Story and photos by Jessica Campbell
Reporting by Jessica Campbell and Allylah Msenya
ELDORET, KENYA — Weighing in at 32 kilograms, or about 70 pounds, Emily Meli registered as a HIV-positive client of AMPATH, and added her name to a list of more than 30,000 families receiving food prescriptions in addition to the antiretroviral drugs that also treat her infection.
In early 2012 Meli visited Module Four of the AMPATH center and was handed a four-pound package of cornmeal. But when she returned, two months later, she was given nothing.
Emily Meli awaits in her home for her family after attending a GISE group in her home town of Kepseret, Kenya.
AMPATH is the Academic Model Providing Access to Healthcare, a consortium of ten North American universities, lead by Indiana University in partnership with Moi University and the Moi Teaching and Referral Hospital (MTRH), both located in Eldoret in western Kenya.
From 2005 to 2012, AMPATH had partnered with the World Food Program (WFP), to provide food to the clients and families of clients living with HIV. That ended when the WFP greatly reduced their funding last year.
The program was initiated after AMPATH workers realized that the antiretroviral medication given to those living with HIV was not properly treating malnourished clients.
With the decline of the donated food necessities, the importance of nutrition and diet has increased among clients and their families. The result has been a greater dependency on supplemental food, a higher number of diagnoses of communicable diseases and an increase demand for education about sustainable practices for growing and providing food.
The WFP funded program had delivered about 250 metric tons of food per day to individual clients of AMPATH. The goal was to support an entire family of one HIV positive client while creating more long-term food secure situations through education. A family was considered “food secure” when its members no longer lived with hunger or fear of starvation.
Now that the WFP has reduced it’s funding of the program, food donations are given only to the HIV positive client, not the entire family.
“Before we used to cover them almost like a blanket and ensure food security,” said Jennifer Kigen, the assistant nutrition manager of AMPATH, “but now we are only dealing directly to the clients.”
Nutritionists and doctors working at AMPATH must now assess a patient on a scale of malnourishment-mild, moderate or severe-based on the person’s Body Mass Index rating, height, weight and size of the middle upper arm. Photographs are taken before and after the start of treatment to track his or her progress. Each client of AMPATH is given an identification number and card, and all interactions with the program is documented and recorded at the center.
A client is then issued the only two supplements. Its all AMPATH has available to distribute now that WFP is gone. The primary contribution from WFP is Plumpynut, a therapeutic feed given more commonly to children, and corn-soy blend (CSB), a special type of flour containing specific nutrients and minerals.
Plumpynut, a gel like supplement made of powered sugar, peanut paste, skimmed milk power, vegetable oil, vegetable fat, vitamins and minerals, is given to severely malnourished children. It is distributed through the government in Nairobi by the U.S. Agency for International Development (USAID) and is sent to Eldoret for AMPATH’s use.
Tekla, an AMPATH client who asked that we do not use her last name so as to remain anonymous, recently found out her status after taking her nine-year-old daughter, Joy, to the hospital for chest pain. She and her daughter both tested positive for HIV and received Plumpynut and CSB rations.
“We eat any time we get, food usually ugali (a cornmeal staple of the local diet) or a mixture of corn and beans,” Tekla said. “We have a small farm so we are able to grow food to eat or sell, but we cannot sustain her [Joy] diet without dairy or meat.”
Because the virus made the child severely malnourished, the therapeutic food was immediately administered and just the one package a day has improved her weight.
“It depends on the age,” said Mary Chelimo, a pediatric nutritionist at AMPATH. “Children six to 23 months take one packet, but as a child gets older they can take two or three a day. For mild to moderate levels of malnourishment, we give the corn flour supplement.”
Originally, the WFP distributed CSB in certain amounts to specific groups of clients, such as pregnant or lactating mothers, young children and teenagers. Though it has decreased, the WFP program continues to provide about 19 pounds for mothers and adults, and 13 pounds for children ages two through seventeen years.
SPECIAL CASES AFFECT THERAPEUTIC FOOD RATIONS
AMPATH nutritionist, Mary Chelimo, advises proper nutrition and diet to clients of all ages living positively with HIV.
Mothers to be, and those currently lactating are special cases in terms of dispensing therapeutic feed. It is recommended that mothers either choose to breast-feed or formula feed their baby for six months without changing methods. According to Chelimo, before 2007, all children were on formula to decrease the chance of spreading HIV through breast milk. Because the percentage of children surviving up to six years old was low, breast-feeding only while on medication for six months is now recommended.
“I can say when children were on formula most mothers were not all faithful,” she said. “They were mixing feeds, maybe giving milk, formula, porridge because they did not know there was a difference.”
After six months, mothers can begin to switch from formula or milk and begin therapeutic feed if necessary.
The Plumpynut packages, cost AMPATH 300 Kenyan shillings, ($4), are free of charge to the clients. They are given to families on a weekly basis, for a maximum of three months, unless adequate weight gain is not achieved.
One of the problems of the therapeutic feed is that it is not an entire meal replacement; it only corrects the body, it does not completely sustain it said Chelimo.
Malnutrition among those taking ARVs is the largest problem Chelimo and her colleagues face.
For Emily Meli, inadequate amounts of food result in more severe side effects from her ARV therapy.
“I am taking the drugs, but without the correct amount of food it is hard,” she said. “The drugs make me weak and sick.”
Before the drugs, Meli was able to plant and harvest produce from her farm regularly, but now that she’s on medication she cannot work due to the persistent dizziness, and frequent coughing, chest pains and spitting up blood.
Another problem the nutritionists at AMPATH see is the sharing and distribution of the free supplements to one’s entire household and others throughout town. If a food insecure mother is given supplemental feed due to her positive HIV status, the probability she will share the feed with family members is very high.
Kigen described the situation as useless, especially if it is the mother living with HIV.
“The mother goes home and one or many of the children are malnourished, she will definitely share and it would not be adequate according to our prescription or according to the dietary allowance,” she said. “So, it poses a great challenge for us… You cannot help, because they [the mother] go back to their homes and share.”
With the introduction of antiretroviral treatment, the discovery was made, that without adequate food the medication for HIV is far less effective.
Before initial ARVs are issued, the first thing measured is the nutrition of the client. Because the drugs and side effects are very strong and can last for weeks, the guarantee that nutrition is available is important to the doctors and nutritionists.
Without adequate food to go around, advice is the only other thing that can be distributed to clients.
Chelimo said they make sure the person receiving the ARVs has knowledge of good nutrition and is aware that the drugs will not work without food.
DIABETES AND HYPERTENSION COMPOUND THE PROBLEM
Even for food secure families, knowledge and education is the first step taken in assessing patients. At the Moi University Teaching and Referral Hospital, the nutritionists working with diabetes and hypertension preach good nutrition through posters and pamphlets given to all of their patients. Diabetes and hypertension are two common diseases in the Eldoret area.
Chelimo, who works exclusively with HIV-positive clients at AMPATH, may have one diabetic person per month, but has a difficult time working with him or her because of the restricted diet they must adhere to.
“You can get a patient with HIV, diabetes and cancer, so we have to sit and come up with a decent meal plan,” she said. “We have to look at diet, blood sugar, and CD4 count.” CD4 count is an indicator of the HIV virus’ impact on the body.
At the MTRH, where a patient’s HIV status may or may not be disclosed to the doctors, most of the patients seen in the nutrition office are known to have been diagnosed with diabetes and hypertension. Though the majority of the patients are food secure, they still lack the knowledge of how to maintain proper nutrition for optimal health.
Type 2 diabetes is the most common type seen by the officers working with the hospital patients. Found in both teenagers and adults, it more frequently affects women than men. It is caused by obesity or stress. Type 1 diabetes can be present at birth or developed during childhood. Type 3 diabetes is induced diabetes, usually developed in adults during pregnancy and among people with dangerous highly blood sugar levels.
A Diabetes Care Diary is given to all diabetic patients so they can track their blood sugar at home for three months. The diary helps the doctors see how patients is doing and teaches the patients how to control the disease and sustain themselves.
Helen Chemoiwo, a nutrition officer working at the MTRH, says nearly 75 percent of all of her diabetic and hypertensive patients are overweight.
“Family history and improper nutrition are the main causes of diabetes and hypertension,” she said. “They just do not know much about proper amounts and how to track their blood sugar.”
According to Chemoiwo, education about exercise and diet is the only way to help prevent these diseases. She recommends regular exercise, such as walking, jogging, and cycling to help maintain proper weight.
At MTRH, the doctors are focusing on preventative techniques, reaching out to individuals and entire villages at a time. They make home visits along with workers doing HIV testing in homes to check the blood sugar of clients.
Deborah Tulienge, an officer of the Chronic Disease Management office at the MTRH, said they are setting up blood sugar readings in towns throughout the region to test people as well as to teach them about how to control and prevent diabetes.
“We do a lot of education,” Tulienge said. “The city worker cannot just go up to a house and prick. They first bring a lot of information on prevention, diet and exercise.”
Preventative care is the number one focus for the CDM office. For those already diagnosed with diabetes or hypertension, prevention of further complications is the next step Tulienge said.
The CDM office began training workers during the past year to go out and screen patients in towns throughout western Kenya, at several clinics that are closer to villages, but far away from the hospital and AMPATH center.
Every few months, physicians and nutritionists travel to each of the clinics to check on patients and reinforce that everyone is being well taken care of.
“We used to think diabetes was a rich man’s disease, but it is not,” she said. “Down in the rural, life has its own stresses that will pre-expose them to these conditions. They are eating what they have on hand and find they are still predisposed to diabetes because it is not a balanced meal.”
HOME VISITS TAKE THE NEXT STEP FOR EDUCATION AND SUSTAINABILITY
A harvested gourd lays in the farm of Emily Meli in Kepseret, Kenya.
Working with the Kenyan Ministry of Health, Tulienge said the officers go to the clinics to teach, and encourage people to grow their own fruits and vegetables to sell and to eat themselves, so they can get a secure meal.
“We educate them and train them on how to grow vegetables,” she said. “We also tell them that they should find ways of making money by planting fruits and selling their fruits.”
For most families, farming and producing their own vegetables and fruits is the only option. Now confronted with this realization, AMPATH has made it a mission to help families and those living with HIV and other communicable diseases become more sustainable food producers.
In the wake of the termination of the WFP donations, Moses Makaya, the nutrition manager at AMPATH, said lessons have definitely been learned from the loss of food support.
“Our focus now is to teach people how to fish and show them where the lake is,” he said, “instead of us just giving people food.”
Programs, such as farming training sessions and Group Integrated for Savings Empowerment (GISE), have been established throughout the local towns promoting a more supportable lifestyle for those unable to afford much.
Specific groups are organized that put together people suffering from similar conditions. There are groups for those who are HIV positive, who are caring for orphans and vulnerable children, who are diabetic patients and so on. The sessions occur from every week to once a month, and provide a dependable teaching atmosphere.
Monica, a mother of five children, lives with her own mother and has to travel many miles by motorcycle to get to the AMPATH clinic every two months. She receives her ARVs each visit and a small bag of CSB.
“I get a little flour when I come to the clinic,” said. “I am able to plant. I grow beans and corn at home.”
According to Chelimo, who worked with Monica when she first came to the clinic, Monica was very weak but has made huge progress during her seven months of treatment. She has learned how to farm and grow her own food.
“I have three meals a day,” Monica said, “The main is rice or ugali. I have milk, meat and eggs and vegetables too.”
With the elimination of the food from the World Food Program in 2012, the amount of pressure to help care for the patients and clients of the MTRH and AMPATH center increased within a couple of months.
Chelimo describes the ending of the donations as a huge blow when the program pulled out, but said there is another way to look at it.
“It helps everyone in the long run to become more self-sufficient,” she said. “Yes, it is a big blow, but maybe some will wake up now and start to look for ways to help their families because organizations cannot feed you forever.”