"Swaziland is dying. Will the last nurse on duty please turn off the lights?"
December 11, 2006 -- Recent articles by IRIN (Integrated Regional Information Networks) highlight the deadly interaction between the HIV/AIDS crisis and the lack of resources for nurses in sub-Saharan Africa. "MALAWI: Health worker shortage a challenge to AIDS treatment," posted on November 17, describes how that nation's acute shortage of nurses and other key health staff impedes ambitious efforts to expand anti-retroviral treatment. Today's "SWAZILAND: Nurses fleeing the HIV/AIDS frontline" focuses more on the nursing shortage. In Swaziland, the shortage reportedly stems from a combination of emigration for better opportunities and attrition caused by HIV/AIDS itself--an estimated 38% of the nation's remaining public and mission sector nurses are HIV positive. Both pieces effectively show how the AIDS crisis and the nursing shortage exacerbate each other. We thank IRIN for this coverage.
The Malawi piece explains that "[w]hile the HIV/AIDS epidemic has multiplied the need for doctors and nurses in southern Africa, the pool of workers has shrunk," as many flee the extreme lack of resources or succumb to the disease itself. To underline the "daily, demoralizing struggle" of such workers, the piece focuses on Sarah Nafere, a nurse who may have to care for more than 100 patients at a time at Nkhata Bay Hospital. Nafere says she has no plans to leave ("I can't leave my relatives suffering here because of money"), but she has also "seen little evidence of the government's efforts to retain its health workers." Although her district hospital's anti-retroviral (ARV) clinic alone treats 926 patients, the hospital has a total of just 18 nurses, five clinical officers, and one physician. The piece quotes government technical advisor Dr. Michael O'Carroll on the scale of the problem. He says Malawi has 100 public hospital physicians for a population of 12 million, and 64% of the nursing posts are unfilled, resulting in "large numbers of people crying for services and  nurses  on their feet 18 hours a day."
The article explains that the lack of human resources is the biggest threat to Malawi's ARV program, which runs largely through the public health services. The nation hopes to add about 40,000 patients per year over the next few years to the 70,000 who now get ARV treatment; each year, an additional 90,000 need ARV treatment. Measures to support this plan include the use of wage supplements from aid agencies, health workers from other nations, simplifying treatment through basic diagnostic approaches, and the use of less trained health workers like health surveillance assistants (HSAs), who get 10 weeks of training, to give the drugs. O'Carroll sounds rightly uncomfortable with reliance on less trained workers in the expanding ARV program, but he stresses the need to get the life-saving drugs to as many patients as possible.
The piece on Swaziland describes a sadly similar situation, but focuses on the plight of the nurses themselves. According to a recent report released by the online journal Human Resources for Health, "emigration and attrition due to HIV/AIDS" were "major factors depleting the health workforce," resulting in public health sector vacancy rates of 19% for nurses and 44% for physicians. However, those figures would seem to understate the problem, since the piece reports that the government's zero growth policy has meant that no new posts have been created in over 30 years. Thus, as the journal report notes, the nurse-to-population ratio in the public and mission sectors is about 70-to-100,000. (In many developed nations the ratio would be more than 10 times that ratio.) The researchers also estimate that about 38% of the 758 nurses working in those sectors are now HIV-positive, and that 3-4% of the nursing workforce is likely to die each year from AIDS-related illness. Overseas migration is an even bigger drain, as the report estimates that about 100 additional nurses--more than 10% of the total--leave the nation each year. And each year, Swaziland's two nursing colleges get hundreds of applicants, but they produce only 80-90 graduates because of a lack of human and other resources.
The piece briefly describes measures that might ease the crisis. The Ministry of Health has asked for the lifting of a ban on the recruitment of foreign nurses, whose salaries "would be paid by the Global Fund to Fight AIDS, Tuberculosis and Malaria." The piece does not explain the reason this ban exists. In addition, the government's ARV rollout could reduce the number of "chronic HIV/AIDS patients" and throw "a lifeline to HIV-positive nurses." The piece might have gotten expert comment on how likely these efforts are to make a significant difference.
The piece also describes the situation of specific nurses to show how this plays out on the ground. A handwritten note at a clinic in Manzini, the "AIDS-hit commercial centre," reads:
Swaziland is dying. Will the last nurse on duty please turn off the lights?
One nurse, who asked that her name not be used, says that the working conditions, including the lack of drugs and equipment, are a key factor in emigration: "It's not just the money--it is hard to watch people die and you are helpless to do anything about it." The piece describes a child screaming in pain as a nurse struggles to remove sutures without the right scissors. Meanwhile, the nurse says that time-intensive AIDS care "is making our work so much harder." The journal reports that "health workers speak of feeling overwhelmed and burned out." The piece closes with a quote from a nurse:
No one wants to talk about it, but Swaziland's AIDS problem is frightening nurses. We are on the frontline of this battle, and it is easy for some to run away from the danger. It takes real patriotism and dedication to your calling as a nurse to work as a nurse in Swaziland today.
We thank IRIN for these important reports.
Please donate to Save the Children or Care, which are among the aid organizations that are working to improve health care in these countries. Save the Children has a program in Malawi, and a program in Swaziland. Care has a program in Malawi. Thank you!