A floating health clinic

Taking it to Lake Tanganyika

Amy Lehman, AB’96, MD’05, MBA’05, devotes her career to building health systems in East Africa

PHOTO BY MARK BLACK

“The idea was to always have a map of the place with me.”

Amy Lehman, AB’96, MD’05, MBA’05

BY DIANE DUNGEY

Amy Lehman grew up along Evanston’s Lake Michigan shore, but her life is defined by another great lake and the people around it.

Lake Tanganyika, vast and deep, is the setting for her work to deliver basic healthcare to a population beset by war, political upheaval, climate emergencies and poverty.

Lehman, AB’96, MD’05, MBA’05, founded the Lake Tanganyika Floating Health Clinic in 2008, not long after a storm shut down an airstrip and marooned her in the area, giving her time to travel along the lakeshore and deepen her longheld interest in East Africa.

She is partnering with the Rustandy Center for Social Sector Innovation at the University of Chicago Booth School of Business on her latest project, to test a new mosquito repellent. Her aim is to interrupt rising malaria transmission in an area with high rates of infections and deaths from the disease—and where insecticide-treated bed nets, she said, are ineffective and even harmful.

Lehman focuses on fishing villages in the Democratic Republic of the Congo on

the west coast of Lake Tanganyika, which is 410 miles long and approaches a mile in depth. Burundi, Tanzania and Zambia also border the lake.

“It’s a part of the world that has had an epic amount of suffering and that gets very little attention,” Lehman said.

The problem with bed nets

During more than a decade working along Lake Tanganyika, Lehman, 49, has learned some disconcerting truths.

For instance: Suffering and deaths can be rising even as nations and aid organizations report progress against disease. The true picture is hidden by the extreme difficulty of collecting data in remote areas, and a crisis can go unrecognized and unaddressed.

“How is it that we’re making the decisions in Geneva and London, in New York and Washington, D.C., or even in the capitals of these countries, when we haven’t even characterized the problems accurately?” Lehman asks.

Another reality: Silver-bullet solutions, like well-funded and popular campaigns to deliver insecticide-treated bed nets, are credited with cutting malaria transmission in sub-Saharan Africa, but they don’t work everywhere. Around Lake Tanganyika, the nets invariably are used for fishing, where they cause environmental harm while failing to protect people, Lehman said.

Aside from dispersing insecticide into the water, the fine-gauge bed nets trap small, recently hatched fish, preventing them from growing and reproducing in a way that sustains local fish populations.

PHOTO COURTESY OF THE LTFHC

Children gather around fishing boats in Sebele, north of the Ubwari Peninsula in the Democratic Republic of the Congo.

BURUNDI

LAKE TANGANYIKA

Longer and deeper than Lake Michigan

DEMOCRATIC REPUBLIC OF THE CONGO TANZANIA

LONGER AND FAR DEEPER

THAN LAKE MICHIGAN, Lake Tanganyika lies within the East African Rift Valley. Most of Lake Tanganyika lies in the Democratic Republic of the Congo on the west and Tanzania on the east, with portions in Burundi and Zambia. At 410 miles, it is the longest freshwater lake in the world, compared to Lake Michigan’s 307 miles. Lake Tanganyika is 4,710 feet deep, second only to Russia’s Lake Baikal and far exceeding Lake Michigan’s 925 feet. The lake contains one fifth of the world’s freshwater, which supports the livelihoods of millions of people. People living around the 1,100mile shoreline use the lake for water, for transportation and for fishing. Rising lake levels threaten some of the 10 million or so people living in the Lake Tanganyika basin, some of whom were previously displaced by disasters and violence. Lake Tanganyika’s beaches and coastal plains rise to steep mountains, such as the Mahale Mountains National Park in Tanzania, where chimpanzees flourish. The Kalambo Falls are near the southeast end of the lake. There are hippos, crocodiles and hundreds of types of cichlids, tiny colorful fish that are losing ground in the wild because so many are collected for use in aquariums.

— Diane Dungey

“You know the marketing material, ‘Spend $10 on a bed net and save a family’s life,’ and everyone looks so happy under their bed net in their bed. But in a lot of really rural environments you have very small structures that house a lot of people and don’t have bedrooms and don’t have beds,” she said.

Meanwhile, after a sharp decline, malaria deaths are rising in the World Health Organization’s Africa Region. The disease remains the number one cause of death around Lake Tanganyika, Lehman said.

A house-to-house survey by the Lake Tanganyika Floating Health Clinic found

an average of 3.8 cases of malaria per household occurring over a three-month period in 2016, with children particularly hard hit. Across the Democratic Republic of the Congo, the disease accounts for 19% of deaths of children under age 5, reports the U.S. President’s Malaria Initiative.

“Are the prevention strategies working in the areas that have the highest caseloads and the highest mortality?” Lehman asked.

Such questioning has made her the “bad girl” in the aid and development space, said Lehman, who has no problem wearing that mantle.

“We need to do better. We need to be accountable to our own intervention strategies. We need to be data-driven. We need to listen to what communities are saying their problems are and where they think interventions would be most impactful.”

‘Easier to go into space’

Lehman’s 10-person team on Lake Tanganyika recently completed a weekslong trip to update data from villages along the Ubwari Peninsula in South Kivu Province, an area torn by violence in the Democratic Republic of the Congo.

Because of the difficulty of traveling and camping, “we go there with many goals,” said Aris Macos, manager of field operations at Lake Tanganyika Floating Health Clinic. Those include going house to house gathering reports of cases of malaria and other illnesses, setting light traps for mosquito surveillance, and

studying fishing practices with the help of a fisheries biologist.

“You need to go talk physically with everyone,” Macos said. “It’s easier to go into space than to go to small villages inside of Congo.”

The meticulous work is aimed at securing funding to test a spatial mosquito repellent in villages on the Lake Tanganyika shore. The controlled-release repellent is on plastic or fiberglass sheets, each about the size of a sheet of paper, that are hung in homes.

But the sheets must be replaced every month or so, compared to bed nets, which last years.

That’s why Lehman teamed up with Bariş Ata, PhD, Sigmund E. Edelstone Distinguished Service Professor of Operations Management in Chicago Booth, and Booth graduate student John

Aris Macos is field operations manager of the Lake Tanganyika Floating Health Clinic.

Lake Tanganyika Floating Health Clinic staff, local nurses and others, above left. The team, including Amy Lehman, MD, arrives after traveling from Kigoma to Kazimia.

PHOTOS COURTESY OF THE LTFHC

Amy Lehman, MD, on a 2019 trip to Lake Tanganyika, above left. Children show off their catch after fishing with bed nets, above right. Such repurposing of bed nets has environmental consequences and represents missed opportunities to protect against mosquito bites and prevent malaria. Montgomery. They are developing a model to manage inventory and delivery of the product that will work across 41 villages totaling about 200,000 people.

They hope to show that reduction in disease per dollar spent is competitive with bed nets, Ata said.

“When one solution doesn’t work perfectly, you may need to look for alternatives that may be more expensive, but will potentially work better,” Ata said.

Secured sheds can store supplies of the repellent sheets in villages around Lake

Tanganyika, and large boats and trucks are the default for deliveries, but flexibility is key in an area where the few roads might be closed by flooding, armed conflict or even a stalled piece of mining equipment.

“When those options aren’t available, we have to rely on motorbikes, people walking the products and things like dugout canoes,” Montgomery said.

A professional pivot

Lehman arrived on the Tanzanian shore of Lake Tanganyika in 2007 at the onset of a period of personal change.

She’d completed her academic studies after earning simultaneous degrees from the University of Chicago Pritzker School of Medicine and Chicago Booth, and was training to be a general thoracic surgeon.

A close friendship with Alwyn AndrewMziray, AB’94, MD’00, IMBA’00, had focused her attention on Tanzania, where he was born. Mziray died in 2011, and a tribute to him is on the website of the Lake Tanganyika Floating Health Clinic, at floatingclinic.org.

During that initial trip, interrupted by a typhoon, Lehman’s travel in the area with her school-age son Max, now 28, introduced her to people who often were refugees, lacking food and shelter, and suffering from illnesses easily treated in the U.S.

Lehman returned to Chicago to “a particularly insane week” in the cardiac surgery

intensive care unit. She was struck by the sometimes-incremental benefits of intensive medical interventions in the U.S. versus the basic healthcare gains the same amount of money would fund in rural Africa.

Then, Lehman’s own health led her to “a professional 180.” She underwent a surgical procedure in 2007 that caused nerve damage, leaving her with chronic pain and, for a while, without use of her right arm.

“I had to totally retrain my arm. I thought to myself, ‘What if physically I can’t do this job that I’ve spent so many years of my young adulthood working towards? What else would I want to do if I couldn’t do that job?’”

Since childhood, Lehman had been primed for helping others. Her father, Ken Lehman, was a Peace Corps volunteer and civically involved, including as a trustee of the University of Chicago Medical Center.

Devoting her career to the people of the Lake Tanganyika area seemed an obvious choice to Lehman.

“I left my residency before completing it and went off in this other direction,” she said.

Lehman lives in Chicago, but leaves little doubt where her heart lies.

A detailed tattoo of a map of Lake Tanganyika, incorporating an okapi and a cichlid fish, covers her back. It’s a representation of her commitment, Lehman said.

“The idea was to always have a map of the place with me.”

Why data is key

The eponymous floating health clinic on Lake Tanganyika remains elusive because of cost and the difficulty of navigating four countries’ borders.

But there is plenty of work to do around the shore aimed at problems ranging from child and maternal mortality to emergency communication and data collection.

Lehman assembled a staff, based in Kalemie in the Democratic Republic of the Congo, whose stories mirror many in the region. One was a child soldier in Laurent Kabila’s “kadogo” army. Others fled their homes in the face of violence and lived in refugee camps for as long as a decade.

In 2011, the Lake Tanganyika Floating Health Clinic partnered with another organization to surgically repair obstetric fistulas for dozens of Congolese and Tanzanian women.

In a region without birth assistance, women with obstructed labor can’t get cesarean deliveries. The baby invariably dies and the mother, if she survives, may have internal injuries that result in uncontrollable leaking of feces or urine

and often leave her an outcast.

Surgical repair is “really meaningful. It’s her whole existence, her ability to be a functional member of society,” Lehman said.

Such work brings Lehman joy. It also has brought a measure of recognition. In 2014, she was named a Chicagoan of the Year by Chicago magazine. The same year, she received a Distinguished Young Alumni Award from Booth.

Big and daunting tasks are the basis for long-term systemic change, and Lehman doesn’t shy from them. Data collection, crucial to commanding resources, is a major effort of the Lake Tanganyika Floating Health Clinic.

Lehman discovered that health information at the community level resided on “all these paper registers. There’s a bunch of arithmetic that gets done, often with mistakes, where you’re abstracting data from all of these registers and then putting that information on another paper booklet. That booklet has to be taken to a regional health office, and then somebody has to manually enter those data,” Lehman said.

The result is that only a small proportion of data is captured, making the plight of these small communities invisible.

Clinic staff began installing solarpowered high-frequency radios in health centers to help with data reporting in 2012. Now, an app developed by the Lake Tanganyika Floating Health Clinic, Iroko Health, is being rolled out to replace the paper registers with digital health records.

It turns out that the work around Lake Tanganyika makes perfect use of Lehman’s dual studies in medicine and business.

“The Lake Tanganyika basin is breathtakingly beautiful—tall mountains and a lake that’s like an inland sea. But I think that for me, Congo is a microcosm of all the things that are most important in the world, about climate, about inequality, about clean energy, about suffering,” Lehman said.

“And yet our global understanding, our investment in just the understanding, let alone constructive engagement, is totally lacking, and that bugs me. And so as long as I have energy to keep broadcasting this message, and to provide data to that effect, I’m going to do it.”