The first of us to arrive in the African country of Cameroon was standing in the night air in the parking lot of Nsmelin Airport on the outskirts of the capital city of Yaounde. He was talking to new friends, the people who had been sent to meet his flight and thereby assure his security. As one of them hefted a suitcase to place it in the trunk of the waiting car, the airport simply disappeared. There were still the noises of people on the move and of people hoping to eke out a living assisting them … but the airport was gone. The night was moonless, and the darkness was nearly tangible. There was a little uncomfortable titter of laughter, and then an accented voice, throaty with the richness of the continent said, “Welcome to Cameroon, doctah.” Then the moment passed, and the airport returned as the electricity went back on line.
Two years earlier, on the North Shore of Massachusetts, the motivation for this and many subsequent journeys had arisen from the words of one of our colleagues, a Cameroonian who was heard to refer to severe renal disease in his country as “a death sentence.” Cameroon is a nation of 16 million citizens with a landmass slightly larger than California (Fig 1). There was some dialysis in Cameroon, but machines continually broke down, people could ill afford the price of the procedure, and sometimes, with the best of intentions, dialysis sessions were spread so thin that patients might dialyze once every 2 weeks. Hemodialysis thus offered the handful of Cameroonians lucky enough to access it little more than a slow and miserable death. “A death sentence” … the words are haunting still, but from them the World Organization of Renal Therapies (WORTH) was born. What follows is the story of WORTH’s experience thus far.
Our mission plans for WORTH developed quickly. We would start slowly, and consolidate our gains before each expansion. We would first bring safe, effective, and permanent hemodialysis to Yaounde. Then, by accomplishing this concrete objective, we would prove that hemodialysis, and, by extension, other medical technologies from developed nations, could be successfully implemented in the developing world.
As we began, we faced some important ethical considerations. First we faced the question of whether or not it is ethical to bring an expensive, highly technical medical treatment like hemodialysis to an impoverished country that has so many other basic medical needs. Our answer is direct. We assiduously avoid, and will not accept, donations made at the expense of other worthy medical causes. Programs for infant inoculations, care for the victims of the AIDS epidemic, nutritional counseling, etc, need every financial resource they can attain, and there is nothing to be gained by having our cause diminish the resources of another health care initiative. We have gone to great lengths to develop both funding and support from new, independent sources so that we would not cause competition for health care dollars. We have been able to recruit support from sources enthused by what we do specifically. And indeed some among our ranks may never have found their current commitment to global medicine had they not found WORTH first.
To date the majority of our support comes from pharmaceutical companies and the large dialysis company, DaVita, as well as the generosity of individual donors. Legal and accounting services have been generously supplied pro bono by major firms. While our scope is global, we began our work in Cameroon not only because the need for our services was great but also because we were able to establish links with the political and educational infrastructure there in an expeditious manner.
The second dilemma we considered early in our mission was a painful but important question: with limited resources available, who would receive the life-saving treatment of hemodialysis? Moosa and Kidd have written about this issue in South Africa. They concluded that in that country, where limited access to dialysis leads to “rationing,” it was socioeconomic factors more than medical factors that influenced the decision as to which patients were accepted to be dialyzed.1 Cameroon has no nationwide system of health insurance. Patients (with or without family support) must pay for every aspect of their medical care. Each medicine, needle, and syringe must be paid for privately. In a country where the per capita annual income is the equivalent of $640, something as sophisticated as dialysis is far beyond the financial reach of nearly everyone. In bordering Nigeria, one of the largest dialysis centers in the country reported that 86 out of 141 chronic renal failure patients were not able to afford more than 3 dialysis sessions. One hundred and sixteen chronic renal failure patients there were discharged home to die after fewer than 10 dialysis sessions because of their inability to continue to pay.2 WORTH was founded on a firm commitment that it will tolerate no discrepancy between the rich and the poor in the acceptance and treatment of patients. A single dialysis session in the United States costs approximately $178. We charge only a few dollars per run, and all of that money is used directly as payment for our patients’ monthly lab tests. We also maintain the policy that if a patient truly cannot afford even our nominal fee, we will treat him or her and WORTH will pay for it.
Our 8 current patients (3 female, 5 male, ranging in age from 21 to 57 years) were selected on a first-come, first-served basis and were required to be otherwise capable of living independently. The patients’ financial status was not a consideration. All patients had documented end-stage renal disease, but limited diagnostic capabilities have thus far made it impossible for us to clearly determine the underlying causes with assurance.
After 2 years of planning, our first unit opened its doors to patients in Yaounde in November 2006. It continues to operate today, performing safe and effective dialysis. While our current long-term dialysis patient population is 8, we have capacity for 24. We have held back on further expansion of our patient load as we work the kinks out of our system, but we are now preparing to double the patient load over several weeks. Amazingly, none of our nurses or biotechnicians had, prior to their training with us, any real concept of dialysis. Today, with close back-up from our organization, they run the dialysis clinic on their own. Roughly once every 3 months, a WORTH staff member goes to Cameroon to troubleshoot, problem solve, and teach. Daily emails are sent between the United States and the WORTH clinic in Cameroon, and instant messaging and international phone calls allow rapid exchange of thoughts. Recently, we have initiated real-time video and audio conferencing, and now through telemedicine we conduct virtual rounds, allowing WORTH physicians in America to see and speak with our Cameroonian colleagues and patients.
The functionality of any dialysis unit is contingent upon the presence of reliable sources of electricity and water. In Africa these basics are not always assured. However, with the support of the Cameroonian government, we have been able to protect our unit and its patients from the nation’s frequent service outages. This support has provided us with a generator to guard our patients from power outages and a private well dug specifically to alleviate the problem of unpredictable discontinuance of water. The government also eased the import duties on the materials we send into the country, and their assistance helped us to renovate the rooms in the Central Hospital University of Yaounde (CHUY) where our unit is situated, and allowed us to obtain the extraordinary nursing and biotechnical support staff that is the lifeblood of the project.
We were also extremely fortunate to obtain the support of a major dialysis company, DaVita. They donated the initial dialysis stock to our project and a commitment for 2 additional years of tapering support. They also supplied us with initial nursing and biotechnical instructors. This generosity provided us with an excellent foothold as we began what will be a perpetual journey of fund raising and garnering resources to perpetuate and expand the scope of WORTH.
WORTH remains an entirely volunteer enterprise. Organizations and individuals have stepped forward and formed a committed, lasting infrastructure of support. Several years ago, an American president called upon the populace to expand volunteerism and try to make a difference. Our doctors, nurses, lawyers, accountants, technicians, computer experts, and others with unique talents and training have forged a corporation that is real, dynamic, and voluntary. We thus maintain a minimal overhead so that available funds flow directly to patient care. WORTH money is spent keeping Cameroonians alive. That is how the service of WORTH members is rewarded.
Critical for our type of work is the ability and drive to make whatever sacrifices it takes to get the job done. Our Cameroonian nursing and biotechnical staff have espoused this philosophy. They began with virtually no knowledge of dialysis. They were given protocols, demonstrations, and lectures, and after they studied these materials they sought out additional journals, textbooks, and online resources. If they need to communicate with us in the United States and CHUY’s internet access is interrupted, it has become their custom to generously pay out of their own pockets at internet cafes to transmit and receive the information of day-to-day care that allows the clinic to function. If a problem delays a day’s dialysis session the nursing staff simply stays in the unit into the late-night hours, serving their patients without being asked, without complaint, and without extra compensation. Their dedication is unparalleled. They are simply the best at what they do in their country. They are proud of their responsibility and they serve it admirably.
So, does all this work? We believe that it most definitely does. Our patients are healthy (Fig 2), our long-term dialysis mortality rate is 0%, we have had only 1 access infection, and we are now confidently moving forward to expand our patient population. Nevertheless, it is important to have metrics if one wishes to claim success. We track many parameters as in the developed world. Although urea kinetic modeling has become an integral part of measuring dialysis adequacy,3 we do not at present have the capacity to measure Kt/V, but we can measure the urea reduction ratio (URR) and track basic electrolytes. URRs are improving as the staff gains experience, and as Figure 3 demonstrates, adequate chronic hemodialysis is indeed possible in Yaounde. (It is not clear why there was a drop in URR in May of 2007, but we suspect technical difficulties in measurement.)
Illustrative of the challenges we face are our continued inadequate hemoglobins, which demonstrate our need for synthetic erythropoietin. These values are reminiscent of the levels seen in dialysis units in the developed world prior to the advent of hormonal stimulation of the erythron by synthetic erythropoietin. Given the prevalence of blood-borne illnesses in Cameroon, obtaining injectable erythropoitin is now one of our highest priorities. It would be tragic indeed to save patients from a uremic death only to have them succumb to blood-borne diseases transmitted during transfusion.
Cameroon, in many ways, is symbolic of all of Africa. It is tribal and that lends support to its beleaguered citizens. It is poor. It is struggling. And it has great promise! We are succeeding in introducing and maintaining, at a high level, a form of technology few would have believed possible to implement in the developing world. We have shown it can be done. We hope to demonstrate to other disciplines that they too can and should do the same, and we are prepared to help them. If cardiology, pulmonary medicine, gastroenterology, and other specialties that require advanced technology can be enticed to join us, then Cameroon would undergo a medical renaissance, one that could spread to the nation’s equally deserving neighbors. Exciting innovations in medicine in their country might also provide the added benefit of enticing Cameroonian physicians to remain in their homeland. This might help mitigate the brain drain that is afflicting medicine there and in the developing world in general, helping avoid its predicted cataclysmic results.
We live in a world of miracles. Science is advancing rapidly and wonderful innovations occur with a frequency never before known in the history of humankind. Advancements in medical care stand in the epicenter of this spectacular phenomenon. Illness continues to be beaten back by a wave of high technology with no apparent limitations in sight. And yet, despite this, huge parts of the planet, the developing world, continue as if these revolutionary changes had never occurred. Dialysis was one of the first advanced medical technologies to appear, and yet in much of the developing world severe renal disease simply means death. Many feel that there is no way to change this as these parts of the world are “underdeveloped,” “backward,” “corrupt,” or any other of a number of pejorative adjectives, and the fact is there are often tremendous obstacles to medical high technology in these places. WORTH is showing that these obstacles are not insurmountable. In Cameroon the potential for development, happiness, and health is real. It is important to know that individuals can make a difference. It is important to remember that potential—born of hope, birthed by sweat, and nurtured by passion—can be fulfilled.
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