One bucket at a time

The transformative impact of global health

Editor’s Note:  Since this story was published in 2006, the Lwala clinic has opened; Milton Ochieng’ earned his medical degree and is now enrolled in the internal medicine residency program at Barnes-Jewish Hospital in St. Louis; Steven Gabbe, M.D., is now senior vice president for Health Sciences and CEO of the Medical Center at Ohio State University; and Peter Wright, M.D., gave up his leadership roles and is splitting his faculty time between Vanderbilt and Dartmouth College.

Stephen Doster
Published: July, 2006

At left, Dennis Ojuki fetches water from a puddle to do his laundry in Lwala.  The lack of running water is only one of the daunting challenges Vanderbilt medical student Milton Ochieng' must overcome to complete his village's first medical clinic.
Photo by Milton Ochieng'
When the residents of Lwala, Kenya, raised $900 for a one-way ticket to send Milton Ochieng’ to college in the United States, they could not have envisioned that he would return to build a medical clinic in the heart of their rural village near the shores of Lake Victoria.

“They sold goats, cows, whatever they could to send me to America,” recalls Ochieng’, who this spring completed his second year at Vanderbilt University School of Medicine.

Since he arrived at Vanderbilt, Ochieng’ has stirred considerable interest in his project among students and faculty across campus. This summer, three Vanderbilt students plan to work on various research projects in Lwala.

The office of medical school Dean Steven Gabbe, M.D., and the school’s new Institute for Global Health are supporting his venture, as is the Vanderbilt Office of Active Citizenship and Service, which organizes service projects for undergraduates.

Ochieng’ also has attracted the attention of Columbia University economist Jeffrey Sachs, Ph.D., former director of the United Nations Millennium Project to eliminate “grinding poverty, hunger and disease.”

“Spend your summers in the Vanderbilt ‘Millennium Village,’” Sachs urged students attending a recent videoconference on the Vanderbilt campus. “This is your generation’s challenge. If you want to end this kind of suffering and poverty, you need to take the lead in this.”

The story of Milton Ochieng’ illustrates how global health is transforming the next generation of doctors, scientists and citizens in the United States.

“Lwala has captured our imagination because here is a Vanderbilt student who’s creating this in his own home village,” says Sten Vermund, M.D., Ph.D., founding director of the Institute for Global Health. “That’s not done every day ... For the university community to come together in support of this is kind of exciting.

The Lwala clinic rises from a pasture.
Photo by Milton Ochieng'
“But let’s be realistic,” he cautions. “We do not have a donor for this project. We are building a clinic with indigenous products at very little cost… The greatest challenge will be funding for staffing and consumables, namely supplies and drugs.

“In the absence of funding, it will be hard to see this dream come to fruition.”

Ochieng’ – whose last name is apostrophized in his native language – is not dissuaded. He has overcome impossible odds before.

Ochieng’ is a courteous, attentive and respectful young man with the body of an athlete. When he speaks, it is with well-considered words in a moderate tone.

His easy-going manner belies the harsh realities of his homeland. Given a chance to describe his world, his passion to help his village becomes immediately apparent – and infectious.

Grim statistics

The remote three square kilometers of Lwala village in western Kenya – more than a mile from the nearest highway—are home to approximately 1,500 people, mostly subsistence farmers.

Poor physical infrastructure, lack of electricity, and lack of reliable drinking water present dramatic challenges, but basic infrastructure is a minor concern compared to the village’s healthcare needs.

During the two annual rainy seasons, the village is virtually cut off from the outside world. The nearest medical facility is seven miles away and provides only basic clinical services. Patients with acute illnesses or injuries must seek treatment at government hospitals in Kisii or Homabay, each 25 miles from the village.

Milton recalls one instance in which a pregnant mother experienced complications during labor. “Her relatives put her in a wheelbarrow and pushed her to get to the main road to the hospital, but she hemorrhaged to death before they reached the highway,” he says. “Unfortunately, the unborn baby died in the womb too.”

A high incidence of HIV/AIDS, malaria, and other diseases contribute to a significant infant, child and adult mortality rate. Nationally, 7 percent of Kenyans have HIV/AIDS, but the HIV infection rate for the Nyanza Province where Lwala is located is closer to 30 percent.

The infant mortality rate in Kenya is about 120 deaths per 1,000 children – 15 times the average rate in the United States.

Ochieng’s own parents reflect another grim statistic: the average 50-year life expectancy in Kenya.

Milton Ochieng’ stands in front of the first of three clinic buildings to be constructed in his village in Kenya.
Photos courtesy of Milton Ochieng'
His father, Erastus, passed away last year at the age of 55 from tuberculosis complicated by HIV infection. His mother, Margaret, a diabetic, died in 2004 at the age of 47 from AIDS-related pneumonia, complicated by typhoid fever and malaria. They had no access to anti-retroviral therapy.

Of the 408 children in the Lwala primary school (grades 1-8), nearly a third has lost one or both parents.

Ochieng’ attended primary school in Lwala and performed well enough on the national exam to be admitted to the prestigious Alliance High School in Kikuyu, near the capital of Nairobi.

There, he learned about Dartmouth College through Alliance High alumni and became further interested after attending Brooks School in Andover, Mass., through a high school exchange program.

In 2002, as an undergraduate at Dartmouth, he helped build a health clinic in Nicaragua.

“A lot of what I saw in Nicaragua were the same things I see in Kenya in terms of poverty and lack of access to primary healthcare,” he says. “Being part of a team that left a lasting impact on a community made me realize that maybe it would be something good to do in my own village.”

When he began applying to medical schools, Ochieng’ looked for a place that had a global health focus. “As I was interviewing with Vanderbilt, I found out about the Emphasis Program, which got my attention,” he says.

Overwhelming need

The Emphasis Program provides students with the opportunity to pursue a variety of research and scholarly activities – from biomedical informatics to medical humanities—during the first two years of medical school. Among the most popular options: international health.

“These students have been brought up thinking it’s a world of global interaction,” explains William Schaffner, M.D., chairman of Preventive Medicine at Vanderbilt who for many years has been involved in international health.

“They have grown up in communities that are diverse. They have high-school exchange programs and summer field trips abroad ... It’s a globalized world now.”

Village masons put up a wall to the first clinic building. Ochieng' planned to name the clinic for his late father, Erastus, a high school chemistry teacher who encouraged his son's audacious dream.
Photos courtesy of Milton Ochieng'
“I’m seeing more students who want to enter the global health field for the long-term,” adds Peter Wright, M.D., chief of the Division of Pediatric Infectious Diseases who leads the international health emphasis focus area. “In fact, it was the students who initiated the international health component… This wasn’t something we envisioned.”

For his Emphasis project, Ochieng’ wants to establish a rural health clinic that will provide sustainable, accessible and affordable healthcare to the villagers of Lwala and surrounding area. He hopes the clinic will be able to offer other services such as HIV/AIDS education programs, tuition assistance for secondary schooling, and physical infrastructure development.

“One of the things we want to do once the clinic is up and running,” he says, “is to conduct voluntary counseling and testing to find out what the exact HIV prevalence is for Lwala, and how to get the message out for prevention and treatment.”

When Ochieng’ presented his proposal to his village, the entire community responded enthusiastically. A council comprised of 21 elders was formed to oversee activities related to the clinic’s construction and funding. Several families offered to donate land.

The local soccer club, along with Ochieng’ and his brothers, dredged sand from the nearby river – one bucket at a time – for foundation sand and mortar. Bricks were manufactured locally, and rocks that serve as a foundation base were collected by locals and hauled to the site using ox-drawn carts.

Ochieng’s plan calls for a three-phased construction. A building that houses a dispensary, laundry and patient treatment rooms has already been completed. Phase II will include a maternal child healthcare center and doctor’s office. A building that houses separate wards for men, women, and children will complete Phase III.

While drumming up support for the clinic, Ochieng’ was referred to Mark Dalhouse, Ph.D., who directs the Vanderbilt Office of Active Citizenship and Service.

While Dalhouse could not provide any funds up front, he accepted Ochieng’s offer to visit Lwala last summer.

“This was a reconnaissance trip to inventory what we would need to do to make the project successful,” he says. “I shadowed Milton for 10 days and met public health officials.

“For me it was a real culture shock. I realized that on my worst day in Nashville, I live like a king compared to most of the world. What struck me was the lack of infrastructure—water, electricity, terrible road conditions. But it gave me a better idea of the logistics needed.”

A team of villagers dredges sand from a nearby river to make the clinic foundation.
Photos courtesy of Milton Ochieng'
Dalhouse quickly realized a number of obstacles would have to be overcome to make the clinic a reality. “One of the chief challenges facing this project is the lack of clean water at the clinic site,” he says. “I saw children sick with malaria with no medication. The need I saw for medicine there is overwhelming.”

Global positioning

Meanwhile, demand among Vanderbilt students for international experiences was burgeoning. In 2005, only a few students responded to postings for volunteers to work on service projects abroad. “This year,” Dalhouse says, “it was standing room only.”

Because the Lwala clinic is not at a point that it can support a large-scale service project, Dalhouse and Gregory Barz, Ph.D., associate professor of Ethnomusicology, are taking about 20 students to Kampala, Uganda, this summer to work in a variety of clinics, orphanages and other settings.

Like the proverbial pebble-in-a-pond, however, the ripple effect of the Lwala Clinic project is attracting students from outside the medical school. Students, faculty and other members of the Dartmouth community have been raising money for the project, as has a new Vanderbilt group – Students for Kenya.

This summer Diana Lemly, a Vanderbilt medical student, Rachel Weaver, a graduating engineering major, and Abbie Foust, a graduating neuroscience major, will travel to Kenya to conduct a needs assessment for the village.

“We'll be conducting a ‘health survey,’ which means going door-to-door to potentially hundreds of homesteads, asking questions about water sanitation, women’s healthcare, and the family's health history,” Foust says.

“We're also planning on passing out brief health surveys at a local market in order to reach as many people as possible. We'll be looking at prevalence rates of HIV/AIDS, malaria, childhood illnesses, child immunizations and maternal and newborn care.”

The students will also establish GPS (Global Positioning System) mapping of the clinic, nearby water sources, and other institutions in the area like primary schools and health facilities so that their house-to-house surveys to be easily replicated.

“We’ll map distinctive landmarks and houses,” Foust explains, “so that other people can return later and repeat our research to assess the impact the clinic is having on the health of the community.

“I hope to walk away with a whole new appreciation of Africa and the work it takes to start a small clinic.”

Ochieng’ understands all too well the frustrations of trying to work in two worlds. In Lwala, even basic communication services can be frustrating. Contacting his older brother, Omondi, who oversees the clinic’s construction, is often a challenge.

Ochieng' examines a child in his village, which is about 30 miles from Lake Victoria.
Photos courtesy of Milton Ochieng'
“If his cell phone battery runs down,” Ochieng’ relates, “he has to go to Rongo, seven miles away, to recharge it. He also has to go to Rongo to check e-mail, which doesn’t work half the time. In that case, he has to go to Kisii or Homabay, 25 miles away, to check my e-mails.”

Wright, who conducts AIDS research in Haiti, is well aware of the hurdles Ochieng’ faces to make the clinic a reality. Yet he can’t help being impressed.

“Milton has done much of the planning on his own,” he says. “He’s mobilized his village in Kenya and the Vanderbilt community…

“When Milton first approached me with the idea for his Emphasis project, it sounded impractical. But I’ve learned not to bet against him.”

“Milton is a fireball,” says Schaffner, “in a very organized, mature, goal-oriented way. One of the qualities of leadership is vision. He has a vision for health care in his country.”

Change the world

Like other global efforts, the Lwala clinic project raises cultural concerns – and opportunities. “All international medical activities have special challenges in that regard,” Schaffner continues, “You also have to be careful that you’re not creating problems when you introduce new things.”

However, the culture also can be a source of education – on both sides of the Atlantic Ocean, says Barz, the ethnomusicologist.

Barz has studied ways traditional music can be used as a means to disseminate disease prevention and treatment information. In Uganda, such programs have had success in reducing the spread of AIDS.

“Lwala can draw on the Uganda model,” he says, “by using historically-rooted modes of communication—song, dance, and drama troops—to spread health education messages in tandem with the medical model, which can consist of question and answer sessions, leaflets, and testimonials.”

For Ochieng’, the possibilities are just beginning.

Next fall, his younger brother Frederick—who already has logged long hours on the clinic—will join him at Vanderbilt as the second member of the Ochieng’ family admitted to the School of Medicine.

“I want to use this experience to learn lessons about what works and what doesn’t work in order to set up other clinics elsewhere,” Ochieng’ says. “I want to be able to work in the U.S. and in Kenya, half of the year in each place, so that once this clinic is up and running on its own, I can look for another similar project in another village or country.

“We want to get Vanderbilt involved as much as possible in the long term so that fourth year medical students or residents can see what international healthcare entails.”

Vermund is excited about the possibilities international education and research offers not only for future physicians but also for students in Vanderbilt’s divinity, law and business schools, as well as those majoring in human and organizational development.

“Students will be impacted by what’s going on—not just in Kenya, but in Uganda, Mozambique, the Sudan, and other parts of the world,” Dalhouse says. “In the long term, (the Lwala clinic) project could be a template for student service experience, for faculty research, and for medical students interested in the developing world.”

Barz puts it this way: “Students know they can’t change the world. But their experiences abroad will change them, and that may eventually change the world they live in.”

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