This month I traveled back to Madagascar for a friend’s graduation. You can read his story here. For a quick recap, he worked with me as a translator in 2015. Before the ship arrived in his city, he lost his wife; became a single dad; and was in a pretty bad road traffic accident. Working in the Medical Capacity Building team opened his eyes to the medical world and how it doesn’t have to be about death and corruption. He decided to be a nurse. Some nice people on the ship and at home helped sponsor him through his studies and a few weeks ago he graduated. I traveled across Africa and the Indian Ocean to be there because I promised I would. I left my baby and my Husband and that’s where the story begins…
Sendra and I are the same age. He is my Gasy Brother. It doesn’t mean that he’s windy, and as many times as I explain it, that joke isn’t funny in another language. ‘Gasy’ can be placed as a prefix for anything that is a Malagasy version or done in a Malagasy way. ‘Madagascan’ doesn’t actually exist here, although it looks nicer without red wiggly lines underneath it. I guess if we referred to vanilla as Malagasy Vanilla no one would know where it came from?
These scissors have a history. A history spanning over 30 years of Nursing experience. 30 years worth of stories that rarely get told. They tell of the desperation as they swiftly tore off the cast of a 9 year old boy who may or may not have sustained a fracture. The answer to such a question is written on the cheque. Will more money be passed over if it’s fractured? Or less? The truth is, these scissors don’t live in a place of justice, they work in a broken work place. Where no one will shout against corruption and where compassion is a fluffy western idea for people without balls or an understanding of the real world.
What can you really judge by a man’s material goods? What can you say of a nurses scissors? Fob watch? Finger nails? It’s interesting to entertain the idea, if just for a moment. Well let me tell you what you can tell about Major from his scissors. You can tell that he has only ever had one pair. You can guess that he saw an advert for a swiss army knife about ten years ago and has used the scissors as transformers ever since. You can see that he cares about cleanliness as they have clearly been through the ward steriliser a few times. You can also tell that they are precious, the top pocket of his white coat displays them with the pride seen in a veteran with a medal.
Major has seen the hospital go from bad to worse over the last 5 years. In 2009 after the coup and all foreign aid was stopped. Money given to healthcare diminished with each new year; the health care budget halved in 2012. Major, unlike other people I have worked with, opens his cupboards and remembers when they had contents. Supplies, bandages, dressings, blood tubes. He told me that before, it was OK. That healthcare was better. All he has seen is digression, yet he encourages and motivates his new staff nurses who know nothing of this better world that was. Isn’t it a little backwards? I mention things and he would reply yes we used to have that years ago. It’s like hoping for a future that has already been, and has since submerged into the past.
I walked on to the ward one day and there was a TV. He said he wanted to motivate his team. Another time there was a water filter. He said he wanted to make them happy. Most hospital leaders drive nice cars, wear nice new shiny shoes. He doesn’t. This is a man of integrity, of standing, of compassion. A man that’s brave enough to care in a world where people see that as a weakness.
When I ran a mentorship program with his staff I didn’t ask him to join; that would disrespectful. One must assume that the Major’s know all. Yet half way through the course he asked if he could join. He wanted to learn, he said. In transformational development and medical capacity building, Humility brings hope.
I like Hope
At the end of the field service we pray that all our patients are well and go home. Sometimes prayers don’t get answered. Everyone knows that. If this prayer got answered then you would never hear the best bit of the story. The story would have already ended there.
Tip-toeing through the year I found myself wondering if any of this makes a difference. I fully recognise and have learnt the hard way that without love, nobody learns, without trust nobody listens and without respect nothing happens. So when I see people listening and showing signs of respect, there is hope for things to be learnt and a chance of change.
When some of our patients needed further post-op care and treatment as we closed our hospital ship, Major was there. I had already picked him and his team to take over the care of those we would have to leave behind. They had received their briefing from our Outpatients Matron and had seemed pleased to be asked (and of course to receive the money we would pay them in return for the care continuum).
Leaving a country with locals in charge of money, patients and supplies is tricky. We haven’t always had good outcomes. In a world where people don’t get paid and everyone else in the ward have no supplies you can see that it’s easy for things go missing, money to disappear and patients to leave with no sign. When the person responsible for the distribution of money looked at me and asked again “Are you sure you want to give all the money straight into this man’s hands for the team?”, I replied “Yes” doubtlessly. I said again, “Major is a man of integrity, a man we can trust”.
I left for England shortly after. Prayed that no patients would need further hospitalisation and that we really could trust Major. My part was over. I had spent 10 weeks with the team, taught them what I could and then left.
In a wet and damp England one week later I received an email that produced tears and a face to reflect the weather forecast. The Matron of Outpatients wrote to say that there was a patient that needed hospitalisation as our hospital shut. He needed treatment and recovery. She recounted the story and explained that she rang Major to arrange a medical transfer. It was late in the day and he said he would be at the hospital to receive the patient, he put his most trusted nurse on the night shift to care for the patient and when money was discussed as it had been before, it was refused.
Major said with the full support of the team that “Mercy Ships has done so much for the people of my country. You have trusted me with these patients and I want to give them the same care that you are giving them. You are all volunteering and I will too. This is my gift to you. Thank you for trusting me.”
And so these nurses cared for our patient without bribes, without money.
This is unheard of!
This happened in a hospital that I have spent 8 months in slogging away and attempting to get people to care. I have seen so much apathy and disregard for people, so many people cast aside because they don’t have money. The compassion that was described in this email suggests hope is alive, that trust has arrived and that change is unstoppable.
All of that is not written on Major’s scissors, you could stare at them for days and analyse his methods of use but you wouldn’t know what is in his heart. I guess we can never know what is happening in someones heart; we can never know whether our teaching is really making a difference to health care but the contents of their pockets and their actions displayed when trusted might give us a clue.
The Majors Chair
I’m a nurse, I work in Madagascar and I teach and train Malagasy nurses.
I work alongside them and they work alongside me.
I learn from them and they learn from me.
I work as a volunteer for Mercy Ships – but these are my thoughts and do not represent the organisation as a whole.
I heard retching. A familiar sound. I turned to see the 17 year old with the stomach ulcer vomiting blood. First old, dark blood that could just be mistaken for an entire cup of coffee, that suddenly decided to expell its self from its host stomach. Then came the fresh blood. A familiar scene. This is a day like any other in the nursing profession.
Or it would have been if I was at home in London.
Nursing brain activated… Get a bowl, close the curtains, get clean laundry, a mop, a bucket, check observations, clean, call the doctor, speed up fluids, give medication, order blood, book endoscopy and throughout all, give a smile, hold a hand and look confident as you proclaim;
“everything is going to be just fine, don’t you worry”.
The problem was I was not in London and there was nothing familiar about my surroundings. But my brain works the same, It has been programmed in a western environment and it has been washed to act a certain way. As a nurse I function according to set guidelines and principles that have been created in the western world. I followed my new nursing colleagues around my new hospital in Madagascar and I felt the need to reboot. My brain needs to work differently. I am here as a learner. My job is to work along side these nurses, mentor them and teach them what I can: But as I follow, listen and integrate with the community here, I am at a loss.
The bloody vomit spreads across the dirty hospital floor… Nursing brain activated. There is no bowl, there are no curtains, there is no laundry, there are no mops, there are no buckets, observations lead to no intervention, no endoscopy, there is nothing to clean with, the patient can’t afford blood, the doctor has nothing to say, fluids are running and any medication will need to be bought by a relative prior to administration, if he has one. So my nursing plan of care shrivels up from a holistic and exuberant bloom to this; speed up fluids and hope he can buy more, wait for the relative to buy medication, hold his hand and throughout proclaim;
” everything is going to be just fine, don’t you worry”
But everything is not fine according to the western nurse. Her compass needs to catch up.
It is useless to take our set of values and knowledge from the western world and try and make that fit in to everyone elses world. History cries out and will echo far in to the future that one size does not fit all and never will. We have to provide something relevant, applicable and useful.
These nurses are strong. A western nurse deals with terrible situations on a daily basis, amongst staffing shortages and continual politics. The NHS is hard work … I can verify that. But in these last few weeks I have seen incredible strength and courage acted out amongst my new colleagues that is not found in the NHS. They work 24hr shifts, with the help of students but no other nurses. One nurse, 24hrs hours, 50 patients and no supplies. I asked them what is hard about your job, one nurses response was heart breaking,
“With emergency cases sometimes I just want to cry, if they can not afford the treatment, there is nothing we can do”
Everything from a fractured femur, appendicitis, perforated bowel, and an obstructed labour comes through the hospital door and if there is not enough money then they walk/ hop/ or get carried back out. Those operations don’t happen and the questions that you are conjuring up are neither asked nor answered. As the pregnant lady walked away I wondered whether she will be in our next VVF schedule, as the baby with 25% burns disappears I wonder if she will require or be ready for plastic surgery by the time our plastic surgeon arrives.
We come because there is a need. We come to fix problems, and it’s beautiful to see the lame walk and the blind see, but it’s devastating to see the very problems we come to fix, actively break before your eyes, knowing there is nothing you can do.
Education hardly seems to scratch anything off the surface.
It feels like it can’t possibly even make a mark.
It seems useless when you focus on the scale of the problem, but we have to focus on the few things we can do, and not on the list of things that we can’t.
Otherwise we wouldn’t get up in the morning and start scratching the surface.
Sometimes you just have to scratch and hope you make a mark.
This is Krissy my beautiful boss, Through the porthole.
The view is of her starting off the basic surgical skills course in E Ward on the Africa Mercy,
A ship docked in Tamatave, Madagascar.
We have Doctors learning precious surgical skills that could change their practice for ever!
With time….
their patients treatment- better
their student’s skills- improved
their competency- growing
their colleagues poor technique- corrected
their hospital – changed!
We approached the hospital with no real expectations. After previous disappointing encounters it’s best not to set the bar too high. High heights to fall from. We went that morning to attempt to evaluate a training course in neonatal resuscitation. The three day course took place 3 months before, led by Nurses from Mercy Ships for Midwives and Neonatal Specialist Nurses in Adolphe-Sicé Hospital, Congo. The subject is definitely not my strong point. I’m trained as an Adult ICU nurse with some A&E experience. But I tagged along with a new hat on. As from August I will have a new title; Clinical Ward Educator. As I am moving into my new job, I went to observe and attempt to learn more about assessment and evaluation in the work place. In the Congolese work place, it’s a little bit different.
We walked up to the hospital hoping that the current Clinical Ward Educator, Hannah, would be recognised and be let in. Luckily the guard unlocked the gate and welcomed us in to the shiny white hospital. We walked up the stairs and entered the neonatal unit to be met by one smiley Mamma. She not only recognised Hannah but threw her arms around her and did the two kissy thing on the cheek (French left overs). We all followed suit and were welcomed in to the unit. Another Nurse greeted Hannah and agreed to answer some questions. We started with our first question:
“How have you found the course material… have you been able to put it in to practice?”
The nurse became animated as she cut of the end of the question to respond.
“Of course, look at that baby there, it was born this morning and it was dead. Now it is alive because of that training! We resuscitated it like you told us!
Neonatal Nurses from Adolphe-Sicé Hospital, Congo.
We were all a little taken aback and that funny inexplicable thing happened when all the hairs stand up on end and you feel a little choked. The next question was about the ambu bag (resuscitation mask); we realised that a lot of the units had one (albeit old) but some didn’t keep them close by. They would be under lock and key to be kept safe and no one really knew how to use them. They were encouraged on the course to use them, shown how and given lots of practice. Hannah asked “did you use the bag and where is it?” The nurse responded “of course, it’s next to the baby incase we need it again!”
And at that moment in my head as I stared at that little baby with it’s quick little breaths and beautiful black fuzzy hair, lying quietly beside a mask… some fat ladies started singing hallelujah inside my head in perfect harmony.
We had impacted something!
We talked to some other nurses across two different units and they all gave the same feedback, they remembered all the information, used it and taught it to their colleagues. And they really did because people showed us how to resuscitate a neonatal baby that weren’t even on the course.
We walked out of that place shocked and to be honest I was slightly ashamed of my original low expectations. The boss lady said they had had fewer deaths since we delivered the training. Amazing.
During the next field service I will be taking over Hannah’s job so I will be running programs for local nurses from Benin (our next destination from Aug 2014- June 2015) It will be a 6 week program where nurses come and work on the ship, learn in the classroom and build relationships at the same time. I will also be organising some day courses and short courses like this one. I’m so excited to teach and learn from the nurses there that I haven’t even met and now, after today, I am expectant not just optimistic.
Expectant of what we can achieve.
Expectant of what we can learn.
Expectant of what will change.
“Education is the most powerful weapon which you can use to change the world” Nelson Mandela
“Wealth, if you use it, comes to an end; learning, if you use it, increases”~Swahili proverb
Some pictures from the last group who participated in the Mercy Ships education program.
Caryle, from Pointe Noire trained for 8 years- Max Fax specialist nurse.
Teaching about wound care.
Christella, A local nurse works on some Medicine Calculations on board.
One of our patients, Alfred who had a pretty large Neurofibroma removed.
We walked out of that place shocked and to be honest I was slightly ashamed of my original low expectations. The boss lady said they had had fewer deaths since we delivered the training. Amazing.
through a porthole 