Anne Elperin, an oncology nurse from Boston, could not speak the language of the Rwandan woman gripping her hand, but fear did not need words. The patient, a young mother named Pelagie, had been suffering from continuous vaginal bleeding and sought treatment at Butaro Hospital in northern rural Rwanda, where Elperin, APRN-BC, MSN, AOCNP was working as an oncology nurse fellow through a program between Boston-based aid organization Partners In Health and the Dana-Farber Cancer Institute.
In Rwanda, historically, patients like Pelagie have been told to go home to die — except for the few with the financial resources to pay for treatment in an urban hospital. When Pelagie learned she had choriocarcinoma in March, the country had no oncologists, no radiotherapy facilities and only a few medications in the national cancer formulary for treatment.
In July, the country and the continent took a monumental step forward in cancer care when, as a result of a collaboration among the Rwandan Ministry of Health, PIH and Dana-Farber/Brigham and Womens Cancer Center, the first cancer unit in rural East Africa opened in Rwanda. The projects goal is to educate Rwandan physicians and nurses about cancer screening, prevention and treatment, and ultimately to establish cancer centers throughout the country.
“Nurses perform the vast majority of the care with cancer,” said Sheila Davis, RN, DNP, ANP, FAAN, director of global nursing at PIH. “They administer the chemotherapy, talk to patients about their symptoms and side effects, and educate the patients and families. If we can share what we know with other nurses around the globe, we can have a significant impact on the quality of patient care.”
Elperin helped to fulfill this mission as the first of four oncology nurse fellows from Dana-Farber to travel to the Butaro Cancer Center of Excellence.
During the centers first year, each fellow will spend three months there training Rwandan nurses.
Cancer: A global disease
Although many Americans may consider cancer a disease of higher-income countries where populations live longer, nurses on the front lines of global healthcare suggest that cancer increasingly is the cause of morbidity and mortality in developing countries. According to the World Health Organization, by 2030 nearly two-thirds of all cancer diagnoses will occur in low- and middle-income countries.
“Five or 10 years ago, patients in the hospitals in many parts of Africa were dying of AIDS,” said Davis. “Now we are seeing things like breast cancer and lymphomas.”
When Elperin arrived in March, she was invited to observe a meeting where Rwandas Ministry of Health, international oncologists and Rwandan physicians, nurses and policy makers had to make difficult decisions about which cancers would be the highest priorities for treatment.
“The technical working group used criteria such as the prevalence of cancers in Rwanda and availability of effective treatments to determine which cancers to prioritize,” explained Neo Tapela, MD, MPH, director of the noncommunicable diseases program for PIH in Rwanda.
The working group decided the center would prioritize treatment of five cancers among children (four blood cancers and Wilms tumor) and seven cancers among adults (breast, colorectal, prostate, gastric and three blood cancers). Treatment for patients, like Pelagie, with cancers outside this list would be determined on a case-by-case basis with consideration given to the availability of effective treatment and resources. These patients also would be entitled to receive palliative care.
When Elperin arrived in Butaro, she learned that pharmacists in Rwanda did not have adequate training to mix chemotherapy, as pharmacists typically do in U.S. This function fell to the nurses, who were mixing chemotherapy agents at the bedside. Elperin went about establishing a chemotherapy mixing room that was separate from an inpatient area for medication administration.
“The Rwandan nurses were very engaged and would come to my chemotherapy classes on their days off or after they had worked a full night shift,” Elperin said. “They took a lot of pride in the fact that they were doing something new for Rwanda.”
After six weeks in Butaro, Elperin knew the training was a success when she stood in the background and the Rwandan nurses performed all the details of chemotherapy treatment independently.
Elprin also saw the effect chemotherapy had on patients, including Pelagie, who started treatment at the Butaro Cancer Center of Excellence. Chemotherapy boosted Pelagies odds of survival, and Elperin noticed her smiling and talking to other patients for the first time.
The power of knowledge
In July, the National Breast Cancer Foundation announced that as part of the Pink Ribbon Red Ribbon initiative, it will provide funding for a health promotion manager in Zambia (the equivalent of a U.S. community health nurse). The initiative is a partnership established in 2011 by several U.S. organizations to combat cervical and breast cancer in sub-Saharan Africa and Latin America.
The Zambian community health worker will speak with women throughout the country and encourage them to visit local community clinics to receive free breast cancer screening and annual exams.
“One of the main reasons why the breast cancer mortality rate has declined in the U.S. is because women are talking about it and getting checked early,” said Douglas Feil, vice president of programs at NBCF. “We need to foster that same level of awareness in countries like Zambia, where the need for information and access to treatment is even greater.”
In 2010, Mary Gullatte, APRN-BC, PhD, AOCN, FAAN, president of the Oncology Nursing Society was invited by the Seattle-based Breast Health Global Initiative to conduct workshops at a four-day breast cancer conference in Ghana, West Africa. While there, Ghanaian nurses expressed a desire for more community education. “The nurses in Ghana shared that women often do not seek breast cancer treatment because they are afraid their spouses will leave them if they need to have a mastectomy,” said Gullatte. “When working in other countries, I believe its really important to understand some of the barriers and challenges in each country first.”
To understand how to support the Ghanaian nurses who were treating patients with lymphodema, Gullatte spent time learning about the resources they had available. In the U.S. caregivers can give patients compression sleeves to promote fluid drainage, but in Ghana she and the nurses improvised by tearing a sheet in half, wrapping it tightly around a patient and securing it with a safety pin or tape.
“The nurses there love getting their hands on any books and materials that teach them about the pathophysiology, treatments and symptoms of cancer,” Gullatte said. “When they understand the mechanics of why things happen, they are ingenious at coming up with ways to help their patients.” •