Food for life
Purdue industrial engineering professor Yuehwern Yih reflects on nutrition program that has helped patients in Kenya survive the HIV pandemic
By David Brandt
In 2004, Yuehwern Yih took a sabbatical from her academic work in manufacturing systems to see how she could invest her time and skills in healthcare systems.
But little did she know that healthcare would take her halfway around the world.
While working over the course of one year at the Richard L. Roudebush VA Medical Center in Indianapolis, Yih, a professor of industrial engineering at Purdue University, got to know physicians and faculty from the Indiana University medical school. Her networking eventually led Yih to the Academic Model Providing Access to Healthcare (AMPATH) program, which represents a consortium of North American universities led by Indiana University in collaboration with Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Kenya.
The program, started in 2001, became the fastest-growing HIV care program in East Africa, according to Dr. Joseph Mamlin, a professor emeritus of medicine at Indiana University who served as AMPATH’s field director from 2000 to 2012. Patients would visit the clinic in Eldoret to undergo exams with physicians and receive drugs to combat HIV, a pandemic in Kenya and the region.
But as often happens, fast growth can create fast problems. In an email to Industrial Engineer, Mamlin, who has been living in Kenya with his wife since 2000, said he believed early on that the HIV pandemic fought by the medical staff was unwinnable.
"This ‘monster’ had three heads – disease, poverty and hunger," he said. "We needed to combine some form of feeding program quickly or our best efforts could not save many wasted patients. And one could be sure there was no food in the home for the children cared for by these patients."
In response, AMPATH began creating its own farms to produce fresh vegetables and partnered with the World Food Program to gain access to corn, beans and cooking oil. Food began to arrive by truckloads, but these efforts provided the nutritional needs for only half of the at-risk families.
"We have to give the whole family food because the mother will not eat if the kids are starving," Yih said.
Mamlin and his team needed help, so they reached out to Purdue University – and Yih responded.
"They have doctors and physicians go there by rotation," she said. "And they will volunteer for any period of time – from three months to a year. Sometimes six months. Sometimes a month. Sometimes just 10 days."
Yih first visited the clinic in Kenya in September 2005 and saw the challenges it faced distributing food to patients, usually delivered in 50-kilogram packages.
"The issue of HIV isn’t just a problem for Kenya," Yih said. "It’s the same for the entire continent. The U.S. government provided a lot of antivirus drugs, which is very expensive, to try to help relieve this problem. But the issue is the people don’t have enough food, so they don’t have nutrition to fight the virus."
Yih said the primary drug delivered to patients helps their immune systems control HIV symptoms. Without nutrition, the drug is not as effective. Yih explained that doctors on site "had a hunch" about the connection between nutrition and the impact of the drugs on patient health. With the link quickly becoming a strong theory for improving results, Yih and a group of graduate students from Purdue went to work.
"I’d never been to the country before, and I didn’t fully understand the problem they were having," Yih said. "OK, they have free food, and they don’t know how to distribute it. OK, they’re medical doctors and can treat patients … but engineering to them is [primarily focused on] plumbing, hardware and electrical stuff. They’re asking, ‘What can you do for us?’ It’s an interesting experience when we can show them how to solve a problem differently."
In 2006, the team developed the Nutritional Information System (NIS), comprising delivery scheduling and inventory tracking capabilities. It also tracks patient food prescriptions and includes that information among medical records for physicians and researchers to study and determine the impact of nutrition on patient health.
"That part of the Nutritional Information System has two functions," Yih said. "One is to trigger when the food should be delivered and how frequently, and the other part is to feed [information] into the patient medical record."
The result, she added, is a synopsis for a doctor, who can research what food the patient has retrieved and how frequently, and the doctor can assess how much medication the patient needs based on that data. Yih said the relationship between the patients and doctors in Kenya is unlike anything seen in modern healthcare in the United States.
"In healthcare, I spent a year in a VA system, and I walked away thinking there is no system. It’s just a bunch of people working in an environment that was somehow at the same building and the same organization. There is no system because it wasn’t designed to be together. It was evolved into some kind of form that we have today – it’s kind of like people picking up jobs whenever it was needed," she said.
"In the old days, the doctor would come to the family and treat a family for two or three generations. Now there are several doctors treating you, and they don’t talk to each other, completely disconnected from what has happened before. Everyone has become so specialized, but there’s no one really in charge to put everything together."
The devotion of the medical team in Kenya to overcome technology woes also speaks volumes about their commitment. Yih said roads are virtually nonexistent and become rivers after any storm, and patient information is typically stored or transferred on USB data keys or by "just texting."
"You’d be surprised by how they use basic technology to get stuff done," Yih said. "They don’t have much else but time, so they’ll do what’s necessary."
Mamlin, who is now AMPATH’s field director for clinical services, said he was grateful for the team’s development of NIS.
"Yuehwern Yih took the time to fully understand our problem," he said. "Then she and her team set out to create [a system] that matched our needs. The result was just what we needed. We could now anticipate with confidence the amount of food that needed to go to every site each week. And we could report to our donors the critical information they needed in order to sustain their support.
"As a result, we sustained the confidence of our donors and the AMPATH food-by-prescription program grew into the largest in the world – feeding more than 35,000 people every day."
Yih said students often ask her where they can find a similar opportunity because of their eagerness to get involved in social causes or services. What is challenging for them, she said, isn’t their desire to work on such a project or for a service organization, but the fact that there isn’t a normal pathway for industrial engineering to have a job opening there.
"You have to be more than an engineer. You have to be an entrepreneur, not necessarily to create your own business, but in the sense of being able to repackage your skill so you can create your own position or your own job description within the company you work for.
"That’s what I always tell my students. Keep looking for new opportunities to be at your best, and they have to communicate that to the people they work with because leadership can use their skill and talent. That’s something we struggle with as industrial engineers because not many really understand."
David Brandt is the Web managing editor for the Institute of Industrial Engineers.