“Where a child lives should not determine whether a child lives,” declared Dr. Apoorva Gomber, associate advocacy director for the NCDI Poverty Network. “And yet children with type 1 diabetes in rural areas of sub-Saharan Africa often die within a year of diagnosis. This reality is morally unconscionable.”

Dr. Gomber delivered those statements at the Multi-Stakeholder Hearing on Universal Health Coverage, held on May 9 in the United Nations Headquarters in New York City. Selected organizations were allowed to deliver two-minute testimonies during an afternoon session; Dr. Gomber represented the NCDI Poverty Network in her testimony.

A physician trained in global health centered around type 1 diabetes, health equity, and disease epidemiology, Dr. Gomber also serves as associate advocacy director for the network’s Boston co-secretariat, the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital. As a long-time advocate for the treatment of type 1 diabetes, Dr. Gomber also works toward overcoming both health inequities in diabetes care globally and the stigmatization of people with diabetes.

“It’s past time that we form a global movement to better serve people doubly afflicted by NCDs and extreme poverty,” Dr. Gomber said, in concluding her United Nations testimony. “The international community can make the fight against disease more equitable and just through leadership, policies, and funding that prioritize NCDs within universal health coverage.”

The World Heart Federation has presented its Outstanding Contribution to Cardiovascular Health Award to Drs. Gene Bukhman and Ana Mocumbi, co-chairs of the NCDI Poverty Network. The presentation took place in May at the World Heart Awards ceremony in Geneva.

The two cardiologists were celebrated in part for their work as co-chairs of the groundbreaking Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion. The commission launched in 2016 to address the crushing burden of noncommunicable diseases (NCDs) and injuries on the world’s poorest people.

In addition to its many findings, the commission highlighted the need for expanded financing and technical partnerships to address this burden. The commission also catalyzed the formation of the NCDI Poverty Network, which aims to prevent and reduce the death and suffering of those doubly afflicted by NCDs and extreme poverty. Drs. Bukhman and Mocumbi now co-chair the network.

Dr. Bukhman, who directs the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital, is an anthropologist as well as a cardiologist. He also serves as director of the Program on Global Noncommunicable Disease and Social Change at Harvard Medical School, where he is an associate professor of medicine and an associate professor of global health and social medicine. He is also the senior health and policy advisor on NCDs at Partners In Health. Between 2010 and 2015, he served as senior technical advisor on NCDs to the Rwanda Ministry of Health.

Over the past 15 years, Dr. Bukhman has argued that for those living in extreme poverty, NCDs are best understood as part of the “long tail” of global health equity, one that demands a new science of integration. He has translated this critique into practical health delivery strategies now being implemented in more than a dozen countries. He has authored more than a hundred peer-reviewed publications and book chapters that apply a range of methodologies — from ethnography and archival research to epidemiology and mathematical modeling — to identify solutions for people living in poverty with severe NCDs.

“It’s an honor to be recognized for carrying on in the tradition of African cardiologists focused on diseases of poverty,” Dr. Bukhman said. “We’re optimistic that by working together with the type 1 diabetes and sickle cell disease communities, we can finally make significant progress on these neglected conditions.”

Dr. Bukhman’s fellow awardee, Dr. Mocumbi, is both an associate professor of cardiology at Universidade Eduardo Mondlane in Maputo, Mozambique, and an affiliated professor in the Department of Global Health at the University of Washington in Seattle. Based in Mozambique, she also leads the Non-Communicable Diseases Division at the National Public Health Institute Mozambique (Instituto Nacional de Saúde).

Although Dr. Mocumbi’s research interests are broad, spanning from education to health management to clinical research, her particular focus is on neglected cardiovascular diseases, including cardiomyopathies and heart failure in children; women’s cardiovascular health; and the use of point-of-care technologies for improving access to health care in low-income settings.

Dr. Mocumbi serves as co-chair of the Taskforce for Access to Reproductive Health Services for Women with Cardiovascular Disease of the Pan African Society of Cardiology, as well as co-chair of the World Heart Federation’s Working Group on Rheumatic Heart Disease Prevention and Control.

“Merci à tous! Thank you!” Dr. Mocumbi said to a group of NCDI Poverty Network members upon being congratulated on the honor. “But this award belongs to all of us. Without you this would not be possible.”

The World Heart Awards celebrate individuals and organizations who have gone above and beyond in their mission to fight cardiovascular disease and promote healthy hearts.

The Center for Integration Science in Global Health Equity has been named a WHO Collaborating Centre in recognition of its work in designing integrated care delivery systems for people living with severe noncommunicable diseases in extreme poverty.

Childhood heart diseases, type 1 diabetes, and sickle cell disease customarily fall into disparate clinical specialties. Even so, those conditions share certain disheartening characteristics: They’re all severe, chronic noncommunicable diseases that cannot be prevented. Their treatment protocols are complex. And, when left untreated, they kill the world’s poorest children and young adults at devastating rates.

Fortunately, these diseases also share a clinical cadence, and it’s in that pattern of services that the field of integration science can offer a solution. In this instance, the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital has been working with an international network to integrate expertise and resources across these diseases to save young lives in rural sub-Saharan Africa and South Asia, where 90 percent of the world’s poorest people live.

For its leadership work in integration science, the Center for Integration Science was recently named the WHO Collaborating Centre on Integration Science and Service Delivery. With this designation from both the World Health Organization and the Pan American Health Organization, the center joins a global network of organizations supporting WHO initiatives.

“We’re honored that both the World Health Organization and the Pan American Health Organization are recognizing our work,” said Gene Bukhman, MD, PhD, executive director of the Center for Integration Science. “We also appreciate the value they’re placing on integration science, a relatively new field that has tremendous potential for delivering care to the people who need it most, which is an essential ingredient in achieving global health equity.”

In many low- and lower-middle income countries, care services for severe, chronic noncommunicable diseases are available only at referral hospitals in major cities, making treatment both inaccessible and unaffordable for the rural poor. As a result, many children and young adults die prematurely — and preventably. The model the Center for Integration Science principally uses, PEN-Plus, addresses this gap by bringing lifesaving care to first-level rural hospitals.

In aiming for an optimal configuration of health care resources, PEN-Plus trains mid-level providers such as nurses and clinical officers to provide crucial services across these diseases. Last summer, all 47 member states of the WHO Regional Office for Africa adopted PEN-Plus as their official strategy for providing care for people with severe noncommunicable diseases.

As part of its WHO Collaborating Centre mandate, the Center for Integration Science will provide technical support to WHO’s work in characterizing and classifying existing models of integrated care for noncommunicable diseases, collaborate with WHO in the integrated care of these diseases in selected countries, and share best practices and lessons learned in the implementation of integrated care of these diseases. The WHO Collaborating Centre designation is slated to continue through April 2027.

The Center for Integration Science is a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Partners In Health. In addition to pursuing an ambitious research agenda, the center serves as the Boston co-secretariat of the NCDI Poverty Network, a global partnership that seeks to bridge the gap in universal health coverage for the world’s poorest billion.

The only other current Harvard-affiliated WHO Collaborating Centre — the Program in Global Surgery and Social Change — is also based at both Harvard Medical School and Brigham and Women’s Hospital. Past Harvard-affiliated WHO Collaborating Centres include three at the Harvard T.H. Chan School of Public Health (one on the biostatistical evaluation of cancers from  1981 to 1994, one on health legislation from 1987 to 2004, and one on nutritional epidemiology and advanced training in public health nutrition from 1993 to 1999); one at Brigham and Women’s Hospital (on surveillance of antimicrobial resistance from 1985 to 2021); and one at Harvard Medical School (on research and training in mental health from 1987 to 1994).

The stark realities of living with severe noncommunicable diseases in extreme poverty became clear to members of the High-Level Advisory Group of the PEN-Plus Partnership when they convened in Mozambique in March to discuss strategies for supporting initiation and scale-up of PEN-Plus in resource-poor countries.

PEN-Plus is an integrated care model that provides diagnosis and treatment for severe NCDs in rural areas of low- and lower-middle-income countries, where more than 90 percent of the world’s poorest people live.

During the three-day meeting, participants visited the new PEN-Plus clinic and training center in Nhamatanda, nearly 800 kilometers north of the capital city of Maputo. The trip provided the participants with the opportunity to meet firsthand those livning with severe NCDs as well as their caregivers.

The plight of the rural poor was underscored for participants when they met with a 14-year-old boy recently diagnosed with rheumatic heart disease. The boy had presented at the PEN-Plus clinic with severe breathing difficulty soon after the clinic opened in February. Upon listening to the boy’s chest, the cardiologists in the group—including the co-chairs of the NCDI Poverty Network, Drs. Gene Bukhman and Ana Mocumbi—immediately realized he had a heart murmur indicative of a serious condition.

At the time of the group’s visit, arrangements were being made for the boy to undergo additional testing and mitral valve repair surgery in Maputo. The matter was complicated, however, by the 900-kilometer distance from the family’s home to the capital city.

On the nearly two-hour drive from Nhamatanda back to the airport, Advisory Group members peppered Dr. Mocumbi with questions about the boy’s future.

“Welcome to Ana’s World, where you have to solve one problem before you can confront another,” she responded. “He doesn’t have the identification papers required to take a flight in Mozambique. So we need to make him exist on paper before he can even travel for his surgery.”

Compounding the boy’s situation is his family’s extreme poverty. The boy lives with his widowed mother and three siblings 20 kilometers from Nhamatanda in a home with neither electricity nor plumbing. The family’s only means of support is his mother’s small-scale farming.

Fortunately, the PEN-Plus clinic provides the boy with additional social support, including money to travel to Nhamatanda for his monthly checkups and a cell phone to enable follow-up calls with his care provider. After his heart operation, the clinic will continue to provide him with the anticoagulation medicine he will need to take for the rest of his life.

“The Nhamatanda PEN-Plus clinic just opened in February,” said Dr. Mocumbi, “and it’s already saving lives.”

Unfortunately, the difficulties the boy’s family faces are familiar to many people living with severe NCDs in rural Mozambique and other low-income areas where PEN-Plus clinics provide health services.

Those difficulties were exactly why representatives from the organizations that compose the High-Level Advisory Group—including the Helmsley Charitable Trust, JDRF International, UNICEF, the World Health Organization Regional Office for Africa, the American Heart Association, the Foundation of Cardiovascular Care in Africa, and the World Diabetes Foundation—had gathered in Mozambique.

In addition to their Nhamatanda visit, members of the group met in Maputo—where the Network’s co-secretariat at Universidade Eduardo Mondlane hosted the event—to review an initial draft of the PEN-Plus Partnership’s strategic plan. The final plan will both clarify the role of PEN-Plus in the global NCD landscape and outline expansion strategies for 2025–2028.

The need to improve the quality and reach of PEN-Plus services was a clear theme throughout the meeting.

“Seeing firsthand the challenges of those living with severe NCDs in extreme poverty underscored for everyone the urgent need to support health systems in low-resource settings, especially in rural areas where health inequities are so stark,” said Dr. Bukhman.

Dr. Mocumbi agreed.

“Integrated care delivery strategies like PEN-Plus make it possible not just to improve access to health care in underserved communities,” she said, “but also to save lives.”

“The Center for Integration Science is a group of clinicians, researchers, and administrators focused on moving health resources to the world’s poorest people. We’re doing this by finding new service delivery models that can expand health care and by mobilizing social movements to enact lasting change.”

Those were CIS Executive Director Gene Bukhman’s opening words in an interview featured in the March edition of Brigham Clinical & Research News, a monthly newsletter of Brigham and Women’s Hospital.

In the interview, Bukhman:

• highlighted the Center’s mission and goals — “to accelerate global health equity by identifying integrated units of operational effectiveness and health care delivery, and then scaling implementation through collective action”;
• identified gaps in global solidarity and financing as the principal obstacle to achieving them; and
• described the new approach the Center is taking to break the impasse — “by forging new kinds of coalitions across multiple disease spaces and among people who treat, advocate for, or live with these diseases.”

“The best example of this,” Bukhman said, “is the PEN-Plus strategy, which stands for Package of Essential Noncommunicable Disease Interventions Plus. It’s an approach developed in the late 2000s at the Brigham with partners in Rwanda to simplify care for different types of severe, chronic noncommunicable diseases. We identified the most essential elements of treating these conditions, trained nurses and other mid-level providers to deliver this care, and forged connections among advocates working on disparate diseases. PEN-Plus has since expanded to 14 countries.”

When asked to sum up what distinguishes the Center from other initiatives and collaborations, Bukhman answered succinctly.

“One major difference is that we’re developing models of service delivery at the same time we’re studying the sociology of advocacy movements. Braiding these crucial strands of work together is unusual in medicine and global public health.”

Read the full interview in Brigham Clinical & Research News.

Momentum has continued since the 47 member states of the African Region of the World Health Organization adopted the regional PEN-Plus strategy to address severe noncommunicable diseases at first-level referral health facilities.

To build on that momentum, WHO/AFRO experts from the non-communicable diseases (NCDs) program were in Boston in late January to meet with leaders and staff from both the Boston and Maputo co-secretariats of the NCDI Poverty Network. The PEN-Plus Regional strategy is designed to increase the capacity of first-level health facilities in rural and peri-urban areas to diagnose and treat severe, chronic NCDs such as type 1 diabetes, sickle cell disease, and rheumatic heart disease using standardized and evidence based, protocols supported by mentorships of the service providers.

During the three days of meetings, the AFRO and Network teams reviewed the PEN-Plus implementation framework that the WHO/AFRO team developed and discussed how the Network can best support achieving the ambitious goal of the regional strategy – to have 70% of member states rolling out PEN-Plus services by 2030. They also covered approaches to country prioritization, operational research needs, and monitoring and reporting methods at national, regional, and global levels.

On the third day, representatives from the Helmsley Charitable Trust, UNICEF, and the American Heart Association joined the WHO/AFRO and NCDI Poverty Network teams. These organizations are key members of a high-level Advisory Group for the PEN-Plus Partnership that focuses on resource mobilization strategies to support PEN-Plus initiation and scale-up.

The meetings were hosted by the Center for Integration Science in Global Health Equity, which serves as the Network’s Boston co-secretariat, working in conjunction with the Maputo co-secretariat based at Universidade Eduardo Mondlane in Mozambique. The Center is a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Partners In Health.

Following the adoption of the PEN-Plus strategy to address severe NCDs at first-level referral health facilities by the World Health Organization Regional Office for Africa (WHO/AFRO), the West African Health Organization (WAHO) hosted a three-day regional review meeting on the WHO Package of Essential NCD Interventions for Primary Health Care (WHO PEN) that included a presentation on PEN-Plus and the NCDI Poverty Network. Participants met in Cape Verde between 14-16 September 2022.

The event included a presentation from Dr. Prebo Barango of the World Health Organization Regional Office for Africa (WHO/AFRO) on PEN-Plusas an integrated care delivery strategy to provide chronic care for severe NCDs such as type 1 diabetes, sickle cell disease, and rheumatic heart disease in rural areas. Center for Integration Science Managing Director and NCDI Poverty Network West Africa Regional Lead Emmanuel Mensah followed Dr. Barango’s presentation by sharing the progress the Network has made in introducing, implementing, and scaling-up PEN-Plus in West Africa.

The meeting focused on achievements in implementing the WHO PEN to address the regional burden of NCDs as well as the challenges. The Africa Center for Disease Control (CDC) and WAHO presented a strategic plan for NCDIs and mental health for the region.