Above the clouds: halfway up Mt. Kilimanjaro Photo:Chris Hildreth

On the May morning I visited the Kilimanjaro Christian Medical Center in Moshi, Tanzania, Na-than Thielman M.D. '90, an epidemiologist and associate professor of medicine at Duke, was on duty in the HIV Clinic. He had arrived the night before on the 9:00 flight from Nairobi and by 7:00 a.m. was already seeing patients in a room the size of a coat closet. Crammed into the space was an examination table, bookshelves, a desk, and two wooden chairs in which, all day long, one patient after another would describe the symptoms of an illness.

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Most were, by Thielman's reckoning, very serious, but all were very treatable: chronic diarrhea, measles, meningitis, thrush, pneumonia, malaria, and tuberculosis. Any of them, Thielman said, could be completely warded off. Any, that is, for which the right drugs were available.

Late in the morning, a slender, feeble-looking man in his early thirties sat down with his wife, who had helped him in. "He is confused sometimes," the wife told Thielman through a Tanzanian nurse-translator. "And his neck is hurting." Thielman looked at the man, eyes squinting behind his glasses, and then his face lit up. "Jambo, Freddy!" he said. "Hello." He took the man's hand. "Habari?" (How are you?)

Thielman recognized him from a previous visit, around three months ago, he thought, although he couldn't say for sure. The trips had begun to blur together. He remembers, of course, like it was yesterday, his first--in 1992, as a resident, fresh out of medical school, wide-eyed and disbelieving. He remembers the overcrowded wards, often two patients to a bed, and how, during morning rounds, you had to be careful not to step on the ones sleeping on the floor in between.

Freddy (patients' last names have been omitted to protect their privacy) gave him a weak smile. "Nzuri" (Good), he said. But he wasn't. His anti-HIV drugs had run out, his wife explained. And his cryptococcal meningitis, a deadly fungal infection of the spinal cord, seemed to have returned.

Collaborative medicine: Thielman, center, analyzes patient histories with visiting doctor from West Africa Photo:Chris Hildreth

Thielman recalled that when he'd found the meningitis he'd prescribed a daily dose of Fluconozol, an anti-fungal medication. "Are you still taking the Fluconozol?" Thielman asked him. The nurse translated. Freddy shook his head. "Why not?" Thielman knew that when patients stopped taking their anti-retroviral drugs, the response was invariably that they couldn't afford them any longer. Even the least expensive anti-HIV drug, Triomune, a generic medication manufactured in India, costs $270 a year, about three-quarters of Tanzanians' average yearly income. But Fluconozol was free. "Right?" said Thielman to the nurse, "It's free, isn't it?" She thought for a moment. "Oh, yes," she said. "But it is--" she searched for the phrase, "out of stock."

Tanzania, like its sub-Saharan neighbors, is a land of limited resources and extreme poverty, and perhaps nowhere is the deficit more striking than in the state of the nation's health care: one doctor for every 25,000 Tanzanians; 30,000 hospital beds for an HIV-infected population of nearly two million.

There is, however, one resource Tanzania is not short on. Among the 200,000 inhabitants of Moshi--a town that has seen, since the mid-1980s, both the rapid spread of AIDS and the rapid decline of a standard of living--among the hawkers of cashews and cigarettes, the woodcarvers and the coffin makers, the taxi drivers and the tour guides, the sidewalk seamstresses and the shoe shiners and the sex workers and the money changers and the Maasai robed in red shukas who roam the city like ghosts, one more group has emerged. Recently, people from a place called "Duke" have been showing up all over town.

In 1985, just as AIDS was beginning to ravage sub-Saharan Africa--approximately a million new infections a year at the time--Duke's first chief of infectious diseases, David Durack, sought to establish a base for research of tropical diseases in the developing world. After a thorough search, Durack settled on Tanzania. "It was English speaking, it had a history of relative stability, and we had one fellow who'd already been there before."

That fellow was Gunter Lallinger, an infectious-diseases specialist and, for seven years, the mainstay of Duke research activities in Tanzania. Together, the two embarked on a collaboration with Muhimbili University, the country's only medical school at the time. "We had no facilities of any kind. No external funding. We were truly starting from scratch," said Durack. "But when Dr. Lallinger and I made our survey visit in the winter of 1986, Halley's Comet was showing in that enormous African sky. We had heard that this was a good omen."

It was. With the aim of exposing Duke faculty members to the health-care environment of a developing nation, where they would conduct research in HIV/AIDS, malaria, and tuberculosis, Duke began building a modest presence in the country. Although the number of full-time faculty members in the division was never more than twelve, according to John Hamilton, chief of infectious diseases since 1994, it was the seed of Duke's commitment to the field. "Before 1980," he said, "you could count the number of major medical centers involved in international health on one hand." Duke was not on the list, he added, "but we are now."

By the early Nineties, research activities had moved to Kilimanjaro Christian Medical Center (KCMC) in northern Tanzania, home of the highest peak on the continent and the highest rates of AIDS cases in the country. There, an educational component was added. The AIDS International Training and Research Program offered a three-month rotation at KCMC for Duke residents and training in research methodology at Duke for Tanzanian colleagues. The former provided residents with a rare opportunity, offering, as few medical schools did at the time, an international rotation. But it was the latter, as Hamilton saw it, that would add a vital human component to the mission of building infrastructure in the region. At Duke, Tanzanians would learn how to care for patients infected with HIV, the most advanced methods of clinical research, and the "survival skills"--writing a grant proposal, publishing research results, and drafting a budget--basic to a successful career.