Indiana on front lines of global poverty struggle

Fran Quigley

"Mary" traveled 50 kilometers to a Mosoriot, Kenya, clinic to be diagnosed and treated for AIDS by the IU-supported AMPATH program.

Mary Koskei lies on the examining table in the clinic in Mosoriot, a rural area in northwest Kenya. Her eyes stare vacantly from below a tight headscarf, and the sleeves of her blouse are pulled up to reveal withered biceps thinner than her forearms.

Mary's son helps raise her to a sitting position, and she gingerly moves her feet, callused and caked with the red clay from the countryside roads, over the table. As she is lowered into a wheelchair, Mary looks much older than her 50 years.

"Severe wasting," clinical officer Naomi Nseri writes on Mary's chart. Nseri says something in Nandi, and Mary (not her real name) responds by opening her mouth wide to reveal a white, cotton-like substance coating her gums and teeth. "Florid oral thrush," Nseri says in English to a visitor.

Mary has AIDS, which just a few years ago was a fatal diagnosis for a poor person in Kenya. But Mary's son has brought her to this clinic, 50 kilometers from their home, to get the life-saving treatment that was once off-limits for the 25 million Africans infected with the disease.

This clinic and others operated by AMPATH (Academic Model for Prevention and Treatment of HIV), a joint program of Indiana University School of Medicine and Eldoret-based Moi University Teaching and Referral Hospital and Moi University School of Medicine, will soon be treating 50,000 HIV patients across western Kenya, half of them with the anti-retroviral drugs that Mary so desperately needs.

The IU-Moi program, which started providing anti-retroviral drugs before almost any other African program, has been described by experts from the Center for Disease Control and the Rockefeller Foundation as the best model for treating the HIV-AIDS pandemic in the developing world (Cover, "Eyewitness to a Pandemic," July 16-23, 2003).

As her son wheels Mary to the pharmacy, Dr. Joe Mamlin, the AMPATH field director and professor emeritus at IU Medical School, treats a patient in the adjacent room. He smiles approvingly as he reads the test results for Grace, who was once as sick as Mary. But Grace has rallied after faithfully complying with the drug regimen Mamlin prescribed. There are visitors from Indianapolis at the clinic today, and Mamlin points out the role that Hoosiers have played in the success story.

"You see this building? You see the wheelchairs the patients are sitting in? You see all these Kenyans now well-trained to provide treatment all over this area of the country?" he asks.

"Hoosiers are all a part of this."

Although AMPATH prides itself on being directed by Kenyan leadership, the Hoosier connections are definitely significant. This Mosoriot clinic building was built last year, thanks to an Indianapolis donor who called Mamlin's wife Sarah Ellen during the couple's annual visit to Indianapolis, made arrangements to meet at Lafayette Square Mall and handed over a check for $50,000. Another half-million dollars has been pledged, also by an anonymous Hoosier, for a pediatric treatment center in Eldoret. Several Indianapolis-area churches and service groups support the program.

AMPATH Director Dr. Sylvester Kimaiyo, Jim Morris of the U.N. World Food Program and Dr. Joe Mamlin of Indiana University at the AMPATH center in Eldoret, Kenya.

AMPATH's largest source of funds is a five-year $15 million grant from the President's Emergency Plan for HIV/AIDS Relief (PEPFAR), which is directed by Indianapolis' Randall Tobias in his role as U.S. global AIDS coordinator. Tobias, in turn, was introduced to the AMPATH program by Indiana Sen. Richard Lugar, who has used his chairmanship of the Senate Foreign Relations Committee to become the Senate's most influential advocate in the fight against global poverty and disease.

Tobias' influence on global poverty will grow even larger since his recent nomination by Secretary of State Condoleezza Rice to be the new administrator of the U.S. Agency for International Development (USAID), as well as director of foreign assistance at the State Department, a new position that will oversee all U.S. foreign aid programs. During his testimony asking the Senate for confirmation to the new post, Tobias cited supporting the AMPATH program as one of his most significant accomplishments as AIDS czar. "Beyond attention to the current health care crisis, what Kenya has needed most - what Africa needs most - is help in growing its own health care capacity," Tobias told the Senate Foreign Relations Committee. "That's exactly what this program is doing, while at the same time delivering healing and hope. This is what transformational development is all about."

Hunger and HIV

But even as they gratefully accepted these donations for medicine and buildings, which have enabled AMPATH to take on 1,000 new patients a month, the leaders of the program have learned that the HIV pandemic does not operate in a vacuum. Unlike in the West, where the anti-retroviral medications alone are famed for their "Lazarus effect," reversing even severe cases of AIDS, drugs alone won't solve Mary's problem.

As many as half of all of the program's 20,000 HIV-positive patients throughout western Kenya suffer from food insecurity, which was interfering with patients' recovery even as anti-retrovirals became available. Malnutrition blunted the treatment's effect, and the side effects of taking the medicine while hungry was affecting patient compliance with the drug regimen.

"I visited the World Food Program's operation in Busia near here, and I saw they were feeding 36,000 people," Mamlin says. "But after some short-term health gains from being fed, HIV-infected people were getting weaker again because no one was treating their disease. Here, we were doing the opposite: giving the drugs but no food. And I saw the exact same problem with our patients. It was obvious what was missing."

So AMPATH began partnering with another Hoosier-led organization, this one the massive United Nations World Food Program, led by former Indianapolis Water Company and Lilly Endowment executive Jim Morris. The WFP now works with AMPATH to provide six months of food supplements to its poorest HIV patients, some of whom come to the clinics so weak that they literally crawl up the hill to the buildings.

Maize, beans and cooking oil from the World Food Program are combined with vegetables, milk and eggs from nearby farms staffed by AMPATH patients. Since, like Mary, most patients are supporting other family members, they are given enough to feed their dependents as well. The six-month food regimen is usually long enough for the patients to benefit from the reconstitution of their immune system, with training programs available for patients who can not return to their previous livelihood.

Morris recently visited the AMPATH operations, which he says is an example for the world on how to address the often-neglected role that hunger plays in the spread and persistence of HIV.

"Not only is hunger interfering with the ability of these drugs to save lives, but hunger is what has forced so many women into a position where they have no choice but to accept sexual practices that lead to spread of the disease," Morris said. "Hungry people are desperate people, so prevention of the spread of HIV is hampered by the fact that there is not enough food available."

A different set of Hoosier values?

Morris says it is not surprising that the AMPATH program is leading the way in addressing hunger's role in HIV. "This truly has the reputation of being one of the finest, if not the finest, HIV program in Africa," he said after a tour of the Mosoriot clinic and briefings from AMPATH care providers and nutrition experts. "By training so many Kenyans and developing so much infrastructure, AMPATH is developing huge capacity for the country, and it is going to take huge capacity to handle this disease."

Morris was visiting Kenya as part of a multiweek tour of African relief efforts, but he said the AMPATH experience was a highlight. "It is very emotional for me to see something so important that Hoosiers have played such a critical role in building. People in Indiana are proud that IU and Purdue [which has helped with the nutrition and pharmacy programs] are part of something like this."

With Morris and Tobias leading such powerful agencies and IU helping run the model HIV program, Indiana is playing an outsized role in the struggle against global poverty. Clearly, Lugar's enormous influence on U.S. foreign aid policy, and his long relationship with Bush Administration appointees Morris and Tobias, explains some of the Hoosier primacy.

But Pierre Atlas, political science professor and director of the Franciscan Center for Global Studies at Marian College, says that Morris, Tobias, Mamlin, et al. may be reflecting a part of the state's culture that runs contrary to the image of Indiana residents rejecting international ties. "These impressive leaders, with their actions and not just words, provide an answer to the Hoosier values question that is much less ideological, politically polarizing or simplistic than what you see in the letters to the editor page of The Indianapolis Star," Atlas says.

Mamlin says he is proud that his home state and his university's medical school have played such a key role in trying to stem one of the worst pandemics in human history. He shows his visitors the Mosoriot teeming waiting rooms, and says the true reward for Hoosiers' efforts - and the challenge to the rest of the world - are found in the lives of these people waiting for testing, treatment and counseling in the Kenyan countryside, where such a program was once thought to be impossible. Likely, Mary's will be one of those lives saved.

"Every one of these people were destined to die," Mamlin says. Then he pauses, reflecting on how Mary is still one of the relative few Africans with HIV who can get the treatment that AMPATH provides. "It's not rocket science what we are doing. The fact that it is not going on everywhere blows my mind."

To learn about and contribute to the AMPATH program, go to To learn about and contribute to the U.N. World Food Program, go to Fran Quigley traveled to Africa as a consultant for the U.N. World Food Program.

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