[at left: Dr. Joe Mamlin, lead clinician in the AMPATH program and me in his garden, Eldoret]
AMPATH is its own organism. It’s grown from the 2,000 patients in 2004, when I was last in Eldoret, and just starting a few clinics outside of the main referral center clinic. It now sees over 40,000 patients in almost 40 clinical sites, a few of which are in tented sites along areas of tribal conflict. Like FACES, AMPATH is acting like a consultant with Kenyan Ministry of Health (MOH) sites – existing clinic sites with infrastructure already built. Unlike FACES, AMPATH has a huge independent endowment and is the darling of Indiana University’s philanthropic efforts. With more funding and more institutional support, AMPATH can grow and build clinical sites much faster and better than FACES can. Why hasn’t UCSF stepped up to building FACES in the same way?
Joe Mamlin, one of the founders and the clinical guru of AMPATH, was nominated for the Nobel Peace Prize this year. I am not surprised and am proud and very respectful of all his work. It is unfair and probably impossible to compare people’s dedication to this work, but if asked, I’d say that he is among the most dedicated clinicians I’ve ever met – one of the top three. Of the other two, one also works with AMPATH: Jane Carter, the Rhode Island TB controller, the TB person at AMPATH, and my first mentor in medicine. The third is Dr. Dan Wlodarczyk, my mentor in HIV primary care back at San Francisco General.
Thinking about this list of mentors, I feel extremely fortunate to have these folks in my life. They show me what is possible in medicine. They show me what is right. Despite the fact that Joe and Sarah Ellen (his wife and partner in humanitarian adventures) are devout Christians, along with Indiana University, I realize that most of our principles match. Basic human rights and principles generally span across most world religions. It’s when you add power and dogma that I find that organizations get into trouble and provide less-than-ideal services.
Working with Joe is great. He has spunk and charisma when interacting with staff and patients. It’s not difficult to see why he, like Paul Farmer, has a cult of personality. At this stage in his career and life, he’s not afraid of calling all his own shots. It allows him to act independent of stupid rules and regulations which often get in the way of providing the best care for patients. “I will lie, cheat and steal in order to get the best care possible for sick Kenyans,” Joe told me. And we all trust him and his judgment well enough that we know that he would be doing all of those things in the right way.
He’ll use what fund he has available to get viral loads on patients so clinicians can more accurately judge when someone is failing their antiretroviral medications. He has a humanitarian fund so that AMPATH can pay for a patient’s hospital bill so they can be released. The humanitarian fund also pays for patient transport, CT scans, other radiology that the patients would otherwise have to pay for themselves but won’t get because they don’t have the money. Or are not willing to spend their entire savings for a weeks’ worth of medications. Some clinicians complain that patients are getting a free ride in life, but if you believe, like I do, that there should be universal, accessible health care everywhere in the world, then there is nothing to complain about. Basic health care is a human right.
At Turbo (is that a great name for a Kenyan village or what??), AMPATH is building a new, larger clinic to see TB and HIV infected patients. The patient load has gotten too high for its small, existing MOH building. They are also digging for clean water for the patients.
That day, two completely unresponsive patients were dumped into our outpatient clinic. I say dumped because they were literally dumped. One was an elderly woman whom Joe knew had TB. She had been abandoned by all her children and other family members. She was left to her own sick self at home, and had probably stopped taking her TB and HIV medications. She was brought in by neighbors on a stretcher, completely unresponsive, with a very stiff neck, and Cheynes-Stokes breathing (a bad clinical sign of severe brain disease). The neighbors jetted as soon as she was dropped, so we had no further information. The other person was a young man, maybe in his early 20s, who was also dumped at the clinic by neighbors who jetted. He was also completely unresponsive, with barely a pulse or blood pressure. No one knew anything about him. He wasn’t known to the staff as a patient at the clinic. I think the neighbors, afraid but trying to do the right thing, thought that no matter what, Joe and AMPATH would take care of these people.
It’s not far off.
However these patients should have been brought directly to the intensive care unit at the referral hospital – not the outpatient clinic!! We had no ability to do anything useful for these patients in the outpatient clinic: no IVs, no ventilators, no bag-mask, no IV drugs. The sad part is that when Joe called an ambulance to transport them to the referral hospital’s ICU stat, the ambulance left without the patients and spent three hours getting petrol, even though they were promised good money to bring the patients there quickly. By the time we realized that they hadn’t done the transport, the patients were nearly dead. They were nearly dead to begin with, but now they were even more nearly dead. Joe called another AMAPTH driver to put the patients in an SUV and transport them instead. Three hours late. Even AMPATH can’t repair some of the fundamental problems of the Kenyan health system.
Joe acknowledges that we, including AMPATH, are getting way too far behind in the HIV epidemic. “We are failing miserably at controlling this pandemic, Sophy,” Joe told me. One of the only reasons the pandemic appears to be stabilizing in Sub-Saharan Africa is that so many people have died from HIV that the prevalence rate is stable simply because people die and thus are not counted. Joe has a project coming up that he’s very excited about to address the deficiencies in HIV care. He was very secretive about it and set up a separate time the next morning to meet with me to talk about it. Since I promised not to leak information about the project before it is started, I will leave it at that. Pole – sorry!