Providing Dialysis in Africa

What is WORTH and why did it get started?

WORTH is an acronym. It stands for World Organization for Renal Therapies, and it was started because in the third word, if you get severe kidney failure, you’re dead. I thought we could do something about that. I’ve done this sort of work on a smaller scale. We have a Hispanic community here in Salem (Mass.), and I started an organization that I was very active in for a number of years. When I set about doing other things, I wanted something more global, and this came about.

How long has WORTH been around, and is Cameroon the first country it has worked with?

It started three years ago. We’re about to open our second (dialysis) unit in Cameroon. We’ve had invitations to other countries that we’ve not accepted because I don’t want to spread us too thin.

What was the process like getting into Cameroon?

One of my residents put me in contact with the dean of the medical school, and he knew people in the government. Through him, I was able to meet with Professor Nkam, who is a very important physician in Cameroon. Through him, I was able to meet other government officials—and that’s how business gets done there.

What has been accomplished in the last three years since you’ve been working in Cameroon?

The first two years was just to create the corporation. The learning curve was huge. We were very fortunate that McDermott Will & Emory took us on pro bono, and helped us through that phase. I was able to attract the support of DaVita. They were very generous in helping us outfit equipment and our first wave of teachers we sent over there. We will forever be grateful to them. The first two years were organizing it all. In November, we just completed our first operational anniversary, and our stats in this incredibly harsh environment, where many people in global health told me this was impossible to do, are actually superior to those in the States. We have a small population of patients because I wanted to build a paradigm that was workable and work out all of the bugs. When I go there in April, we’re going to double the size and a few months later we’re going to triple the current size.

What was the dialysis system like in Cameroon when you first arrived?

They have a couple of dialysis units. There is an article I wrote in the American Journal of Kidney Disease, and in it I allude to the other dialysis units and what I consider to be their less than superior quality. There are two units that I know of, and I have been assured that I have generated the complete, dedicated, 100 percent animosity of the other nephrologists there. Suffice it to say, if you look at the statistics of General Hospital’s dialysis unit, which is another hospital in Cameroon; they have 57.⁸ percent mortality per year. In the United States, the mortality is 10 to 20 percent, but we dialyze older people, people who don’t want to die yet. In our unit in Yaoundé, we have not had a single death in 16 months. The only complication we’ve had is one man got an infection, and he got better. One unit in Cameroon used to dialyze a patient every two weeks. In the United States, of course, it’s up to three times a week. That unit is now up to twice a week.

How does a patient in Cameroon get covered for the treatment?

There is no insurance system there. If a person needs a shot he, himself, has to purchase the syringe, the needle, the medicine, the alcohol swab, and the band-aid. If you can’t afford the band-aid, you don’t get the band-aid. For the other units in Cameroon, the patients have to bear the cost. In the United States, the typical dialysis treatment costs about $170. We were going to do it for free, but every Cameroonian I know said, “Don’t do that because they won’t respect it.” So we charge them, in Cameroonian francs, the equivalent of $4. And we take that $4 and apply it to their lab expenses. So they really are getting free dialysis, but they don’t know it.

How do you educate the providers in Cameroon?

In all fairness to the government, I have to say that through all the talented efforts of Dr. Nkam, the government was able to renovate a suite for us at Central Hospital University of Yaoundé. They supplied us with renovations, nursing staff and other important commodities. So the government did help. We were able to convince the powers at be we need an edifice. If we didn’t do that, we would have had to have our own security force too. Poverty and death are everywhere in that country. Things can disappear and be sold on the black market. The start-up of it was because of the cooperation of key members of government and Professor Nkam, WORTH and DaVita.

The problem is (the doctors) don’t have equipment. Cameroon has a national treasure of $623 million, and the national debt is over $7.³ billion. That makes 1929 look good. Yet, these people put out docs that are well trained. I’ve been to their medical school, made rounds and lectures. When I was there, they only had a handful of computers and a very sparse library. Then I learned that 10 or 20 thousand people apply to med school each year and 100 of these kids get in. Of that 100, 90 of them know that their brothers and sisters may not wear shoes and may skip a meal for the next six years. So the screening for intelligence is high and the moral imperative is pressing. The Cameroonian doctors that I’ve trained have just been wonderful.

Does most of the funding come through donations?

Fund-raising is just a permanent part of my life. So is lecturing. I lecture all over the place. If they want to open a unit in Mars, I’ll go there. An integral part of WORTH’s funding is provided by Genzyme Corp., which has been a long-standing supporter of WORTH and its causes.

Is there anything U.S. dialysis system can learn from your experience in Cameroon?

What I would like to see our system learn is to be more generous with the third world. There were pundits who said we couldn’t succeed in that environment, and we did. Not only did we succeed, but we excelled here. If we could do that, then other disciplines could too. I would like to see the nephrology community here reach out and work with us.

What is the goal of your April trip to Cameroon?

There are three main goals. One, the Minister of Health has been replaced; I need to get to know the new powers that be. The other is I want to build the population in Yaoundé, the capital, which is where our unit is. Then we are looking to build a unit in the township of Nbingo. It has a hospital run by the Baptists, and they are interested in us and we are interested in them. This is close enough to the city of Bamenda, which serves several tribes and a large population of people we would be able to help. Strategically, it’s located close enough to our first unit, so the first unit can help the second unit and, eventually, vice versa.

It sounds like you want to start small and replicate out. Is it possible to replicate through in Cameroon and expand into other countries in Africa?

That’s exactly my intent. We have had invitations to Madagascar, Nigeria, Vietnam, India, Pakistan—several places. Eventually we might do that. But for now, we are going to work on Cameroon. I think any military expert would tell you that if you create a venture where you have influence, you need to consolidate before you expand, and maintain appropriate supply lines. Our supply lines now are incredibly challenging because if you consider some our donors are in California, we have a 7,000-mile supply line, about half-a-million, soon to be three-quarters-of-a-million, dollars of equipment in the field, and about 30 players in the field who are doing work for us every day. The logistics of this are challenging. One of the things we’ve done is create a telemedicine network. For example, just today, I was on my computer and I could see the head nurse in our unit in Cameroon and we chatted face-to-face in real time—with a tenth-of-a-second delay. He was able to tell me his issues, and I was able to tell him my suggestions. At the end of every dialysis day, they send a written report, and we keep very detailed statistics of urea kinetic modeling, potassiums, weights, flowrate and so forth.

What other long-term plans does WORTH have?

Within Cameroon, the president has called for more dialysis units. I’m not sure what our role will be. I would imagine we’ll play some role, I hope. In terms of other countries, this will depend on personnel and funding. I can’t expand beyond our capacity. We can’t fail. If we fail, people die. Once you embark on this, it becomes a lifetime effort. We can’t grandiose. We can’t get beyond our means. Fundraising will help this. The whole purpose of this is just to do some good. No one makes a salary at this, except for our nursing and biotechnical staff in Africa; they earn a salary from the hospital. Our desire to expand to other countries is real, genuine and present, but will be tempered by our means to do so.

What are some of the major cultural hurdles you have to overcome while working in Cameroon?

The witchcraft has not been a problem for us. It’s out in the bush. The country was originally a German colony, and it was taken away by the Brits and French after World War I and divided into two colonies. In the 1960s, independence occurred. First the French part became independent, and the English part was given the choice to join Nigeria or join Cameroon. So they joined French Cameroon. Today, there are eight provinces that speak French and two that speak English, so there’s competition. They don’t kill each other. While the lingua franca of the country is English and French, there’s a third subculture language of pidgin English. Then are 200 to 250 indigenous languages, which are tribal. I’m a member of the Bali tribe, which is near Bamenda. So I know a few words of their language. Language and culture are issues of unification that can cause mischief, but they tend to hold it together pretty well. In addition, there is great religious diversity and very little religious prejudice. There’s a cultural growth curve that one has to have. A little piece of my heart is Cameroonian. I miss home, of course, when I’m there. But when I’m home, I miss Cameroon too, and I can’t wait to get back.