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Text by Christine Gorman and photographs by Eileen Hohmuth-Lemonick rom June through August 2008, photographer Eileen Hohmuth-Lemonick and I traveled throughout Malawi in southeastern Africa, documenting the everyday life of its nurses. For years, I had written tightly focused articles on advances in the treatment of asthma, diabetes, and other diseases and on important issues like the nursing shortage. But when I was given a Nieman Fellowship for Global Health Reporting at

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Harvard University, I decided to look at a larger theme: how health systems affect the way health care is delivered. I decided to focus on nurses. I chose Malawi because in recent years its health system had nearly collapsed. Nurses are the strong connective tissue that holds Malawi’s health programs together. I also hoped to study innovative efforts to stop the exodus of nurses from this tiny African country. ajnonline.com


p Hundreds of women and children wait patiently— the occasional temper tantrum aside—for the mobile clinic to arrive in Emazwini, Malawi.

www.who.int/whosis/data.) Lots of countries have nursing shortages, but Malawi has one of the lowest ratios of health care workers to total population in the world. In 2004 in Malawi, there were officially 7,264 nurses— including RNs and nurse midwife technicians—for 13 to 14 million people. That’s about a quarter of the minimum the WHO considers adequate for countries in the developing world. During our travels, I learned that the flight of nurses from the country has slowed, falling from a high of 111 nurses and midwives who registered to emigrate in 2001 to 23 in 2007 and to just six in the first half of 2008. Much of the positive trend can be tied to an emergency human resource program—designed by Malawi’s Ministry of Health and supported by funding from the United Kingdom’s Department for International Development—that boosted nurses’ salaries and nursing school enrollments by 50%. However, shortages remain, fueled in part by a growing number of international nongovernmental organizations that hire nurses to work in record-keeping and administrative positions, not clinical services; the organizations also tend not to be concentrated in the rural areas where the need and the population are greatest. In addition, a paucity of science and math teachers at the high school level

Malawi has always been poor, but the health of its people has suffered dramatically over the past decade. According to the World Health Organization (WHO) Statistical Information System, healthy life expectancy at birth fell to 35 years in 2003. HIV, lower respiratory infections, and malaria are the three leading causes of death. The prevalence of HIV in adults 15 years old and older stands at about 12.5%. One bright spot: infant mortality per 1,000 live births fell from 95 in 2000 to 76 in 2006. (Data on health indicators in countries around the world is available at ajn@wolterskluwer.com

means that many students are unable to qualify for nursing school. Christine Gorman is a New York City–based independent journalist and 2008 Nieman Fellow for Global Health Reporting at Harvard University. She wrote about health and medicine for Time magazine for more than 20 years. Eileen Hohmuth-Lemonick is a photographer who teaches at Princeton Day School in Princeton, NJ. Contact author: cgormanhealth@gmail.com. Funding for the project was provided by the Nieman Foundation for Journalism at Harvard University, supported by a grant from the Bill and Melinda Gates Foundation. All photographs © 2008 Eileen Hohmuth-Lemonick.

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q At Embangweni Mission Hospital in rural northern Malawi, nurse Walinase Ndovi takes the temperature of a child who is suspected of having malaria. Thanks to a combination of education, prevention, and treatment efforts, the death rate from malaria among children in this area has fallen dramatically over the past five years.

o Community health nurse Joyce Ngo’ma listens for a fetal heartbeat at a mobile clinic in Emazwini, Malawi.

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q Nurse midwife technician Jane Chibaka delivers a healthy baby at Embangweni Mission Hospital. Although Malawi’s national guidelines call for at least two health care workers to staff each shift on the labor and delivery ward, the nursing shortage means that Chibaka is alone today.

o Even without fertility drugs, the birth of twins is surprisingly common. Madalitso Chosalowa, a nurse midwife technician at Embangweni Mission Hospital, tends to one newborn while the other is still being delivered via cesarean section. Both children prove healthy.

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r The crowd is all ears as Matilda Nyambo conducts a lesson in female reproductive biology. Nyambo is a nurse at Neno District Hospital in southwestern Malawi, which is jointly operated by Malawi’s Ministry of Health and the Massachusetts-based nongovernmental organization Partners in Health. Partners in Health makes a point of working with local governments in rural areas to attract more health workers to the public sector.

q The work is never finished. After completing a shift at the hospital, nurse midwife Dorothy Nyirongo chops wood before cooking dinner over an open fire. ▼

To see more photos and commentary on nursing in Malawi by Gorman and Hohmuth-Lemonick, go to http://links.lww.com/A1319. To listen to Gorman discuss why she focused on Malawi and how the nurses there responded to her interest in them and in their work, click on “Podcasts” at ajnonline.com. 30

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"At work with Malawi's Nurses