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F rom June through August 2008, photographerEileen Hohmuth-Lemonick and I traveledthroughout Malawi in south eastern Africa,

documenting the everyday life of its nurses.For years, I had written tightly focused articleson advances in the treatment of asthma, diabetes,and other diseases and on important issues likethe nursing shortage. But when I was given aNieman Fellowship for Global Health Reporting at

Harvard University, I decided to look at a largertheme: how health systems affect the way healthcare is delivered. I decided to focus on nurses.I chose Malawi because in recent years its healthsystem had nearly collapsed. Nurses are thestrong connective tissue that holds Malawi’shealth programs together. I also hoped to studyinnovative efforts to stop the exodus of nursesfrom this tiny African country.

Text by Christine Gorman and photographs by Eileen Hohmuth-Lemonick

Malawi has always been poor, but the healthof its people has suffered dramatically overthe past decade. According to the World HealthOrganization (WHO) Statistical InformationSystem, healthy life expectancy at birth fell to35 years in 2003. HIV, lower respiratory infections,and malaria are the three leading causes of death.The prevalence of HIV in adults 15 years old andolder stands at about 12.5%. One bright spot:infant mortality per 1,000 live births fell from 95 in2000 to 76 in 2006. (Data on health indicatorsin countries around the world is available at

www.who.int/whosis/data.)Lots of countries have nursing shortages, but

Malawi has one of the lowest ratios of health careworkers to total population in the world. In 2004in Malawi, there were officially 7,264 nurses—including RNs and nurse midwife technicians—for13 to 14 million people. That’s about a quarter ofthe minimum the WHO considers adequate forcountries in the developing world.

During our travels, I learned that the flight ofnurses from the country has slowed, falling froma high of 111 nurses and midwives who registeredto emigrate in 2001 to 23 in 2007 and to just sixin the first half of 2008. Much of the positivetrend can be tied to an emergency human resourceprogram—designed by Malawi’s Ministry ofHealth and supported by funding from theUnited Kingdom’s Department for InternationalDevelopment—that boosted nurses’ salaries andnursing school enrollments by 50%. However,shortages remain, fueled in part by a growingnumber of international nongovernmental organi -zations that hire nurses to work in record-keepingand administrative positions, not clinical services;the organizations also tend not to be concentratedin the rural areas where the need and thepopulation are greatest. In addition, a paucity ofscience and math teachers at the high school level

means that many students are unable to qualifyfor nursing school.

Christine Gorman is a New York City–based independentjournalist and 2008 Nieman Fellow for Global HealthReporting at Harvard University. She wrote about health andmedicine for Time magazine for more than 20 years. EileenHohmuth-Lemonick is a photographer who teaches atPrinceton Day School in Princeton, NJ. Contact author:cgormanhealth@gmail.com.

Funding for the project was provided by the NiemanFoundation for Journalism at Harvard University, supportedby a grant from the Bill and Melinda Gates Foundation. Allphotographs © 2008 Eileen Hohmuth-Lemonick.

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p Hundreds of women and children wait patiently—the occasional temper tantrum aside—for the mobileclinic to arrive in Emazwini, Malawi.

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q At Embangweni Mission Hospital inrural northern Malawi, nurse Walinase

Ndovi takes the temperature of a child whois suspected of having malaria. Thanks to acombination of education, prevention, and

treatment efforts, the death rate frommalaria among children in this area has

fallen dramatically over the past five years.

o Community health nurseJoyce Ngo’ma listens for a fetalheartbeat at a mobile clinic inEmazwini, Malawi.

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q Nurse midwife technician Jane Chibakadelivers a healthy baby at Embangweni

Mission Hospital. Although Malawi’s nationalguidelines call for at least two health care

workers to staff each shift on the labor anddelivery ward, the nursing shortage means

that Chibaka is alone today.

o Even without fertility drugs, the birth of twins is surprisingly common. MadalitsoChosalowa, a nurse midwife technician atEmbangweni Mission Hospital, tends to one new-born while the other is still being de livered viacesarean section. Both chil dren prove healthy.

r The crowd is all ears as Matilda Nyamboconducts a lesson in female reproductivebiology. Nyambo is a nurse at Neno DistrictHospital in southwestern Malawi, which isjointly operated by Malawi’s Ministry ofHealth and the Massachusetts-based non-governmental organization Partners inHealth. Partners in Health makes a point of working with local governments in ruralareas to attract more health workers to thepublic sector.

q The work is never finished. Aftercompleting a shift at the hospital,nurse midwife Dorothy Nyirongo

chops wood before cooking dinner over an open fire. ▼

To see more photos and commentary on nursing inMalawi by Gorman and Hohmuth-Lemonick, go tohttp://links.lww.com/A1319. To listen to Gorman discuss why she focused on Malawi and how thenurses there responded to her interest in them andin their work, click on “Podcasts” at ajnonline.com.

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