We spent the first part of this week in the westernmost part of Kenya, working with one physician (Dr. Dennis featured below) and several clinical officers.
We've spoken to the magnitude of the AIDS pandemic, and to the impressiveness of the AMPATH response, and I think the patient stories we heard on this trip really exemplified both. [Below is one of the clinics, two shipping containers side by side with a thatched roof - the quickest, easiest, and cheapest model found so far]
AMPATH is the academic model providing access to healthcare, and was started by a group including Dr. Joe Mamlin (who I also learned is responsible for the Wishard community health centers in Indianapolis) in 1990. Dr. Mamlin describes the first clinic sort of operating out of one room when AIDS was still relatively unheard of. Now AMPATH (recently a part of USAID) has blossomed to a network of 19 clinics in Western Kenya, providing free anti-retrovirals (ARVs, a common regimen below), prophylaxis against opportunistic infection, food, counseling, and medical care to upwards of 80,000 patients.
AMPATH also has several programs in place to help patients establish food security, financial progress, and occupational skills. There is also a network of homes for orphans and vulnerable children. All of this to say that even with this longstanding infrastructure in place, HIV is still rampant, the stigma of being positive remains devastating, and people with families (big families!) are dying every day.
Many of the women we saw on Tuesday were widowed, their husband never being tested or seeking treatment for AIDS. AMPATH clients are overwhelmingly female, and I asked the clinical officer (non-physician, three year diploma, can see patients and prescribe drugs) why this was. He explained that many men in Kenya see illness as a threat to manhood and suffering admirable, and so eventually die at home, never being diagnosed with AIDS, and therefore never disclosing this diagnosis with their sexual partners. (VCT stands for voluntary counseling and testing)
I met one woman, who tested positive pre-natally. Within a year, her husband had died, and she gave birth to her sixth child. Luckily, she was placed on ARVs, and did not transmit the virus to her newest born, the other five children have yet to be tested. We examined the baby, and then addressed the more complicated issue of depression. What will this woman do with no income, six children, and fragile health? All day women with the same story came through the clinic. (This is a scene right outside the clinic in Busia)
Another common theme was the use of protection. All the women, widowed or not, were advised to use protection if their partners' status was unknown. Often they would be shy when addressing the topic, but would eventually admit that their husband wouldn't or "couldn't" use a condom. One woman explained to us that since she had been found HIV positive, her husband married again, and is no longer having intercourse with her. Neither the husband, nor the second wife have been tested.
On the trip, I was reminded of just how rural Kenya really is. Over 90% of Kenyans live in rural areas (below a scene outside the Busia clinic), and that means without water, electricity, or much access to education and healthcare. We had a patient in the hospital today, and the history of present illness was something like this: while the mother was milking a cow, her toddler fell into a well, and drowned for around 10 minutes before he was found. This particular child was doing really well this morning, all things considering.
All of this to say, I find the complexities of the AIDS pandemic overwhelming. AMPATH is pouring millions of dollars worth of resources and brain power into slowing the spread of the disease. I asked Dr. Mamlin if anyone else in sub-Saharan Africa was doing anything like AMPATH, and he responded that there was maybe a program in Gambia, but not really. I can't imagine the devastation in a place without such aggressive testing and treatment. (Between the clinic and the food storage facility)
Further, there are other preventable illnesses killing plenty of Kenyans daily, diarrhea, malnutrition (we consulted the nutritionist on over half of my pediatric patients because they were severely underweight), rheumatic heart disease, and the list goes on. Despite the daunting statistics, I find encouragement in the future of Kenyan medicine. So many of the students I have worked with are really, really good, and their country needs them. I look forward to their eventual takeover of AMPATH or organizations like it. For now, I'll finish philosophizing and say goodnight (one of my favorite, or at least most comfortable phrases in Kiswahili), Lala Salama.
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