in April 2021 is unchanged.
We have a lot of work to do, and none of it would be possible without the steadfast support from all of you. Thank you. Tenki!
With high hopes for 2021,
Jon Lascher, Executive Director, PIH Sierra Leone
Responding to COVID-19
Community Health Workers Lead the Way
Time and again, community health workers (CHWs) prove to be the backbone of any health system, providing a link between households and health facilities. As PIH learned during the Ebola epidemic in Sierra Leone, this link is especially critical during an infectious disease outbreak.
So when COVID-19 arrived in Sierra Leone, PIH wasted no time in mobilizing our community-based teams in Kono. Amid a highly infectious, largely unknown virus, we doubled the size of the team to ensure every corner of the district could be reached with COVID-19 education, screening, and referrals to care.
A social mobilizer conducts a socially-distant home visit to screen for COVID-19 and educate about the virus.
Community health workers and COVID-19 social mobilizers, out in one of 14 of Kono’s chiefdoms to make COVID-19 education and screening home visits.
In partnership with the Ministry of Health & Sanitation, Government of Canada, and other supporters, we trained 126 CHWs and 135 new social mobilizers—community health staff hired specifically to provide COVID-19 screening and education—on identifying the most common signs and symptoms of the novel coronavirus, and on strict infection prevention and control measures to keep themselves and others safe. Wearing face masks and carrying hand sanitizer, they visited homes across all of Kono’s 14 chiefdoms to screen patients for COVID-19 and promote handwashing, social distancing, and seeking care early.
Importantly, CHWs continued their routine home visits during the response, not letting any of their regular patients slip through the cracks. One of the most vital messages that CHWs and social mobilizers shared in communities was to continue visiting health facilities for routine care—explaining that, despite any experiences or trauma from Ebola, hospitals and clinics remained safe and necessary to visit.
In fact, our community-based response helped identify not only potential COVID-19 cases, but also identified more than 1,500 patients with other health conditions in need of medical attention. CHWs connected these patients with care at local primary health clinics, Koidu Government Hospital, and Wellbody Clinic—where new COVID-19 triage systems and safety protocols ensured all facility staff and patients would remain safe.
65,960
people screened for COVID-19 signs and symptoms
270,120
people educated on key COVID-19 health messages
1,538
people referred to health facilities for non-COVID-19 conditions
127
people referred to social support from PIH
National Accompaniment
Dr. Bailor Barrie provides a contact tracing training.
As the government of Sierra Leone launched its national COVID-19 response, applying lessons from Ebola, PIH—a trusted government partner—supported the efforts. His Excellency President Julius Maada Bio called on PIH to provide leadership from contact tracing to direct patient care.
Dr. Bailor Barrie, PIH strategic advisor, partnered with Sierra Leone’s Ministry of Health & Sanitation on a national contact tracing plan, drawing from PIH’s deep experience during Ebola. In partnership with the Ministry, PIH trained 1,540 contact tracers, who provided specialized accompaniment to all 16 districts’ contact tracing efforts.
In Freetown—the epicenter of Sierra Leone’s COVID-19 outbreak—PIH’s infrastructure team helped build and open a 120-bed community care center for mild and asymptomatic cases, allowing clinicians to monitor patients’ health and prevent unchecked community transmission.
And since the first cases of the virus arrived in Sierra Leone, PIH sent staff and resources to 34 Military Hospital in Freetown, the country’s main referral hospital and primary COVID-19 intensive care unit. Our then-Chief Medical Officer, Dr. Marta Lado, cared for the country’s sickest COVID-19 patients there and helped support and train clinicians to provide 24-hour monitoring and care, based on World Health Organization standards. PIH also stocked the hospital’s isolation ward with critical equipment and medications, including oxygen concentrators, ICU-level drugs, PPE, and other respiratory equipment.
Dr. Marta Lado coordinates care for COVID-19 patients at 34 Military Hospital. Lado said that hospital staff were giving “300 percent.”
Transforming Care at Koidu Government Hospital
No Small Thing: New Care for Neonates
Dr. Nyirimanzi holds Naphtal during the hospital’s World Prematurity Day celebration.
Baby Naphtal was unexpectedly delivered on a small, rural farm, away from any health facility. He was 14 weeks early and weighed less than 2 pounds.
As is often the tragic, preventable case, his mother did not survive childbirth. One year ago, Naphtal likely wouldn’t have lived, either. Today, however, he is a healthy 6-month-old, named after one of his doctors: Dr. Naphtal Nyirimanzi, PIH’s pediatrician in charge at Koidu Government Hospital (KGH).
Dr. Nyirimanzi helped care for Naphtal at our special care baby unit—a new facility at KGH providing lifesaving care to infants born prematurely or experiencing other complications at birth. The unit was opened in May by the Ministry of Health & Sanitation with support from UNICEF and PIH.
For clinicians, the unit provides access to advanced equipment, from infant warmers to oxygen concentrators. And it is strategically located next to KGH’s maternity ward, allowing for quick transport of newborns in need of emergency care.
It is also designed for mothers, providing them an adjoining ward to stay while their newborns are receiving around-the-clock care, as well as offering support with breastfeeding and newborn care.
The unit is already dramatically improving health outcomes—and it is giving new hope to families across Kono. In the first four months of the facility’s opening, KGH’s neonatal mortality rate was cut in half.
Neonatal Mortality Rate at KGH (%)
Nurses work in the special care baby unit.
“You need to be willing to push yourself and to always think: ‘This baby today could be my baby. It could be my sister’s baby. Or my friend’s baby.’ This is not just someone else’s baby. It’s someone else’s life—someone’s future.”
A Compassionate Clinic for Teens
Isata Dumbuya, nurse midwife and PIH’s reproductive, maternal, neonatal, and child health lead, speaks about the newly opened adolescent and youth-friendly services clinic on a local Kono radio show, encouraging young residents to visit.
Sierra Leone faces one of the highest teenage pregnancy rates in the world, fueled by relatives of poverty: lack of access to health care, stigma associated with family planning, gender inequity, and barriers to education and job opportunities for young people, especially in rural areas like Kono.
In response, PIH launched a new adolescent and youth-friendly services clinic at KGH in July, through support from Global Affairs Canada. Located in the hospital’s maternity ward, with a separate entrance for privacy, the clinic provides care to patients ages 14-24, including family planning, screening and treatment for sexually transmitted infections, general sex education, prenatal care, post-abortion care, and referrals to the mental health clinic.
And the clinic offers more than clinical care: Nurses provide career counseling and a listening ear for young people in search of guidance and a safe space as they build their futures.
Attendance at the clinic has steadily risen, largely thanks to clinicians visiting schools and appearing on local radio to reach out to students.
325
young people have accessed services at the clinic
218
patients were newly introduced to family planning methods
“I have to stand by my patients. They need people who they can trust, who tell them, ‘You have a purpose to fulfill.’”
Improving Access to NCD Care
Nurses from Koidu Government Hospital’s noncommunicable disease clinic walk to provide monitoring and a new supply of medications to a patient with hypertension.
In Sierra Leone, a country with a high prevalence of infectious diseases such as HIV and TB, chronic, non-infectious illnesses, such as diabetes and hypertension, have often gone unaddressed. In Kono, this injustice began to fade in 2018, when PIH established KGH’s first noncommunicable disease (NCD) clinic.
Amid the clinic’s rapid growth, clinicians noticed a lingering issue: many patients struggled to manage their chronic illnesses at home, without clinicians present. Yet having to continuously attend clinic appointments, often from far distances, also proved burdensome—especially as COVID-19 looms. Clinicians realized that care needed to be brought directly to patients.
This November, the NCD clinic launched its first-ever at-home care program. Two days a week, nurses travel in PIH vehicles to patient homes throughout Kono, carrying a scale, blood pressure cuff, glucometer, and personalized supplies of medication. Patients receive the same monitoring and replenished medication they would at KGH—without any strenuous additional costs.
Sheku Kamara, a 50-year-old patient who was diagnosed with diabetes two years ago, recently received his first visit from the NCD team—though not at home, as is the case for most patients in the program, but at the secondary school in Koidu where he is principal. Finding time away from school is challenging for Kamara—he manages a student body of 4,000 with only 92 teachers—so the at-work care has proven essential, allowing him to regularly monitor his blood sugar alongside clinicians and replenish his supply of insulin pens.
“I’m so glad to be a patient at this clinic. I feel lively again.”
3,874
patients were enrolled in NCD care this year— an 80% increase from last year.
Moving Toward the Maternal Center of Excellence
A Bold Vision
At PIH-supported Koidu Government Hospital, clinicians in the maternity ward face a growing challenge: they are running out of beds for all of the women coming to deliver babies and receive reproductive health care.
It’s a good problem to have—indicative of the improvements to the quality and accessibility of care at KGH and newfound trust in health care that PIH has fostered within communities. But it’s a problem nonetheless, as nurses and midwives must quickly discharge patients to make room for new women arriving.
In partnership with the Ministry of Health & Sanitation, PIH is implementing a bold solution: Rather than incrementally expand the current maternity ward, we’re building the Maternal Center of Excellence (MCOE), a state-of-the-art teaching hospital aimed at accelerating progress in women’s health and that of their children.
An aerial rendering of the MCOE
The outpatient department
This year, our vision for the MCOE moved that much closer to reality. With much planning, consulting, and collaboration with the Sierra Leonean government and our architectural partners—health care infrastructure nonprofit Build Health International and design innovation firm The Living—we developed the MCOE’s design and made plans to break ground in 2021.
Designed to be energy-efficient, eco-friendly, and responsive to Sierra Leone’s climate, the future MCOE will triple the number of beds available in the current maternity ward and will include modern medical spaces, including a neonatal intensive care unit, operating theaters pressurized to prevent infection spread, and simulation labs for clinical training.
And beyond the advanced design and clinical features, the MCOE carries symbolic power, as a tangible investment in the idea that women’s rights are human rights, no matter where those women live. Stones from the nearby diamond mine—one of the largest in the world and long a means of colonial exploitation and extraction—will appear in the building’s facade, reclaiming a symbol of destruction for a symbol of hope.
The MCOE’s courtyard
An operating theater
Bigger Than A Building
Best selling novelists and YouTube stars John and Hank Green and their families have not only helped catalyze the establishment of the Maternal Center of Excellence. They’ve also fostered a global community dedicated to radically reducing maternal and child mortality, and to shining a light on long neglected injustice.
This community grew to more than 9,300 strong this year, and continues to prove instrumental in pushing the MCOE forward. It’s thanks to all of these PIHers, new and old, that the MCOE’s development continued—even through a pandemic—and that we remain on target to break ground in April 2021.
“We do not have to accept a world where so many women living in impoverished communities experience pregnancy as a life-threatening condition.”
A Solid Foundation
The MCOE won’t be starting from scratch in its mission to advance the health of women and children. Rather, it will be built on—and will expand—PIH and the Ministry of Health & Sanitation’s foundation of transformational progress in maternal and child health in Kono District.
This year, as all others, we grew this progress at Wellbody Clinic and Koidu Government Hospital (KGH), saving more women and children’s lives than ever before:
26%
increase in medically-necessary C-sections at KGH
97%
increase in family planning uptake at Wellbody and KGH
0
maternal deaths at Wellbody—for the fourth year in a row
86%
reduction in stillbirth rate at Wellbody—from 1.8% to 0.3%
96%
of severely malnourished children stabilized, safely discharged from KGH
26%
increase in HIV tests at KGH—and 13,644 total at KGH and Wellbody
Marking A New Era at Sierra Leone Psychiatric Teaching Hospital
A Presidential Celebration
(Left to right) PIH Program Officer Umaru Sheriff, His Excellency President Julius Maada Bio, and Honourable Minister of Health Dr. Alpha Wurie unveil a new plauqe marking the presidential commissioning of the hospital.
This year, Sierra Leone Psychiatric Teaching Hospital turned 200 years old—a milestone we marked with our most key partners.
His Excellency President Julius Maada Bio and Honourable Minister of Health Dr. Alpha Wurie joined PIH, hospital staff, and patients in May to celebrate the vast infrastructure renovations and improvements to care made at the PIH-supported hospital. The President officially commissioned the hospital, marking Sierra Leone’s renewed commitment to mental health care—the world’s most underfunded area of health.
Opened in 1820, Sierra Leone Psychiatric Teaching Hospital—previously known as Kissy Mental Hospital—is the oldest psychiatric hospital in sub-Saharan Africa, and the only dedicated mental health facility in Sierra Leone. In spite of its stature and singularity, the hospital operated for nearly 200 years without electricity, running water, or modern psychiatric medications. In the past, many patients spent days and nights chained to their beds—a technique turned to as a last resort by desperate clinicians who lacked the resources to provide care and keep patients safe.
That all began to change when PIH partnered with the government to transform the facility into a dignified, well-resourced hospital. PIH introduced plumbing and electricity; established a supply chain for food, medical supplies, and never-before available psychiatric medications; and renovated the hospital campus. Now, patients live in clean, comfortable spaces, and clinicians are equipped to deliver high-quality care. Chains are no longer used, or even necessary.
His Excellency President Julius Maada Bio delivers a speech at the hospital’s celebration.
An Influx of Outpatients
For nearly 200 years, patients were typically admitted to Sierra Leone Psychiatric Teaching Hospital for life. The hospital’s pharmacy shelves, absent of any modern psychiatric medications, meant there was little hope for people living with schizophrenia, psychosis, bipolar disorder, and other severe mental health conditions to reintegrate into their communities and live safe, independent lives. Inpatient treatment was the only option—with no clear path elsewhere.
Now, thanks to our investment in the hospital’s pharmacy, patients no longer face this limitation. With a robust supply chain providing life-changing medications, and with the specialized clinicians to prescribe these drugs and support patients through their treatment plans, for the first time in its history, Sierra Leone Psychiatric Teaching Hospital has more outpatients than inpatients.
Upon accessing this new level of care, many inpatients have transitioned to outpatient. And as the reputation of the hospital continues to improve—especially after the president’s visit—visits to the hospital are rising rapidly. Many of these new patients are now seeking mental health care for the first time because they have a dignified facility to turn to and trust.
SLPTH Admissions
Haja Salimatu Bah, 33, was diagnosed with psychosis and was living at SLPTH. Because she received proper medication and care, she’s since left the facility and now receives outpatient care. She has a 10-month-old daughter, Ceray.
“People in Sierra Leone are starting to open up about mental health.”
Strengthening Rural Clinics and Community-Based Care
Unrecognizable Clinics—With More to Come
Kombayendeh Community Health Centre before PIH renovation
Kombayendeh Community Health Centre during PIH renovation
Kombayendeh Community Health Centre after PIH renovation
In our mission to strengthen Kono’s entire health system, top to bottom, we’ve expanded our support to six community health centers throughout the district.
These small clinics are most accessible to rural families, who would otherwise have to take an hours-long motorbike ride over oft impassable roads to visit Wellbody Clinic or Koidu Government Hospital—a journey that can be catastrophically expensive, not to mention detrimental in an emergency. Yet, in spite of their accessibility, these facilities have been vastly under-resourced, lacking adequate infrastructure, supplies, and highly-trained staff.
This year, we began the process of renovating and improving care at local rural clinics in partnership with local leaders. Our initiative has begun with two: Sewafe Community Health Center and Kombayendeh Community Health Center.
At Sewafe, a 45-minute drive from Koidu, we installed solar power and dug a new well for access to safe water. At Kombayendeh, a 3-hour drive from Koidu, we expanded the building to accommodate a new laboratory. And at both facilities, we improved air circulation, installed air conditioning for the safe storage of medications, introduced plumbing and 24-hour electricity, and completely renovated building interiors.
Combined with support from PIH’s supply chain and clinical mentors, Sewafe and Kombayendeh—and four more community health centers to come—are increasingly positioned to provide patients with high-quality, facility-based care close to home.
Addressing Mental Health and Homelessness
In Kono, as is common throughout the world, people living with mental health conditions often experience homelessness, as a result of stigma and lack of access to mental health care. Those living on the streets, without access to resources, familial support, or ways to manage their mental health, are some of the most vulnerable members of the communities PIH serves.
Last year, we launched a program—piloted by our neighbors at PIH Liberia—to address both mental illness and homelessness.
As part of this program, our team of mental health community health workers (CHWs) use their deep connections in communities throughout Koidu to identify homeless people exhibiting signs of a mental health condition and to refer them to the mental health clinic at Koidu Government Hospital. If and when a patient is enrolled in care, a dedicated CHW visits them daily to monitor their health and wellbeing. Treatment consists of not only medication and therapy, but also social support in the form of a monthly stipend to pay for food, toiletries and, eventually, new housing.
47
patients currently enrolled in the mental health homelessness program
83%
of enrolled patients have shown improved functioning (self care practices, social connections, ability to participate in daily activities)
Musu Tarawally was living with psychosis. With medication and social support from PIH, she now has a bed to sleep in, neighbors who accept her, and plans to start a business in town. Neighbors often knock on her door to ask what healer she consulted, to which she replies, “You can find help at Koidu Government Hospital.”
“One day, the team brought me food, and they asked me to go to the hospital. When they started giving me the first dose of medication, I started realizing myself. And when I started realizing myself, things started changing positively. I can clean for myself, cook for myself, take care of my hygiene. I associate myself with my community, and people will be looking and admiring. There is still stigma—but even if you talk, point, or laugh, I will not respond. I will just go ahead and do what will make me happy.”
Innovating at Wellbody Clinic
Digitizing Health Care
The former records room at Wellbody Clinic
Staff at Wellbody register patients with the new EMR system.
2020 marked the beginning of a new era at Wellbody Clinic, as digitized medical records paved the way for more comprehensive, patient-centered care. This year at Wellbody, PIH rolled out OpenMRS, an open-source electronic medical records system that we co-developed in 2004.
Before this rollout, patient records at Wellbody were held in a storage room overflowing with folders, making the records vulnerable to damage and a hassle for staff to update. Now, with the new system in place, clinicians, lab technicians, pharmacists, and administrators are able to retrieve updated patient information in real time to make more accurate diagnoses and treatment plans. And with less time needed for paper-based administrative work, staff can allocate more time to helping patients directly.
The new system also allows for more and higher-quality data, giving clinicians a deeper understanding of the diseases being treated, as well as patient behavior, and informing decision-making at Wellbody and for Kono’s health system at large.
OpenMRS isn’t a first for the clinic alone—it’s also a first for the nation. Wellbody is the first and only health facility in all of Sierra Leone to be fully reliant on electronic medical records, providing a new model for clinics and hospitals throughout the country to replicate.
Food as Medicine in HIV and TB Care
Food insecurity often accompanies—and makes worse—diagnoses of HIV and tuberculosis. Patients living with these illnesses need extra calories and nutrition to regain their health, and treatment regimens are harsh on empty stomachs. To help patients recover, healthy, nutrient-rich foods prove just as essential as any medication.
This year, PIH started the HIV/TB Nutrition Program in order to equip vulnerable patients with the means to keep themselves fed and on the path to health. All patients newly diagnosed with TB and patients living with HIV who are children, pregnant, or have a low BMI, are enrolled and receive monthly clinical monitoring and social support.
This support comes in the form of a stipend, so patients can purchase their own food and, as many opt to do, save up to start a small business that will generate income to pull them further away from poverty and malnutrition in the long run.
So far, the program has proven to be life-changing, with the majority of patients gaining necessary weight and able to comfortably take their daily medications.
60%
of undernourished patients have already achieved a healthy BMI
98%
of enrolled patients have not missed their medication in the last week
Fanta Koroma lives with HIV in Koidu. With support from the nutrition program, as well as from her community health worker, she has returned to a healthy weight, can take her medication daily, and used some of her stipend to start a small business selling sandals in town.
Advancing TB Care at Lakka Government Hospital
New Facilities, New Life
TB specialist Dr. Michael Mazzi monitors a patient in the high-dependency unit.
At Lakka Government Hospital—Sierra Leone’s only dedicated tuberculosis hospital and the country’s first facility to offer care for multidrug-resistant tuberculosis (MDR-TB)—inadequate infrastructure had long prevented some of the sickest patients in the country from receiving high-quality, dignified care. That began to change in 2017, when PIH and the Ministry of Health and Sanitation partnered to rehabilitate Lakka.
This year marked important milestones for this effort: We opened the hospital’s first-ever high dependency unit, providing clinicians the space and supplies to closely monitor and treat critically ill patients. We completed renovations of the MDR-TB ward, providing inpatients more comfortable accommodations during their treatment regimens. And we made progress on building a new triage center to more efficiently receive new patients and renovating a new kitchen for more space in which to cook meals key to patients’ treatment and recovery.
Such improvements are already enabling clinicians to provide a new standard of care, and setting new precedents for TB outcomes.
The MDR-TB ward, last year amid construction. Patient rooms are on the right.
The MDR-TB ward, newly renovated
Patient-Centered Treatment
Bedaquiline—a new TB drug, proven to improve patient care—is now being widely used at Lakka.
Treatment plans for tuberculosis and multidrug-resistant tuberculosis are notoriously punishing—especially for patients whose regimens include injectables, which can cause side effects as extreme as psychosis or permanent deafness.
Newer, safer drugs do exist. Rather than being injected, TB drugs like bedaquiline are delivered orally, through pills. And thanks to global research—including the endTB clinical trials which PIH helps carry out in 17 countries—these all oral treatment regimens have proven effective.
With this evidence base, PIH has supported Sierra Leone’s Ministry of Health & Sanitation to revamp TB treatment guidelines—a process that, this year, safely transitioned most patients at Lakka, including all new patients, to all oral regimens.
Swapping painful, daily shots (which must be administered by clinicians for up to six months) for these pills has reduced the toxicity of treatment and given more patients the freedom to recover at home.
Still, bedaquiline and other TB medications can also be harsh on the body—so we’ve continued to complement the Ministry’s stock of TB treatment with pharmacy shelves full of ancillary drugs to alleviate uncomfortable, dangerous side effects.
This modern, comprehensive care has the double impact of being clinically effective and helping patients adhere to treatment. Offering treatment that prioritizes human safety and comfort allows more patients to complete their regimens—contributing to a cure rate above the global average, and helping slow the spread of the world’s top infectious disease killer.
A pharmacy shelf stocked with drugs to manage the side effects of TB and its treatment.
MDR-TB Cure Rates (%)
“The biggest reward is continuing to see these clinical miracles: patients who were about to die, but because they have affordable, quality care, they are able to be saved.”
