NYTimes.com Article: An Exodus of African Nurses Puts Infants and the Ill in Peril
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An Exodus of African Nurses Puts Infants and the Ill in Peril
July 12, 2004
By CELIA W. DUGGER
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
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
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
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
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
"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
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
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
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
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
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
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
"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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Copyright 2004 The New York Times Company
- 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.
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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