Ep 135: A public health miracle: preventing HIV transmission from mother to child. With Dr Mitch Besser, founder of Mothers 2 Mothers.

Are you ready to feel inspired?!? Episode 135 of Ask Dr Jessica with founder of Mother's to Mother's Dr Mitch Besser.  Dr. Mitch Besser discusses his journey from being an OBGYN in the United States to creating the Mothers to Mothers (m2m) program in South Africa, which aims to prevent mother-to-child transmission of HIV .  In this episode Dr Besser explains how m2m persevered despite funding and cultural challenges.    Since beginning in 2001, m2m  has achieved remarkable success in reducing transmission rates and improving the lives of mothers and their children.  It has created nearly 12,000 jobs for women living with HIV, and reached more than 15 million people with critical health services in sub-Saharan Africa.  Currrent enrolled m2m clients now have a 0.5% mother-to-child HIV transmission rate.

Dr Mitch Besser has dedicated his career to the public health needs of women.  After graduating from Harvard Medical school, in 1999, he joined the University of Cape Town, assisting with the development of services for pregnant women living with HIV to prevent mother-to child transmission of HIV.  It was through that work that he recognized a need for further support to help improve medical and social outcomes of HIV in the South African community, and he then founded m2m.  Dr Besser has received many awards including the Skoll Award for Social Entrepreneurship and the US Presidential Citizen's award. 

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Transcript

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Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor, but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. Hi, everybody. I have a really special episode for you today get ready to be inspired. We're talking to Dr. Mitch besser, who in my view, is a modern day hero. Mitch is an OBGYN who during the height of the AIDS epidemic, started an organisation called mothers to mothers in Cape Town, South Africa. Mother's Day mother's provides medical and social support to women pregnant with HIV, and thereby prevents the transmission of HIV to their babies. In today's episode, you will hear all about Mitch his journey and how mothers to mothers has saved lives in multiple countries. Mitch is so humble, he has wonderful insights to share. And I'm truly in awe of what one person with vision and a big heart can accomplish. I know you will enjoy Dr. Mitch besser, it is such an honour and a privilege to have you here on my podcast, I've been reading about all that you've accomplished in your young life. And it is inspiring to say the least. So thank you so much for coming on here to tell us your story. Well, it's joy. And thank you very much for having the time to to have a fair conversation. So I've been reading about you and I see you started off as an OBGYN or you are an OBGYN. And you create it. I just want to read this straight from your website, you created a programme called mothers to mothers, which now your website says the impact of mothers to mothers, you've created nearly 12,000 jobs for women living with HIV as frontline health care workers, you've reached more than 50 million people in Sub Saharan Africa with life changing health care services, and you've achieved virtually the elimination of mother to child transmission of HIV with your enrolled clients. This is incredible. Yes, it's incredible. I, you know, I have kind of a parental of what it's become, because it started as a very little idea in one place, and it came traction. And the impact it's had over the years is a tribute really to those 12,000. Mothers with HIV who, you know, have gone to work every day, taking care of women who like themselves, are living with HIV and want to have healthy happy babies and normal lives. So I'm just so curious how we got from Dr. Besser as an OBGYN into this amazing career with such tremendous impact in Africa. Can you tell us about yourself? How did you end up on this career path? Well, I come from a medical family. My father, my grandfather was a GP in Philadelphia, practised in his home, my father was an OB GYN. And I had a love of medicine. It was in our family DNA. I went into obstetrics because I felt it was an opportunity to do serious medicine, but in most cases, obstetrics is happy medicine. And was drawn to just the ability to help people who want have families have families, and far more of an obstetrician and gynaecologist. I spent a decade in San Diego, practising with midwives, establishing a birth centre there for mostly for women coming across the border women who didn't have access to care, and established a practice that gave access to care for two women through community clinics. And we did our very best to meet their needs through the 90s. But while they're also became involved at the University of California, in San Diego in their HIV programme, and this is in the early 90s, when there was very little care, available appraisal treatment available for mothers living with HIV. And we established early research studies that demonstrated medicines could have a beneficial effect in reducing mother to child transmission. And by the middle of the 1990s, we had effectively eliminated Mother Child transmission with the medicines that were available to us. And remembering when I was a child, if you heard about the diagnosis of HIV was essentially a death sentence. That's right. And, and, in truth, one of my business partners in the practice I was in, came to me one day in the early 90s and said, Mitch, you know, I have HIV. I'm ill can you take care of my clinic while I go for treatment? And he never came back. And so in many respects, you know, I inherited his practice, and his interest in caring for a woman with HIV. And that was that kickstarted a second really a second career for me because I went from, you know, being a provider for women who just needed access to care to a whole new realm of needs around HIV. And I think what struck me in the mid 90s, and through to the end of the 90s, when he eventually left San Diego was how effective treatment could be when delivered in the right context. And so, you know, with a growing epidemic in Africa, what if we get to the same thing there? I was, you know, I was inspired by what we'd achieved in America and thought, how do we translate these learnings to a population, which was so adversely affected on the African continent? Do you know any of these statistics offhand in terms of what was the transmission rate of HIV from pregnant mothers to their to their children, before taking medication? And then what would the statistics be after taking appropriate treatment? Well, I mean, if you start from the beginning of pregnancy through pregnancy, and include breastfeeding, the transmission rates can be as high as 40%. And that's with breastfeeding. If you remove breastfeeding, it's can be done, you know, in the range of 25%. But, you know, on the African continent where women were, were breastfeeding, transmission rates were very, very high. What we achieved with the availability of the best medicines, our transmission rates have effectively zero, if you can suppress a mother's viral load by giving her medicine during pregnancy, and then giving the baby a bit of medicine after it's been born. We're looking at transmission rates in America of close to 0%. The the women who transmit in America are really women who don't have access to care, you know, so that the women who don't get treatment, but when I arrived in Africa in late 1999, there were no programmes for testing, there were no programmes for treatment, outside of research protocols, and transmission rates were in the realm of 40%. And babies that were infected with HIV during pregnancy, or breastfeeding. 50% of them were dead by the age of two. So terrible, it was terrible. And, and when you go to South Africa, 30% of the mothers were living with HIV 3% of pregnant women were HIV positive when tested in pregnancy. So the scale of the problems of mess. So I just have to ask you, so you are a burgeoning OBGYN in the States, and you're practising in San Diego, and you're learning about HIV protocols and how to reduce transmission rates effectively. How did you end up in South Africa? I mean, that's a big deal to move your life and your family over to South Africa. How did how did that come to be? Two parts? Well, back in 1971, I was in high school and became an American Field Service student, I was an American Field Service exchange student, and spent a year in Cape Town in 1971. This is when you're a high school student, as a high school student, I was 1617. In 1974, as one does, I dropped out of college, and went back to Africa and worked in mission hospitals, in what was then called pseudo land, and Swaziland. And so became, you know, in my first experience in South Africa exposed to, you know, an urban, predominantly white experience. In my second experience, it was a very rural and predominantly black African experience, and was, I felt I fell in love with, with with with Southern Africa, I have to ask you just just just, I'm just thinking myself as a mother, what did your parents have to say, when you left college and move to Africa, you know, on a one to 10 scale, that was probably about a two, like in terms of joy, and we think this is a good idea. But to, to their credit, they didn't stand in my way. And were very pleased when I came home. Clearly, it was a decision that I'm sure looking back, they're very, very proud of, well, you know, the the irony is the decisions we make going forward through life, you don't know until you look back whether they were good choices or not good choices. And this turned out to be a good choice. In retrospect, I think, in retrospect, people might have been concerned, what is he thinking? But as I look back, it was one of those transformational experiences in my life. And you never know till you do. Right? Exactly. And sometimes you don't know what to reflect. So yes, it was the right thing to do. At the time, it's the array was the right thing to do looking back and it opened the door for me to possibilities. How do you leave yourself open to possibilities? I think that's always been part of my life, considering, you know, what could we do if we had an opportunity to try and so that my learnings from San Diego ago, I thought what can I? What can we do to take what we've learned in San Diego? And we've been so successful? And how do we apply this in a South African context? And you don't do this in ways which are prescriptive, because, you know, the, the environments are very different. We talking in medicine often about studies and when you can generalise from outcomes, you know, when you learn something is a generalizable can you apply this in other realms and other geographies with other people in other settings? And so the learnings we acquired in San Diego, which were so effective, the question becomes how do you apply those same learnings in an African context? You know, where the resources are different. cultures are different, everything's different. And that became the challenge. And I think that's what became interesting to me is transitioning from being a doctor like you, who takes care of patients one at a time, to being a doctor, like you, who accesses populations through a podcast. And so that, you know, my interest was in going from that document takes care of patients one at a time, to what can I do to address the needs of a population of, in this case, pregnant women with HIV? Yes, and I think both are so beautiful in their different respects, I talked about this with my husband all the time, that there's nothing that can replace that one to one relationship with the doctor and the patient. But at the same time addressing public health, there's so much need, and there's such an impact you can make on such a large scale, that they're both they're both important in different respects. But I guess it depends on what drives you. And I think in many respects, as as you have done, as your husband Mike has done, you can have a foot in each camp. And it's wonderful when you can have a foot in each camp. So I was able to see patients in San Diego and build a model of care with my colleagues there. And when I went to South Africa, I did the same thing started with seeing patients and trying to understand their experience of medical care, living with HIV, you know, understand the culture, the environment within which they were living. And, and to me, that was, you know, an extraordinary opportunity for learning. You know, that the mothers were very generous with me in sharing their experiences and their insights and bringing me into their lives so that I could in turn, trying to understand how best I could meet them where they lived, to deliver care in a context that was acceptable to them. So when you moved from San Diego to South Africa, I want to visualise this, you moved there. And you started working in South Africa with the goal to implement a public health programme or what was what was on your mind. What did you envision when you Sure? So I mean, how did I come to land there? Several years earlier, I had gone to Africa on a visit and had been invited to give a lecture in the department of obstetrics and gynaecology, at the University of Cape Town, University of Cape Town is is an August institution. It's one of the two great hospitals on the African continent, and one of the two great medical schools on the African continent. And I was invited to give a talk and I talked about our experiences with HIV medicine in San Diego. And they invited me to join the faculty, and to help them establish programmes in South Africa for mothers living with HIV. It was a dream offer, I joined as a volunteer in the faculty and started to work with the services that they were already providing to bring in an HIV focus. So what we were doing is we established maternity clinics for women living with HIV in the main hospital, and then in many of the community clinics and hospitals, ringing Cape Town, but essentially saying, you know, starting with, you know, we have a population of women who are right now mixed in so that women with HIV are mixed in with women who don't have HIV, and that wasn't really working. So let's see if we can create a separate space. But to their credit, the University of Cape Town was very, very generous in giving me the space to try and design and implement a model of care. And at the time, can you do you have any rough numbers in terms of the prevalence rates of women affected with HIV in Africa? Well, in South Africa, 30% of the mothers were living with HIV, as we as we scaled up maternal testing, we came to learn that, you know, there was some places KwaZulu Natal where the numbers were as high as 60%. In some of the neighbourhoods in where I was working in Cape Town was 10%. But you know, when you took the country as a whole, the rates on average were 30%. And so, you know, the the numbers of women who were affected was almost beyond beyond conception. So you moved to South Africa, and you saw this tremendous need to say the least to help women living with HIV in the population afflicted with HIV. And you came in with this knowledge from San Diego on how to effectively reduce transmission of HIV. So how did you take that knowledge and start to implement it in South Africa? Was it hard to be Christian thing and raise questions how you got started? Well, the first thing you do is you crash. Because what you realise is that all the things that you had access to in America, when present, you know, you start with assumptions that you can test women for HIV, you didn't have tests, even if we had had tests, you follow with an assumption that if you test someone, they're positive, there'll be medicine, we didn't have medicines. So, you know, you start, you know, essentially with a clear slate and say, Okay, what would it take? And it always starts with, what would it take? What would it take to get tests, and we were able to get tests. Again, and this isn't through my solo efforts. This is, you know, these were efforts that came from the provincial authorities and from the municipal authorities, and from the hospital authorities so that we were all working together meeting regularly, essentially, with it, the same question, what would it take? So what would it take to get tests? And when you start to think about how do you test women, we were looking, we had to overcome barriers that ended up in constitutional court, because there was a time in South Africa where there was opposition to the testing and treatment for HIV. So there were, we ended up in constitutional court to get permission at the highest levels, to provide services for mothers living with HIV. And part of this involves doing research around the country, in all of, you know, just in all the different geographies of South Africa to understand what their experiences were with HIV, and to try and present a compelling case, that this is a need that needs to be met. I'm just astounded because I think most people out there, once you talk about court, and you're in a different country, that's enough to make them quit and give up. Well, this wasn't this wasn't me, this was I mean, there was a collective effort, there was a groundswell of interest, and effort dedicated to this. And it was really the most, it was the most inspiring, professional experience of my life to be involved in a movement that had that was so fundamentally important in the wellbeing of a population and a population of women and children, and to be able to be involved, you know, in the very beginnings of what it would take to make a change. And, you know, if you look back and what started in 2000, and where are we today, everything, of course, has changed. And so, you know, it was a battle well fought. And I don't like to use war analogy. But it was, it was an important effort, and it achieved what it set out to achieve. Albeit it took a long time, and people suffered. And, you know, there were unnecessary deaths along the way that we would have loved to have accelerated what we did. But the jumps cut down, and where we are today, we're now at a transmission rate of under 1%. And so, you know, on the African continent, you know, in the presence of care, Mother Child transmission is under 1%. And that's, you know, that's, that's amazing. It is, it is amazing, I'm thinking, What a life you've led to go from, you have this inspiration enough to drop out of college, you're pulled towards South Africa, you know, there's obviously important work for you to do. And to have done what you've done is, is, I mean, there's inspiring isn't strong enough of a word for me to use what you know, I view myself as the luckiest person on earth, for having an interest that's been met, you know, I know so many people who, who are looking longing for something that they can do that's important. I mean, again, if I can just hold up a mirror and and look at what you're doing, look what your husband Mike is doing in terms of meeting what Mike is doing in terms of meeting the needs of people living on the streets, and how that's very similar to me to what's going on with the what went on with the HIV epidemic. You know, that how do you how do you address a population level problem that is so deeply embedded in the world around us? And how do you meet that need in ways which are humane and caring? And I've I've been equally inspired by what I've seen your husband Mike do. Thank you so much. I don't even know if I've ever told my listeners what he does, but that's how I met you is that you work alongside with Mike serving the a population that is currently living on house, so you're a volunteer in the organisation he works with, you're continuing to do such amazing work talking to you has been so inspiring. And it's so it's it's so wonderful to know people like you and my life. So thank you so much. Thank you. And again, I've I've, I feel that same spirit in healthcare and action, your husband's organisation, that same spirit of there's a need, that's immense, it's unmet. And the people who are who have come together to meet that need, you know, feel that same level of inspiration. Yes, I can definitely see the parallels that you're drawing. Absolutely. Okay. So I want to go back to South Africa, because I'm just so fascinated. So I'm just thinking you, especially as an American, you're going there, it must have been quite an endeavour to get people to trust you, especially when you're talking about something like HIV, which carries carry still today. But back then such stigma. How did you get people to agree with what you were recommending your protocols? Was that a challenge? That's the point that was the discovery. That was the Insight is, why would anyone believe me? I mean, I'm an American, I'm a man, I've never got to be pregnant. I wasn't HIV positive, I wasn't of the culture. Why me? And that was, that's the light that went on. How do you cross that bridge? And how do you deliver care in a way which is culturally separable accessible? And that's where mothers to mothers came from? The Insight was, I'm not the answer can't be the answer. Let's find carers who can address the needs of, of women in ways which are culturally acceptable. And that was the notion that if I could enlist my patients who had come to my clinics and had babies to return to my clinic, and become carers for that next, if you will, generation of pregnant women, they could transmit the messages, they could do it ways, in culture and language in ways as someone similarly affected, their recommendations might carry more weight than mine. Is that how the name mothers to mothers came, the original thing was mothers to mothers to be. So we had mothers, you know, who were talking to mothers to be. And eventually, we just chopped it into mothers to mothers. But yeah, that's exactly it. We took the mothers who had come through care, who had learned about the HIV test to learn how to take their medicines, who had learned how to take care of their babies, and we had overcome the stigma associated with HIV. We brought that back, brought that back in to the clinics and employ them, train them and employ them. So they were paid to be part of the healthcare team. And in that context, we're contributing to the outcomes of the mothers with whom they were speaking. And in every respect, they were far more important than that careful than I was. So in essence, you took mothers that were literally facing a death sentence from a diagnosis of HIV, you save their lives, you save their baby's lives, and you employ them. It's incredible. Well, they save their lives, and they save their baby's lives, through their willingness to abide by these measures. And in their willingness to do that, and their willingness to save their own lives and their babies lives. They then became the vehicle to teach others. I mean, it's astounding. And this is something i i. And I said, as I said before, I give far too much credit for this, because it's in truth. It's the effort of these 12,000 mothers that we've employed over 20 years. They're the heroes. I mean, they get up, they live in shacks, very often they get dressed, they come to work under the most difficult circumstances. And they do it every day, and they change people's lives every single day. And, you know, I was just the guy with a spark of an idea 20 years ago, they're the ones who are acting on it and continue to act on it. And they're the ones who make possible, you know, the outcomes that we celebrate every year, they say that if you want to live a life with meaning, a really effective way to do that is is through service providing, you know, acts of service serving others, and this seems like the highest form of that. Well, you know, we talked, you know, one of the goals of the organisation was to find ways for women to be empowered, you know, and, you know, and the language around that which has shifted, you know, we said, we're here to empower women. And then we realise, well, we can't empower anybody but, you know, we can put people in a position where they can find ways to empower themselves. And the notion that, you know, women who were living with HIV were often ostracised from their communities from from their households from their relationships but in putting them in positions where they were trained and employed and professionalised, it gave them a status. It gave them an opportunity with an income to be independent of relationships, which can be damaging, it gave them an opportunity to feel empowered. And so much of the language that we hear coming from what we call mentor mothers, these are the mothers living with HIV. This is how they have been empowered through their through these opportunities. And to me, that's kind of that's a generational shift, or has the opportunity to be a generational shift, that if we can find ways that women can be empowered, it changes generations of of lives. Was it tricky to get funding initially? Yeah, it was. And in 2003, George W. Bush Institute what was called PEPFAR, which was the President's Emergency Plan for AIDS Relief. And I think there was $8 billion pumped into care for people living with HIV, in I think, 21 countries around the world. It was transformational. It provided suddenly, as much resources, any of us would need to build programmes, and we were just growing our programme and these monies became available. And PEPFAR has continued until this day, to be a transformational source of funding. There's issues now in in Congress, where there's been a reluctance to pass a refunding measures since last year since 2003, to five year to five year measure, and very sad to see that Congress is wrestling with this and hasn't passed it. But the funding for HIV care, across most of the sub Saharan African continent has come from PEPFAR funding mothers mothers have our funding comes from PEPFAR. And it gave us the opportunity to expand our services across South Africa, and eventually, to more than 10 countries in Sub Saharan Africa. And I'm just curious as their relative cost and expensive per mother. I mean, ARV is antiretroviral medicines, the medicines that prevent people from getting sick and dying of AIDS, and better the same medicines that people take in the states are available in Africa, they cost less than $1 a day. So that, you know, in every respect, it's It's inexpensive, it's inexpensive, as a pill. It's inexpensive, insofar as the illnesses it prevents. It's inexpensive, in keeping mothers alive to take care of their families and fathers alive to take care of their family. So it's, it's it's one of the great, great deals out there. And just to paint a picture for people listening, what does the medication regimen look like? So if a woman is pregnant, she finds that she has HIV. What does that medication day to day look like? Does she take it towards the end of her pregnancy? One pill a day, one pill a day, one pill a day. And I mean, they're now increasingly available injections, you get an objection once a month. But his you know, for the last decade, it's been one petal day. And that reduces the amount of virus in circulation, you call it the viral load to levels which are very low, which we call non detectable. And when a mother is able to take her pillow day, and reduce her viral level, to undetectable the chances of her having virus crossover to the baby is almost zero. And while she's taking the one pill a day, she's taking the antiretrovirals if the virus level is undetectable, is she able to breastfeed? I know you had mentioned there is a transmission risk while breastfeeding. There is. So if there was a time where we discourage others from breastfeeding, because we felt that the risk was too great. And the babies who were breastfed would acquire HIV. We learned sadly, there are women who don't breastfeed their babies expose their babies to enormous risks. You know, you know, well, you know, breast milk is the best food for babies, and especially on the African continent that if you don't breastfeed, babies don't get the the immunologic benefits and nutritional benefits of the milk and babies that suffer. So we were looking very much for ways to to allow women to continue to breastfeed and very happily, mothers who breastfeed take medicine, the baby takes medicine. And so you've got two ways of stopping transmission. And mothers then can continue to nourish their baby in the best way possible. What I find so fascinating and reading about mothers to mothers is the treatment does not require mothers to come into clinics Correct. You have mother's going out to mothers themselves in their homes. So there's been education, so that, you know, to me the perfect blend of care is, is that care which reaches people where they are, and also appropriately brings them into facilities where they need facility based care. And so that we recruit mothers in the field to come into clinics as needed. We reach mothers where they live, because you can access their partners and their children, you know, you see the context in which they live so that, to me, the best Karis community based, you know, you can immunise a family, you can test a family, you can you can educate a family, and so that your mother's mother's has had the good fortune of being able to provide service both in facilities and in communities. And our and our metro brothers, you know, who often come from the communities often serve the communities from which they come, especially in the healthcare setting, I think it's so important to meet people where they are. And I mean, I imagine if you had an opportunity to go into your patients homes, the context that that would offer you in terms of, you know, what become reasonable requests. What are the other challenges that patients are facing that they may not reveal? When they walk through a door in your clinic? It's, it's very telling. I'm curious, are there any repeated misconceptions that you find when you talk to people out there about HIV and how to decrease the spread of HIV? Well, I mean, I think the single biggest misconception is that it's a death sentence. And I think that we've had to overcome that. Because once it was a death sentence, and the notion that you can give somebody care and turn it into a chronic illness, which is no different than diabetes. You know, I think diabetes is the closest parallel diabetes, hypertension, but we've reduced it to a chronic illness. And I think that what's important about that is first it's life affirming. And that's very important. I think the second is that we want to take away the stigma from conditions that are so easily and readily treatable. So that we want to make sure that people understand that there are ways of preventing this, this safer sex practices, their ways of treating this, that make it a lifelong chronic condition. And just take the stigma away. I mean, it was so stigmatising in the 80s. In America, it was so stigmatised in the 80s and 90s. And still in Africa that, you know, what can we do to normalise our views? You really can live a normal life with HIV? Absolutely. Absolutely. And, you know, there's almost no excuse not to. So how many years did you end up living in South Africa? About 20. And now the programme is still continuing on without you living there, and it's continuing to grow? Well, I mean, yes, and yes. And, again, I'm, I'm not a manager. And so my programmes succeed best when I stopped managing them early. So that we found people who were better managers very soon after this got going. So within three years or four years, we had managers in place who were able to take it to the next level, then another manager who took to the next level, and our current CEO, Frank beetle has been with us for 12 years, living in Cape Town. He's also from California. But he's been running the organisation for 12 years. And he is taken from strength to strength. Again, I I enjoy the reflected glory of the work that others are now doing. And I'm in awe of what Frank and the teams have been able to accomplish. And we are now extending it to Nigeria, and the DRC. We have programmes in places where we would we've always aspired to go, because the numbers are so high, but we've never been able to get into those countries. And can you tell me yourself the statistics I was reading, you know, as I read the beginning of the podcast, the numbers, every woman that's enrolled in your programme, the risk of acquiring HIV is virtually zero. Is that correct? Well, for the last six or seven years, our transmission rates, I think you've been running about point 6%. Wow. And I want to be real clear, we don't do the tests and we don't dispense the medicine. We're supporting government efforts or community efforts in care. And it's we only exists in the context of an established care system, that we can then help you to get the best outcomes get the best results. So we work with governments, we work with hospitals, we work with clinics. To ensure that, you know, there's good end to end service doing that, that peer to peer model, I imagine must really help with trust. Absolutely. And that's, I mean, I think that that was my, what drove the initiation of the programme is, why would anybody trust me? And why would they trust someone who was similarly affected? And I'm curious for your family? What was it like living in South Africa? You know, we have two kids. And when they went to, when I went to South Africa, they were five and eight. And they went through school, their college, they came back to the states for college. But you know, they grew up in a very South African experience. And, you know, we were excited that they could, they could grow up in a world other than here in the States, and then they'd have choices. So one of my sons lives in LA, and the other still lives in Cape Town. Wow. It's amazing. It was an absolute gift. Do you have goals to like, in your mind? I know you've already done so much. But do you have goals for mothers to mothers to continue growing? Yeah. And I think that, you know, there's, there's the, there's the organisation, mothers, mothers, but there's also the model of care. And what what intrigues me is the applications of peer to peer support, which has been continued to be an interest. So after mother's mother's I started a programme called AGEWELL, which was dedicated to meeting the needs of seniors. And it was an opportunity to enlist Abell seniors to provide peer to peer support for less able seniors, in an effort to try and reduce isolation and loneliness. And to identify evolving health problems speak for the became serious. And we did this in South Africa and Ireland, and in the States. And, you know, the only place right now that it's gotten traction is it's still running in Ireland, you know, we still have aspirations to continue it in the States. But it's this notion that peer to peer content contact, you know, we we live for the, our friends and for people who we can be with, and it's a resource as well, so that, to the extent that enable senior can address the needs of a growing population of less able seniors, you know, what a wonderful way of, of tapping a human resource to meet a human need. And I'm very excited. You know, I, you know, I've been absolutely thrilled, you know, in my learning about what Mike and healthcare and action is doing, and trying, how do we build models of care for women who are living on the streets? And can we, again, create a model of peer to peer support so that people who have the lived experience can apply that lived experience in the care of others, I can definitely see how your model that is so effective in Africa, you can use that information for so many other areas of need, and in the world. That's right. And I think that, you know, the applications are almost universal. And it's just a question of what is ever what would it take? It's true right here. It's it is universal human needs are so universal. That's right. And my approach in general, is that why can't we do something? But what would it take? You might not have an answer for this. But I'm just curious, are there are there any stories that have really made an impact in your life, I mean, experience in South Africa, I think the one that we go back until all the time is there was a mother years and years ago, came to our clinic, and we she was HIV positive. And she, she was shamed, but she wanted to tell her family. So she asked one of our mothers, our mentor mothers to come with her back to the house, so that she could tell her parents, and I think a brother and a sister that she was living with HIV. And I met her mother with with her and the family was convenient. And they all sat there. And she said to her parents and her brother and sister, I'm really sorry, I have to tell you. I'm living with HIV. And the mother and father were shocked. And then the sister said, I am too and I haven't been able to tell you. And then the brother said, I'm also HIV positive. And I haven't been able to tell you. And so each of these three children had been carrying this burden by themselves, and hadn't been able to share it in their households because of the terrible stigma associated with it. So they were alone and lonely and isolated with it. But through this intervention, if you will with a mentor mother, who was able to help convene a family in a safe space. Everybody was able to share the experience with each other and then they were able to support each other and each other was baby surprised, shocked, but also gratified that they weren't ostracised they were embraced, that's such a great story. Because not only is it hard to live with an illness, but to carry that burden internally and not be able to share that with loved ones and not feel that support. What a gift that mothers to mothers provided so that people can be honest and open with their, with their condition. And again, I'm in awe of the mentor mothers who who do this, who are the conveners, you know, we, the our organisations, philosophies that we work for them, you know, if you invert the pyramid, you know, we work for the people who are, you know, at the coalface providing care directly to the mothers and what can we do to optimise their experience of this and to give them the tools, the resources, support they need to do the job they're doing? It's so inspiring to say the least the impact that one person can have in this world. And you're such a joy to talk to, you're so humble. There's no ego on you. It's amazing. Well, I see us as we're catalysts, you know, you know, we catalyse the efforts of others, and to the extent as a catalyst, if you can, if you can put others in motion, who expand your interest, expand the work that needs to be done, and do the work. I think, to me, that's the that's that's, that's success. Mitch, thank you so much. Thank you for your time and for sharing your story. I really, really mean so much. Thank you. Thank you. Thanks for inviting me. Thank you for listening. And I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica See you next Monday.