Annette Galassi, MA, BSN, OCN - photographed by Claudio Papapietro
In November 2011, Annette Galassi, MA, BSN, OCN, traveled to Ethiopia with the organization Health Volunteers Overseas to help start a new project. She had long wanted to volunteer and had a growing interest in oncology nursing in low-resource settings. When she ran across an advertisement in an oncology publication looking for nurses and doctors to volunteer, Galassi was in the right place in life and ready to commit. She followed the pull and applied.
Communicable diseases were coming under control in many places. People were living longer, but more were developing cancer.1 Access to cancer care was a growing problem, and Galassi wanted to help.
“Ethiopia had a population of 90 million people. They had 1 public hospital with 2 cobalt radiation machines for the entire country,” Galassi said in an interview with Oncology Nursing News®. “Patients presented with latestage, often incurable disease. Nurses had little or no personal protective equipment, and they would mix chemotherapy right at the bedside. Resources, supplies, and medication were extremely limited, as was knowledge about cancer and cancer care.”
Galassi made several trips to Ethiopia to help educate and train the nurses, and she and a colleague work with the school of nursing to draft a certificate program in oncology nursing. She sees a silver lining in partnerships like the one between the Addis Ababa University School of Nursing and Midwifery in Ethiopia and the University of Oslo in Norway to offer an oncology master’s program.
TEACHING NURSES TO BE TEACHERS
The issues facing low- and middle-income countries (LMICs) are complicated and multifactorial. Problems such as political and financial barriers to cultural views on cancer, as well as the undervalued role of nurses, can seem insurmountable.1-3
But nurses such as Galassi, along with volunteer healthcare organizations that provide collaborative, sustainable programs and tailored approaches to problem solving, are leading to desperately needed improvements in cancer care. One top priority for oncology nurse volunteers is providing education and training for nurses, who provide most of the cancer care. Nursing education typically does not include training on cancer.3 Standards and protocols are often inconsistent or nonexistent.
Most patients in LMICs purchase their own chemotherapy medications and bring them to the hospital. By insisting that the nurse stay at the bedside to mix the drugs, they know they are getting what they paid for. Patients also pay for supplies out of pocket, and expect them to be resused.
Showing senior nurses how to perform skills and assessments and teaching them to instruct less experienced staff helps all involved grow and build confidence.
Some nurses may see patient education as the doctor’s responsibility and not realize that patients may need to hear information several times before they remember and understand or that, patients may feel more comfortable asking questions of a nurse than a doctor.
In many countries, nursing is not considered a prestigious profession. Galassi, who is involved in volunteer work with a pediatric oncology unit in Delhi, described the situation in India: “Nurses are often looked down upon and not treated as equal. This can get in the way of moving their practice forward.” She said her team worked hard to get nurses to competently assess and present patients’ problems to physicians, rather than passively taking orders, doing whatever the physician said, and never questioning anything.
“Physicians needed to understand that although they could teach about the disease process and action of drugs, they didn’t have the nursing expertise to teach nursing at the bedside, nursing assessments, [or] nursing interventions or how to conduct a root cause analysis for spikes in PICC [peripherally inserted central catheter] line infections, figure out potential reasons, and figure out what could be done to change things,” Galassi said.
FINDING THE RIGHT FIT
Galassi, who continues volunteering in places like Bhutan and India, encourages nurses who are interested in global volunteer work to do their research when selecting an organization with which to partner.
Virginia LeBaron, PhD, APRN, ANCP-BC, FAANP, wholeheartedly agrees. LeBaron and Galassi coauthored a resource article for nurses interested in volunteering.4
In 2004, LeBaron was working as an oncology nurse and palliative care nurse practitioner. She had always been interested in global health work, but struggled to find the right organizational fit. She eventually connected with a global oncology group working in partnership with countries to build palliative care capacity. It was a perfect match, and LeBaron made her own eye-opening first trip as a global oncology nurse volunteer in Nepal.
The volunteer organization’s work was based on sustainable partnerships, and they collaborated with healthcare providers to tailor their approach. LeBaron became involved in education about capacity building related to palliative care.
There were (and are) huge disparities in access to basic pain medicine.5 She worked in hospitals and saw that patients with late-stage cancer were unable to get prescriptions for morphine.
“There are multifactorial issues regarding pain medication,” LeBaron told Oncology Nursing News®. “There is a physical lack of supply of opioids. This lack is perpetuated and exacerbated by regulations that make if difficult for providers to prescribe medication or for pharmacies and formularies to stock medication.”
These factors contribute to what appears to be low demand, creating a cycle of inability to create enough supply, she said: “It circles back to regulations. Low demand is not lack of need. Need is great; supply and access are low.” Even when opioids are accessible, they may not be in the correct form. Intravenous (IV) morphine is not helpful for patients who need oral medication for home use.
Pain management and access to pain medication are issues not only in Nepal but also in many other low-income countries. For LeBaron, knowing that patients’ pain was not adequately managed set her on a path to explore how to improve that situation. She started working with other organizations related to pain management and policies around opioids. Around the same time, as she was completing her dissertation on access to opioids and pain management, issues began emerging about the opioid epidemic in the United States. Her research was caught in the crosshairs of patients suffering in agony without pain medication and the significant concerns about misuse and diversion of opioids.
“It is an interesting place to be,” she recalled. “People are asking, ‘How do we achieve balance between not putting patients and communities at risk but, at the same time, not contributing to the undertreatment of pain or stigmatizing opioid therapy for people who legitimately needed it?’” Now, in the United States, data are emerging about patients’ difficulty in accessing necessary pain management and the unintended effects of good-intentioned regulations. “Global health work is colliding with what’s happening domestically,” LeBaron said.
MEETING GLOBAL ONCOLOGY NEEDS
Lori Buswell, NP, MS, is the executive director at the Dana-Farber Cancer Institute’s Center for Global Cancer Medicine, which was established in 2012 and, alongside the nonprofit group Partners in Health (PIH), supports the advancement of cancer care in LMICs. She shared with Oncology Nursing News® about the work she has been involved with in Rwanda.
“In 2012, the center, PIH, and the Rwandan Ministry of Health kicked off a national weeklong training course for doctors and nurses throughout the country to raise awareness of what cancer is, what it looks like, and how it is treated. In-depth training was provided for hospitals that treat patients with cancer. Most of the chemotherapy was given at a hospital in Butaro because the drugs were free—PIH paid for them—or [at] the private hospital for patients who had money, could purchase the drugs, and be treated. There were only 2 places where people could get chemo and only 1 oncologist in the entire country. Now there are 4 [or] 5, although they are all in the capital city. The first radiation center didn’t open until 2019. Before then, patients were sent to Uganda and Kenya for radiation, also paid for by PIH.”
Volunteers from several cancer centers work in Butaro for a couple of weeks to teach nurses and physicians, including general practitioners, about oncology and how to take care of patients, Buswell said. They provide protocols for treating patients with cancer—how to work up, stage, and treat them. “Cancer is an interdisciplinary team event. We try to build expertise in all disciplines,” she said.
Buswell travels to Rwanda twice a year for 4 to 8 weeks. The volunteers help write policies and procedures to solidify what nursing practice should look like and encourage efficiency.
“One thing we did was to write down all the elements needed to administer chemo,” Buswell said. “Now they have a standard template for the patient to bring to the pharmacy and get everything needed.”
Although the need is great, opportunities are limited for volunteers, and it is important for nurses to realize that meaningful work requires an investment in time. “Volunteers who drop in for a week or 2 have helped a patient but haven’t helped the country build a workforce,” Buswell noted. Sending tubing, IV pumps, or 100 doses of medication also is not necessarily helpful. The real needs: sustainable partnerships and donations of time and money.
Buswell believes that it will take a couple of generations or more to get essential workforces in place. “There is great satisfaction, however, in paying it forward,” she said. “Global oncology volunteer work is incredibly satisfying on a personal and a professional level.”
- Varmus H, Kumar HS. Addressing the growing international challenge of cancer: a multinational perspective. Sci Transl Med. 2013;5(175):175cm2. doi: 10.1126/scitranslmed.3005899.
- Galassi A, Morgan C, Muha C. Making the invisible visible: oncology nursing efforts of NCI-designated cancer centers in LMICs. J Cancer Policy. 2018;17:34-37. doi: 10.1016/j.jcpo.2017.03.013.
- Challinor JM, Galassi AL, Al-Ruzzieh MA, et al. Nursing’s potential to address the growing cancer burden in low- and middle-income countries. J Glob Oncol. 2016;2(3):154-163. doi: 10.1200/JGO.2015.001974.
- Galassi A, Pradhan R, Palat G, LeBaron VT. Global oncology volunteering: making an effective contribution. Oncol Nurs Forum. 2017;44(5):530-533. doi: 10.1188/17.ONF.530-533.
- LeBaron VT, Palat G, Sinha S, et al. Recommendations to support nurses and improve the delivery of oncology and palliative care in India. Indian J Palliat Care. 2017;23(2):188-198. doi: 10.4103/IJPC.IJPC_153_16.