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NYTimes.com Article: An Exodus of African Nurses Puts Infants and the Ill in Peril

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  • varshaghosh@hotmail.com
    The article below from NYTimes.com has been sent to you by varshaghosh@hotmail.com. Saw this in today s NY Times-- take care-Varsha varshaghosh@hotmail.com
    Message 1 of 2 , Jul 12, 2004
      The article below from NYTimes.com
      has been sent to you by varshaghosh@....

      Saw this in today's NY Times--

      take care-Varsha


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      An Exodus of African Nurses Puts Infants and the Ill in Peril

      July 12, 2004

      LILONGWE, Malawi - Six women suddenly went into the final,
      agonized minutes of childbirth. Hlalapi Kunkeyani was the
      only nurse. There were no doctors.

      Panicky cries rent the fetid air of the ward, a cavernous
      space jammed with 20 women laboring in beds, on benches,
      even on the concrete floor. Mrs. Kunkeyani worked with
      intense concentration, her face glowing with sweat, but she
      was overwhelmed.

      Four of the babies arrived in a rush without her to ease
      their passage into the world. She found one trapped between
      his mother's legs with the umbilical cord wrapped around
      his chest. The face of another was smeared with his
      mother's feces. Yet a third lay still on his mother's
      breast, desperate to breathe. The nurse swiftly suctioned
      his tiny mouth until at last he gulped a breath.

      Mrs. Kunkeyani, 36, is the stalwart nurse in charge of this
      capital city's main labor ward, where 10 overworked nurse
      midwives deliver more than 10,000 babies a year. But soon,
      she will vanish from this impoverished nation, joining
      thousands of African nurses streaming away from their
      AIDS-haunted continent for rich countries, primarily

      "My friends are telling me there's work there, there's
      money there," said Mrs. Kunkeyani, who will soon make in a
      day's overtime in Britain what she earns in a month in
      Malawi. "They're telling me I'm wasting my time here."

      The nursing staffs of public health systems across the poor
      countries of Africa - grossly insufficient to begin with -
      are being battered by numerous factors that include
      attrition and AIDS. But none are creating greater anxiety
      in Africa than the growing flight of nurses discouraged by
      low pay and grueling conditions.

      The result of the nursing crisis - the neglect of the sick
      - is starkly apparent here on the dilapidated wards of
      Lilongwe Central Hospital, where a single nurse often looks
      after 50 or more desperately ill people. What is equally
      visible is the boon to Britain, where Lilongwe Central's
      former nurses minister to the elderly in the carpeted
      lounges of nursing homes and to patients in hushed private
      hospital rooms.

      It is the poor subsidizing the rich, since African
      governments paid to educate many of the health care workers
      who are leaving.

      In May, African countries banded together at the annual
      assembly of the World Health Organization to urge developed
      nations to compensate them for their lost investment. After
      an intense debate, the assembled countries resolved to
      search for ways to lessen the damage of what they called
      increasing rates of emigration.

      The brain drain of health professionals from Africa, and,
      more broadly, the severe staffing shortages, will be an
      issue at the 15th International AIDS Conference in Bangkok.
      Physicians for Human Rights, a Boston-based nonprofit group
      that shared the Nobel Peace Prize in 1997, will be
      releasing a report on the topic and proposing steps to
      avert a deepening of the human resources crisis.

      At Lilongwe Central, an 830-bed hospital, there are
      supposed to be 532 nurses. Only 183 are left. That is about
      half as many as there were just six years ago. And only 30
      of those are registered nurses, the highly skilled cadre
      that is most sought abroad.

      The hospital's director, Dr. Damson Kathyola, a peasant's
      son educated at University College London, seems to feel an
      almost physical pain when he describes trying to run a
      major medical institution that is hemorrhaging nurses.

      "Unbearable," he said, leaning his head back and squeezing
      his eyes shut. "Unbearable."

      In Malawi, afflicted with one of Africa's most severe
      nursing shortages, almost two-thirds of the nursing jobs in
      the public health system are vacant. More registered nurses
      have left to work abroad in the past four years than the
      336 who remain in the public hospitals and clinics that
      serve most of the country's 11.6 million people, according
      to Malawi's Nurses and Midwives Council.

      Many of these English-speaking nurses have flocked to
      Britain, which is confronting its own acute shortage of
      nurses to care for an aging population. Its central nursing
      register shows that the number of nurses being certified
      from Malawi, South Africa, Nigeria, Ghana, Kenya, Zambia,
      Zimbabwe and Botswana - all former British colonies - has
      soared since 1999.

      African nurses are also migrating, though in smaller
      numbers, to the United States and New Zealand, with
      trickles to Australia and Canada. There are now more than
      3,100 registered nurses from Africa in the United States,
      according to a national survey of nurses by the Department
      of Health and Human Services.

      As projections show the shortfall of nurses in the United
      States ballooning to 800,000 by 2020, the pressure to
      recruit abroad is likely to grow.

      "The U.K.'s experience could be a harbinger of what we'll
      see in the U.S.," said Julie Sochalski, associate professor
      of nursing at the University of Pennsylvania.

      But Africa's nurses are not just moving overseas. They are
      also quitting government service for better-paying jobs in
      their own countries at private hospitals and
      foreign-financed nonprofit groups and research

      Thousands more have left the profession or are simply
      dying, especially in southern Africa, where rates of H.I.V.
      infection are highest. In Malawi, a quarter of public
      health workers, including nurses, will be dead, mostly of
      AIDS and tuberculosis, by 2009, according to a study of
      worker death rates in 40 hospitals here. Drugs for people
      with AIDS have been unaffordable up to now.

      The bottom line: sub-Saharan Africa's low-income countries
      need to more than double their nursing work forces, adding
      at least 620,000 nurses to grapple with severe health
      emergencies, according to estimates developed for the Joint
      Learning Initiative, a network of more than 100 scholars
      and analysts studying human resources for health and
      coordinated from Harvard University.

      The nursing crisis is intensifying just as billions of
      dollars in foreign aid is beginning to pour into Africa to
      provide life-saving drugs to millions of people afflicted
      with AIDS and tuberculosis.

      The money includes the first installment on a total of $15
      billion promised by President Bush and $2 billion from the
      Global Fund to Fight AIDS, Tuberculosis and Malaria.

      The shortage of nurses compromises the ability of countries
      to use this money effectively, and the money itself is
      likely to aggravate the nursing shortage in public
      hospitals. A substantial portion will be channeled to
      nonprofit groups that are likely to hire away yet more
      nurses at higher pay.

      As the world focuses its resources on AIDS, the risk is
      that more women giving birth and more children needing
      hospital care for easily treatable conditions like
      respiratory infections and diarrhea will die, experts say.

      "I think it will destroy the whole system," Dr. Kathyola

      One Nurse and 26 Babies To spend a few weeks roaming the
      wards of Lilongwe Central is to see the human cost of the
      nursing shortage.

      Late one night on the nursery for sick and premature
      newborns, the sole nurse on duty stepped away - and 26
      babies, packed two and three to a bassinet, were on their

      In one crib, a tiny baby girl, blue and dead, lay next to
      her sister, eyes open, tiny fists clenched, mouth yawning.

      Earlier, on the day shift, Tereza Kachingwe, a rotund,
      kindly nurse, had steadfastly stood by the premature
      babies, trying to keep them alive. But the hospital had run
      out of the thinnest tubes needed to suction such miniature

      "If this tube was smaller, I could go deeper into the
      trachea," she said ruefully, as she easily held one of the
      featherweight newborns in her palm, sweeping the tube back
      and forth in the infant's mouth.

      Mrs. Kachingwe looked around at the many other babies who
      needed her attention, then turned back to the tiniest ones
      barely clinging to life. "Today, I'm stranded," she sighed.

      On another day in the gynecological ward, Tandu Mbvundula
      was the only nurse tending 51 patients, dispensing pills
      and a bare minimum of words. Unsmiling, she pushed a
      medicine cart into a room so packed with patients that some
      lay on the concrete floor in the darkened spaces beneath
      the beds.

      She rolled up to Mary Kaliyati, a mother of five whose
      uterus had ruptured giving birth in a mission hospital.
      Mrs. Kaliyati was transferred to Lilongwe Central. After
      surgery to remove her uterus, she had developed an

      The nurse explained that the hospital was out of its most
      potent antibiotic, so she had given Mrs. Kaliyati a weaker
      combination. The first round had failed. The woman was
      still feverish. So the nurse was giving her a second round
      of the same weaker antibiotics.

      Will the treatment work?

      Mrs. Mbvundula shrugged numbly. "Maybe," she said, and
      then moved on.

      Hospital officials say the rate at which women die of
      causes related to pregnancy at Lilongwe Central has held
      steady in recent years, but cases of ruptured uteruses have
      sharply spiked. Dr. Bernard Reich, one of only two
      obstetricians working at Lilongwe Central, said such
      complications should simply not happen to women giving
      birth in a hospital.

      In Malawi as a whole, the rate at which women die of causes
      related to pregnancy almost doubled from 1992 to 2000. One
      in 89 births results in the death of the mother, among the
      worst such rates in the world.

      A 2001 review of hundreds of confidential maternal death
      audits from 18 hospitals in southern Malawi found that more
      than half the deaths were associated with substandard
      hospital care.

      "It's the worst change in a health indicator - outside of
      wars and natural disasters - that I've seen in the 36 years
      I've been knocking around developing countries," said
      William Aldis, who represents the World Health Organization
      in Malawi. "It tells me that there's a catastrophic failure
      of the health system in this country to meet the minimum
      needs of the population. The sheer lack of skilled people
      is the major contributing factor."

      The Ministry of Health in Malawi is proposing an increase
      in the number of nurses and health professionals being
      trained, while more than doubling their pay. Major donors,
      including Britain and the Global Fund, said they recognized
      that Malawi faced a staffing emergency and would provide
      financial support to help it hang on to its health workers.

      Here at Lilongwe Central, registered nurses, who make about
      $1,900 a year, said if their pay were doubled or tripled,
      they would be more likely to stay, but added that they had
      heard such promises before.

      In recent interviews with the hospital's 30 remaining
      registered nurses, 20 said they planned to leave for better
      paying jobs in Malawi or abroad. Six more said they were
      thinking about it.

      Beatrice Mkandawire, 40, a senior nurse on the children's
      ward and a mother of four, dedicated her entire salary from
      the month of May - $145 - toward paying the initial $215
      fee to register as a nurse in Britain. She and her husband
      will beg for help from relatives and skimp on food to make
      ends meet. She hopes to be there by the end of the year.

      Tall and stately in a pristine white dress, she wondered
      sorrowfully, "If I leave, who will look after the patients
      when I'm gone?"

      A good deal of damage to the hospital's staff is already
      done. Workloads worsen every time another nurse leaves.
      Even the most basic supplies and medicines are in short
      supply or simply absent.

      The labor ward at Bottom Hospital, an aging appendage to
      Lilongwe Central, is especially afflicted. The hospital got
      its name because it is at the bottom of a hill and also
      because it served poor Africans during British rule. The
      British went to Top Hospital at the top of the hill.

      The sewage system at Bottom has never worked properly. The
      maternity ward often smells like a toilet. Blood, sweat and
      amniotic fluid have seeped through torn vinyl covers into
      the thin mattresses, adding to the stale odor.

      There are no bed linens, or enough scissors to cut
      umbilical cords. Pregnant women are required to bring a
      thin plastic sheet to lie on and a razor blade to slice the
      cord. If they forget the razor, nurses scold them and take
      one from the supply cabinet, breaking it in half to double
      its use.

      Bathrooms used by nurses often lack soap, raising the risk
      of passing infection. For two days in May, nurses refused
      to do vaginal exams because the ward was almost out of
      latex gloves - this in a country where nurses have to
      assume that any woman they examine may be H.I.V. positive.

      With only 10 nurses to cover the ward around the clock,
      they often have to work extra shifts. The hospital has
      almost no money for such expenses. For overtime, they earn
      less than 20 cents an hour.

      Lured by Money and Comfort

      Mrs. Kunkeyani, the glue who holds the labor ward together,
      has decided she must leave Malawi for the sake of her

      Like many employed people in a country where life
      expectancy has fallen to 38 years, she and her husband,
      Isaac, a civil engineer, are helping support eight orphaned
      nieces and nephews, as well as their 9-year-old daughter.

      The Kunkeyanis have been trying to complete construction of
      their red brick home over the past two and a half years,
      but money has been scarce.

      For almost a year, they lived without electricity. They
      cooked over a wood fire behind the house. They ate dinner
      by the light of a hurricane lantern. Mrs. Kunkeyani rose at
      5 each morning to heat pails of water for bathing.

      Their money woes are constant and nagging. Her daughter was
      recently sent home from the private school she attends
      because the Kunkeyanis had not kept up with the fees. They
      can only afford meat once a week, on Saturday. They drink
      their tea black, to save on the cost of milk.

      When the letter of acceptance from Britain's Nursing and
      Midwifery Council arrived in April, Mr. Kunkeyani ripped it
      open. He phoned his wife, at work on the ward. She said she
      literally jumped for joy.

      Mrs. Kunkeyani has only to look to her elder cousin, Jane
      Banda, to see what her family can gain by moving to
      Britain. Like Mrs. Kunkeyani, Mrs. Banda was herself the
      nurse in charge on the labor ward at Bottom in the
      mid-1990's and led Malawi's national breast-feeding program
      until she moved to England in 2001.

      Mrs. Banda, 44, reared the teenage Mrs. Kunkeyani and
      inspired her to be a nurse. Once again, she has scouted the
      way ahead.

      She now lives in a modest two-story house on a quiet,
      winding lane in a tidy English city that she asked not be
      named to protect her privacy. She works full time as a
      nurse on a surgical recovery ward in a National Health
      Service hospital where she cares for five patients or so.

      "Here, you go into wards, they're spic and span, like
      hotels," she said admiringly.

      She puts in another 10 hours a week in an elegantly
      appointed nursing home looking after elderly men and women
      who sit in comfortable club chairs watching television.

      Her husband, B. F. Banda, a slender, bespectacled former
      bureaucrat, used to be in charge of human resources
      planning for Malawi in the office of the president - a good
      perch for assessing the shortcomings in pay for government
      nurses and their value elsewhere.

      He explained that Malawian nurses like his wife who go to
      Britain generally started in private nursing homes. Once
      established, they apply to the National Health Service,
      which offers a steady salary and good benefits.

      Despite taxes and the higher cost of living, Mrs. Banda
      said she lived comfortably. Starting pay for a nurse in the
      National Health Service is about $31,000, but she has
      progressed beyond that. She also earns $21 for each hour of

      Mrs. Banda is able to send more money home to her parents
      each month than her cousin, Mrs. Kunkeyani, earns in a

      "If I'm broke, I simply phone her and the following day she
      sends me 200 pounds," said Mrs. Banda's husband, who
      remains in Malawi and now works as a management consultant.

      With their expanded income, the Bandas are building a new
      house in Lilongwe, where she will settle after their three
      children finish school in Britain. It is ornamented with
      intricate, wood-inlaid ceilings and glittery terrazzo
      pillars. It will boast servants quarters, an orchard of
      mango, guava and banana trees and security cameras at a
      gated entrance.

      Another nurse who left Lilongwe Central, after 15 years
      there, is Chimewmwe Nhlane, who has worked in a private
      hospital in Bristol for three years. She is thrilled with
      her new job. Her salary tops $35,000 a year, and she
      receives annual merit raises and bonuses. For outstanding
      work, the hospital gives her a box of chocolates or a
      bottle of wine.

      She tells the British nurses she works with, "What I'm
      doing here is child's play compared to what I was doing at

      The recruitment of nurses like Mrs. Banda and Mrs. Nhlane
      has long been a sore subject with Britain's former African

      Nelson Mandela, when he was South Africa's president,
      criticized Britain for recruiting its health workers. The
      country has spent $1 billion educating health workers who
      migrated abroad - the equivalent of a third of all
      development aid it received from 1994 to 2000, according to
      a report of the Organization for Economic Cooperation and

      But even as the British prime minister, Tony Blair, has
      championed increased foreign aid to Africa, his government
      has faced political pressure to improve health care at
      home. The government has since hired tens of thousands of
      nurses, many from overseas.

      In 2001, Britain adopted codes to limit the government's
      active recruitment of health professionals from developing
      countries. But the code does not apply to private
      recruitment agencies or private employers.

      Nor does it prohibit the National Health Service from
      hiring foreign nurses who apply on their own. Since 1998,
      12,115 African nurses have registered to work in Britain.

      A debate has begun within the British government about the
      migration of health workers. Sarah Mullally, chief nursing
      officer for the Department of Health, said, "We can't stop
      mobility - that would be against human rights to say people
      can't move."

      But Suma Chakrabarti, who heads Britain's Department for
      International Development, voiced discomfort with some
      consequences of government policies.

      "Frankly, it's too easy to get into the U.K., which may be
      good for the U.K., but may have a deleterious effect on
      Malawi," said Mr. Chakrabarti, who visited Lilongwe Central
      earlier this year and saw firsthand its depleted staff.

      A similar debate is going on in Malawi. Joseph Mutso-Bengo,
      a professor of bioethics at Malawi's College of Medicine,
      noted that nurses could barely make ends meet and asked,
      "Do we have the right to force them to stay?"

      But Anthony D. Harries, a British doctor who has lived and
      worked here for 15 years and advises the Health Ministry,
      called it immoral for Britain to allow the easy migration
      of Malawian nurses.

      "Come on," he said, "train your own unemployed people."

      Hard Time at the Labor Ward

      Night had fallen. The labor ward at Bottom seethed with the
      moans, shrieks and whimpers of women suffering through
      childbirth. "The Look of Love" played scratchily on a
      transistor radio propped on the counter. Babies were being
      born at a steady, intense pace. The two nurses on duty
      sometimes did not have time even to mop up puddles of
      amniotic fluid and blood the new mothers lay in before
      moving to another bedside.

      As the clock neared midnight, the two nurses had already
      delivered a dozen babies and still had eight or nine hours
      of work ahead of them.

      "Nurse, nurse, please help me, I'm in pain," pleaded one

      Lesnat Chatambalala, a small-boned, soft-spoken nurse,
      approached her and said tersely, "It isn't time yet."

      "Please, help me, I'm begging you," the woman insisted in a
      quavering voice.

      Mrs. Chatambalala walked away.

      She began talking about her desire to quit for work in a
      private organization in Malawi that pays better. "I'm
      willing to go to the U.K., but I can't leave my kids," she
      said miserably.

      For Mrs. Chatambalala, 36, there is no respite. Her
      husband, a high school biology teacher, was hospitalized
      last year. Doctors found he had a candida infection common
      to people with AIDS. But before he could be tested, he
      jumped off a fourth-floor balcony in Lilongwe Central. Mrs.
      Chatambalala is now the sole support for their four

      After 15 hours of hard labor on the ward, she trudged the
      final steps home in her dusty black pumps and white dress.
      Her children were in the courtyard waiting for her.
      Two-year-old Sterns climbed in her lap and wrapped his arms
      around her neck. More work lay ahead of her. There were
      children to be bathed, a house to be cleaned.

      Back on the labor ward, an exhausted Mrs. Kunkeyani was
      starting her seventh straight day shift. She was alone when
      the babies started coming out in such rapid succession that
      she could not be there for four of the births. She and the
      women there described later what had happened.

      Faida Yusuf, 20, had her first baby alone on the floor. The
      force of the final push ripped her vaginal wall because
      Mrs. Kunkeyani was not present to guide the baby boy's head
      at its narrowest diameter or to make a neat incision.

      Finally, four hours later, Mrs. Kunkeyani found time to
      suture the tear, but Mrs. Yusuf pulled away. A big-hearted
      woman with reserves of steely religious faith, Mrs.
      Kunkeyani coaxed and cajoled the frightened young mother.
      "Don't be scared," she said soothingly. "You've already
      been brave. Please trust me. You know when somebody is cut
      by a razor blade. It hurts, right?"

      "Yes," Mrs. Faida said uncertainly.

      "So it's like that,"
      the nurse told her, explaining she needed to give her an
      injection to blunt the pain. "Be brave. The tear is

      Again, the mother drew away, pulling her legs close into
      her body.

      "You must lie back," Mrs. Kunkeyani insisted. "We can't
      leave the wound. It has to be stitched. There's no other
      way. You're saying you're hungry. You can't eat until I
      finish. What do you want me to do? Leave?"



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    • Vyrle Owens
      18 July 2004 Dear Varsha and all you ujeni folks, By chance I read parts of the NY Times on Monday, 12 July. The article about Malawi nurses and Lilongwe
      Message 2 of 2 , Jul 18, 2004
        18 July 2004

        Dear Varsha and all you ujeni folks,

        By chance I read parts of the NY Times on Monday, 12 July. The article
        about Malawi nurses and Lilongwe Central Hospital was among the first to
        get my attention.

        Later that day I visited a patient (grandson) in the Yale University
        Neo-Natal Intensive Care Unit. Incredible contrast. There are 110
        highly qualified, fully experienced nurses caring for 50 premature
        babies. (They actually had 55 on Monday and were required to bring in
        additional equipment but the actual number of babies in the unit is
        usually a bit below the 50 bed capacity.)

        I am grateful for the resources available for my daughter and grandson.
        In another time or place I most probably would have been attending a
        funeral. Nevertheless, the stark contrast and resource imbalance makes
        for sober reflection.

        Another subject

        Checked the e-mail yesterday after 10 days absence and was gratified to
        read a number of ujeni messages. It is really nice to hear from/about
        people I know. Congratulations and all my best to you new parents, new
        spouses, new travelers (or is it "renewed" travelers?), and successful
        job seekers. Let us hear/read more about your adventures, especially in

        Y'all have a great day,


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