Over the summer of 2012, I traveled to Mozambique with funding from the International Research Opportunities Program (IROP) to research the experiences of specially trained health care professionals who perform essential surgeries in the rural village of Manjacaze. After twenty-one hours on a plane and no sleep, I arrived in the capital of Maputo filled with excitement for what was to come. An hour passed and there I was, standing in the airport watching the same piece of luggage rotate through the conveyer belt without having retrieved my own. My excitement quickly faded as I stood there all alone, with no luggage, ready to cry.

When I turned around, I saw a woman approaching with a smile that stretched from ear to ear. I knew right away that this was Emilia Cumbane, my soon to be second mother and mentor, as well as a surgical nurse who specializes in obstetrics and gynecology. We greeted each other in Portuguese, the primary language of Mozambique and one I speak fluently. I quickly explained my situation, assuming she would be upset, but instead she calmly took me to customer assistance and we left our information so that we could be contacted as soon as my luggage arrived.  

After four hours of driving through rough, sandy terrain, I finally arrived in Manjacaze. It was 6:00 p.m. and pitch-black; there were no street lights, yet people were walking around everywhere. The women wore kapulanas, large pieces of fabric that can be worn around the waist, on the head, and on the back to carry children.  As we pulled up in front of Emilia’s house, four people ran out the door, all smiling from ear to ear. Emilia’s three year old daughter Daniella and eleven year old son Aldir were the first ones out, followed by Fifi, who helped Emilia cook, clean, and take care of the kids, and Dolce, Emilia’s sister. After parking in the rocky driveway, I stepped out of the car and felt my feet sink into the sandy earth. Emilia kindly welcomed me into her home and made me feel as though I was already a part of her family. Although my research had yet to begin, I could already see kindness, independence, strength, and passion to help others in her heart.

One Step Closer to Solving the Shortage

I became interested in studying these specially trained health care professionals after watching the PBS documentary Birth of a Surgeon. I was hooked from the beginning, learning pregnant women in Mozambique are 160 times more likely to die from a complication during pregnancy than those in a developed country, simply due to the lack of obstetricians (Bernal, 2009). There is about one physician for every 35,000 people in Mozambique and much fewer surgeons. This is because many doctors leave the country in order to practice medicine where there are better conditions and higher pay (WHO, 2003-2007).

Over two decades ago, due to the extreme shortage of surgeons, government programs were developed to train both male and female nurses to provide independent surgical services in rural and underserved areas (Cumbi, Pereira, Malalane, Vaz, McCrod, Bacci, and Bergstrom, 2007). These surgically trained nurses are known as técnicos de cirurgia.  More recently, in order to decrease the growing maternal and infant mortality rates, similar programs were developed to train enfermeiras de saúde materna to perform obstetrical and gynecological surgeries.

Técnicos perform general surgery, while enfermeiras perform c-sections, tubal ligations, hysterectomies, and other surgeries related to females and childbirth. These two groups are able to perform many different types of surgery, but are specifically trained in emergency surgeries. Not only do these professionals operate, but they also conduct consults: técnicos can handle consults in all areas, while enfermeiras handle consults related to gynecology, obstetrics, and high risk obstetrics. They are on call twenty-four hours a day with just every other weekend off, at which time critical patients in need of surgery must travel to another hospital that performs surgery, the closest of which is located two hours away.

I could not help but wonder why these técnicos and enfermeiras were choosing to work in these rural areas and were not following the same path of the physicians. What was their motivation for staying? With this in mind, I traveled to three different rural hospitals where I interviewed three técnicos de cirurgia and two enfermeiras de saúde materna. My research experience became hands on as I was able to work as a nurse, helping with supplies in the operating room and providing patient care. Due to transportation difficulties, I could not spend observation time in each hospital, so instead I spent eight weeks observing the work, role, and motivation of Emilia Cumbane, an incredible representation of what it means to be an enfermeira de saúde materna.   

Overcoming the Conditional Crisis

I stepped into the rural hospital of Manjacaze expecting to see difficult working conditions, but not truly prepared for the reality of the situation. I was greeted by many unfamiliar sights: numerous patients’ family members sleeping on the cold, dirt ground as they waited outside the hospital; a wide expanse of sand separating the hospital buildings; and the smell and sight of blood covering a thin mattress with no sheets . Then I heard that familiar noise— the first cry of a newborn baby. Despite all of the challenging conditions, I was able to witness selfless, caring healthcare professionals perform many lifesaving surgeries for babies and mothers alike.  

The conditions under which the hospital staff works are strenuous. In most rural hospitals, the operating rooms are located in spots that are exceptionally inconvenient and the hospital in Manjacaze is no different—its operating room is in the building opposite maternity, forcing nurses to transport patients across the sand in order to perform proper surgery. This is not nearly as challenging as the rural hospital of Chibuto, where the operating room is located two miles down the road.

At all the hospitals I visited, there is absolutely no patient privacy due to lack of space; each room can hold only five to ten patients and there are no barriers between beds. Materials, medications, and equipment are also scarce —each department usually has just one of everything and if something breaks, it can take weeks or months before the item can be replaced. When asked about the hardest part of his job, one técnico responded: “For me, it’s the conditions under which I work. I have been trained to perform a lot of different types of surgeries and have the knowledge to perform those surgeries, but do not have the equipment. It’s really tough. Not only the lack of equipment, but also the space restriction.”

I also observed many troubles with electricity and running water. Because the electricity can often shut off and there is no back-up generator available, the first week there I waited alone in the operating room with a patient on the table for three hours until power came back on. Running water is available intermittently and we had to pump it from a well if it wasn’t available. The lack of running water and electricity was not only experienced in the hospitals, but in my home as well. I was in Mozambique during the winter months and from June through August, the sun set at 5:00 p.m. every night. An hour after sunset, we would often lose power and were forced to use candlelight to accomplish everything we needed to in the evening hours. 

One of the conditions that concerned me the most was in the rural hospital of Manjacaze where I spent most of my time. Here, all of the bed sheets, surgical gowns, drapes, and other linens are washed by hand, thereby exposing the people washing the hospital linen to large amounts of blood and infectious disease. With such high rates of HIV and Tuberculosis I found it hard to believe that people would ever agree to such risky jobs, and I worried about their safety.

These técnicos de cirurgia and enfermeiras de saúde materna are subject to more than inadequate conditions while still being expected to save lives. When I asked if they could change one thing, the técnicos and enfermeiras mentioned both the conditions under which they work and the number of nurses working in the hospital, wanting more nurses before anything else. No matter how excellent the conditions are and how much technology is available, it would be pointless without a sufficient number of nurses. Each building of the hospital has either one or two nurses, which is simply not enough.  As one técnico stated, “We are in a crisis with employment.”

The Drive to Help Those in Need

Through the passion in their hearts and the skills they have been taught, técnicos and enfermeiras strive to be the best they can be when it comes to the constant struggle of saving lives. In my research, I observed how demanding and stressful this profession can be. Because of the lack of personnel, there is usually only one técnico or enfermeira per hospital and as a result, they do not have the privilege of discussing the care of a patient with colleagues. As the only decision makers, the técnicos and enfermeiras know they are the patients’ only hope and that without them, their patients would likely die. This fact alone provided enough motivation for many of the healthcare professionals I spoke with to stay in Mozambique.

Many health care professionals recognize that they were fortunate to have been given an education which allows them to save lives and they know that their opportunity cannot be put to waste. One técnico indicated “We are all human and it is in our nature to see people succeed by living happy and healthy lives. Knowing I can help someone succeed in this way is my motivation.”  When I questioned why they continue to work in rural areas under such difficult conditions, most of the interviewees discussed the same reasons. In the words of one enfermeira, “We have a lot of difficulties here, but I always look past that and try to work from the heart. When I am helping someone, I do everything from the bottom of my heart.”

What impressed me the most was how salary played absolutely no role in their motivation to stay in Mozambique. No matter how many hours they actually work, the técnicos and enfermeiras  are paid for only eight hours a day. On call twenty-four hours a day, seven days a week, técnicos and enfermeiras spend most of their time in the hospital, but receive no further financial compensation. For many, the satisfaction of saving lives is enough of a reward.  

In addition to professional hardships, on a personal level the técnicos de cirurgia and enfermeiras de saúde materna sacrifice whatever normal lives they had prior to this occupation and completely devote themselves to their patients. However, at times, they feel as though they’re prisoners, trapped because they want to help save lives, but forced to give up living their own to do so. Time is of the essence when it comes to emergency care and thus it is crucial for the técnicos and enfermeiras to live close to the hospital. On their days off, if a patient has to be transferred to another surgical hospital and dies, the técnicos and enfermeiras feel extremely guilty, as if they personally caused the death. They can never take time off or a vacation without wondering whether the phone is going to ring.

In the end técnicos and enfermeiras are only human and can only do so much. Every life cannot be saved and some will slip out of their hands. Every day these nurses feel the weight of the world on their shoulders and this feeling never really goes away. If they were to ever decide to leave these hospitals it would be at the cost of many lives. How can they ever decide against it?

These nurses work from the bottom of their hearts and have such a passion for healing people who are in critical condition. Despite these hardships and poor conditions, they seem to maintain a smile that stretches from ear to ear.

Beauty in Life and Death

Beautiful is the first word that comes to my mind when thinking about the culture in Mozambique. These people are warm, inviting, and respectful. Although I am not a blood relative, the children called me “Tia Sofia” (Aunt Sofia) out of respect. The older women are referred to as mother or grandmother, even if they are not blood relatives.  People always stop to chat and to see how everyone is doing. While many people in the United States are friendly and polite to each other, I felt a different vibe in Mozambique. There people are truly respectful, not only because they know it is right, but because they want to be kind to one another. 

I also found beauty in the simplicity of food. Breakfast was always something small, usually bread and tea. If we were back early enough from the hospital to eat lunch, it was typically whatever was left over from dinner, which usually consisted of rice and fish. People also raise chickens to eat and although I was a little hesitant about killing animals to eat, as I had never done it before, this whole trip was about first time experiences. Before I left for Mozambique, I told myself I would do anything and everything the people there did, so I picked up the knife and killed the chicken, as if the action was a part of my own culture.     

Unfortunately, I also experienced a very difficult part of any culture—what happens when a family member dies. On August 8 at around 2:00 p. m., Emilia’s sister, Dolce, passed away at the age of thirty-seven. Dolce had lived with Emilia for four years and I had lived with her for eight weeks. We would greet each other every morning, danced on our free time, and would often just hang out in the living room at night. On that unfortunate day, we found her in her room and covered her body, believing she had passed after having an epileptic seizure. Her body was brought to the hospital, and at around 4:30 p.m. friends, colleagues, and members of the community started arriving at our home. Some stayed for fifteen minutes, while others stayed all night. At times they would sing and pray, but the majority of the time, everyone sat on the floor in silence. Around ten women slept on the living room floor that night in order to support and help Emilia and our family. When we woke the next day, the women were cleaning and cooking, helping out our family in any way they could. Whoever was not cooking would sit on the floor in silence. This continued for the whole day with some singing and praying in between. 

Emilia was extremely strong throughout this process. Dolce’s casket was made of wood and was brought to the house with her body in it at around 8:00 p.m on August 9. The casket stayed at our house for the night and the funeral was held the next day in their hometown of Inhambane, four hours away. Four days after Dolce passed away, a woman came to our home to “cleanse” it as well as us. We rubbed holy water on our face and arms and ate some black ash. The woman then dipped special leaves into the holy water and splashed them throughout the house. Although it was under unfortunate circumstances, seeing this end of life process was a gift to me and put into perspective the importance of love and community.

Lessons Learned

Upon my return, I had a hard time adapting to life in the U.S., especially the people. The women in Mozambique were so strong and grateful for the care they were given, whereas in the U.S., people take this care for granted and complain about the little things, such as waiting for an hour to see the doctor. There was often no medication to take away the pain of childbirth or any other condition and most still remained strong and grateful. We take a lot for granted in this country and don’t even think twice about how lucky we are to be able to take a little pill that will rid us of most pain.

My nine weeks in Mozambique were an incredible journey and they will forever be an important part of my life. I was able to witness and experience people and moments which were truly once in a lifetime. Before I left for Mozambique, with the help of friends and family, I was able to raise $2,000 as well as collect a suitcase full of supplies and uniforms. Now back in the U. S. I remain in contact with Emilia and the rural hospital of Manjacaze and I continue to raise money and collect supplies. I hope to plan another trip in a couple of years after gaining more knowledge and hands on nursing experience.

Thanks to my experience, I was able to see how lives can be saved without physicians and technology and that in the end, passion and determination can prevail. These técnicos de cirurgia and enfermeiras de saúde materna are the most incredible, selfless people I have ever had the pleasure of meeting. They provide care from the bottom of their hearts and truly inspire me to become a better nurse, daughter, sister, student, friend, and overall person.

This journey would not have been possible without: Mr. Ellis Woodward, Mr. Frank and Ms. Patricia Noonan, and Mr. Carlton Allen, for their generosity and support; Georgeann Murphy and the rest of the Hamel Center staff for their incredible support and encouragement in preparing for my trip; Dr. Gene Harkless, whose mentorship and passion for research inspired my decision to follow through with this incredible experience; and Emilia Cumbane, my international mentor, who made me a part of her family both in her home and hospital. A final thank you to my friends and family for their love and encouragement throughout this life changing experience.

References

Bernal, L. (producer). (2009, July 14). Birth of a surgeon. PBS wide angle. Retrieved from

http://www.pbs.org/wnet/wideangle/episodes/birth-of-a-surgeon/credits/5145/

Cumbi, A.,  Pereira, C., Malalane, R., Vaz, F., McCord, C., Bacci, A., and Bergström, S. (2007), Major surgery delegation to mid-level health practitioners in Mozambique: health professionals’ perceptions. Human Resources for Health 2007, 5:27.

World Health Organization. (2003-2007). Age distribution by country. Retrieved from

http://apps.who.int/globalatlas/docs/HRH/HTML/Age_ctry.htm

Author and Mentor Bios

Sofia Cadime of Ashland, Massachusetts is a senior nursing major. Knowing that she always wanted to travel to Africa, Sofia felt a particularly strong pull to Mozambique after watching Birth of a Surgeon, a documentary recommended to her by her mentor Gene Harkless. The film, which reports on the grassroots initiative to train midwives in surgical delivery-related techniques in order to combat a high maternal death rate, inspired Sofia to conduct research of her own. The most satisfactory aspect of her International Research Opportunities Program (IROP) project was “having the honor of meeting and working with selfless people who gave up so much to do what they love and save lives.” She found out about Inquiry through IROP and the nursing department and knew that after spending over nine incredible weeks in Mozambique she needed to share her story with as many people as she could. Sofia, who will graduate with Honors in Major, hopes to become an acute care nurse and to continue traveling, particularly to underdeveloped countries like Mozambique. She also hopes to bring her foreign mentor, Emilia Cumbane, to the United States to visit.

Gene Harkless, DNSC, ARNP, is an associate professor in the Department of Nursing. A family nurse practitioner who has taught at the University of New Hampshire since 1985, Dr. Harkless is a frequent mentor and enjoys working with students such as Sofia as they take on international endeavors. “For past IROPers, it has been life-changing. They create a whole new lens through which to see the world,” she says. “Students grow to understand their own academic abilities, to ask a question and search for answers and perspectives outside of expert text materials.”

Emilia Cumbane is an enfermeira de saúde materna at the Rural Hospital of Manjacaze, Mozambique. She was featured in the documentary Birth of a Surgeon, which prompted Sofia to seek her out as a mentor.

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