What seemed like a case of incurable childhood eczema and an encounter with a kind doctor stirred up young and impressionable girl’s desire to become a doctor. Many years and numerous hurdles later, Professor Ruth Wanjiru Nduati is credited for the groundbreaking research that allows HIV-positive mothers to safely breastfeed their children.
When Professor Ruth Nduati was young, she had terrible eczema that seemed to defy medication. The doctors who were attending her virtually lost interest in her case. That was until she went to the clinic while the regular doctor was away. The stand-in, an elderly Czech doctor, was so touched by the girl’s condition that he referred her to a consultant dermatologist in Nairobi, who managed to clear the eczema. My dream is to see us grow from training at KNH so as to develop several county hospitals to become a network of training centres. The compassionate act sowed in Nduati a seed that blossomed into who she is today. “I was very young, and although I had no idea what it entailed, I knew I wanted to be a doctor.” Nduati was in school at a time when the government of the newly independent Kenya was striving to Africanise schools. This opened up incredible opportunities for students like her, laying the foundation for a generation of high-level technocrats.
A deliberate investment by the government in girls’ secondary schools markedly changed the gender balance at university. Nduati was among the first group of women at the University of Nairobi’s School of Medicine. “Our class was the first to have many girls — about 25. Previously, there were three or four per year, or even none,” she remembers. This caused quite a stir. Nduati graduated and after working for a while, enrolled for a master’s degree. At work, she saw medics blaming patients for their conditions and a lack of compassion, resulting in unnecessary trauma and death. She felt the need for counselling and compassion in patient management. She recalls with amusement the first time her group was assigned practical duties. Being women and so young — between 23 and 24 years old — the hospital’s administration was nervous. Quite a few patients were also put off about being attended to by female doctors. By the end of the first year, however, the women had proved themselves.
Her secret was professional focus. “I always carried some reference material because you don’t know everything. You need to know when to look up information to get the correct diagnosis.”
Words of Wisdom
• “Do your best to serve others. Don’t be satisfied with the status quo. To the dying babies, we could have said pole sana there is nothing we can do, but instead we said it is not right.”
• “It is a real privilege to be part of development in Kenya. Strive to make a difference in your country and continent. Each of us has the power to bring change.”
• “You cannot succeed alone. The walls you build around your house cannot be high enough if your neighbour is in trouble.”
• “We should not boast over what we have. We should use our skills in a positive way.”
She shares that understanding that you do not know everything helps doctors remain humble to avoid ‘playing God’. The more she grew in medicine, the greater her debt of gratitude to the community and to Kenya became. Her guiding principle has always been, “to whom much is given, much is demanded.” As a young doctor, Nduati delighted in seeing patients she had treated or referred recover fully, the same way she got healed after the Czech physician’s referral. A six-week lactation management course soon after graduating as a paediatrician provided her with an opportunity to make a difference for HIV-positive mothers and their babies. “Rather than relying on textbooks, the course used primary data and the latest journal articles to create an evidence-based treatment approach.” After the course, the organisers continued sending participants journals on breastfeeding. The power of modern medical research impressed and inspired Nduati. Around 1987, HIV had just emerged as the grim reaper. Nduati was dismayed by the HIV-positive babies dying in droves in paediatric wards. Challenged, she studied epidemiology and did a term paper on mother-to-child HIV transmission through lactation, an issue over which the medical fraternity was in a dilemma. In 1985, the US Centers for Disease Control and Prevention (CDC) had advised HIV- positive mothers against breastfeeding. They issued completely opposite guidelines later, saying, babies should be breastfed regardless of their mothers’ HIV status. Nduati’s professor-cum-mentor took an interest in her paper and approved further investigation. “I developed a proposal funded by the National Institutes of Health (NIH) — a biomedical research facility based in Bethesda, Maryland, to study whether mothers should breastfeed or not. We recruited 2504 HIV-infected women and followed them over seven years collecting data.” The results showed that HIV- positive mothers died more during breastfeeding. Bottle-feeding was therefore recommended.
She then embarked on further studies focusing on better ways of curbing mother-to- child transmission of HIV. She came upon a 1996 study by American and French scientists showing that use of AZT — an anti-HIV drug that reduces the amount of virus in the body — helped prevent transmission. She and a colleague, Dr Dorothy Mbori-Ngacha, published groundbreaking findings focusing on the prevention of mother-to-child transmission (PMTCT).
Their lives took on a different direction. “Dorothy and I decided that we could not, as African women, do research and not translate it into healthcare services.” The researchers called a special meeting of delegates from the UN, the United States Agency for International Development (USAID) and other eminent research organisations. During the meeting, they emphasised the need to implement their
research by providing services. They were challenged to evaluate the feasibility of translating PMTCT into local health care. “That was a big thing, because they felt healthcare systems in Africa were so broken down that service delivery would be impossible. Underlying that was the suggestion that African women were not smart enough to follow instructions.” Not only did they write the proposal; they also liaised with government clinics in the areas worst hit by HIV infection to do a pilot programme on providing these treatment modalities. The result was that in the first two samples in Nyanza and Central provinces, the rate of child mortality fell significantly. They scaled the programme up countrywide to spread the benefits, an intricate process involving much effort.
Nduati and Mbori-Ngacha wrote a manual to provide guidance on PMTCT in sub- Saharan Africa. They then cascaded the process by training trainers, who in turn reached out to every district. “None of the hospitals records looked the same, so through the Ministry of Health, we standardised hospital cards to ensure they showed the mother’s HIV status.” As they began to work with local hospitals, they faced suspicion and lukewarm cooperation. The doctors therefore enlisted respected retired matrons as district co- coordinators, who would carry out training, facilitate the initiative and collect the data. Government health workers were extremely supportive as a result, leading to a fivefold drop in infant deaths. Nduati was thrilled by the health workers’ commitment, especially in their push for full community mobilisation. “They would give talks on HIV prevention at churches, at bus stops where they addressed matatu touts and drivers, and in bars (before revellers got too drunk to listen).”
Nduati and her colleagues, who were previously traumatised by watching patients succumb to AIDS, became optimistic because of the progress they were making. “Now, there was something we could do about it. And not just individually as physicians. Many people could now benefit.” She confesses that she had not anticipated such a tremendous impact. “It was a God-given opportunity to make a difference.” Alongside other doctors, Nduati then started a non-governmental organisation, the Network of AIDS Researchers of Eastern and Southern Africa (NARESA), which provided a vehicle for this kind of community work. Although it remains a research outfit, it focuses more on drug options. Nduati’s studies contributed to the current guidelines on treatment with antiretroviral (ARV) drugs, putting her on the cutting edge of intervention. “When administered during delivery, ARVs protect breastfeeding infants. The result is healthy, uninfected babies and living mothers.”
She further explains that, “infant formula is only an option when there were no ARVs”. Otherwise, bottle-feeding poses more risk of HIV infection than breastfeeding does, according to the doctor. The researcher’s typical day begins at 5am when she wakes up. “I’m a morning
person, so I start my day early doing my reading and writing projects.” When she is on sabbatical leave, she spends time writing papers. During her regular schedule, she begins her day with an early lecture, followed by bi-weekly ward rounds at Kenyatta National Hospital (KNH). She loves teaching and takes pride in being part of a medical education programme that received an award from the American Academy of Paediatrics. “This indicates that we are training health professionals to achieve the same goals as our world-class counterparts. Nduati would like to see equitable service provision in all hospitals. “My dream is to see us grow from training at KNH so as to develop several county hospitals to become a network of training centres. The university will thus have more impact in healthcare
delivery for all.”
Looking to the future, the don looks forward to a point when HIV will be eliminated. She feels “it should reach a point where HIV is not our big issue; a point where we are raising young men and women to follow moral values that will help protect them from HIV and other STDs [sexually transmitted diseases].” She reasons that behind HIV is a society that has fallen apart — multiple sex partners, drugs, abuse of young people, and normalisation of transactional sex. She acknowledges the government’s commendable effort through the cash transfer programme to destitute families. Where this is done, girls have a much lower HIV prevalence. The initiative provides hope, according to Nduati, who strongly advocates for scaling up such programmes. As a parting shot, Nduati recognises that you cannot be successful alone: “A lot has gone into making me, some of which I had no control over. Regardless of your field, do what you’re supposed to do and do it well. That is the legacy you should leave!”