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Entry #4
Posted July 22, 2008
My time in Kenya is about to end so this will be my last message. AMPATH had its monthly meeting where leaders of all departments meet and offer brief oral reports plus data updates where relevant. These range from support groups to the oncology clinic to those programs I have discussed in previous essays. Allow me to share some data. As of the end of June,
 Dr. Robert Blount of the IU School of Medicine rounds with a group of U.S. and Moi University medical students and residents at the Moi Teaching and Referral Hospital. |
I am sure that all have a feel for how complicated this effort is. There are so many moving parts. What has made things even tougher is that we receive grants in US dollars. The weakening dollar coupled with inflation here and everywhere we have to buy things means that the purchasing power of grant funds has decreased almost 30%. The solution aside from continual fund raising is that people are working harder. I wager that we all have a preconceived notion that things are inefficient in the developing world and that part of that inefficiency is a poor work ethic. Systems here are inefficient, but after meeting scores of people involved in this program, I can testify the work ethic is commendable. I have commented before that so many people see their work as a true mission to help not only individuals but their whole country; they have a passion for what they are doing and you see it manifest in myriad ways. This also means they set an example for others so this spirit of commitment feeds on itself. If someone were to try to cut a corner, their colleagues would quickly weed them out.
Most of you who have not visited the program are not aware of the spirit of the place. Beyond the full-time employees are all of us who rotate through the clinics and hospital. During my time here, we have had first and fourth year IU medical students, Purdue Pharmacy students, students from the U of Toronto, faculty from Brown, Utah, Washington, Yale, and Toronto and others that come in and out on various projects. This totals upwards of 40 people most of who stay at the "IU House." The IU House originally was one rented house. Now we rent 10 and the moniker collectively refers to them all. Most are clustered in one area within easy walking distance to the hospital. This allows good security, but it also allows us to have group meals where all gather for lunch and dinner to share our experiences. Just sitting at these tables is a joy to listen as people talk about what they have done and relay their impressions. This program started and continues with an overarching goal to reinforce the altruistic spirit of medicine. It is doing one heck of a job.
As I get close to leaving Kenya to come home, I have very mixed emotions. I am always happy to get home even though it means tall grass to mow, a mountain of mail and countless meetings many of which seem like a waste of time relative to needs here. But home is home and I love the School. But I struggle with the needs we see and the reality that this is just a snapshot of issues that are widespread throughout the world. At home we get exorcised about things that pale to insignificance when staring at someone who weighs 50 pounds soaking wet and is so weak they cannot stand. But these same people look me in the eye and thank me—me—for helping them even though they assume they are going to die. And I am basically an observer. Even in their desperate condition, they genuinely appreciate that someone is trying and someone cares. Their expressiveness is so genuine and sincere that even when spoken in a tribal language where you do not understand a word, the message is louder and clearer than most of us ever here from anyone. Everyone here tells similar stories—incredible gratitude and hope in the face of incredible privations and human tragedy. So on the one hand, I am immensely proud of what our colleagues are doing and simultaneously overwhelmed with guilt that personally and collectively we are not doing more. I think it is similar for most if not all who come here. Our students are smarter than me. They tell me it is this very juxtaposition of grinding poverty and misery with hope and gratitude that makes it such a meaningful experience. This program helps all of us reinforce what the profession of medicine is all about—individuals doing what they can wherever they are to help their fellow man. When I and others are thanked, they are also thanking all of us at the School because they know this is a collective commitment that goes beyond the faces they see on the ground here. Be proud.
Best wishes from Kenya,
Craig
Last week I spoke about the house to house program where counselors are visiting every home in a region to seek invitation to enter and talk about HIV and test people. The last two weeks were spent covering a catchment area that comprises about 1500 households. Early this week we met to assess results and to work out any kinks in anticipation of tackling the next area. Of the 1500 households, 15 refused entry-15!! Some other remarkable events occurred: people were stopping counselors along the road asking to be tested; many households had relatives or friends who had come from other areas so they could be tested; people who were tested proudly displayed their cards and asked others to show theirs-if someone could not show a card they were assumed positive and labeled "spreaders". Many of these then came back to be tested. All this shows that stigma has reversed itself in a few short years! There are still challenges of course. In homes with negative parents and teenage children, the children would often express willingness to be tested but not in front of their parents. Without the ability to link them to a household (owing to anonymity), follow up will be difficult. Overall though, this has been a wildly successful program-let's hope it continues as it rolls across the rest of the 2 million person catchment area. But no matter what the case, it is clear that the culture of HIV is changing dramatically. The implications in terms of getting on top of this scourge are obvious.
We visited FPI this week. As a quick reminder, once we had drugs to treat people, we uncovered starvation so a bridging food program was started (in partnership with the World Food Programme), but a persisting problem was that people had no way to support themselves. Thus the Family Preservation Initiative (FPI) was birthed. This includes a variety of microfinance programs from learning arts and crafts, to setting up a small business, to changing farming methods to grow more money crops. The traditional crop here is corn. Fields are planted in corn year after year requiring more and more fertilizer to obtain a reasonable yield. (They need to read "Omnivores Dilemma"). If one calculates all the expenses that go into raising this corn, negligible if any profit can be made so this strategy does not meet the need to generate income for sending kids to school, etc. We went to Samuel's shamba (house and farm) who through FPI has converted some of his land to soy beans and to passion fruit. Within less than two years Samuel is financially independent, his kids are in school and he is employing another man in the community to help him. As you can imagine he is an eloquent spokesperson for alternative approaches to farming. An interesting anecdote is that a neighbor of Samuel's went to the AMPATH clinic even though he had tested negative for HIV. He asked the clinic to record him as positive so he could get in on this FPI farming program!!
We also met a woman who is running a successful small restaurant and a man who has a fruit stand-best in Eldoret. Both these patients have the taste of success and are seeking financing to expand! Needless to say, there are no malnourished patients and no orphans to worry about in these families--and there is no dependence on hand outs.
My comments have focused on clinical care. This platform is also blossoming in terms of research. We have one of the NIH funded international ACTG's (AIDS Clinical Trials Group) and there are a host of studies being done. At the upcoming International AIDS meeting in Mexico City there will be 21 posters and 4 oral presentations from work here. My personal assessment is that we are still scratching the surface so expect even more recognition for research in the future.
Overall I have experienced a third week being amazed at people's dedication and the impact they are having. All of us should be proud of our colleagues. Therein, it bears emphasis that this is a true collaboration with our Kenyan partners. We are few and they are many. Our goal is to also succeed in helping them build capacity so that at the end of the day they have a more robust health system that is run by them and we are consultants watching from the side lines. We are not there yet but it is within sight.
Best wishes from Kenya,
Craig
Entry #2
Posted Monday June 30, 2008
Last week in Kenya was as illuminating, refreshing, exhausting and provoking of thought as the prior. One of the approximately 20 outreach clinics run by AMPATH is in a town called Kitale. This is a new clinic, so facilities have not been built to accommodate the rush of patients there who need treatment for HIV. Imagine an 8 by 10 foot room. In that room place two small desks that are just wide enough for two chairs touching one another-thus four chairs on one side and four on the other. Add an "examining table" and a make shift curtain that can be placed along its side. From clinic opening till the last patient is seen, four days a week, this room is filled-thus four patients at a time one after another facing four medical officers (MD generalists) or clinical officers (equivalent of a physician assistant). As most of the patients seem to be women, a majority are also accompanied by one or two children. It is reminiscent of those days of contests to see how many people you could pack into a VW Beetle! The patients are unfailingly polite, patient and grateful for receiving care no matter how confined the setting. For the few who could speak English, each and every one would look me in the eye and say how appreciative they were for helping their community-not them as individuals but their community. So these are people who are in the most dire straits imaginable, and still they have hope, appreciation and a sense beyond themselves. The "me world" has not reached this part of Kenya and let's hope it never does. Imagine the impact seeing this has on our learners.
Another day we went to one of the camps for "IDPs". This stands for Internally Displaced Persons-basically refuge camps for those of the "wrong" tribe who ran for their lives as their homes and possessions were burned in the ethnic rage that followed the tainted election at the end of December. A number of clinic patients sought refuge in these camps, so we have gone seeking them to maintain continuity of care. Our visit was part of the testing of individual homes that I spoke about in my prior message. For the time being their homes are in these camps. Even in the face of this injustice, often separation or death of family members, and incalculable loss, they were appreciative of what AMPATH is doing. They were coming forward to be tested. Those who were positive were then given follow up appointments in clinic coupled with on the spot counseling on how to avoid infecting others; those negative received on the spot counseling on staying negative.
This is such a sea change from a few years ago when no one would even talk about HIV except in euphemisms because the stigma was too severe. This is not to say that all is well. There are still many challenges. In my last message, I spoke about how the current system identifies people too late. Our house to house testing program is aimed to get at that issue. Another hurdle is the status of women. They are the victims disproportionately; many women deal with impossible scenarios such as a presumably infected husband who refuses to be tested and who would potentially throw her and her children out of the house hold if she demands safe sex. So one has to keep pushing and that is what AMPATH does-for example, now if a patient shows up with TB, they are automatically tested for HIV no matter what their gender. Seventy percent of patients with TB in Kenya are HIV positive.
Another experience was going with one of the house to house councilors and testers. This required a harrowing trip across dirt "roads" to get to a small village-thank goodness for 4 wheel drive and strong shock absorbers! We were so far out that the son of one patient who I would guess to be about 4 years old was terrified of the vehicle as he had never seen one before. Patients were welcoming of a stranger like me to come into their home, which in most cases was a one room mud hut with a thatched roof. They too expressed gratitude just as we have seen everywhere. What also struck me to the core was talking with the councilors who also have this extra-ordinary sense of community. One after another, they spontaneously and repeatedly told me they felt they were on a mission to literally save the fabric of their community. They fully understood what they were doing and its potential. Theirs was not a job or a task; this was/is passion-how inspiring and humbling. We are the supposed sophisticates; I wonder.
Best wishes from Kenya,
Craig
Entry #1
Posted Sunday June 22, 2008
Friends, I thought I would take this opportunity to describe a couple of experiences so far.
Friday we spent the day at the Imani workshop that is teaching crafts to HIV positive patients so they can make a living. Recall that the recent violence in January and February was tribe against tribe stirred up by rhetoric from rival politicians. People were literally killing one another and burning each other's homes. It got as close to civil war as you can get before there was a "cease fire". Of course our patients come from all tribes so we asked what happened among them during that time. The response was that we are all from one tribe, the AMPATH tribe so we all worked together and helped one another through the crisis. This spirit permeated the 600 or so Kenyan employees of AMPATH and proves that if you can get people to work together for a common cause, those historical boundaries dissipate.
On Saturday we were able to participate in a special event. The current practice paradigm here and elsewhere in the world is to discover people with HIV when they are sick enough to present themselves to the clinic or hospital. By this time many cannot be saved and die, or they have already lost a spouse, and/or they have infected others in the household including their children, and/or they have lost all their land and possessions and are malnourished and in poverty. So even if therapy rescues someone, most are still in dire straights (hence things like the Imani program mentioned above). The only way to forestall that scenario is to catch the disease earlier before parents have died and land has been lost. To do that, AMPATH has successfully completed a pilot program in about 7000 people where they went door to door to every household in several villages to test everyone in the household for HIV on site and plan treatment and follow up based on those results. Over 90% of households allowed our people in and were tested. This proved feasibility. Our Saturday event was launching this program in a larger catchment area of 120.000 people. As preparation, all leaders in the community were educated and became supportive and volunteers living in the villages began educating people. Saturday was a community gathering on the soccer field of a local school where there were events such as bicycle races, foot races, soccer games, tugs of war, and dancing all interspersed with education and advocacy of the house to house testing program. On Monday, about 70 counselors will fan out across this district and begin knocking on doors. Impressive was the fact that close to 1000 people attended many of whom walked for long distances. The enthusiasm was palpable both among the citizens and the AMPATH workers who are truly committed to the good they are doing. It was truly remarkable to see and feel this.
Each household will have its location documented by GPS and all data will be captured by PDA for downloading into a comprehensive database. This census survey will not only allow earlier detection but it will provide the opportunity for intervention followed by repeat data gathering to determine the impact of an intervention on true incidence. No other place in the world will have these kinds of data. Thus, in addition to the public health impact will be a rich opportunity for research.
So we have hit the ground running. We are spectators and as such I want to make sure you get a glimpse of what is going on so you can be proud of the work being done here under the banner of the IU School of Medicine.
Best wishes from Kenya,
Craig
