Afghanistan RPCV Joe Mamlin works in AIDS crisis in Kenya
“Dying Right in Our Hands”
IU Med School Faces the African AIDS Crisis
By Fran Quigley
"I’m afraid we are going to look back on our time 200 years from now and say that this epidemic raged on, we could have stopped it, yet we chose to stand by and let it happen."
-Dr. Bob Einterz
It is early morning at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and Dr. Joe Mamlin is making rounds. The wards he walks through are made up of several open rooms with a half-dozen small, cot-like beds, which usually contain two patients, each lying with her head at the feet of her bed partner. Today, some of the narrow beds actually contain three patients.
Most of the patients are between the ages of 18 and 35. Many are mothers and fathers of young children. Most have AIDS. Mamlin is trailed on his rounds by nearly 20 people, including Indiana University and Kenyan medical students and interns. They stop to examine Jane Jeptoo (Kenyan patient names have been changed), a 45-year-old mother of 10 who came to the hospital significantly underweight and with a severe headache, confusion and blurry vision. She is going blind from AIDS.
Mamlin and an intern walk to the next bed and try to counsel a reluctant Helen Jepkoech. Jepkoech is a 28-year-old mother of two who won’t discuss her illness, even though she is rapidly wasting away with tuberculosis related to underlying AIDS. Jepkoech says her husband has been losing weight, too, but he refuses to see a doctor.
Joe Mamlin knows that proper medication can prolong these women’s lives and the lives of the 68 other AIDS patients he is seeing today. For most, anti-retroviral medicine would even allow them to return to their families and enjoy good health for many years. But Mamlin can’t prescribe it. "In the West, patients with HIV are treated and the majority can expect to return to a normal life again," Mamlin says. "In Africa, they are expected to get the dying over with."
Mamlin is on his 14th trip to Kenya, this time spending five years at the Moi Hospital after a so-called retirement from IU last year. He is a faculty member at the Indiana University School of Medicine and something of a local legend for his three-decade role in building the city’s respected indigent health care system. Among other accomplishments, Mamlin was instrumental in expanding primary health care out to neighborhood community health centers affiliated with Wishard and for helping create the IU Medical Group, which provides care to indigent and paying patients throughout the city.
In "retirement," Mamlin serves as the on-site team leader of the IU School of Medicine’s partnership with the Moi University faculty of health science in Eldoret, Kenya. Mamlin’s presence on these hospital wards is just the latest product of a decade’s worth of collaboration between the schools. Since 1989, over 200 IU medical students, residents and faculty members have come to Eldoret as part of the program, with at least one full-time IU faculty member always on-site for at least a one-year term. Over 65 Kenyan faculty members and students, most on full fellowships or scholarships, have traveled to Indianapolis or to one of the other academic medical institutions like Brown and Wayne State that have followed IU’s lead into the project.
By any measure, the IU-Moi program has been a remarkable success story. Praise for the program flows in from faculty, students and international relations experts from both countries. Impoverished Kenyans have been treated, technical and cultural information has been exchanged. Collaborative research has been conducted. Current and future generations of U.S. and Kenyan doctors have forged cross-cultural relationships that have enriched both communities.
Fine, says Mamlin. But there’s this matter of the young Kenyan people dying all around him.
By now, the scope of the African AIDS crisis is well-known. According to United Nations estimates, 25.3 million people in sub-Saharan Africa are infected with HIV/AIDS, a number more than four times as large as Indiana's entire population. Last year, 2.4 million Africans died from the disease and nearly 4 million were newly infected with it. In many parts of Africa, entire villages have been so ravaged by AIDS that they are populated almost entirely by old people and orphaned children.
In the midst of this continent-wide nightmare, Mamlin’s commitment to the IU-Moi collaboration is unquestioned. Just a few weeks ago, he stayed behind with his students and patients in Kenya while his wife traveled back to the U.S. for the birth of their first grandchild. But Mamlin also bluntly insists that the AIDS crisis dictates that the IU program can not go on in its current form. "It is no longer possible to simply maintain an exchange between a U.S. medical school and a Kenyan medical school," he says. "We are forced to either fold our tents and retreat to the day-to-day ‘crises’ of Indiana, or we completely redefine our relationship to our colleagues in Kenya." Mamlin makes clear which option he prefers. "IU needs to be engaged in this struggle," he says. "Because we are here and we identify ourselves as a university with a worldwide mission, and because this part of our broader family is struggling for their very survival."
"You can’t treat me anyway"
Well over 6 feet tall and wearing thick glasses, Dr. Sylvester Kimaiyo leads a visitor into a darkened conference room looking out onto West 10th Street from the third floor of Wishard Hospital. At first, Kimaiyo speaks with such gentleness that it is hard to see how he commands the attention that has him widely regarded as the best medical teacher in all of Kenya. But then he starts explaining the HIV/AIDS crisis in Kenya. Kimaiyo’s quiet introduction dissolves into a careful verbal dissection of the tangle of culture, pathology and poverty that is killing off his generation of countrymen.
"There is an incredibly high stigma that our culture attaches to having HIV," Kimaiyo says, who is spending a year on a fellowship at IU. To many in Kenya, he explains, the disease marks a person as promiscuous and unclean. "Very few people will admit to having the disease. If I make the diagnosis with the husband, even educated men will try to keep me from telling their wives. Some men have been infected for years and never tell their wives. At funerals for people who died of AIDS, they go to great lengths to blame another disease."
Kimaiyo has seen friends and relations die from AIDS and says a number of his fellow medical faculty members have HIV. When he is teaching and practicing medicine in Kenya, Kimaiyo usually makes two or three new diagnoses of AIDS every day. In explaining the remarkable spread of the disease that is thought to infect 10 percent of his country’s people, Kimaiyo identifies several culprits. He discusses the cultural stigma, the patriarchal nature of a Kenyan society that tolerates a high level of male promiscuity and the cultural and religious objections to condom use.
But Kimaiyo insists that culture is not solely to blame for the pandemic. At least equally responsible is the country’s grinding poverty, which sends young girls — often AIDS orphans themselves — into prostitution, where they often spread the disease. Poverty is also what leaves Kenyans without access to HIV treatment readily available in Western countries. Kimaiyo says the inability to afford treatment fuels the spread of AIDS, since most of his patients see little point in being tested for a disease when its monthly treatment costs 60,000 Keyan shillings, or twice as much as a Kenyan doctor’s salary and 20 times a Kenyan farmer’s monthly wages. "If I want to test a patient who has symptoms that make me suspect HIV, many will tell me, ‘If you know I am HIV-positive, you can’t treat me anyway,’" Kimaiyo says. "So they would rather not go through the psychological trauma of knowing. They leave, and they won’t come back until they have full-blown AIDS. By then they have spread the disease."
The prohibitive cost of AIDS medication in Africa has been a topic of international concern for several years. When Brazil and Argentina began providing generic AIDS drugs to their citizens at a fraction of the cost charged by the patent-holding pharmaceutical companies, several African governments took notice. South Africa, where nearly 25 percent of adults are infected with the virus, began a process in 1998 that would have also led to the importing of generic anti-retroviral drugs. Then 39 major drug companies — including Indianapolis-based Eli Lilly and Company, which does not manufacture anti-retroviral drugs — filed suit seeking to block South Africa from importing the generics. This legal action was just one component of the pharmaceutical industry’s campaign of global resistance to generic drug alternatives for poor countries, and it earned them international condemnation by groups such as the Nobel Peace Prize-winning Doctors Without Borders. In the face of a growing international outcry focused on the high profits earned by the patent-holding companies, the companies dropped the suit last month.
With the lawsuit’s withdrawal and the drug companies’ offers to sell their AIDS medications in Africa at a greatly reduced price, the global AIDS spotlight now seems to have been diverted. Even AIDS activists who spare no love for the pharmaceutical industry seem to be glad the discussion has broadened beyond patents and profit margins toward an examination of the role to be played by Western and African governments, multinational corporations and relief organizations. As Kimaiyo points out, even reduced or generic drug prices are still out of the range of affordability for his Kenyan patients, so organizations other than drug companies will have to contribute if the medicines are ever to be widely available. After the South Africa lawsuit was withdrawn, United Nations Secretary General Kofi Annan called for the creation of a global fund to fight AIDS and other infectious diseases. It’s a proposal sure to be the key agenda item at the June 25 U.N. General Assembly’s special session on AIDS.
"Our hope is our students — here and there"
The disparate worlds of Kenya and Central Indiana collide in Dr. Bob Einterz’s cluttered Wishard Hospital office. Photographs of smiling Kenya AIDS orphans and a Kenyan child with a grotesquely swollen face share wall space with photographs of Einterz’s young sons playing Little League and running the Indianapolis Mini Marathon. A Peters Projection Map, showing the world more accurately reflective of Africa’s immense geographic space, hangs on an opposing wall. Outside the office is a huge black suitcase partially filled with back copies of the New England Journal of Medicine, soap, toothpaste and a batch of anti-retroviral drugs. The next IU doctor to visit Kenya will be charged with delivering the suitcase to Mamlin.
Einterz is technically on vacation this week. But in a style reminiscent of Mamlin’s "retirement," he has just completed a 7 a.m. conference call to Kenya and is now sorting through papers on his desk, looking for a copy of a study he wants to give a nursing school administrator interested in the IU-Moi program. Einterz was one of the founders of the program and still serves as its Indianapolis-based director. As a young doctor, he worked in Haiti for a year, a life-transforming experience he wanted to share with his own students. With Mamlin and other IU faculty members, most of whom have devoted their careers to indigent health care in Indianapolis, Einterz devised a program to benefit both Kenya and the United States. "We are influenced by the Peace Corps philosophy that we link with a counterpart in a developing country," he says. "We want to change the world, but we need to change institutions and individuals — ourselves — first. So we have chosen to link through education."
When Einterz and other doctors in the program discuss the IU-Moi collaboration, they take great care to emphasize its focus on education. It is tempting to paint these Indianapolis doctors as secular saints, tirelessly shuttling between Kenya and Wishard while ministering to the medical needs of the poor in both countries. But the doctors would object to that portrait, partly out of modesty but mostly because it is incomplete. Einterz says the program’s most important contribution is to the medical educational process in both countries, which they serve by conducting joint research and training the future physicians of Indianapolis and Kenya. "We want to empower the current academic leadership in Kenya so they can address the epidemic," he says. "But we are really working on future generations. Our hope is our students, because they are the future of our country — both here and there."
With personnel and expertise flowing into Kenya from IU, the Kenyan medical community is the most obvious beneficiary of the exchange. But program participants from both countries are quick to point out that Indianapolis enjoys significant benefits as well. Many IU medical students and doctors in the IU/Wishard network have spent time in Kenya, and they often return from the experience more sensitive to the impact of lifestyle and poverty on the health of their patients.
Ben Wince, a third-year IU medical student originally from Carmel, says his Kenya experience will make him a better doctor. "Dr. Einterz swears that Kenya is the best place to learn medicine, and I know what he means now," Wince says. "I had a college background in bio-medical engineering, and I used to think technology was everything. But the experience in Kenya, where literally all you have is patient history and an examination, forced me to learn that you need to treat the whole person, not just the disease. What I know now is that sometimes technology can interfere with the doctor-patient relationship." Wince and others also express admiration for Moi University’s models of problem-based medical education and the Kenyan school’s emphasis on learning through community-based research and practice in underserved rural areas.
Einterz is proud of the impact the program has had in Indianapolis and Kenya. But with 2 million Kenyans infected with a deadly disease his colleagues and students can’t treat effectively, Einterz admits his pride can give way to frustration. "We all need to be doing more: the U.S. government, institutions, all of us," he says. "I’m afraid we are going to look back on our time 200 years from now and say that this epidemic raged on, we could have stopped it, yet we chose to stand by and let it happen."
"If they could only see what I’m seeing”
No AIDS vaccine is expected in the near future, so easy answers to the African AIDS crisis are elusive. Kenyan physicians such as Dr. Lameck Diero, in Indianapolis completing a fellowship on medical informatics at IU, say the first step must be prevention. Diero points to the success of neighboring Uganda, where a massive government-supported AIDS education program has led to a significant decrease in the infection rate there. He says the Ugandan example is helping some slow progress to be made in Kenya, with most Kenyans now at least understanding how the disease is contracted.
But Diero acknowledges education is not going to be the answer for the millions of Kenyan adults and children already infected with HIV. In all of his practice with the HIV/AIDS patients who fill up half the beds in his hometown hospital, Diero has not once been able to administer anti-retroviral drugs. "It’s very frustrating," he says. "We see people wasting and dying right in our hands, and we really can’t help them."
Diero and other health experts say that even if the proper medicines become available in Kenya, there is no infrastructure to use in administering the multidrug regimen that must be maintained indefinitely for each patient. "What we need," Diero says, "is a department of the hospital that deals only with HIV and AIDS."
Diero’s IU counterparts could not agree more. Mamlin predicts that the coming months will see affordable anti-retroviral therapy becoming available in sub-Saharan Africa. "But we are not ready for this miracle," he says. He ticks off a laundry list of barriers to effective HIV treatment in Kenya, saying that infrastructure and personnel do not exist to detect the disease and insure treatment compliance.
Mamlin and his IU-Moi colleagues want to address these needs, and vastly increase IU’s commitment to Kenya in the process. Their hope is to create a comprehensive HIV care system in Eldoret and a nearby rural area. The system would serve as a laboratory to demonstrate how tests should be conducted, drugs administered, research conducted and records kept. The goal is nothing less than providing a model for how the AIDS pandemic can be most effectively addressed, not only in Kenya but throughout the developing world. That’s an ambitious goal, but the IU-Moi team members say it’s a task they are perfectly positioned to take on. More importantly, Mamlin says, it is a task they are morally obligated to take on.
"All of the confidence that I have gained over the years regarding the power of an academic medical center to respond creatively when faced with a complex challenge will now be sorely tested," he says. "But in my judgment, we have no choice."
Of course, a new HIV care system will not come cheap. Although Dr. Mamlin is in Kenya, he realizes the challenge he readily accepts also has to be accepted by funders back home. Mamlin says it would be an easy sell to anyone who could be here with him as he treats patients like Akiru.
Akiru was a 23-year-old woman who traveled to the Eldoret hospital all the way from Turkana in Northern Kenya. With her was her 3-year-old daughter, Ekipetot. By the time she made it to the hospital, Akiru’s body was already wasted with tuberculosis and HIV. She had no money for even an X-ray, so Mamlin paid out of his pocket for the tests that confirmed the obvious diagnosis. Although Mamlin could do little for her, Akiru stayed on the ward with her daughter, who lived at the foot of her mother’s cot. As the days and weeks went by and Akiru grew sicker, everyone in the hospital became attached to her child. Mamlin regularly brought little Ekipetot to a small shop near the hospital to get a mandosi, a donut-like treat.
One morning when Mamlin was doing rounds, he approached Akiru’s bed, only to see that she had just died. He saw Ekipetot on the bed, too; still smiling while holding and tugging at her mother’s hand. The veteran of 30-plus years of medicine could not hold back his tears.
"I find this to be the most difficult task of my entire career," Mamlin says. "Every person of conscience would feel outrage if they could see what I’m seeing every day."
fquigley@nuvo.net
To contribute to or learn more about the IU School of Medicine’s Kenya program, contact Joyce Dobson, program manager, at 630-8695 or jdobson@iupui.edu.
