USC Upstate News

Nursing and AIDS: USC Upstate Nursing Instructor Confronts An Unforgiving Disease in Lesotho, Africa

12- 01- 2008

Spartanburg, S.C. - “God forgives. AIDS does not,” reads the billboard at a busy intersection in Maseru, the capital of Lesotho, a small country the size of Maryland land-locked by its neighbor South Africa. For every three people who walk or ride by the billboard, at least one of them will be infected with HIV, a figure that gives the country the dubious distinction of having the third highest infection rate in the world behind Swaziland and Botswana.

Chances are also strong that whoever passes under the billboard’s shadow will not live past the age of 40, almost half will be living in poverty and about as many will be unemployed. Sadly, children under 17 account for 18,000 pediatric AIDS cases. And the population  - aged 15 to 49, or 320,000 adults -  has been severely hit by the disease.

Becky CarrWhile preparing to travel to Lesotho on a President's Emergency Plan for AIDS Relief (PEPFAR) -sponsored teaching grant, Becky Carr, University of South Carolina Upstate Mary Black School of Nursing instructor who teaches at the University Center of Greenville, acknowledged that the statistics were grim.

“AIDS in Lesotho is an absolute, tremendous problem,” Carr says.

But having been on the front lines of the battle against AIDS here in the Upstate, she was excited to be a teaching resource to nurses in another country battling the same disease. With her vivacious mix of practicality, humor, flexibility and Southern charm - mixed with 30 years worth of a nurse’s stoicism and realism - Carr knew she was not going on a relief mission with a happy ending.

“Ground Zero:” St. Joseph’s Hospital

“There were two stethoscopes in the whole hospital, no infection control, filthy communal bathrooms, no heat in the middle of winter, no hot water, crumbling walls, infectious patients grouped with others, makeshift medicine carts, no record-keeping, no paper, copier, internet, computers, and often there was no electricity,” says Carr, who, within hours of arriving at St. Joseph’s Hospital, a teaching hospital for the Roma College of Nursing, sized up the list of “issues” that would make any American nurse cringe. In fact, the hospital had just received a failing grade by the Christian Health Alliance of Lesotho days before her team’s arrival.

“The hospital was easily 50 years behind an American one,” she says, and although the students being trained to work with the AIDS patients were aware of modern infection control methods, they didn’t have the resources, financial and otherwise, to make changes suggested by the Alliance.

With no computers, paper or copying machines, record keeping was almost non-existent. With no money to purchase paper towels for the bathroom, the communal towel by the sink was the only alternative.  Even though it was the middle of winter, the hospital staff kept the windows wide open in an effort to thwart the spread of tuberculosis (TB), an airborne bacteria. There was no heat, except for the coal stoves placed one per ward, around which patients huddled, covered in their blankets.

Even as she was experiencing the medical form of “culture shock” Carr realized that her mission as a nurse-educator would have to continue despite the conditions. For four wintery weeks from May 25 to June 22 Carr travelled 20 miles daily from her hotel in Maseru to the Roma College of Nursing, with its 85 students, located near the National University of Lesotho.

Lesotho Nursing StudentsLugging a portable laptop and LCD projector, Carr spent her days in the nursing school with a class of 25 undergraduate students and 18 midwife students. Wearing their uniform of white creased pants, a blue top, and an ever-present winter coat, the students were very attentive as she shared lesson plans covering everything from AIDS transmission to treatment regimens. The students were in a three-year diploma course, and could opt to stay an additional year to become a midwife.

“The students were very bright, very intelligent, and had fairly good English” says Carr, adding that the nursing profession is well-respected in Lesotho, with nurses earning about $800 a month. Unfortunately, she laments, there was little professional clinical follow-up or supervision of the nurses once they graduated.

On Thursdays, Carr visited the antiretroviral clinic at the hospital where the magnitude of what she had taken for granted at U.S. hospitals and clinics was made painfully clear.

“Rest in peace”

It is almost impossible to imagine an American doctor’s office or hospital without patient files in which the doctor documents symptoms, treatments, and medical regimens. Patient records are in many ways taken for granted, just as a modern office takes for granted copiers, computers, internet, pens, electricity and paper.

Carr was surprised to find that in Lesotho, the patient was responsible for maintaining their medical file. Lesothoans carry a passport-sized booklet with them to doctor’s appointments. The doctor writes notes in it depending on what shots or medication was administered, what procedures were performed or needed to be done. The patient kept the book with them when they left the office or hospital.

With HIV patients, the nurses noted which antiretroviral medication was administered. In Lesotho there are two regimens available for a possible mix of six medication combinations. In the majority of cases, patients wait to see a doctor until the disease has progressed significantly beyond help. Regardless, the test that lets doctors know whether, or to what extent, the antiretroviral medication is working, is not available in Lesotho.

“They’ll come in for help when they’re almost dead,” says Carr, adding that sometimes AIDS patients don’t come in at all in the winter.

One particular notation in the patients’ record books haunts Carr. In the first few days after her arrival in Lesotho, a patient died of pneumocystis, an AIDS-related opportunistic infection. The nurse’s final notation made in his medical passport was “May his soul rest in peace.” It was the first of many times she saw this entry in the books.

Saturday is Funeral Day

Fresh graves, many without headstones that were just mounds of newly dug earth, were plentiful in the cemetery she passed daily on her way to the Roma College of Nursing. Saturday was the day that was set aside for families to bury their dead.

AIDS has taken a tremendous toll on families in Lesotho, says Carr. When parents die, their children are shuffled around to other family members to care for. Many women had husbands who refused to be tested for the disease, putting the wife and ultimately her children at risk.  Sadly, many mothers who are infected don’t have access to medication that prevents transmission of the disease through breast milk to their children.

“You would think their spirits would be broken,” says Carr of the nurses, “because they are so limited in what they can do.” She says that the nurses, while kind, “had a barrier, a detachment” as they went about their job. But she did not observe a sense of hopelessness, despite the facts of the disease and the reality of their limited resources to treat it.  “You just have to work with what you’ve got,” she says.

Since Carr’s return to the United States, she’s had time to reflect upon her experiences and share them with her nursing students. She knows that she wants to travel abroad again through the PEPFAR initiative, probably to Swaziland, another country hard-hit by AIDS. 

“You don’t go there thinking you’re going to change the world, but if you’ve done any little small thing, you’ve done something!”

For further information about this story or USC Upstate’s celebration of World AIDS Day, contact Becky Carr at (864) 503-4249 .