A Case Study in Global Health
Harnessing the Power of Partnerships
By Bob Einterz
To awaken the inherent power of academic medical centers and their research based universities like Indiana University and Moi University in Kenya, we must measure their success not just in terms of profits and publications, but also in terms of the health of our population and community, such as infant mortality, maternal mortality, HIV incidence, and other such indicators.
After all, if we do the best health research in the world, but that research is not translated into improved health for the population, what have we accomplished? And if my Kenyan counterparts train the best medical student in the world, but that student graduates into a dysfunctional medical system that robs him of hope and spurs him to migrate to another country, have we improved the health of the individuals in Kenya who right now are not able to access health care?
Instead, let’s try a different approach. Let’s dare to lead with care. Let’s roll up our sleeves and get our hands dirty in the actual delivery of health care services, but in so doing, deliberately create a health care system that hosts research and hosts training, so that at the end of the day, no one of those three missions—care, research, or training—is any more or any less important than the other two.
Indiana University partnered with Moi University in Eldoret, Kenya in 1990 to help bring up Kenya’s second medical school. In the first decade, we focused on teaching medical students, doing collaborative research and delivering health care services primarily at Mio Teaching and Referral Hospital (MTRH). But, by the year 2000, the HIV epidemic had exploded across the continent.
In the US, the triple drug cocktail that transforms HIV from a certain death sentence into a manageable chronic disease had been discovered, the drugs were available in the health system here, and the incidence of AIDS here was plummeting. But, in Kenya, and throughout sub-Saharan Africa, the story was very different.
Wander into any community, and this is the scene one might see, repeated over and again, a grandmother caring for her gaggle of grandkids, their parents dead of AIDS. Efforts to prevent the epidemic had been a crushing failure, and most folks, ourselves included, doubted our capacity and Kenya’s capacity to embrace the pandemic.
But, all of that changed in 2001 with a young gentleman, named Daniel Ochieng, a Kenyan medical student who had contracted HIV and was dying on the wards of the hospital in Eldoret. He was the first person ever treated in the public sector in Kenya, the first person in whom we witnessed the miraculous “Lazarus effect” of the triple drug regimen. When he got up from his deathbed and walked out of the hospital, he filled us with hope that we could take on this horrible epidemic.
We began to dream, and on paper, we created AMPATH. And when I say we, I mean Kenyans and Americans working together, mostly Kenyans, and always under the leadership of Kenyans. We began one clinic in Eldoret city, and one clinic in a rural health center in the town of Mosoriot. Importantly, we made an unwavering commitment to developing an electronic information system to anchor all of our care and research, making possible the complex integration that is key to a successful care system, and inviting cutting edge technology so that we can discover or make the next leap forward.
Many of our first patients quickly convinced us that Kenyans are as adherent to their medications as the average American. We were privileged to treat patients who demonstrated the courage to get up out of their death beds and walk back into their communities, HIV positive and living positively, to fight the stigma and to spread their message of hope throughout the country.
From two clinics and 45 patients, AMPATH grew to eight clinics and thousands of patients, and then 25 clinics and tens of thousands of patients. Today, there are more than 500 care delivery sites serving a population of 3.5 million people. This makes us the largest HIV control program in Kenya, and one of the largest in the world.
We have learned some important lessons along the way. Salina taught us one of our first lessons as we found here dying of HIV. My colleague Joe Mamlin started her on ARVs, and though she did not die, she did not really get better, until it finally dawned on Joe that Salina and her children were slowly starving to death. So, digging his hand into his pocket each week he saw her, he gave her a few shillings. Joe told her to go buy some food for her and her children. And Salina did just that, and Salina got better.
For sure, the cause of HIV is a virus that is transmitted primarily through sexual intercourse. But, its root causes and the root cause of the misery that it extracts on a society go much deeper, to matters of gender inequity and food and income insecurity. So we, created our own farms and reaching out to World Food Program, began to feed 30,000 people a day, making a number of very hungry people very happy.
But, it became very clear very quickly that such a response was not sustainable. So, we reached out to our colleagues at Purdue University and their world-class school of agriculture as well as the business school at Notre Dame. More recently, companies like DowAgroSciences have joined the effort alongside Kenyan agricultural experts at Moi and in the Ministry of Ag. This dynamic collaboration has developed a number of programs in the agricultural and business sectors to assure food and income security.
For example, we organized women’s groups in the urban slum of Kitale to begin sack gardens, an ingenious yet simple technology that is of particular value to the poorest of the poor. The process begins by taking a gunny sack and filling it with soil in just the right way, planting vegetables like kale on the top and in holes along the sides, and watering just two times weekly. With this, a family of five with just three such sacks can grow their minimum daily requirements of vegetables and even a bit of excess to sell in the market.
We also learned that by organizing small groups of men and women—usually women—to make small loans among themselves and to take responsibility for their investments, we helped thousands of individuals step up to the first rung of the ladder to self-sufficiency. And, working with several thousand subsistence farmers to facilitate a number of farming cooperatives that are now competing for tens of thousands of dollars of forward delivery contracts. Particularly gratifying, a few of the groups have now reached the point where they are donating some of their cereals back to the most needy in their community, in effect, creating community food banks.
And then there were more challenges. An untreated pregnant woman infected with HIV has nearly a 50% likelihood of transmitting the virus to her infant but a treated mother has less than 5% chance of transmitting the virus to her infant. So, we had implemented aggressive treatment protocols in every ante-natal clinic throughout our area.
We soon discovered, however, that some woman never came to antenatal clinic, and in that population of women who never came to antenatal clinic, the prevalence of HIV was three to four times higher than in the cohort of women who came to ANC. In other words, we discovered that doing a near perfect job of treating women who came to our facilities meant that we were still failing to prevent most of the infants from getting HIV.
So, we said to ourselves, if they won’t come here to our facilities, we will go into the community. We developed a cadre of community health workers, testers and counselors, and off they went, onto the rutted roads, over the river, through the maize fields, past the lurking crocodiles, and into the homes, testing every pregnant woman and every man and woman in the household who had the potential to engage in sexual intercourse.
The results were striking. Nearly 98% of all households welcomed AMPATH’s testers and counselors into their homes. Since the inception of AMPATH, we enrolled more than 160,000 HIV infected individuals, and we reduced the rate of transmission of HIV from mother to child from nearly 50% to less than 3%. The body of scientific evidence now suggests that if we get enough HIV infected individuals on treatment, and reduce the “community viral load”, we will likely stop the epidemic. We believe AMPATH is on track to doing just that.
As our successes in HIV control and treatment multiplied, we turned our attention to the challenge of primary health care in the population as whole irrespective of HIV status. We reached out to our colleagues at University of Toronto, and linking them with their Kenyan counterparts began to address maternal and child health. With help from Purdue School of Pharmacy, we are assuring secure and stable drug supplies and training the pharmacists to manage them. We are also addressing issues of safe water and other related challenges.
That is where we are today, transitioning our HIV care system into a comprehensive primary health care system, in effect, getting back to the reason Indiana and Moi partnered in the first place in 1990. Along the way, we discovered that a large and growing segment of the Kenyan population had become more like us than we would like to admit. Rather than just HIV and the diseases of poverty, Kenya—like so much of sub-Saharan Africa—is now facing a growing epidemic of non-communicable, chronic diseases. Specifically, Africans face a burgeoning prevalence of diabetes, hypertension, chronic lung disease, cancer, and heart disease.
AMPATH responded. In March 2013, we are breaking ground on the first building in East Africa dedicated to the control of chronic diseases, applying the same principles and academic approach that were keys to success in controlling HIV: the first two floors are for care, the next floor for research, and the top floor for education and administration. With help from our colleagues at Duke and Brown, we are bringing up Centers of Excellence in Oncology and Cardiopulmonary diseases linking this building anchored in a tertiary care center to all levels of the health care system, including the most remote community in AMPATH’s catchment area.
Now that I’ve outlined the benefits of AMPATH’s approach, I would like to conclude this essay with a description of three of the key features of our model. First is our relentless emphasis on “care leading the way.” Research and education are critical components of any academic mission. Indeed, if we look at the amount of funds that AMPATH attracts for just research alone, not counting the tens of millions of dollars for care, it is substantial. But, AMPATH has been successful because the academic health centers that comprise it dare to hold themselves accountable for the health of the population, and that then becomes the foundation for all research. We must Lead with care…and leave nobody behind!
Second, to be successful in the global sphere and to be an agent of enduring transformation for the good of all, the circle that defines who we are must encompass not just ourselves but also our partner institutions and our global communities. AMPATH’s success is a reflection of the capacity of North American universities to cooperate over the long haul, to be inclusive, collaborative, and unfailingly respectful of host Kenyan leadership.
Third, we must embrace technology. In our case, an Open MRS platform and the AMPATH electronic Medical Record System is the foundation for all of our care and research activities. Created and designed by AMPATH’s investigators and scientists for AMPATH and with demonstrated proof of concept within AMPATH, this technology has now been adopted in more than 40 other countries. This is just a wonderful example of bidirectional innovation.
The reward for our work comes in many forms. Consider the story of Rose who was dying of HIV when we met her years ago. She was successfully treated with food and medicines and returned to the clinic with a bag of potatoes and onions in her right hand as a gift to those who gave her hope. She wanted to thank the PEPFAR program, Moi, IU and their academic partners, and for their many supporters too numerous to name. Her thanks was literally for her life and life of her children.
Then there is Pamela who appeared to us not HIV infected but rather she was afflicted with rheumatic heart disease, a preventable and surgically treatable disease in this country. Unfortunately, she died a short while after she arrived and her death spurs us to bring up a more effective PHC program for thousands like her.
We will remain inspired by success stories like Rose’s and deeply burdened for losses like Pamela’s. Indiana University will remain in the pursuit of giving our best gifts—medical skill and innovation—to African partners who took the lead and will sustain our shared success for generations. This East Africa partnership saves lives there and enriches our own lives here. Taken together, hope has replaced despair and global health is being reinvented.
Bob Einterz, MD, co-founded the Academic Model Providing Access to Healthcare (AMPATH), a consortium of North American universities in partnership with Moi University and Moi Teaching and Referral Hospital. AMPATH, which Einterz currently directs, is responsible for creating a comprehensive system of health care services, research and training — run entirely by Kenyans. AMPATH’s primary care and chronic disease management programs deliver healthcare services to a population of more than 3 million people in western Kenya. Einterz is also the Donald E. Brown Professor of Global Health and Associate Dean for Global Health at Indiana University School of Medicine, and director of the Indiana University Center for Global Health.
photo credit: AMPATH
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