Physiciains Joe Mamlin, Bob Einterz,Charles Kelley and David Van Reken wanted to build a medical training program in Kenya to give other physicians and students an opportunity akin to what they had experienced earlier in their careers, during Peace Corps and mission work in Afghanistan, Haiti, and Liberia
Medicine with a Mission
On a continent ravaged by AIDS, in a country devastated by poverty, an Indiana University flag hangs on the wall of a small, nondescript office at the Moi University Faculty of Health Sciences in Eldoret, Kenya. The office belongs to Joe Mamlin, an Indiana University professor emeritus of medicine and the current team leader of the IU School of Medicine's medical exchange program at Moi University.
In a place where computers are rare and cows and pedestrians walk side by side along the road, the bright red flag is about the only reminder of Mamlin's Hoosier home. With the exception, of course, of the constant flow of IUSM students, residents, and faculty who make the 8,000-mile journey to Eldoret.
They come to the western highlands of Kenya to work in the Moi Teaching and Referral Hospital, one of only two such hospitals in the country. IU physicians help teach Moi University medical students and share patient management practices with the Moi Hospital faculty and staff. In turn, they learn from the Moi medical staff to diagnose and treat diseases that are rare or nonexistent in the United States and how to manage without an array of Western technology.
But perhaps most important, according to Bob Einterz, MD'81, assistant dean for international affairs and one of the program's founders, are the lessons in world citizenship learned by all participants, Kenyan and American.
"Medicine is the medium, but the program transcends medicine," says Einterz.
Seeking a partner
In the late 1980s four IUSM faculty with experience in Third World medicine began the process of turning a dream into reality. Mamlin and Einterz, along with Charles Kelley and pediatrician David Van Reken, wanted to build a medical training program in a developing country. They hoped to give other IU physicians and students an opportunity akin to what they had experienced earlier in their careers, during Peace Corps and mission work in Afghanistan, Haiti, and Liberia. Their search for the best place to start such a program took them around the world to Nepal, Ghana, and Kenya.
"Getting long-term visas in Nepal appeared to be a problem, and Ghana's crumbling infrastructure, coupled with the departure of most of its medical students, was a concern," Einterz explains. "So Kenya quickly became the obvious choice."
According to the IU Department of Medicine's Web site, "The primary goals of the program are to enhance medical education at both institutions, to promote collegial relationships between American and Kenyan medical doctors and students, and to develop leaders in health care in Kenya and the United States."
Although the program is rooted in IUSM's Department of Medicine, in recent years it has grown to include participation by the departments of pediatrics, surgery, anesthesia, OB/GYN, and dermatology.
"IU's pool of clinicians who have worked overseas is probably larger than any other medical school," says Mamlin.
The program is partially funded by the School of Medicine but relies primarily on private donations.
ONE ON ONE
Author Ellen Gullett with some of the youngsters she met as a volunteer in the hospital's pediatrics ward. Courtesy photo.
An unlikely exchange
Moi University's medical school was established in 1985, and its first class of students entered in October 1990. Early on, the university was assisted in curriculum and laboratory development by a group known as "Friends of Moi," which included Linköping University in Sweden, the University of Limburg in the Netherlands, Ben Gurion University in Israel, and McMaster University in Canada. IU came on board in December 1989 and remains Moi's primary academic partner.
To help support and staff the program, IUSM created a consortium of U.S. medical schools that currently includes Brown University School of Medicine, Lehigh Valley Hospital (affiliated with Penn State), Portland Providence Medical Center (affiliated with Oregon Health Services), and Wayne State University School of Medicine.
When the IUSM team made its first site visit to Moi, the school had only four faculty members, and the hospital, at the time a district hospital, was in disarray. Thirteen years later, there are 110 clinical and basic science faculty at Moi, although many are the sole members of their departments, and 300 medical students, who represent the best and brightest Kenya has to offer. The school employs a problem-based learning curriculum and is focused on community-based health care.
Some might argue that the hospital is still in disarray. By Western standards, it certainly is. Moi Hospital comprises several one-story buildings. Every ward is packed with patients, often two or three to a twin bed. The aluminum-frame beds are old and rusty, the mattresses thin. The sight of insects crawling on the walls and the odor of unbathed bodies and soiled bedding can be overwhelming. Simple tests that produce nearly instantaneous results in the United States can take days - if the results come back at all. Inefficiency is a way of life, and medicines and equipment are so limited that providing basic care can be extremely difficult.
So what attracts Western doctors to work in this environment? Deanne Kashiwagi, a fourth-year medicine/pediatrics resident, explains, "Beyond what I hoped to learn medically, I wanted the experience of being immersed in another culture."
The IU-Moi program was one of the primary reasons Kashiwagi chose to do her residency at IUSM. She says her experience as a physician and teacher on both the medicine and pediatric wards at Moi Hospital was more than she ever dreamed: "I saw diseases I've never seen before, I learned to approach things in a nonjudgmental way, I formed meaningful relationships with the Kenyan students and doctors, and I'm certainly more appreciative of the resources we have in the United States."
The program is equally rewarding for Moi University. Joshua Nderitu, an intern and graduate of Moi who spent six weeks at IUSM in the summer of 1998, was both challenged by and appreciative of the exposure to Western medical technology. "I learned about tests and treatments that we cannot do here [in Kenya]," he says.
BACK HOME FROM INDIANA
Joshua Nderitu rotated through IU, Riley, and Wishard hospitals during his six weeks at the School of Medicine. Courtesy photo.
He also was impressed by the IU faculty's commitment to teaching. Most Moi faculty must supplement their income through private practices, which means less time spent engaged in bedside teaching with students at Moi Hospital.
Nderitu was one of 20 fifth-year medical students chosen by an annual lottery system to study abroad. A second lottery determines where the students go. Every fall IUSM hosts between six and eight Moi students who rotate through IU, Riley, and Wishard hospitals.
Moi faculty also travel to Indiana to do basic science research and fellowships in medical informatics. B.O. Khwa-Otsyula, dean of Moi Medical School, values this multilevel exchange. "Moi is a young medical school," he says. "We benefit from IU's experience."
Otsyula did advanced training in England and is one of only five thoracic surgeons in Kenya. He cites the personal interaction and cultural exchange as a strong asset to the program. "If you work in just one place, you don't advance in your work because you never gain new perspective," he says.
What's difficult, explains Otsyula, is that although Moi students and faculty may learn new practices and methods while studying abroad, when they return home to limited facilities and resources, they may not be able to implement what they have learned.
A senior lecturer in pharmacology, Alice Maritim knows this reality all too well. She coordinates the exchange of basic science faculty and was the first Moi faculty member to participate. She spent three months on the IU Bloomington campus as a guest of the medical sciences program headed by Tal Bosin, PhD'67. The visit was productive for Maritim, resulting in two published papers that would have been impossible at Moi because of the lack of facilities, resources, and funding.
Both IU and Moi faculty hope the partnership will result in more research collaborations. As Einterz points out, Kenya provides research opportunities in HIV/AIDS and malaria that can't be replicated anywhere else. In addition, IUSM is exploring collaborations with other U.S. schools that have strong research arms in tropical disease.
Medical informatics is another growth area for the IU-Moi program. IU's Regenstrief Institute for Health Care has been training Moi faculty in this high-tech specialty and recently built and installed the first medical database system in sub-Saharan Africa at a pilot site just 30 minutes outside of Eldoret.
ON AN INDIVIDUAL LEVEL
Tina Schmehr Harrison, an IU resident, does an eye exam at the Eldoret Children's Rescue Center. Courtesy photo.
The effect this system will have on patient care at the Mosoriot Rural Health Center is dramatic. A single computer now replaces the old system of haphazard, handwritten patient records. The system holds all patient records and ensures that patients' vital information, diagnoses, and treatments are recorded in a consistent manner. Regenstrief developers hope to install similar systems throughout eastern Africa.
But progress in Kenya is slow. Mamlin notes that when Kenya became independent in 1963, it was not ready for the responsibilities of independence. Unemployment, high inflation, and tribal clashes have further hindered the country's development.
"If you want to see immediate results from your investment here, this isn't the place for you," Mamlin points out. "I know that I likely won't have an impact on the children or even the grandchildren of the people I treat, teach, and interact with here."
ON AN INDIVIDUAL LEVEL
Third-year pediatric resident Steve Steiner examines a young patient. Courtesy photo.
Steve Steiner, MD'98, a third-year pediatric resident, learned that lesson firsthand in Eldoret. "I had to accept the fact that in two short months I wouldn't be able to make lasting changes," he says. "That's why people like Dr. Mamlin, who stay for long periods, are important.
"Instead, I tried to make a difference on an individual level with my patients and students," Steiner continues, "teaching a student a better way to treat diabetes or helping a dying patient rest comfortably."
Steiner and fellow resident Kashiwagi hope to return to Moi Hospital someday. Says Steiner, "The experience has influenced the way I now approach each day as a doctor in the United States."
Ellen Gullett, BA'92, is public relations manager for the Indiana Historical Society in Indianapolis. She previously worked for the IU School of Medicine's Office of Public and Media Relations. She and her husband, Steve Steiner, MD'98, participated in the IU-Moi program in February and March.
