Patients with their arms or legs suspended by strings for skeletal traction to treat bones broken in car accidents lay several to a cot in rooms with more than a dozen beds.

The seeds of the collaboration were sown in the 1980s, when Duke collaborated with Tanzanian colleagues in Dar es Salaam, where Prof. John Shao worked before he moved to Moshi to become KCMC executive director in the mid-1990s.

The KCMC/Duke relationship moved with Shao and in 2002 expanded its focus on HIV/AIDS prevention, treatment and care. NIH funding followed and snowballed as grants to develop the site’s infrastructure and capacity, launch an initial HIV voluntary counseling and testing service and establish training opportunities built on each other. The synergy of KCMC and Duke leadership, the number and diversity of international research grants and community involvement make Moshi an example of the complexities of conducting global health projects.

Dr. John Crump, Duke’s principal investigator at the site, says they are fortunate to collaborate closely with two of Tanzania’s leading health care and research organizations: KCMC and Kiwakkuki (the name is an abbreviation of the Swahili phrase, “Women aggressively fighting HIV/AIDS”). Although the site’s research focus has been HIV/AIDS and other infectious diseases, it is expanding into other health issues: cervical cancer, cardiovascular disease and car crashes.

“I take a long time-horizon—decades—to measure progress,” said Crump. “Over that length of time, what staff can we train, what infrastructure can we establish and what papers can we publish with data that will influence health policies? Our goal is to deliver all aspects of the program into well-equipped Tanzanian hands. That’s probably about 10 years away.”

Dr. John Crump, an infectious disease physician and medical microbiologist at Duke University, serves as principal investigator at the Moshi site.

According to Shao, the country’s current ratio of physicians to patients is one to 23,000. Programs such as the Fogarty International Center’s AIDS International Training and Research Program (AITRP), which began in 1988 to provide training for scientists in low- and middle-income countries and strengthen their institutions’ HIV-related research and public health capacities, address this eagerness for increasing medical heft. “AITRP complements our training efforts. KCMC staff return from their experiences and train others,” Shao said.

One of the Moshi site’s biggest challenges was meeting NIH criteria for biotechnology labs. International NIH-funded sites must meet the same standards as NIH-funded labs within the U.S. on everything from maintaining lab instruments to keeping room temperature within a set range. Those might seem like easy tasks until you consider the frequent power outages that can last minutes, hours or days and daily power surges.

Lab supervisor Anne Morrissey, who arrived in Moshi in 2005, established the quality control system now in place. “It’s very gratifying to watch the lab work as it should. We’ve had very interesting findings in our research, saved lives, given physicians information that will help them make better clinical decisions, trained the next generation and made a difference,” she said.

Community feedback is critical to sustaining the site’s projects. The Moshi community advisory board is the mechanism for discussing clinical research in plain language understandable to local people, in this case, Kiswahili.

Kiwakkuki also partners with the site. A response from the women of Moshi to HIV/AIDS in 1990, the group’s more than 6,000 volunteers and 44 employees teach their neighbors about HIV prevention and help individuals and families affected by the disease.

Kiwakkuki penetrates deep into rural villages through a network of grassroots volunteers. Its research involvement took the global stage during summer 2008 at the XVII International AIDS Conference in Mexico City, where the Duke team presented research on barriers to accessing HIV services and awareness of antiretroviral therapy (ART). About 7 percent of Tanzanians are HIV-positive. The study, which Kiwakkuki assisted by distributing questionnaires, found that 98 percent of first-time HIV testers knew that ART exists, but fewer than 50 percent believed that they could get ART if they tested positive. Although ART was made free of charge in Tanzania in 2004, only about 15 percent of people know of their HIV status and only 18 percent of those who need ART are receiving it.

Fighting infectious diseases and addressing chronic, underserved health issues in developing countries is a goal that requires many partners. In the crucible of Moshi, Tanzania, committed individuals and organizations—including NIH, KCMC, Duke and Kiwakkuki—are making progress in bringing that vision to reality.