NPR science correspondent explains it all for you: Kenyan clinical officers are "not quite a doctor, but more than a nurse"
November 3, 2005 -- Today National Public Radio's Morning Edition ran a lengthy report by "Science Desk Correspondent and Editor" Brenda Wilson about the trend of developing world physicians migrating to wealthier nations. "Developing Countries See Health Care 'Brain Drain,'" which is part of NPR's extensive global health series airing this week, highlights some of the worrisome effects of this "exodus" on developing world health. But as the quote in the headline above makes clear, the piece regards nurses as peripheral health workers who have only basic physician skills, rather than members of a distinct profession with its own unique skills and approach to care. The report also portrays nurses as qualified to care only for patients with less serious illnesses, and as workers poor nations will have to settle for until a solution to physician migration is found. We would not necessarily ask the piece to discuss the devastating nursing exodus from these same nations. Many good nursing shortage pieces do not discuss physicians, and the brief introduction from the Morning Edition hosts does mention that the brain drain includes physicians and nurses. And the severe shortage of nurses in African nations has received significant coverage, notably in the U.K. But because the Wilson report does focus so closely on who is left in places like Kenya when the physicians leave, its apparent failure to even mention the nursing shortage is glaring. It is, however, consistent with the overwhelming physician-centrism (even physician glorification) in the prior reports Wilson has filed on Africa as part of this week's series, which focus on the work of Doctors Without Borders and the Flying Doctors in Africa. In these reports, only diagnosis and treatment by heroic roving physicians matters in the health of the population. Nurses are ignored, except to receive the occasional "order."
Today's piece on the physician shortage focuses on Kenya. It explains that huge numbers of physicians that poor nations in Africa and Asia have trained at great expense have recently migrated to wealthier nations like the U.K., Canada and the U.S., where there are better opportunities. The natural result is a shortage in Africa, with severe negative effects on already fragile health systems. The piece notes that Kenya has only one physician for every 10,000 people, and it quotes Kenyan physicians with regard to the difficulties posed by this situation.
About half way through the piece, Wilson reports from a community health center at a Masai village near the Tanzanian border. She does briefly quote a nurse from a community health center there, who says that a patient with an OB emergency, prolonged labor, will have to be taken to a hospital some distance away. The piece suggests that it is common for such women in Kenya to face labor without "anyone" trained to assist them with complications, leading to one of the highest rates of maternal mortality in the world. The report also says that "because there are not enough doctors, the center is run by a clinical officer." This assumes, wrongly, that only physicians are qualified to run health clinics. The piece does not explain exactly what training clinical officers have; it notes that they can do some surgical procedures, but not caesarian sections. But by way of fixing their expertise in our minds, Wilson states--without citation--that they are "not quite a doctor but more than a nurse." This, of course, is like saying that someone is not quite a doctor, but more than a science correspondent. Contrary to Wilson's assertion, physicians and clinical officers are not "more than" nurses. Most nurses do have less formal education than physicians, but nursing is an autonomous profession with a unique, holistic approach to care. And although there obviously is an overlap with medicine, nurses as a group have skills and expertise that physicians do not have. No doubt Kenyan nurses (like Kenyan physicians) face daunting challenges in getting the best training. But nursing is not a basic subset of medicine.
The piece goes on to state that clinical officers are the "backbone of Kenya's health system. They run most of the health centers. They have some medical training. They know anatomy, and can perform minor surgery." In fact, a recent report relying on Kenyan government statistics suggested that the number of clinical officers was similar to the number of physicians, and that there were roughly ten times as many nurses and nurse/midwives in the nation. We are not endorsing the idea that nurses are the "backbone" either. We have been ambivalent when others (like Dr. Phil) have said as much, as it tends to suggest that nursing is about being reliable, but not about thinking. But in this report the statement that the clinical officers are the "backbone" would seem to indicate a belief that nurses are of little significance. And the somewhat condescending measurement of clinical officers against physicians appears to reflect the complementary view that serious health care consists of whatever physicians do.
Later, the piece states that for now Kenya's poor and rural people will "probably have to depend on clinical officers, and comprehensive health nurses, because they have broader skills." It's not clear whether this is a suggestion that physicians would be doing the jobs of these nurses if they were available, or just that the nurses have broader skills than clinical officers. Of course physicians have unique skills, but so do nurses, and what most listeners will take away from this is that patients will have to settle for nurses because physicians are not available. Would the piece suggest that patients have to settle for physicians when nurses are not available?
Then, a Kenyan physician whom the report regards as an expert says: "We know nurses can deal with 80% of the problems, but it is this 20% which kills people." This is a brilliant distortion of the relative roles of physicians and nurses (though it is not unique--the Robert Romano character on NBC's "ER" once asserted that nurses can treat 90% patients at the cost of killing the other 10%). The distortion starts with an indisputable fact: physicians have some medical knowledge that most nurses do not have. From that limited fact, it leaps to the idea that nurses can care for most illnesses by themselves, but that they cannot handle the most serious illnesses. The end result is that the listener concludes that nursing is merely a subset of medicine, and that nurses are essentially inferior physician assistants. However, seriously ill patients need both medical and nursing care, and neither group of professional has all of the knowledge or skill that the other has. Patients will die just as quickly without nursing care as without medical care--and thousands do. The statement also seems to suggest that nurses cannot handle conditions that are life-threatening; obviously, that is not correct, as a quick look at the Boston Globe's recent series on SICU nurses at Massachusetts General would show. (The physician in the NPR piece may have been thinking only of medical expertise, rather than nursing expertise, but few if any listeners will make that distinction.)
This piece and the others Wilson has filed this week also appear to equate physician diagnosis and treatment with all health care. But it is nurses who are the critical sentinels who use advanced skills and technology to monitor patients' conditions day and night, who assess and intervene with skilled care, who advocate for their patients and teach them how to cope with their conditions. Hospitals exist primarily to provide nursing care. Simply diagnosing a problem and recommending treatment does not solve the problem, and in any case, physicians do not diagnose or treat by themselves. Nor is a patient healthy ten minutes after a serious operation. Nurses are irreplaceable at every stage of patient care.
At the end of the piece, Wilson notes that normally at the clinic near the border, "four nurses and a nurse-midwife are preoccupied with 80% of the illnesses." She mentions diarrhea, TB, and malaria. This again suggests that nurses and physicians do the same basic thing, it's just that nurses handle the easy stuff. Of course, as the piece itself recognizes, these conditions are some of the biggest killers in the world, which may at least counter the earlier suggestions that nurses don't deal with the life-threatening illnesses. Perhaps it's just the more extreme forms of these illnesses that nurses can't handle. In any case, the piece concludes with a brief profile of a young Kenyan health provider at the clinic. We hear that this woman is examining children, we hear a brief audio quote, and Wilson suggests that she longs to "advanc[e] her career in medicine." Obviously this suggests that she is a physician, or perhaps a clinical officer. But of course it is common to use "medicine" to refer to all health care, so it's not impossible that she is the nurse-midwife or one of the nurses, because as far as we can tell, she is never identified by profession. Perhaps Wilson just assumes that because she is worthy of attention, listeners will know that she is a physician.
We commend Ms. Wilson and NPR for highlighting some of the critical health issues facing poorer nations. Unfortunately, the treatment of nursing in her reports is very poor indeed. And in the context of the devastating nursing shortage that is taking lives in Kenya and elsewhere, that's not good news.
See Brenda Wilson's recent articles:
"Developing Countries See Health Care 'Brain Drain'" on November 3, 2005;
"New Malarial Therapy Reaches Remote Africa" on November 2, 2005;
"Flying Doctors to the Rescue" on October 30, 2005.