The RNs profiled in this issue never planned to become global nurses nurses serving the underprivileged at home and abroad and certainly never imagined how global nursing would change their lives. They joined health teams in developing countries or traveled overseas because of a sense of adventure, a love of travel or an opportunity that seemed too good to pass up. They stayed or returned because the people, the culture and the need pulled them in; and, for some, their international work has become their lifes work.
Tea and Empathy
In the rural villages of Pakistan and Afghanistan where Greg Mortenson, RN, has been quietly building schools for more than 15 years, the local people whom he has helped to empower call him Dr. Greg. His work in Pakistan first became known to Americans in his best-selling book Three Cups of Tea. The book turned Mortenson into a minor celebrity who is sought as a motivational speaker and to whom leading politicians and U.S. military generals turn for advice about the terrorism-ravaged countries.
When he is not in Pakistan or Afghanistan, Mortenson maintains a speaking schedule that would rival that of politicians during the height of a campaign season. Last year he was nominated for the Nobel Peace Prize by several U.S. congressmen. He and the other nominees lost to President Barack Obama, but Obama donated $100,000 to Mortensons Central Asia Institute.
Few people know that Dr. Greg is actually an emergency nurse and former Army medic who used money from working night shifts in California hospitals to fund the first of his many schools for girls. He vowed to build the first school when he found sustenance and refuge in a rural village after becoming lost in some of the worlds tallest mountains in Pakistan during a climbing trip. The work has become his passion and singular vision.
Last November, Sigma Theta Tau International, the Indianapolis-based honor society of nursing, awarded Mortenson its Archon Award for demonstrating exceptional leadership in promoting health and welfare throughout the world during its 40th Biennial Convention in Indianapolis. Mortenson recently was in Chicago for his annual Central Asia Institute fundraising event, which was attended by more than 1,000 supporters. Nursing Spectrum spoke with Mortenson in Indianapolis and then again in Chicago about his work.
In Three Cups of Tea, Mortenson mentions he is a nurse, but it is not a central theme in his narrative. But nursing, he said, has had a profound impact on my journey.
Nursing taught him to listen to people and to ask questions, he says. In Pakistan and Afghanistan, Mortenson went in saying, I want to help you. What do you want? They answered, We want our babies to stop dying, and we want our children to go to school.
Working the night shift as a nurse gave Mortenson the stamina he needed to go without sleep. Consumed by the important work he is doing, Mortenson usually sleeps only four or five hours a day. He lives in Bozeman, Mont., with his wife Tara Bishop, a clinical psychologist, and two young children, but spends several months a year in Afghanistan and Pakistan.
Mortenson says that after building schools for girls in Pakistan and Afghanistan for 16 years, he is now focusing on the training of healthcare workers, as well, although it has proved difficult because of the lack of basic resources in the remote villages where he locates his schools.
[Healthcare] kept tugging at my heart, Mortenson says. One out of three children are dying.
Mortenson, who co-founded the Central Asia Institute (with Jean Hoerni, a silicon transistor pioneer who died in 1997) to carry out his work, said when he first started his humanitarian efforts in Pakistan, he considered building clinics instead of schools. But he said he wanted to build something that would directly empower the Pakistanis, a goal more easily achieved with schools than clinics.
Mortenson recently started a maternal health training program, teaching local women about the basics of good maternal-child healthcare. Afghanistan has one of the highest maternal and infant mortality rates in the world.
Many women die, but not from difficult problems, he said. Often mothers die from common complications of pregnancy such as cephalopelvic disproportion, placenta previa or placenta abruptio because there are no obstetricians to perform cesarean sections.
The remote region of central Asia has a high infant-mortality rate from outbreaks of diseases such as diphtheria, and from malnutrition. Babies in that part of Central Asia begin life nutritionally disadvantaged because women believe that colostrum is poison and do not let their infants nurse for the first three days after birth, Mortenson said.
Some women in Afghanistan and Pakistan also are malnourished because their husbands do not give them enough protein to eat and save the meat, poultry and eggs for themselves. Mortenson did a study of women in Korphe and found the average hemoglobin level was eight or nine. The women have so little body fat they stop menstruating and are infertile, he said.
Mortenson said he also plans to send health workers to his schools to teach the teachers how to do rudimentary health screenings for children.
Broken HeartsEgidia Rugwizangoga, RN
At King Faisal Hospital in Rwanda, two teenage girls captured Egidia Rugwizangogas heart. Their names are Claudine and Dorothy. Rugwizangoga, RN, BSN, met them while she was working in Kigali, Rwandas capital, with Team Heart, a cardiac surgery team from Brigham and Womens Hospital in Boston.
Claudine and Dorothy looked about 8 years old, shrunken by their illnesses, Rugwizangoga says. Despite being so sick, they were so full of life and laughter. It was amazing to see. She brought them nail polish. They told her stories of growing up in the countryside and how their parents took them to traditional healers who tried to cure their rheumatic heart disease with herbs.
Rugwizangoga was born in Rwanda but left when she was 19 and had not returned for nine years. She went to nursing school in Boston and worked at Brigham and Womens as a surgical nurse, but her home country never left her mind. I always remembered how tough it is back in Rwanda, she says. How people dont have access to healthcare, how the nurses there are very scarce. I always thought about going back at some point and giving back to the community.
Rugwizangoga got her chance completely by accident. An instructor of a class she attended at Brigham and Womens mentioned starting a surgery program in Rwanda to repair heart valves damaged by rheumatic heart disease. Rugwizangoga approached the instructor, saying she was from Rwanda and wanted to help. She was immediately recruited, not only for nursing care, but to work as an interpreter and translator, creating educational materials in her native language.
Team Heart treats patients with heart disease caused by rheumatic fever, often a complication of untreated strep throat. The illness is fairly rare in most Western countries, probably because of widespread use of antibiotics. But in many parts of the developing world, where children do not get treatment, the fever is common and can seriously damage heart valves and cause heart failure.
Since 2007, Team Heart has visited Rwanda regularly, first to do surgeries and then for follow-up visits about six months later. The surgical visits last two to three weeks, and the follow-ups last about 10 days.
Nurses who go overseas to developing countries need to be flexible, patient and open-minded, Rugwizangoga says. The things you take for granted, even water to wash your hands are scarce in Rwanda. Many items considered disposable in the U.S. had to be sterilized and re-used. Before you threw anything away, you had to think if it could be used again.
Rugwizangoga emphasizes the importance of going with a group, especially for those who are visiting a country for the first time. Though she knows the culture and language of Rwanda, she says, she likes working with a team that can make arrangements with hospitals and find accommodations, allowing her to focus on nursing.
Her greatest frustration, she says, is seeing people suffer from diseases that could have been prevented with early intervention. But, she adds, she finds great joy in her work. You give people hope to know they can get better. Its a great feeling. It makes me want to do this even more.
Claudine and Dorothy grew up in extreme poverty. One said her family had given up on her they thought she was going to die, Rugwizangoga says. She gave up on herself. But now she told me she has a second chance. She is going to go back to school. One of the girls plans to be a teacher, Rugwizangoga says. The other wants to be a nurse.
Cultural ExplorerJoe Niemczura, RN
Joe Niemczura, RN, MS, worked hard to prepare himself for a three-month stint at a mission hospital in Nepal in 2007. He considers himself open-minded and adaptable to new situations. He sought out a native Nepalese teacher to instruct him in the language and read everything he could about the country and the rural town where he would be working. He even read about culture shock the feelings of disorientation and sometimes depression that those working in foreign countries often experience.
He was not as well prepared for his return home. He felt bewildered and overwhelmed in the supermarket, surrounded by shelves of goods unknown in Nepal. He found no one wanted to listen to his intense and often horrific stories how he saw babies and children die of burn wounds, or how he managed to get an ancient ventilator working to keep a snakebite victim alive, Ambu-bagging when power in the hospital failed.
Eventually he decided to write a book about his experiences, in part to get it all out, and in part to help other nurses who are working or thinking of working overseas, he says. The Hospital at the End of the World, a story of his first visit to Nepal, was published last year.
Niemczura stumbled into international nursing. In exchange for some lectures, the University of Hawaii at Manoa in Honolulu where he teaches offered him grant money for a project of his choosing, related to the universitys international efforts. He loves travel and had always wanted to work in a developing country. He wanted to spend at least a few months in an area, getting to know its customs and people. Originally he focused on India but couldnt find an organization recruiting nurses. An Internet search of countries near India that needed nurses led him to United Missions to Nepal, a Methodist-run non-governmental organization with years of experience in the area.
Niemczura, who is Catholic, didnt think of his trip abroad as particularly spiritual. I partly did it out of a sense of adventure, and the faith issues were secondary, he says. Being religious and reading the Bible is not enough for a medical person to get the most out of working in a developing country, he says. Its a lot more sophisticated than that. Its critical to study the culture of where youll be going.
Most important for nurses traveling abroad, he says, is getting out of what he calls their comfort bubble, be that religion, culture or language. Eat the local food, ride the local transportation and practice the language, he says. Talk to your neighbors. Think of no one as them.
He considers his book a collection of war stories. The patients he remembers most, he says, are not the ones he saved but those who died. In the eight weeks he was at the mission in 2007, 110 patients died, 24 on his watch. Further visits to Nepal he returned in 2008 and 2009 have been considerably easier than the first, he says, partly because there were fewer deaths, but also because he knows better what to expect, both in the country and when he returns home.
After a while you realize we did save people, he says. But its not all perfect.
Women’s LiberationArlene Samen, RN
In 1987, Arlene Samen, APRN, began volunteering with Interplast, an international organization that performs free surgeries in developing countries to repair cleft lips and palettes. Nearly 10 years later, she founded One HEART (Health, Education And Research in Tibet), an international organization to prevent birth-related deaths among women and children in poor Tibetan communities.
Samen, who left her job at the University of Utah in 2004 to devote herself full time to One HEART, never intended to go into global nursing. The first trip with Interplast changed her life, she says, and she always felt she had to do more. Sometimes I think you step on that path and I dont know how you walk away from it.
Samens work with Interplast led to an audience with the Dalai Lama, she says. He asked her to come to Tibet to help poor women and children there. After seeing a Tibetan woman give birth on a dirt floor in a tent, Samen, a maternal-child specialist, knew how she wanted to help. She returned to the U.S., developed a training program, and gathered a team of medical experts who traveled with her to Lhasa, Tibets capital. First they worked in hospitals, training birth attendants and physicians in maternal and infant care. But Samen realized women in crisis werent coming to the hospital soon enough. The team needed to reach them where they were going into labor in the villages.
Samen and her colleagues spent months observing Tibetan birth customs and collecting data to see how they could prevent unnecessary deaths in rural areas. They found that two-thirds of women in Tibet give birth at home, often alone and outside, in tents or open sheds. Birth fluids are considered unclean, and offensive to spirits dwelling in Tibetan houses, Samen says. So the team developed a clean birthing kit that included a sterilized sheet and disposable cloths to be placed over a bed in the house. The cloths and sheet, along with the fluids, could be burned or buried; the spirits would not be offended.
The team also trained a network of birth attendants who could be with women in labor, drawn from family members, village leaders and local health workers. The attendants learned how to stop women from hemorrhaging, and when to get the woman to a hospital or clinic if something was starting to go wrong. In 2008 four years after the inception of the village outreach program for the first time ever there were no maternal deaths in the counties where One HEART worked, and newborn deaths decreased from 10% of all births to 4%.
Despite this success, political instability in Tibet made it impossible for Samen to continue working there. The One HEART team had expanded to include 11 Tibetans as well as the international staff, and last year when the Chinese government revoked the foreigners permission to be in the country, Samen was forced to leave the project in the hands of the local group.
We did everything we could to make the staff self-sustaining from the beginning, Samen says, because they knew the political situation in Tibet was volatile. But she wasnt ready to leave. I probably would have been there forever, she says.
Samen and One HEART have since started laying groundwork for maternal-child health projects in the Copper Canyon in Mexico and in Nepal, where rural women face conditions and customs similar to those in Tibet. She has moved the groups U.S. base from Utah to San Francisco, and hopes to eventually return to Tibet.
Commitment is the most important quality for those who want to do global nursing, she believes. You need to be really able to overcome challenges and obstacles, she says, to think on your feet, to work with a team. A lot of people see problems and they get stuck.
Nurses who want to work overseas also need to understand the risks involved. Samen was sitting in a restaurant that exploded during the uprising in Tibet. There are marijuana farms in the area of Mexico where she is working, and Maoist rebels have bases in rural Nepal. When a colleague suggested the team should only work in safe areas, she replied, Were working in developing countries. They are not always stable.
For Samen, the risks are worth taking. If I can die doing what I love to do, fighting for womens rights in countries [where they] are very marginalized, she says, then Ive lived a perfect life.
Janet Boivin, RN, is a freelance writer for Nurse.com. Cathryn Domrose is a staff writer for Nurse.com.