Unbearable

July 12, 2004 -- Today the New York Times ran Celia W. Dugger's "An Exodus of African Nurses Puts Infants and the Ill in Peril," an unusually powerful and comprehensive look at the catastrophic effects of the emigration of Malawian nurses to developing world nations with nursing shortages. Dugger outlines the staggering overall depletion of health resources in the AIDS-ravaged nation, where more registered nurses have left to work abroad in the last four years than remain in the public hospitals and clinics that serve most of the country, and where almost two thirds of the public health system's nursing jobs are vacant. But her special focus is the labor and delivery ward at the capital's Lilongwe Central Hospital, where 10 overwhelmed nurse midwives now attempt to deliver more than 10,000 babies a year--with the apparent result that many births are attended by no one.

The heart of the piece is its harrowing account of the work of senior nurse Hlalapi Kunkeyani, "a big-hearted woman with reserves of steely religious faith," and her nursing colleagues at the 830-bed Lilongwe Central. There, "a single nurse often looks after 50 or more desperately ill people." On the cramped labor ward, a number of women go into labor at the same time, and the lone nurse on duty obviously cannot attend each one. Babies are born in various states. The piece describes how Kunkeyani found one on his mother's breast, desperate to breathe; she reached him in time to suction his tiny mouth until he was able to do so. At another point, the article describes Kunkeyani's inability to attend a birth and prevent vaginal tearing, and her subsequent efforts to persuade the fearful, suffering mother to let her suture the tear. And one night, in a crib in the nursery for sick newborns, "a tiny baby girl, blue and dead, lay next to her sister, eyes open, tiny fists clenched, mouth yawning," after the day shift nurse had "steadfastly" tried to keep the premature babies alive. Already, the physician who directs Lilongwe Central describes efforts to run the hospital in the midst of the nursing drain as "unbearable."

Kunkeyani's cousin, who preceded her as nurse in charge of the labor ward at Lilongwe Central, had led Malawi's national breastfeeding program--until she emigrated to Britain in 2001. Soon, Ms. Kunkeyani plans to join her cousin and other Malawian nurses there, where she will earn in a day's overtime what she makes in a month in Malawi. The piece describes the luxurious house this cousin is now building in Lilongwe, where she will settle after her children finish schooling in Britain. But the piece stresses that Kunkeyani's move is one she believes she must make for the sake of the extended family she helps to support, including her daughter and eight orphaned nieces and nephews. The piece makes clear that most if not all of the nurses considering emigration now live in desperate circumstances.

The piece stresses that Malawi and other African nations would be in a public health crisis even without the nursing shortage. Africa has been devastated by AIDS and tuberculosis, diseases that have also claimed many health care workers. In Malawi, where life expectancy has fallen to 38 years, "the rate at which women die of causes related to pregnancy almost doubled from 1992 to 2000", and "one in 89 births results in the death of the mother, among the worst such rates in the world." A 2001 review of maternal death audits in southern Malawi hospitals found that more than half the deaths were associated with substandard hospital care. Hospitals are in awful shape, short on medicines and basic supplies. The piece describes shortages of supplies, including a lack of effective antibiotics, razors to cut umbilical cords, and even soap for nurses to wash their hands and prevent deadly infections. The crowded maternity wards smell like toilets. Women labor on the concrete floor and lie in puddles of their own amniotic fluid and blood. According to the piece, nurses at Lilongwe Central, who must assume that any woman they examine is H.I.V. positive, refused to do vaginal exams for two days in May because of a shortage of latex gloves.

The article spends significant time on the policy problems all this represents. It describes the growing concern in African nations over the flight of nurses to the developed world, and recent discussions at a World Health Organization meeting and elsewhere as to whether developed world nations should compensate poor nations for having trained the nurses who emigrate. One painfully ironic complication is the impending infusion of billions of dollars worth of aid to fight AIDS and other diseases in Africa. Because much of this money will be distributed through higher-paying nonprofit groups, still more nurses will be lured away from public hospitals, potentially resulting in even more deaths from normally manageable conditions such as childbirth, infections and intestinal disease, and a further breakdown in the overall health system. In Malawi, the government has proposed increases in funds for nurse training and salaries, and major foreign donors have promised to support those efforts. But nurses appear to remain skeptical; 26 of Lilongwe Central's 30 remaining registered nurses are either planning to leave or considering leaving for better paying jobs in Malawi or abroad. The article highlights the tensions between those, like former South African president Nelson Mandela, who have criticized nations like Britain for recruiting developed nation nurses, and those who stress the health needs of the wealthier nations and the opportunities offered to the emigrating nurses themselves. One British physician working in Malawi scolds his nation: "train your own unemployed people."

The lengthy piece might have explored more of the policy arguments surrounding the nursing migration, including the extent to which the nurses return home, the overall effects of their remittances back to their native countries, and whether recruitment of desperate foreign nurses is a long-term solution to the developed world nursing shortage. And it relies a little too heavily on policy opinions from physicians and other non-nurses, and not enough on the many nurses who are expert in the shortage and related policy. But the piece's main focus is on "the human cost of the nursing shortage." Ms. Dugger and the Times deserve credit for a wrenching, nuanced exploration of the ground-level effects of a global public health crisis that has received too little attention, and for making clear that nurses do a little more than smile and hold people's hands.

See Celia W. Dugger's "An Exodus of African Nurses Puts Infants and the Ill in Peril" in the July 12, 2004 issue of the New York Times.

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Celia W. Dugger
The New York Times
229 West 43rd Street
New York, New York 10036

Thank you.