Health Check: Hands off their nurses
Wednesday 19 June 2002
We used to call the movement of human cargo from poor countries to rich ones the slave trade. I have just returned from a visit to Malawi, a country ravaged by disease, poverty and hunger on a biblical scale, which lost 47 of its nurses to the UK in 2001. That is one fifth of the total – 235 – trained in the country each year.
This modern slave trade is in some ways worse than the old. It is still cheap labour we are buying, to be sure. But it is skilled, professional labour – the vital resource of an impoverished nation that represents one of the last vestiges of hope against the overwhelming ills that confront it.
I was in Malawi to run a course in health reporting for local journalists, organised by the British Council. In a country where there is one doctor to every 43,000 people and a desperate shortage of all medical staff, self-help is for most the only help, and the press is a vital resource.
We visited Bottom hospital (located at the bottom of the town), in the capital Lilongwe, where two nurses provide all the postnatal care to around 50 women. Beds are crammed into every available space on the two wards – lining each wall and ranged down the centre – and every one was occupied. Guardians – the relatives who provide food and comfort to the sick – sat on the floor. The crowd was so dense it was impossible to step between them.
All the women were recovering from Caesareans, but they were children, aged 14, 15, 16, not women. "By 20, a woman here is mother of three," said Jennifer Banda, the matron.
There are no sheets, the supply of drugs is erratic and because of the nursing shortage there is little care. Last year, 48 mothers died in childbirth here and the national maternal mortality rate has doubled since 1997, partly fuelled by the staffing shortage. At the main central hospital in Lilongwe there are 111 nursing posts but in the first quarter of this year only 60 were filled.
The picture is, if anything, even worse in the 21 district hospitals that serve Malawi's 12 million population. According to Wesley Sangala, technical adviser to the Ministry of Health and a former permanent secretary, most of the district hospitals should employ between 50 and 60 nurses when fully staffed but are currently operating with only 15 to 20. "We are facing a crisis," he says.
Two years ago, following an appeal from Nelson Mandela, ministers in the UK issued a directive banning all NHS trusts from recruiting in the developing world. But the ban did not include private recruitment agencies, which are now doing the NHS's dirty work on its behalf.
At Mulanje Mission hospital in the south of Malawi I was shown a list of recruitment agencies offering generous terms to nurses prepared to work abroad, including one based in Hatfield, Hertfordshire. Another in Sandton, South Africa was also said to recruit nurses for the UK.
A nurse in Malawi earns an average 10,000-15,000 kwacha a month (£100-£150), including housing and other allowances – less than a tenth of that of their UK nursing counterparts.
Last year, Bridget le Huray, a British volunteer at the neighbouring hospital of St Luke's in Chilema, wrote to Clare Short, Secretary of State for International Development, to protest at the trade in nurses. She received a reply on 1 October from Michael Peoples in the Department of Health which said: "Private nursing agencies are not under the remit of the NHS and as such I am unable to comment on their recruitment practices."
That is a pathetic excuse. All it takes is for ministers to instruct NHS trusts to blacklist those agencies that are recruiting from the developing world.
Professor Robin Broadhead, a British consultant paediatrician who has spent 11 years building up the College of Medicine in Blantyre, which he now heads, to train Malawian doctors, says: "It's the grossest hypocrisy, it's almost unspeakable. Tony Blair can say he is not encouraging them to come, that the NHS doesn't advertise, but of course it relies on the agencies to do it. It's absolutely cynical."
The poor have to seek their fortune where they can. But that does not license rich countries to strip less developed ones of their most vital resource. Instead of luring nurses to the UK with the promise of generous wages here, we should be offering aid to boost their poverty-level wages at home.
The British Council is spearheading a project in Malawi to assist decentralisation of the health system, which could give local hospitals the freedom to offer extra pay and incentives to encourage staff to stay – if only they had the resources.
Only by investing in people do countries such as Malawi have a chance of ever tackling their crippling problems. I have said it before – after visits to Namibia and Jamaica where I found the same trade in nurses – and today I say it again: come on, Mr Milburn, it is time to act.
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