Filling out the Picture

7 August 2008

When I first came to Malawi, one of the questions that was uppermost in my mind was why nurses leave the country to work in the U.K. or other English-speaking countries or why so many leave the public sector to work for non-government organizations or private hospitals and clinics. But in truth, that's pretty easy to understand. Much of it boils down to better pay, better working conditions (fewer hours, fewer patients, more resources), better housing and more opportunities for their children.

What has been a lot harder to get at is why nurses stay in Malawi, particularly why they stay in the public sector. Catherine Ndolo in Embangweni taught me to look at relationships, at how much the workplace demonstrates that it cares about both its patients and its staff. Others have talked about the opportunity to advance—that they stay with government positions because, after a few years, the Ministry of Health will pay to upgrade their education.

Then in just the past two days I spoke with two nurses—Grant Ngugluwe and Maureen Juma—who had almost diametrically opposed views. Both of them work in Mulanje. Maureen is a nurse tutor at the Mulanje Mission College of Nursing. Grant works in the male ward at the Mulanje Mission Hospital. I talked with each of them separately so it's a little unfair to compare their responses. But they stated their positions so eloquently like that I couldn't help but play one against the other.

Both of them are from the younger generation of Malawians, who have graduated from nursing school in just the past five years. Neither has the sense of caution that I witnessed so often in older nurses—many of whom learned from bitter experience during the Banda era not to rock any boats.

Grant took the more cynical view. When I told him that many nurses told me they stayed because they loved their country—and who would look after their remaining family if everyone left—he told me he wasn't so sure patriotism played such a big role. "Maybe they don't know how to go overseas?" he said. "Much as everyone talks of professional dedication, everyone is looking for better jobs."

He confirmed my suspicion that one way many nurses make the contacts needed to emigrate is by first working for an international NGO. "If you work for an NGO, then you have access to the internet," Grant said. "You also have more access to information in general. You make contact with people in the field."

Then of course there are also friends and classmates who have already made the move abroad.

Grant thought family ties played a stronger role than patriotism in determining whether registered nurses stayed or left. (Nurse midwife technicians—who provide the bulk of Malawi's nursing care—do not have an internationally marketable degree. But it's impressive to see how many upgrade to a bachelor's in registered nursing.)

Maureen Juma, on the other hand, was passionate about the need to serve—and she sounded very sincere to me.

(I've also talked with several nursing students who clearly thought that the patriotic line was a good one and had probably used it for their nursing school interviews. I had to make sure not to smile during some of those interviews—especially when I heard the almost identical phrases coming out of different students' mouths.)

What's particularly interesting to me is to compare the transcript of what Maureen said to the actual recording of her words. Her passion really grabs you through the headphones in a way that the simple transcript doesn't. Comes back to that issue of what each medium does best. Audio is ideal for conveying emotion. Print is an excellent vehicle for giving detailed information—facts, figures and analyses.

One thing Maureen was especially passionate about was how often Europeans and Americans focus on what's missing in Malawi. She says she was particularly struck by this during a recent trip to Norway for advanced training in nursing education. One person very patronizingly started to explain to her what a computer was. "As if we didn't have computers in Malawi," she exclaimed. Another went so far as to ask "if they have cars in your country?"

Her words were coming out so fast by this point in the interview that some of them got a little jumbled up. But the point was clear. A lot of people come to Malawi prepared only to see the worst.

"These people take only bad pictures and they don't know that there's the good side of things," Maureen said. "They think that when you go to Malawi you are going to find people that are dying of hunger, people that are all HIV positive. That's not the news and that's not the situation. Malawi is also a country that has got its own potentials. And it's got things that are good—a lot of them. Apart from having the Lake [Lake Malawi], apart from having the Mountain [Mulanje Massif], we've got people like us who are willing to work in Malawi and stay here for good."

It was a message to the world but also a message to me and to Eileen about what we are doing in Malawi—about making sure we show both the positive and the negative.

I told Maureen I agree that photos and stories from Malawi often emphasize the negative at the expense of the positives that do exist. I've tried on this trip to get a much broader picture—no whitewashing but no unnecessary gloom either. Realize this could be a tough one to pull off. But I'm going to give it my best shot.