Perspective in Mosoriot

Perspective in Mosoriot

Today I went to the AMPATH clinic in Mosoriot with Dr. Mamlin. This came none too soon, as the wards have really been starting to wear on me, and with Patel and 2 other kids dying, I really needed a break. It was great to get out of the city and drive through the countryside. The scenery here is completely beautiful. I could take thousands of pictures and never quite capture it, I think. Every time I look at it, I can’t help but think “I wish the people I loved could see this.”

So, the Mosoriot clinic. It was great. I’m so glad that I went. When we first got there this morning, I got a little tour of the place. It’s a government rural health clinic, so there’s a lot of different services there every day – OB/GYN, General practice, peds, etc. There’s even a very small 6 bed “hospital” (3 beds on the male side, 3 beds on the female side) as well as a mess hall and a dormitory. Mosoriot was the very first place that Dr. Mamlin started an AMPATH clinic. First, maybe I should back up and explain a little more about AMPATH. It stands for “Academic Model for the Prevention and Treatment of HIV/AIDS.” Back in 1982, IU School of Medicine was looking for a foreign medical school to have an exchange with. It took several years of looking, but eventually Moi Teaching and Referral Hospital (MTRH) in Eldoret was chosen. The program continued as just a simple US/Kenya faculty, resident, and student exchange for a few years. But, this was about the time that HIV/AIDS was becoming a true and recognized epidemic in Sub-Saharan Africa. The IU faculty and residents on the wards felt powerless as literally dozens of people died every day from HIV/AIDS. As the story goes, Dr. Mamlin was rounding with his team one day, when one of the Kenyan medical students kept leaving rounds and reappearing. Eventually Dr. Mamlin asked him where he kept going, and the student replied that his friend and fellow medical student was very sick in a bed in the other ward, and he had just recently been diagnosed with AIDS. Dr. Mamlin and the rest of the faculty realized that an exchange was worthless if they were not addressing the epidemic disease right in front of them – a disease that they saw could affect anyone. So, AMPATH was born.
At its minimum, the program is two-fold – addressing the prevention of HIV/AIDS transmission, as well as treating those who have the disease. But it’s really so much more than that. AMPATH, over the years, has attempted to address the AIDS epidemic as a whole. One major component is through education, attempting to reduce disease stigma and therefore compelling more people to get tested. Another huge part of the program is food security through various AMPATH farms and the Family Preservation Initiative (FPI). If a patient cannot afford food for his/her family, or spends all of their energy in the acquisition of that food, there is no hope of them being compliant with their antiretroviral therapy. So, AMPATH has attempted to address this major facet of noncompliance. The other major issue with treatment compliance is transportation. 150 kSH for a round-trip matutu trip to Eldoret is out of the reach of so many Kenyans. So, AMPATH went to where the patients were. First, by putting an AMPATH clinic in the pre-existing clinic building at Mosoriot. As that took off, various other clinics sprung up, and there are now 25 or so spread out through western Kenya. The distance from clinic issue has also been taken one step farther, as I saw today. Just before we got to the clinic, Dr. Mamlin pointed out to me a shelter that had been built about 2 years ago using funds from North United Methodist Church (the church that Mike and I are members of, as well as the Mamlins, when they lived in the US). The people who stay in this shelter are the sickest of patients, those who need to be seen every week or two times a week, and who otherwise would never be able to come to clinic. I met one such patient today. Her name is Jane.

Jane is 45, she was diagnosed with HIV not too long ago. At the time, she was severely malnourished, weighing only 26 kg (about 57 lbs) and days away from death. She was immediately put in the shelter right by the clinic, where she was initially visited by a CO (clinical officer) every day. Her weight is up to 32 kg, and she is now coming to the clinic once per week with the help of her daughter. I met Jane today, and she is still so emaciated you think a gust of wind would knock her over. The main thing Dr. Mamlin discussed with her and her daughter today was food. Making sure they had enough, where were they getting it, what were they eating, etc etc. He gave them money out of his own wallet so they could buy food. He took a picture of me with Jane, so I could “show (my) church what they’ve done.” Afterwards, I saw her daughter in the hallway, she had tears in her eyes as she gave me a huge hug, just saying “asante, asante asante” over and over again. It was amazing.

The rest of the clinic was great too. I saw some interesting things – like a woman with an 8 year history of “leg sore” that was the biggest, ugliest sore I’ve ever seen. The skin on her foot and leg was completely necrosed away, and you could see her bone underneath. We referred her immediately to orthopedics, but it’s likely she will need an amputation. Mostly, though, it was good to see healthy people. Sure, they all carried the diagnosis of HIV, but for the most part they were completely med compliant and living healthy lives. Our last patient of the day was great – it was an HIV positive mom who had been bringing her little girl to the clinic for monthly checkups. Because of maternal antibodies, you have to wait until a child is 18 months old to determine if they are truly HIV positive. Well, this little girl had her 18 month check-up, and she was negative. The mother was so happy she cried. (And then I mad the little girl cry by trying to give her a sticker, but she just screamed and jerked her hand away. Ah, I’m going to be a great pediatritican).

The other thing I enjoyed about the day was just chatting with Dr. Mamlin. I find him to be such an inspirational figure with what he has created in AMPATH. And it’s absolutely proof that one person can change the world. He told me that when he first went to Mosoriot, he had only one room at the clinic, so he put a wall down the middle of it so one side could be for check in/check out and the other side for examinations. He went into the local village and said “I have enough money to treat 15 people” and he was immediately told his presence was unnecessary, as no one in Mosoriot had HIV/AIDS. So, Dr. Mamlin sort of scratched his head and said, ok, send me the people with diabetes and hypertension, then. They came, were tested, and what do you know, Mosoriot had HIV after all. Eventually the clinic grew far larger than 15 people, and a generous but anonymous donor from Indianapolis gave funds for AMPATH to have their own independent building at the Mosoriot clinic. The building houses rooms for counseling after diagnosis, adherence counseling (a HUGE part of AMPATH. Antiretrovirals and clinic visits are completely free through AMPATH, but patients have to show compliance by showing up to 3 visits straight before they are even given the initial treatment. If they fail visits, they have to start the process all over again), nutritional counseling, and a fully functional pharmacy (Dr. Mamlin said that when he first started at Mosoriot, he could carry all of AMPATH’s meds in one small backpack). Plans for a psychiatric counseling component of the clinic are currently underway. Mosoriot AMPATH clinic was the first free-standing rural clinic for HIV/AIDS treatment built in Eastern Africa. And until a few years ago, it was the only one.

And so the program continues to grow. But of course things are not free, so funding is always an issue. AMPATH is currently run fully out of a grant from PEPFAR, but someday even this money will be gone. Last week’s fireside chat was about the ethics of treating “third world” diseases, who pays, and where do we get the money after the grants are gone. It was very interesting and uncomfortably thought-provoking. If, for example, you had the choice between treating 100 people with 1st line antiretrovirals or 50 people with 2nd line antiretrovirals (which are fore more expensive), which would you choose? The obvious answer seems the 100, but say 25 of those 100 people are going to end up needing 2nd line drugs eventually because of resistance mutations in the virus and noncompliance issues? And, how do you or should you even reward compliant patients? How do you measure true compliance, when so many of the reasons our patients don’t take their drugs or show up to clinic are valid? And, what motivation can we give to US pharmaceutical companies to allow developing nations to produce necessary medications for free? It was a great discussion. So many questions that I want to help the world answer.

Overall, it was a great day. I certainly feel a little more inspired about what I’m doing, and today reminded me of all the reasons I wanted to come here in the first place.