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In urban, government-run hospitals in Malawi, patients
are grouped together in open wards, regardless of their
illness. Tuberculosis patients lie next to AIDS patients.
One nurse and one or two paid attendants may look after
40 very ill patients, Norr said. "The situation
is overwhelming." The training program she helped
develop aims to teach AIDS education and prevention
to everyone in the hospital, including maintenance workers
and security guards.
"Because very little testing occurs and the majority
of people in the hospital are HIV-positive, there's
really no such thing as an AIDS nurse," she said.
"Most health workers have no idea whether they
themselves are infected."
Educating hospital workers about how to prevent HIV
infection is difficult because hospitals and clinics
have little money for protective supplies, she said.
Norr has seen nurses use a cardboard box to dispose
of used needles. She has seen workers sweep used needles
from the floor and deposit them into an open incinerator,
where curious children might pick them up.
"There are a lot of things that health care workers
can do something about" to protect themselves,
she said.
Even when the supplies are available, she said, hospital
workers continue to treat them as scarce commodities.
"Nurses put on one pair of gloves and wear them
all day," she said. More gloves may be available,
but these are kept locked up. Family members, who do
much of the feeding, bathing and basic bodily care in
a Malawi hospital, usually receive no protective supplies
or instruction on how to protect themselves.
In some ways, the situation for health care workers
in sub-Saharan Africa now is similar to what it was
in the United States in the early 1980s, say nurses
who have worked there. Some governments are unwilling
to spend money on AIDS/HIV prevention and education.
Talking about AIDS is a social taboo. People don't want
to admit they have the disease.
But Africa's situation is also far more dire than that
of any other country dealing with an epidemic, nurses
say, because of the continent's extreme poverty, hunger,
civil unrest and wars in some areas, a mix of languages,
traditions and cultures and an exodus of health care
workers.
Educating communities about AIDS is difficult, nurses
say, partly because of the stigma of the disease and
partly because nurses and other health care workers
are not used to talking to young people about sexual
practices.
Although the epidemic has been going strong for several
years and so many have died, in many countries the stigma
of having AIDS has not abated.
"The major problem is the silence," Makoae
said. "At home, we don't talk about AIDS. If a
man is known to be infected, the community believes
his whole house is infected."
Because fewer than 1 percent of people with HIV in
sub-Saharan Africa have access to or can afford drugs,
people see no reason to get tested, Norr said. "Most
people die without being tested."
In Malawi, many young people learn about sex culturally
through ceremonies, Norr said. "Parents don't talk
to their children about sexuality and generally, adults
don't talk to young people about sexuality." In
Lesotho, as in other parts of Africa, women can't talk
about things like condom use with their husbands, Makoae
said, let alone talk to their children about safe sex
and HIV transmission.
Such attitudes mean that solutions from the United
States and Western Europe will not always work in Africa,
nurses say. "We are so different," Makoae
said. "We don't have resources like your countries
do. Culturally, we are totally different. We need to
understand the stigma of this disease from our perspective."
Maria Kosmetatos, MS, FNP, arrived in Mutare, Zimbabwe,
two years ago carrying a box of donated medical supplies
for a rural clinic and about $20,000 she and other community
members had raised in Portland, Ore. She found nothing
as she had expected it to be-even though she thought
she was arriving with almost no expectations.
The clinic where she had imagined she would be working
had been leveled because it was ready to fall down.
The community she intended to work with was an Anglican
mission village called St. Werburgh, where tribal leaders
and clergy worked together. It was in a rural area,
where nearly half the adults were infected with HIV,
but no one admitted to having AIDS. Most were cared
for in homes without even basic pain medications.
"I got there and it was one of those eye-opening
experiences," said Kosmetatos, an HIV nurse practitioner
at the Multnomah County Health Department HIV clinic
in Portland. At first, she felt overwhelmed. Then she
realized that the best way to help was to offer whatever
support she could to grass-roots organizations already
working in Africa.
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