A Rush of Hope

Led by a ‘retired’ physician, IU-Kenya partnership is conquering HIV/AIDS throughout Kenya

Indiana University and Kenya

An IU doctor examines a young Kenyan girl.

Originally published March/April 2007

A feeling of horror crept over Joe Mamlin as he stood amid the emaciated, AIDS-afflicted patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. The disease had spread quickly during the years since his visit seven years before, and the number of AIDS patients at this familiar ward had increased more than tenfold.

For the first time in his medical career, Mamlin felt helpless.

“I realized something beyond hell was happening,” says Mamlin, Indiana University School of Medicine professor emeritus, who moved to Kenya upon his retirement in 2000. “I knew AIDS was everywhere, but to realize everyone was dying in enormous numbers gave you the feeling, ‘This is something historically very horrible going on.’”

Mamlin initially visited Kenya in the late 1980s when he and three other School of Medicine faculty — Charlie Kelley, Dave Van Reken, and Bob Einterz, MD’81 — traveled the world to find the ideal location for an international partnership agreement. The four ultimately settled on Moi University School of Medicine in Kenya. The IU-Kenya partnership was formed in 1989 with the first official student and faculty exchanges taking place in 1990.

Mamlin and his wife, Sarah Ellen (Dozier), MS’76, lived in Kenya for a year in 1992–93 when he served as the program’s third physician-in-residence. Moving back to Africa in 2000 to serve as the program’s field director felt like coming home, Mamlin says. But what had started as a simple exchange program seemed woefully inadequate when Mamlin saw how many rural Kenyans were now dying of AIDS. Seven years before, he’d watched about 85 people, most of them in their 50s, perish from AIDS in the Moi hospital throughout the year. Now he learned that about 1,000 people, with an average age of 30, died of the disease in that same ward each year.

A lot had changed since 1992. Although it was expensive, an HIV treatment had become available. AIDS was no longer the death sentence it once was. Still, Mamlin knew there would be no easy way to bring the costly treatment to the poverty-stricken people before him.

“I had a serious disconnect that I’d never had before,” says Mamlin. “It didn’t seem so relevant what [IU] was doing — ‘Here’s a nice, young, bright med student from Indiana seeing Africa and getting more sensitized to needs of the world.’ This parallel monster was coming down the runway that just was not on my mind when I signed up to go back over.”

Something Could Be Done

In the midst of the sweeping pandemic came an event that changed everything.

I suddenly had this rush of hope, because I realized something could be done instead of nothing.”

Mamlin entered the Moi hospital one evening in 2000 and saw a fifth-year student from the Moi University School of Medicine sitting at the bedside of an HIV patient. When Mamlin asked the student what he was doing, the young man replied that he was trying to feed Daniel Ochieng, one of his classmates from Moi University.

Mamlin was stunned — and unwilling to let this student die. “It’s a shame it has to be a med student before you say, ‘Hey, I better treat one person,’” says Mamlin. But it was treating one patient that opened his eyes to the possibility of treating more.

At the time, treatment for a single patient was $1,000 per month. Mamlin sent an e-mail to his colleagues at IU asking for $24,000 to treat Daniel, and soon received word from a School of Medicine faculty member who offered to cover the full amount.

Slowly, Daniel began to heal.

“It was one of the most miraculous experiences medically that I’ve ever had,” says Mamlin. “Everyone was dying around us, and I saw one person come back to life. You can’t help but say, ‘If he came back to life, what about all these other people?’ I suddenly had this rush of hope, because I realized something could be done instead of nothing.”

Not long after Daniel’s recovery, generic AIDS drugs were being manufactured in India, cutting the price of treatment from $12,000 to $253 a year per patient.

“Now you can see there was no great plan for Indiana to go out and save the world,” says Mamlin. “Nothing you’re going to hear about was the result of a brilliant strategic plan. It was the result of historically finding ourselves in a mess and then making some key decisions on how to respond to that reality.”

Reconstituting Bodies, Reconstituting Lives

The initial partnership agreement has led to a host of programs that have impacted hundreds of thousands of Kenyans and the Americans who come into contact with them. In 1990 three medical students and a handful of residents participated in the partnership program’s exchange. Since then, more than 800 have participated, says Einterz, associate dean for international programs at the IU School of Medicine and the Indianapolis-based director of the IU-Kenya partnership.

Several other universities have joined the IU-Kenya partnership, both independently and through the ASANTE Consortium (America/sub-Saharan Africa Network for Training and Education in Medicine). Other partners include Brown University, University of Utah, Duke University, University of Toronto, and the resident training programs in Portland-Providence, Ore., and Lehigh Valley, Penn.

“It has grown quite a bit over the past 15 years,” says Einterz, who served as the program’s first physician-in-residence. “We have invited other universities to join with us in Kenya in large part because we envision a rich network of medical schools linking with counterparts in Africa. We love to see other U.S. medical schools developing partnerships with Moi University.”

Then there’s AMPATH (Academic Model for the Prevention and Treatment of HIV/AIDS), the rural AIDS program inspired by Daniel Ochieng’s recovery that IU started as an extension of the initial partnership agreement. Its three vital components are care programs that foster HIV treatment and prevention, research programs that enable development of “best-practices” strategies for prevention and treatment, and education programs for health professionals and outreach workers.

AMPATH treats more than 33,000 people each year and feeds more than 30,000, adding about 2,000 new patients per month. It is the largest and most comprehensive HIV-control system in all of Africa. Through its extension programs, AMPATH has created pediatric facilities for children, done HIV-prevention outreach, fostered agricultural training and created factories to further sustainable living options, and built shelters for women and children with AIDS.

Ochieng himself is actively involved with AMPATH, running the patient-adherence outreach program and happily married to another former patient treated for AIDS at the clinic.

Government funding for AMPATH came in the form of an emergency AIDS-relief program known as PEPFAR, the President’s Emergency Plan for AIDS Relief, a U.S.-sponsored grant for large populations. The program has been sustained by numerous other grants, foundations, and individual donations. Today it has expanded to 18 sites, extending from Kenya’s Rift Valley to the Uganda border, and is on track to treat 50,000 people a year by the end of 2007.

Citing the widespread influence of AMPATH and Mamlin’s role in the program, two Hoosier professors, Scott Pegg of IUPUI and David Mason, PhD’78, of Butler University, have nominated AMPATH for the 2007 Nobel Peace Prize. The professors suggested in their letter to the Norwegian Nobel Committee that it would be “perfectly fitting to recognize [Mamlin] as a co-recipient of the peace prize.”

Challenges unique to the African medical system have inspired innovative treatment solutions. In America, says Mamlin, a doctor writes prescriptions and sends patients on their way.

“Forget that in Africa,” he says. Treating HIV among the poor people of western Kenya, Mamlin says, “extends beyond offering drugs to reconstitute the damaged immune system to offering solutions that reconstitute people’s lives.

“You have to care about the food of their children. And find a way to pay the rent if they have any hope of going back to work. And create an infrastructure so they can heal themselves. The list goes on and on.”

AMPATH has its own farms with support from the World Food Programme, a United Nations agency, headed until April by former IU trustee Jim Morris, BA’65, that supports economic and social development. Mamlin says the program’s distribution system “would be the envy of Wal-Mart.” Its food program is the first in the world to offer full food support along with HIV care — for the patient’s entire family.

“You can’t just feed the patient,” says Mamlin. “Can you imagine having an impoverished mama with HIV who has no food, and you give her food and say, ‘This is for you, not your children’? We feed everyone in the house so that everyone comes up together.”

AMPATH’s services extend beyond treatment to prevention. The program will screen 30,000 pregnant women for HIV this year, cutting the transmission rate of the virus from 50 percent to less than 5 percent. Programs are also being developed around each of AMPATH’s health centers, which offer orphans a place to sleep, clothing, and food, as well as a chance to continue their education and acclimate themselves into society.

“Otherwise, it’s going to be another wave of disaster — this large number of young people growing up who never had any boundaries or training or schooling,” says Mamlin.

‘The Fact Is, IU Stepped Up in a Unique Way’

Mamlin emphasizes that AMPATH is not an IU program superimposed on Kenya. It is a Kenyan program that IU works with to make it as successful as possible.

“Every site we work in belongs to the Ministry of Health. Every employee we have is a Kenyan government employee,” says Mamlin. “None of it has been built around us; it’s been built around Kenyan institutions and Kenyan programs. It has to be that way. That’s fundamental to any hope of long-term sustainability. We have over 750 people now working in AMPATH on an ongoing, regular basis, and I’m often the only white face there.”

In early November, IU signed a strategic agreement with Moi University to further build upon the initial partnership agreement. Now other IU schools beyond the School of Medicine on the Indianapolis campus will work with counterparts at Moi University to develop or expand programs in areas from curriculum development and institution building to exchange programs, collaborative research projects, distance education, and study-abroad opportunities. IU hopes to develop similar partnerships in Mexico, India, China, and Europe.

Mamlin is proud that IU has provided a model demonstrating how HIV can be treated effectively and affordably in developing countries, but he hopes other American academic medical centers will create partnerships of their own so a greater number of people can be helped.

“As you can see, this task has gotten a little bit complicated,” Mamlin says with a chuckle. “We just wanted to go where we had an opportunity for some Hoosier medical students to see another part of the world and vice versa. By accident, Indiana found itself in the epicenter of history’s most powerfully destructive pandemic. It’s not something Indiana would particularly be chosen as a group to get involved in, but just by the luck of the draw we happened to be there and in the middle of it.
“I think that’s one of the important things that everyone understands about Indiana and IU. There are other universities and medical schools all over the place — I understand that we’re not the only ones who ever went abroad. But the fact is, IU stepped up in a unique way, unlike any other university anywhere in [the U.S.]”

Mamlin says IU responded to a need at a time when there was no major funding, little if any treatment for AIDS, and there was an opportunity for bad press if they started treatment and then didn’t have the money to follow through with it. “It just was a no-brainer; you don’t do this. And yet IU stuck its neck out. I can’t tell you how proud I am to be part of Indiana University.”

Jennifer Piurek, MA’01, is a Web-content specialist with the IU Office of Creative Services and a freelance writer living in Bloomington, Ind. To learn more about the IU-Kenya Partnership, see www.iukenya.org or call (317) 630-6770.