Durham, NC - The younger ones are told about the askari -- the little soldiers in their bodies that fight sickness -- and the wadudu -- the bugs that want to destroy them. That's why it's important to take your medicine every day, the doctors and nurses tell them: So your askari stay strong and the wadudu go to sleep.

The boy in front of Rebecca Carson, PNP'10, was older, perhaps 16. For him, the medical team at Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania spoke more plainly: You have HIV, they said.

He sat stoically with his father by his side. The boy understood the wicked truth of what he was told because he sees every day how HIV/AIDS is ravaging the people of Africa. Every day since his mother died when he was 2, the boy has taken medicine at the insistence of his father. That day he learned why.

"He was so somber," Carson recalls. "He was keeping a straight face but tears were pouring down his cheeks. To him it was a death sentence. "

For Carson, it was among the most emotionally difficult conversations she'd had with a patient. She comforted the boy and assured him that he can still fulfill his dream of becoming a pilot and achieve anything he wants to in life if he just remembers to take his anti-retroviral medicine every day.

The boy simply said he wanted to go home.

 

Mutual Benefits

Like the dozens of DUSON students who each year participate in two- to six-week service, education, and research programs in developing countries around the world, Carson found personal and professional nourishment from her 6-week pediatric nurse practitioner clinical work in Tanzania.  She attended rounds in the KCMC pediatric ward, treated infants and counseled parents in a well-baby clinic, and provided primary and palliative care in the KCMC pediatric outpatient department. She treated patients with conditions she would rarely, if ever, see in the U.S. such as congenital hypothyroidism, rheumatic heart disease, rabies, malaria, and tuberculosis.

"I am much more aware of the strain that disease and chronic illness can have on a family," she said.  "It has given me a much bigger heart for the disenfranchised."

In Africa, the disenfranchised are many, the health care needs are staggering, and the opportunities to provide care, counseling, and education are infinite. Which is why DUSON is passionately forging new partnerships with hospitals, clinics, and nursing schools around the continent. DUSON's global health mission is to address health disparities and care for the sick both locally and abroad, and in the process, give nursing students valuable experience by enhancing their diagnostic and problem-solving skills, and challenging them to find creative solutions to simple and complex health care problems.

"To be a global citizen is very important," said Dorothy Powell, EdD, RN, FAAN, the associate dean for Global and Community Health Initiatives at DUSON, who seeks out and secures distance-learning opportunities for Duke's nursing students.  "Our students need to be able to offer their services to anybody, and that means they have to have opportunities to serve people who are different than they are. They become adaptable to new situations and are able to have impact in a meaningful way. "

This kind of cultural immersion is translatable to anywhere DUSON graduates go, Powell said, whether it's a rural clinic in Mississippi, a hospital in a major city, or a country with scant resources and vastly different culture and traditions.

In addition to KCMC and its numerous regional clinics and nursing school, DUSON has established partnerships, or is in the process of developing them, with Marangu Lutheran Hospital, Kilema Hospital, Machame Hospital, and Muhimbili University. And this August, DUSON begins a promising new alliance with the humanitarian project Teamwork Ministries City of Hope, a self-sustaining 50-acre children's campus located in the remote village of Ntagatcha in Western Tanzania. It includes a 300-bed orphanage for children whose parents have been lost to HIV/AIDS, a medical center, schools, a farm, and a skills training center. The mission of City of Hope is to give its children just that -- hope in the desperate world surrounding them -- and to provide education and work skills training that will help shape them into community leaders.

Ten Duke students in the Accelerated Bachelor's of Science in Nursing (ABSN) Program will have a two-week experience there shaped around health promotion, disease prevention and screening services. The plan that Powell designed also has the students conducting an environmental assessment and compiling a health promotion guide to assist providers there.

For City of Hope leaders, DUSON's commitment is a God-send.

"There is much we can learn from DUSON that will help us better serve the people in the community," said John N. Chacha, D.Min, a native on Tanzania who is the founder and executive director of Teamwork Ministries International based in Martinsville, Va. that launched the project. "And there will be immediate benefits with DUSON helping to provide care."

Chacha hopes the DUSON students experience personal growth and see the possibilities for brining hope and inspiration to the people of Africa.

"I hope it encourages them to get involved in fighting poverty and the health issues that accompany poverty," he said.

Powell first made contact with Chacha through Duke nursing alum Ashley Joyner Hase, N'82, and her husband Steve, T'82, who are on the board of directors of City of Hope. The Hases have given $50,000 to the School of Nursing's Office of Global and Community Health Initiatives to provide travel stipends to nursing students for overseas placement in impoverished communities like Ntagatcha.

"We want to help facilitate the attitude that there is hope and there can be transformation even in settings of great poverty and despair," Ashley said. "And we also want to provide for students to be in settings to improve their nursing skills while contributing to patient care."

For her Tanzania trip, Carson received a Hase International Travel Scholarship. She said she is grateful to the Hases for helping to make the trip possible.

Powell's efforts to broaden DUSON's push into Africa -- and especially Tanzania -- is aided by the long history Duke Medicine has in Tanzania, through noted Duke AIDS researcher John A. Bartlett, MD, and other researchers, students and faculty who spend time at KCMC and other hospitals in Moshi. The Duke Global Health Institute established a presence there when it launched five years ago.

"The Duke name is well known in Moshi," Carson said, "because they do so much for the hospitals and the people. For me it was a sense of pride that I could tell people where I was from. Duke should be very proud of what they are doing there."

 

Making Progress with HIV/AIDS

Marangu Hospital in Moshi is a small, 45-bed facility that serves a population of more than 200,000. It has three doctors, 14 nurses, around 30 support staff, and a steady flow of patients who come to receive anti-retroviral medications or be screened for HIV/AIDS.

This is where Anisha Jones, ABSN'10, met a family of three, whose story touched her in a way she didn't expect by bringing into clear focus both the gravity and the optimism of the African situation.

She spent a two-week undergraduate clinical rotation at Marangu and Kilema hospitals performing HIV/AIDS screenings. One day at Marangu, an HIV-positive couple came in with their 8-month-old daughter, who they wanted tested yet again.

The couple spoke no English, but when they were told in Swahili that their child remained HIV-free, the joy on their faces transcended language.

"They couldn't stop laughing and smiling," Jones said. "I was so glad that I could be a part of that moment."

More deeply, Jones took comfort in the case for its illustration of the positive strides being made in HIV/AIDS prevention and care.

"Most people might think that the baby would have been HIV positive," Jones said. "But just because the mother is positive doesn't mean her baby will be. If a pregnant woman tests positive for HIV she will receive treatment in an effort to prevent transmission to the baby. This is a huge change from how it used to be."

Her time in Tanzania "was the best experience I've had in my life, she said. "I got to see another culture and a health care environment without all of the amenities that we take for granted here, like gloves and hand sanitizer." In her current practice as a nurse in the Duke Hospital neuroscience unit, "I don't complain about the small stuff because I know there are people in much worse situations. Going to Tanzania really solidified that for me. It has given me a different outlook on life."

 

Teaching African Nurses

The School of Nursing's touch is not limited to Tanzania, but is being felt continent-wide, especially in the education and training of nurses. 

DUSON Associate Professor and Assistant Dean of Undergraduate Education Michael V. Relf has led the effort for the continent's widespread adoption of consistent training and core competencies to enable nurses to move into expanded roles similar to nurse practitioners in the U.S. That is especially important with respect to administering anti-retroviral drugs, which many nurses currently do without adequate training. 

This task shifting of some duties away from physicians to nurses is greatly needed because of massive shortages of physicians, especially in rural areas, Relf said. 

"Nurses are the largest part of the health care environment, and in some rural areas they are the only provider," Relf said. "A physician might come by once a week or once a month, and many nurses are performing tasks they were not trained to do." 

In Africa, there currently is no role equivalent to a nurse practitioner, and gender stereotypes make it difficult for some to accept increased health care responsibilities for women. Carson noticed this on her first day there. 

"I had a difficult time in my first couple of days there explaining that I needed to follow the doctors and not the nurses," Carson said.  

Initially working with colleagues at Georgetown University prior to coming to Duke in 2008, Relf was the primary investigator for the core competencies project.  

Shortly after arriving here, Relf brought together 35 nurse leaders from sub-Saharan countries to address nursing needs around HIV/AIDS prevention and care. He took more than a dozen trips to Africa to facilitate meetings, gather evidence, and keep the process moving.  

"It was amazing when we brought these nurses together how they very quickly found commonalities and shared best practices with each other. They were clearly focused on what they needed to do," Relf said.  

In 2010 the panel adopted a set of core competencies that also were endorsed by The Elizabeth Glaser Pediatric AIDS Foundation and the Association of Nurses in AIDS Care. They currently are being incorporated into nursing curriculums in multiple African countries.  

On the student front, two DUSON masters in nursing education students recently returned from Africa where they completed a four-week capstone teaching experience. Jessamy R. Fisher, MSN'11, taught the Harvard Referencing System and ethics in nursing to students in the KCMC bachelors of science in nursing program.  

"Having the opportunity to jump in and teach nurses in a totally different environment gave me an opportunity to challenge myself and think differently. I had to think of creative ways to get information across in that environment. I can use that in my practice as a nurse educator." 

Fisher is an emergency department nurse at the University of California-Los Angeles Medical Center, where she acts as a preceptor. She wants to get more involved in staff development and clinical training, and hasn't ruled out teaching at a nursing school some day. 

"Tanzania really broadened by perspective in terms of what nursing education is," Fisher says. "I probably got more out of it than they did." 

 

A Beautiful Place

Three months after she returned from Tanzania, Carson sat at a desk in a common area at DUSON recounting her time there.  She remembered the vegetables being the most delicious she'd ever eaten, the parachichi (avocado), maembe (mangos), and mananasi (pineapple) the sweetest tasting fruit.

Day trips to remote waterfalls, a safari in the Serengeti National Park, shopping adventures to small villages, and the ever-present beauty of snow-peaked Mt. Kilimanjaro looming out the window of her simple bedroom are cherished memories.

"I am pretty sure we sang the entire soundtrack to The Lion King from start to finish," she said of her eventful Serengeti safari.

These are things she remembers every time she puts on the large, round, silver earrings she was wearing that day, purchased from a female street vendor in the village of Arusha.

She touched an earring and was silent for a moment, perhaps thinking about the other side of being in Africa -- the frequent power outages, the muddy streets and sidewalks after it rains, overcrowded clinics and wards with dozens of children looking up at her with their big brown eyes.

Or perhaps she was wondering what ever happened to that 16-year-old boy who just wanted to go home.