I'd like to start by thanking you for coming today to hear our stories as well as our ideas for creating opportunities for nurses to follow their dreams and volunteer in developing countries. We'll begin by sharing our stories and pictures with you, and then we'll talk about what you as nurses and other medical professionals can do to get involved.

I started 2006 with the idea of volunteering abroad as a focus in my mind. It wasn't really a new interest, as I have long enjoyed traveling to different countries and actually decided to become a nurse because I wanted to offer something to people on my travels. As a student at Duke's accelerated nursing program, I was able to travel with classmates and students from the medical school on a volunteering trip to Honduras, which proved to me that not only was doing so rewarding and exciting, but worthwhile to the many people we met and treated.

So, I began the lengthy planning process, which I will talk about later. I eventually was presented with an opportunity to volunteer in small clinic outside of the city of Mombasa, southeast Kenya, for seven weeks. Although we were only dating at the time, Jessica didn't want me to have to go alone, so she decided to come along for three weeks. In early September, we boarded our plane for a twenty-seven hour trip to a completely different reality.

I think that there are different kinds of culture shock. There is the culture shock that you experience when you visit a country and observe if from a distance. Then there's the culture shock of becoming very involved in a culture, by spending all of your time with people in that culture and in the community. We were thrown in completely from the start. Our first day at the clinic, we unpacked in the morning, and by noon we were in the clinic working, giving shots and learning about the numerous illnesses that are common to the area.

- pills vs. shots
- baby situation
- home visits

Slideshow

Jess's Talk

Catherine's Talk

As you can see, conditions do exist for the need for nurse volunteers abroad. An interesting conversation that I had with the doctor that I worked with was about the staff problems that face Kenya, for example. Only a few medical schools exist in Kenya, and most of the doctors that do emerge from the system head out to other countries such as England because they can earn far more money. The medical system in Kenya relies almost entirely on house officers, which are the same as physician assistants, and nurses, many of whom aren’t well trained. So there is a critical need for manpower in nations such as Kenya.

Of course, health volunteers from the States cannot fill this overwhelming need. This problem has to be taken on by the people of these countries, not by volunteers. So, where do nurses fit in to the solution to this problem?

One of the most obvious nursing roles that we noticed was the need for education. There is an immense need for people to learn about the basics of sanitation and hygiene, sterilization, diet, and environmental concerns. There was an amazing lack of knowledge of such things in just the area that we were in. One example was the clinic, which we found to be quite dirty and unsanitary. The exam and delivery tables still had bodily fluids from past patients. The walls were splattered with dirt, medicine, and iodine. Bits of broken glasses from medicine vials were all over the floors in the injection room. Within the first few days that we spent at the clinic, we purchased bleach and cleaned the surfaces throughout the clinic. The needles were only used once, but they were burned in a furnace outside the clinic by a worker who had no idea about infectious diseases and had to be trained to wear gloves and be wary of sticking herself when disposing of used needles. It seemed the only person knowledgeable about sanitation was the doctor, who wouldn't even eat at any of the local food stands for fear of catching a GI bug. He understood sanitation, but found it difficult to convince his staff of following the same standards.

A common cause of many of the diseases that we saw, including bilarzia and typhoid fever, were directly related to the water supply of the people in the area. Being without running water, they relied on water from a nearby lake for bathing, cooking and drinking water. The problem that faced them was that not only did they bath and swim in the same water, they used the hills surrounding the water to use the restroom, as many people didn't even have a pit latrine outside their homes. Walking these surrounding hills, we had to watch our step to avoid the frequent pitstop; it didn't take much consideration to realize how the bacteria ran through the soil and into the very water they drank. With time and resources, it wouldn't be hard to educate people about using a pit latrine, about how to prepare cooking and drinking water, and about how their actions were directly related to the illnesses that they suffered from.

Of course there are plenty of other educational opportunities waiting for nurses, such as nutrition, hygiene as simple as washing hands, and so on. From books and guides that I studied, the issues that we experienced outside the Kokotoni Clinic were not limited strictly to that area. Lack of knowledge holds an enormous part of the responsibility for diseases worldwide. A lack of resources is of course also important, as we saw that many of our patients could hardly afford the few dollars for medical treatment, much less buying more nutritious food, frequently using soap, and building pit latrines in their backyards.

It isn't simply the normal populations who need our help. The nurse in the clinic was one of the staff members who suffered from the deficit in basic hygiene knowledge. From what I learned from the doctors, there is certainly a lack of knowledge in nurses both in clinic and hospital settings. This is a perfect educational situation for US nurses. There are gaps in knowledge that we could fill. Information as essential to us as basic life support and sterile technique can be an important lesson that we can share. Ideally, I would imagine a team of nurses visiting a location, whether it be a clinic or hospital, and scoping what educational needs that facility requires. Later teams could fill those needs. This is important in that the information provided must fit the facilities capabilities. After all, what good is basic life support without a defibrillator in the facility, not to mention additional life support measures such as ventilators and certain medications. Yet some knowledge is universally needed; that is where we can contribute.

Beyond the educational opportunities for volunteer nurses, there definitely is a logistical need as well. I found myself in a strange position at the clinic. Since I was an outsider, I was asked to offer my advice on how to resolve the numerous managerial and financial issues they were struggling with. They were losing about $150 a month, which is a tremendous strain for a clinic in Africa. While I was there, the clinic actually ran out of medications, and the doctor had to loan the money to buy them until funds could be obtained. I outlined several ways for the clinic to cut back on its spending and save more money. Also, the clinic suffered internal strife because the staff didn't have specific duties assigned to them. Less appealing chores, such as washing and sterilizing table covers following childbirth, didn't get done because no one accepted the chore as theirs. So, I was able to sit with the doctor and write out duty rosters for each employee. My experience in nursing in the States helped me identify how the clinic could be more smoothly run.

Of course, there are plenty of hands-on opportunities as well. We spent part of our time examining patients, discussing with the doctor the possible diagnoses, giving injections, the kind of work I had imagined doing before even leaving. There are plenty of opportunities to join groups that travel to dig pit latrines and build schools; since sanitation and increased knowledge certainly assist in nursing, these activities are equally as important as giving immunization injections.

The question is, how great is the need for medical volunteers?

I tend to imagine the developing world's health issues as an enormous dam. I imagine a river of illness that for most of history has flowed along on its natural course. When people became sick, they frequently suffered along to a natural recovery or demise. We’ve made many, many improvements in medicine, and so have begun building this dam through research and medications, where poor health and death are held back. In the US, there are people that slip through the system for various reasons, but for the most part, the dam holds well. In these developing countries, though, there aren’t occasional small leaks here and there. Instead, you find geysers of people shooting straight through this dam of knowledge and medicine. You find entire communities with no access whatsoever to medical help. You find people suffering from diseases like malaria, standing in line for hours after walking 50 km or more, only to be turned away because they have no money. You have hospitals set up to serve a large population that have no supplies, no staff, and no knowledge. These are the conditions that are ideal for nurses to become involved.

I believe that all nurses who have any interest in global health should be able to take advantage of that interest. The personal benefits of following that interest are enormous, not even considering the implications that volunteering as a nurse in a developing nation has for our careers. Being as important as taking a trip is, I believe that nurses should have avenues that lead them to the many opportunities and needs in developing nations. From experience, I can tell you that volunteering abroad is a life-changing experience. It forces people to examine many aspects of their lives. Of course it causes you to examine the professional aspect. Spending even a single day in a clinic where supplies are nearly non-existent, where patients are being turned away because of the lack of medications, where basic sanitation isn't being followed because of the lack of knowledge and resources, encourages us to examine our own environments. This examination can often be critical, especially coming from a clinic where the deprivation is forced, to returning to an environment where waste can be excessive. I am also inclined to consider my interactions with my patients, not to mention the problems and issues facing my patients. When I returned to work, I frequently compared the ailments, difficulties and expectancy of my patients to those I saw in Kenya.

Of course, being immersed in a developing country has a profound impact personally as well. The house that I was able to live in for my stay at the clinic was quite rustic in American standards, yet compared to the conditions of that the people in the area of the clinic lived in, it was luxurious. We had solid concrete walls and floors, for example, compared to the mud walls and dirt floors of many homes in the area. We had electricity, a luxury reserved for those closest to the road, as well as running water, an incredible benefit. Being immersed in the culture pushed realities through my head that I couldn't have grasped from my comforts at home in North Carolina. I started to understand the conditions that people lived existed with in developing countries, whether it be a mud hut or an impoverished apartment complex or anything in between. One home visit sharpened this idea in my head, where I found myself sitting on a small bench, in a tiny dirt-floored home, the mud walls on one side of the house collapsed from recent rains and now covered with plastic. Small children played, a young girl worked at crushing corn, and chickens were roosting right above my head. It was one of those moments where I realized that people actually did live in these homes, they didn't just build them to give the area a traditional look. People did walk around barefoot, not because they chose to, but because they couldn't even afford flip-flops. I had created these constructs in my head to protect myself from the reality that these people lived, and it took experiencing that reality to break those constructs. All in all, it was a terrific experience, and I grew invaluably professionally as well as personally.

Because of that experience, I feel strongly about encouraging other nurses to follow their interests in volunteering. Part of what I'd like to discuss today is how to research and chose organizations to go with.

I found that it was very necessary for me to define exactly what I wanted for a volunteering trip. There are a large number of organizations for healthcare workers, all of which are tailored for interests of any sort. For example, you must decide first which region of the world that you want to volunteer in--Asia, Africa, and South America. Once I decided on going to Africa, I then had to start looking at the viable options. There has to be a kind of structure existing within countries in which volunteer organizations can operate, so some countries aren't even options. Soon I found myself looking at the options of Kenya, Ghana, Tanzania, Malawi, South Africa, as well as a few other countries.

Doing so narrowed down the list of possible organizations considerably. From there, I only had to start looking at what was offered. As all of the organizations that I considered had websites, it was fairly easy to see what sort of focus they had. They offered all sorts of programs, some medical, some not. Choosing an organization required that I considered what I wanted to be doing in-country. Would I want to be building schools or digging pit latrines? Would I want to be involved in AIDS education and community development? Did I want to be up to my elbows in an extremely busy clinic? Deciding this considerably narrowed down my options.

I'd like to share my experience in choosing an organization to illustrate this point. Let's say that you've decided that you want to volunteer in a tropical African nation, in a healthcare setting, for approximately four weeks. At this point, another essential consideration is what you are willing to spend on your trip. It is important to realize that while you may envision yourself as the noble volunteer, these organizations see you as a customer, and you will have to pay for their services. The only question is how much you are willing to spend. I found that organizations charge anywhere from $400 to $3000 for a four-week period. To continue using myself as an example, let's say that you've decided that $1000 to $1200 is the most that you'd be willing to pay.

From there, you will have to look at what the organizations are involved in. I wanted to be involved in a healthcare setting, but on the other hand, I didn't want to shadow a doctor or non-profit worker and not get hands-on experience. I wanted contact with patients, to see illnesses and remedies from a caregiver perspective instead of as an observer. Interestingly, I had a friend volunteer in a Ghana in May of 2006, and when I talked to her about her experience, I found that she was disappointed because she mostly followed around some doctors and an organization guide, making tours of various facilities. My greatest fear in volunteering abroad was that I would be sidelined by my decision in the organization and find myself doing nothing at a great cost in effort and money.

Finally, it's important to consider how professional an organization is. This can be difficult to tell from the Internet, as anyone can have a website. Two of the most professional organizations that I found offered something that no other organization did--references. Both the Global Volunteer Network as well as STAESA had a list of past participants with email addresses that I was able to contact and ask about how their experiences were. Of course, these guys could have been the same dude in an office somewhere, so I also researched how well known these organizations were, what people outside of the organizations were saying about them, that sort of thing. It was a little like trying to decide which person to hire for a job, I googled them and tried to find out as much information as possible. If you can find a recommendation from a credible source, you're on the right track to finding a good organization.

By the end of my search, I'd made out a list of organizations that I was considering. I'd emailed all of the organizations and was in contact with them about what they did, what they offered, and what sort of trip I would be taking with them.

Show list, talk about it

There is also the prospect of going with certain groups such as your church, which would probably lead to projects such building schools and such. As I mentioned, anything that provides better sanitation or education is worthy of being considered medical volunteering. You can always consider organizations like US Doctors For Africa, where your experience pays for your trip. While I didn't get involved in these types of organizations, it seems that you apply for volunteer positions using your career as your currency. Jessica and I are both looking into that type of organization for future trips.

In the end, I actually was extremely fortunate in that I was working with a doctor from Kenya, whose mother coincidently was working as an in-country organizer for Choice Humanitarian, an American non-profit. Through her, I was able to get set up in a small clinic, including my housing and so on. I was unusually fortunate in this, because it was exactly what I wanted, there was a large degree of ease in getting started on my trip, and the only costs were preparation, travel, and food while in-country. I wouldn’t expect this to be the typical experience.

Also, I found that my expectation for my trip changed during the trip. If my expectations had remained the same, I might have been a little disappointed, because I had expected to be very busy every day taking care of patients. In reality, the clinic only saw an average of 15-20 people a day, so there was a fair amount of down time. That time, however, turned out to be incredibly important, because it gave us the opportunity to talk in depth with the doctor and other staff members about Kenyan culture and people, as well as many medical discussions. Much of our information that we learned about Kenya came from our sessions with the staff, and we humored the staff greatly with our attempts at learning Swahili.

At any rate, once you’ve decided which organization you want to go with, the adventure is only beginning. Next would be the preparation phase, for which I can provide a few pointers.

First, deciding to volunteer is a financial decision. Unless you have a sponsor, there is a financial commitment being made. There are the obvious costs, like to the organization and the plane ticket. You can expect to spend some money while you are in-country, for food, gifts, travel, and all the other unknown costs. As the idea of volunteering is to give your time and energy for free, the loss of income is a reality for most. I took six weeks off from work, using the minimum amount of PTO to keep my health insurance. Basically it was an unpaid leave of absence. Health insurance should always be purchased, which costs from $20 a month up. Just before I left, I noticed that Duke has a health coverage program for travel abroad supposedly covered by your policy, although I wasn’t able to take advantage of it and can’t say for sure. Then there are the costs of preparing for your trip. Vaccinations can cost up to $500 depending on what you need to be vaccinated for, and it’s not covered by insurance. I took a lot of insect repellent as well as a mosquito net. Not sure what I would need, I purchased a fair amount unnecessary things, like flashlights, clothes and so on.

After one of my first long trips, when I had to drag everything I brought with me in boxes, I decided from then on I would only take what I could carry at one time on my back. Volunteering in Africa can be reduced even more. I took four or five pairs of pants, only to wear the same two the entire trip. Some days I would put on one of the pants just because I felt bad that I hadn’t worn them. I had an excessive amount of stuff with me; a lot of it ended up being left behind. Anyhow, I did have a list of things I felt were necessary:

At any rate, at this point the trip seems to take on a life of its own, and no one can predict the path it will take. I went to Kenya hoping to make a big difference, hoping that I could save some lives and change some people. Perhaps some of my actions did help people, whether it be in a medical sense or just having an impact in their lives. More importantly, I came away from my trip with a completely different perspective on what life means for the huge majority of humans, these people we lump into the developing world. I wanted to change and mold, but instead it was me that was changed and molded.

As a sort of last note, I'd like to share my longterm vision for nurse volunteer work. As I said before, the ease of my trip was extraordinary and unusual, and I'd like to see those kinds of avenues opening up for other nurses. I feel that nurses, as medical professionals, our own separate entities, can and should be able to follow their dreams of helping others. What we do in the US, and here at Duke, is essential, and it is no less important in Africa or Asia or anywhere else. I want to become involved in creating avenues for nurses to pursue that interest, where nurses can take two or three week trips, living among the population they came to serve, and being able to accomplish their goals while soaking up the lessons that being in these environments provide. If anyone here is interested in becoming involved in this, then we should talk about it later.

People that I have talked to about their time spent in developing countries seem to have a common thought, which I found as well. There is an overwhelming need, a need so great that it almost seems insurmountable. But if you take the time to really look at these places, past the dirt and crime and poverty, you'll see the hope and potential and opportunity that is there. That is what we can start with to make a difference.

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