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.