There is little that a nurse hasn’t seen. In a hospital, the unexpected can happen around any turn, and many of the things I’ve encountered left a lasting impression. Still, it is what I have seen as a volunteer that remains the most vivid.
I have been a nurse practitioner since 1994, and I currently work at the Montefiore Medical Center for Positive Living/Infectious Diseases Clinic in the Bronx, New York. My duties include managing the care of HIV patients, and I recently started a diabetes clinic within our HIV clinic to help people dealing with this co-morbidity.
My work has instilled an interest in me for educating people about HIV and developing curriculums for nurses and nurse practitioners in developing countries, particularly regarding HIV care and co-morbidities. For the last five years, I’ve spent my summers traveling to work with patients infected with HIV/AIDS and provide both treatment and management education to health care providers. My travels have taken me around the world, from Nigeria, Israel, Lesotho, and India to the Dominican Republic and Kenya.
Leaving the greatest city on earth to spend a summer with the sick may not sound like a season well spent to many, but I knew the need for nurses was great. When a group of colleagues returned from a recent trip to Africa, they mentioned that they never saw any African American volunteers. I was amazed and saddened, and I decided I needed to make a difference.
In March 2005, I took my first volunteer trip to Ife, Nigeria. I traveled with two nurse practitioner colleagues. Our mission was to conduct an HIV management seminar for nurses, community workers, and physicians. We also visited a hospital and participated in support groups, speaking to HIV-positive patients. All were highly knowledgeable of HIV prevention methods, but I noticed that stigma was still a big problem for infected Nigerians.
This trip was quite the eye opener. I had to learn very quickly about the class system in Nigeria, where people do not mingle and cohort with those “lower” than themselves. This had an impact on the treatment of HIV-positive patients. Health care workers did not work long hours. Patients admitted to the hospital slept on bare mattresses, because there were no bed sheets. Those who needed to be dialyzed were not allowed to use the one dialysis machine in the building, which was reserved for all other patients—we were told there was no “dirty machine.”
Few patients were offered antiretroviral drugs because there was only a limited supply, provided by a clinic in New York City. I worked with many patients and met several who did not survive much longer after we left the country. I came home appreciative of my life and determined to continue to give back.
During the summer of 2009, I spent three weeks in the village of Dagoretti in the Lenana slums area of Nairobi, Kenya. I went there not knowing anything about my living facility, but I decided I would make do with whatever the circumstances. When I arrived in Kenya I could not help but think about how I was going to leave shortly, but the people there had no other way out.
Author Sherlan Thomas (right)
I ended up living with a woman named Margaret, a pastor born and raised in Lenana. She was very proud of her heritage, but I confess, I had a hard time understanding why. Most people living in the slums rented from her parents but had no means of paying. She lived on the ground floor of an apartment building that would be considered well-off by slum standards. We had electricity, indoor plumbing with a hot water shower, a maid, and plenty of food to eat. The first night of my visit was quiet, but filled with anxiety over what the following day would hold.
I woke up at 8:00 a.m. the next morning and chatted with Pastor Margaret until 10:00 a.m., when Elosie arrived. She was to be my escort to the patients I would be seeing that day, and she had walked three miles to meet me. During our 90-minute walk back to her clinic, Elosie explained what I would be doing. She worked in a very small office with one other person, Josephine, and their job was to provide care to homebound HIV patients and their families.
Elosie and Josephine had no medical training or experience. They both were in charge of a testing and counseling center, yet had run out of testing supplies over six months before. When people stopped by for testing, they had to be turned away. We visited two HIV-positive patients. Both lived in one-room homes with deplorable facilities. We were finished before 2:00 p.m., the end of their workday. I walked back home, knowing I needed something else to do for the rest of the afternoon.
Pastor Margaret then took me to meet Kilowsi, an HIV infected patient who was in charge of the testing and counseling center within the slums. Again, there were no supplies, so he could only provide counseling. If someone needed testing, Kilowsi would personally escort him or her to another clinic about three miles from the village. He knew everyone with HIV in the community and had developed a personal relationship with each. I continued helping Kilowsi after my work was finished with Elosie for the remainder of my stay, doing simple health assessments and blood pressure screenings in the community.
The next day, Pastor Margaret told me there was a very ill HIV-positive woman nearby named Carol who was possibly dying of malaria. I had limited knowledge of treating malaria, so I went feeling nervous. I packed my medical bag and was escorted to Carol’s home, where I found her lying in bed in a very dark and damp one room house made of metal and concrete. On the floor were two small bowls of rice her neighbors had dropped off three days before, but she could not eat.
Carol’s daughter had come home from boarding school because of her condition, and her 12-year-old son, who had a developmental delay, was there too. The boy had a history of seizures and no access to medication. It was clear he was having frequent attacks because his seizure induced falling had caused a lot of bumps and bruises over his eyes and around his head. The family was especially concerned for him, as it was thought that the only one who could manage him during his seizure attacks was his mother. A minister was also in the room, giving Carol her last rights, and some neighbors had gathered as well.
Carol did look ill, but I immediately knew she was not dying. I found no high fever, a sign of malaria. She was also fully awake, alert, and oriented. Carol said her back was bothering her the most. We flipped her onto her side and found the problem—ulcerated herpes lesions on her buttocks. I went back to my room at Pastor Margaret’s and collected Valtrex, multivitamins, and some Motrin. I started Carol on as much medication as I could spare.
By the next day, Carol was already feeling better and had eaten the then four-day-old rice. I brought her cornmeal and some vegetables because she had no money to buy food. On day three, Carol was sitting in the chair awaiting my arrival, and by day five she was fully recovered from the lesions. I often wonder what would have happened to her if I had not intervened; I know the mind has a powerful affect on health.
Inspired by my experience with Carol, I began making home visits within my immediate surroundings. If I saw 20 patients in a day, over half had high blood pressure. A standard clinical visit in Kenya did not entail a blood pressure check, as it required an extra fee people could rarely afford. I worried about these findings because people could not afford health care or medications. I counseled the patients I saw regarding diet and restricting their sodium intake, and they were open to my suggestions.
One of the more heartbreaking cases I encountered was another patient from Lenana, who was both HIV-positive and diagnosed with cervical cancer. She came seeking help, and I learned that she had five children, her husband died of AIDS, and she was on the brink of eviction. Her biopsy revealed high-grade carcinoma, and she needed $300 to be admitted to the hospital, though that did not include surgery or medicine. She worried about her children and who would care for them if she died. She said she waited for death every day, because there was no other way out of her suffering. This situation affected me more deeply because I knew how different her life would be if she lived somewhere else.
It seemed that every day there were new health issues. The community was plagued by asthma, caused or exacerbated by the garbage and animal feces surrounding the slums, a condition I didn’t come equipped to treat. I saw an HIV-positive patient with an infected great toe that had gone untreated for years, who felt hospital visits were a waste of time and money. I visited a maternity ward that did not resemble a hospital at all, where I was shocked at the haphazard treatment of newborns and babies waited their turn for a single nebulizer. And I ventured to a Maasai tribal village, where there is absolutely no form of modern health care.
It is estimated that 2.2 million people are infected with HIV/ AIDS in Kenya—almost 7% of the population—with 800 new infections happening every day. Hundreds of thousands of Kenyans have already died from the virus, and hundreds more die daily. BBC News recently reported that in some of the poorest parts of Nairobi, the capital of Kenya, every fifth house is run entirely by children orphaned by AIDS.
A visit to a Maasai tribal village
More than 50% of hospital beds in Nairobi are occupied by people suffering from AIDS-related complications, causing an immense strain on the already limited medical facilities. As is commonly seen across Africa, women are at much higher risk of becoming infected with the virus. Four percent of men and nearly 8% of women have HIV/AIDS.
Fueling the epidemic is a lack of access to medication. The estimate of antiretroviral medication use has increased dramatically in recent years among adults to over 70%. However, only 25% of infected children receive treatment, due to a combination of factors, including neglect, lack of resources, and social stigma and family shame. As I have witnessed through my travels, antiretroviral medications are often left unused and even expire, due to a shortage of trained medical personnel and a lack of understanding among providers. Though efforts to get more patients on medication have been increasing, logistical and manpower issues and rampant corruption prevent significant change.
When the country experienced political upheaval in December 2007, more than 1,200 people were killed and some 350,000 displaced into temporary camps. Part of my journey included a visit to an Internally Displaced Persons camp in the Rift Valley for the opening of a new clinic. There were no medicines or equipment to run the clinic, but the people were happy because it was a start. I took vitamins and other medical supplies with me, and the doctors and nurses there seemed appreciative. The children living in the camp ran around covered in dirt, carrying their younger siblings on their backs. There was no water, very little food, and a lack of medical care available to the residents. More importantly, there were no immediate plans for improving the situation.
Admittedly, my frustration mounted daily. Volunteering overseas is not without its hardships, and it is difficult to see patients suffering from a lack of supplies that are always prevalent where I work. There is so much that needs to be done, but I have learned from my visits that caring goes a long way in providing comfort to those that have nothing. Volunteering brings me the joy of knowing that while I may not be able to provide much, a blood pressure check or just a hug makes a big difference. The people I’ve treated are always very grateful for whatever health care knowledge I share with them. It is an unbelievably rewarding and fulfilling experience, and nurses are able to make such a difference in the lives of other health care providers and patients infected with HIV, all over the world.
Infant mortality. Sociologically, it is the litmus test for a nation’s overall health. Emotionally, it represents unfathomable loss.
Of course, nurses and other health care professionals must discuss the issue clinically, distancing themselves from the emotional ramifications. Yet, the shocking but rarely discussed statistics surrounding infant mortality in the United States merit more attention than calm discussion. Because when nearly twice as many minority babies are dying than their Caucasian counterparts, complacency is unacceptable.
There’s no dancing around the issue: African American infants are 2.5 times more likely to die than non-Hispanic white infants. Statistics are comparable among Native American infants. Research spanning the last 30–50 years shows these disparities have remained consistent for generations. On average the United States has an infant mortality rate of 6.7/1,000. Among non-Hispanic African Americans, the rates are nearly doubled, with 13.4/1,000 infant deaths, according to statistics compiled by Spong et al.1
The CIA publishes a list of the world’s countries ranked by their infant mortality rates. At the bottom, with the highest rates of neonatal deaths: Afghanistan, Angola, Somalia. At the top: Monaco, Singapore, Sweden. Where’s the United States? It doesn’t even crack the top 30, falling behind nearly all of its “first world” contemporaries.
Direct causes of infant death are primarily congenital anomalies/birth defects, followed by premature births, then SIDS. SIDS was the second-leading cause of neonatal deaths, but after years of concentrated efforts and outreach, it is now third. Yet, in some states, including Mississippi, Alabama, and Arkansas, the infant mortality rates among African Americans are comparable to those found in third-world countries, with 18–22/1,000 live births in certain counties.
The solutions seem so simple: take care of women before they become mothers and teach them how to properly care for their babies. But the statistics remain stagnant, pointing to an urgent need for more education, community resources, and government action. And, as always, nurses are on the front lines.
Spreading the word
The U.S. Office of Minority Health approached Tonya Lewis Lee, director of the documentary Crisis in the Crib, to act as its national spokeswoman for A Healthy Baby Begins with You Campaign about four years ago. She accepted, and soon learned the seriousness of infant mortality in the United States. She says she had no idea the rates were so high.
“I had to get involved to spread the word, to figure out why the rates are what they are, “Lewis Lee says. “I’ve learned a lot and shared a lot.” She says she is now healthier now than ever before. “I really feel that taking care of yourself first is critical,” she says. “We need to lead by example.” And the crux of A Healthy Baby Begins with You is teaching mothers the importance of self-care.
“Nurses have been extremely powerful in the information they give to patients,” Lewis Lee says. They have a relatively intimate relationship with patients, and with cross-cultural training nurses can help them at their most vulnerable and effectively treat people from different backgrounds.
Lewis Lee also works closely with the U.S. Health and Human Services Office of Minority Health’s Preconception Peer Educator (PPE) program, which coordinates student ambassadors educating others about healthy pregnancies. “The idea of peer education is great because it goes back to understanding the community they’re talking to,” Lewis Lee says. The program, which started with 60 students, now has over 1,000 ambassadors. “I’m very proud of our students,” Lewis Lee says. “It’s a movement. It’s a health movement for young people.”
Yet, while grassroots efforts are commendable, higher-level changes are needed as well. “A lot depends on what goes on politically,” Lewis Lee says. During the ongoing health care reform debate, infant mortality seems to be swept under the rug. Lewis Lee envisions a move toward preventable care, an improved focus on health disparities, and perhaps advances in genetic research and its affect on personal health, such as obesity.
Every child is an opportunity to improve the nation as a whole. “I don’t know that we as a nation really take the health of every citizen very seriously…. Some people we think are expendable,” Lewis Lee says. “Somehow we need to figure out a way to make that better.”
Room for improvement
“As a public health official, we are the eternal optimists,” says Garth Graham, M.D., M.P.H., F.A.C.P., Deputy Assistant Secretary for Minority Health for the Office of Minority Health at the Department of Health and Human Services.
Graham lists three reasons he sees potential for improvement in U.S. infant mortality rates:
Infant mortality is related to many other factors, such as the preconception health of mother, and with efforts to expand preventive care, “we will see healthier mothers” and subsequently, healthier babies.
Advances in medical care will continue to help care for premature babies and other complicated births, particularly as urban areas see medical advances.
A number of areas, such as Tennessee, following both local and federal efforts, has seen improved infant mortality rates, offering an imitable example and showing progress is possible.
But the eternal optimist acknowledged several obstacles as well, such as social determinants, lack of access to care, and high rates of teenage pregnancies. “The major challenge is how to deal with all of this holistically,” Graham says. “Nurses, more than any other profession, are on the front lines of infant mortality.”
Community resource nurses serve a key, multifaceted role in helping would-be and young mothers, Graham says. “We really want to encourage nurses…to be as proactive as they have been,” but even more so. “Nurses are more than just healers,” Graham says. They are influencers. “People who serve as role models make a huge impact.”
The situation in the United States
Despite the country’s wealth and technological advances, theUnited States’ infant mortality ranking has actually worsened since the 1960s, when the nation was 12th in the world. Today, according to CIA estimates, the United States is approximately 40th.
“This international standing is largely driven by large racial and ethnic disparities that exist in infant mortality in the United States,” says Peter C. van Dyck, M.D., M.P.H., Associate Administrator for Maternal and Child Health for the U.S. Department of Health and Human Services’ Health Resources and Services Administration. “If all United States infants had the infant mortality rate of white infants, the overall infant mortality rate would decline about 15%, and our infant rate mortality ranking would improve about four places.” The United States also lacks many European nations’ paid parental leave, welfare, and access to health care. “According to the latest data in 2007, less than 70% of women received prenatal care in the first trimester,” van Dyck says.
The clearest cause of racial disparity is the higher preterm birth rate for black infants. “Black women are four times as likely as white women to deliver very early,” van Dyck says. “This racial disparity may be caused by socioeconomic disparities not just in adulthood but across the lifecourse, stress and discrimination, environmental quality differences as a consequence of residential segregation (e.g., pollution, crime, access to parks and supermarkets), and also differences in infant sleep practices.”
Van Dyck points to the Patient Protection and Affordable Care Act of 2010 and its creation of the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV), a provision put in place “to respond to the diverse needs of children and families in communities at risk and provides an unprecedented opportunity for collaboration and partnership at the federal, state, and community levels to improve health and development outcomes for at-risk children through evidence-based home visiting programs.”
MIECHV aims to provide comprehensive health services to these children and families, particularly expectant mothers. “Maternal health, especially the health of the mother during the prenatal period, is a critically important factor to ensure a healthy birth outcome,” van Dyck says. Some of the benefits of home visits include decreased instances of smoking, substance abuse, hypertensive disorders, and domestic abuse. Regarding child health outcomes, families receiving home visits experienced lower risk of low birth weight children, higher attendance at well child visits, more prevalent health insurance coverage, higher intellectual, and improved rates of breastfeeding, among others.
“It is our vision that positive changes in maternal and child health outcomes will be significantly enhanced as the states implement evidence-based home visiting programs, embedded within a high-quality early childhood system,” van Dyck says.
Understanding and combating
“We strongly believe that a child needs a good beginning,” says Yvonne Maddox, B.S., Ph.D., Deputy Director of the National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH). She stresses that leaders need to take a more aggressive approach in making child health a top priority. “It is really very, very disappointing that we haven’t done more.”
In the infant mortality crisis, Maddox says other environmental factors must be taken into account as well, such as community and overall maternal health, the quality and accessibility of the health care system, the socioeconomic status of community, and public health regulations. “We are targeting all the areas,” she says.
Maddox focuses specifically with minority communities, including African Americans and Native Americans. Like the gross disparities that exist among black communities, Native American infants in some areas of the country, such as Minnesota and the Dakotas, are also twice as likely to die as their white counterparts. Routine nurse home visit to a young mother on a reservation, for example, may provide the hands-on care and continued support needed to ensure the child sees its first birthday. “It pains me” to see the extremes, Maddox says. “I don’t want my country to look this way.”
“We found that the way to address these issues is to launch strong education campaigns,” Maddox says. But health care providers also need to build a foundation of trust in their communities. As one of the most trusted professionals, nurses can hit the ground running.
“We need to really study these things in a systematic way,” Maddox says. And now, with the launch of the National Children’s Study, researchers are. Though still in the recruitment stages, this unprecedented study hopes to follow 100,000 children across the country from pre-birth to 21 years old. “There are a lot of things we can look at in 21 years.”
Researchers will monitor the environments American mothers and children occupy, and how factors such as air quality, nutrition, family dynamics, genetics, and culture affect children’s health, growth, and development. By working with expectant mothers, the study can incorporate the effects of family medical history and pre-pregnancy exposures on birth outcomes, providing important insights for the future.
Maddox says the study should shine new light on chronic issues such as obesity, autism, and depression/mental health. Though findings will be published throughout the study, researchers are years away from answers. Maddox hopes the economic downfall and recession do not damage the study’s viability—or the essential health care services already in place. “It’s critical that we work with our policy makers and educators,” she says. “We’re already working with such dismal numbers.”
Minority communities may not participate in infant mortality outreach as often, Maddox says, perhaps due to lack of trust or simply not knowing the resources were available. Some may assume these at-risk groups do not “get it” or don’t want to try to improve the situation, but “the communities want information. They want to know. They want the facts,” Maddox says. Such misunderstandings make group feedback essential.
“Cultural competency in messaging is critical,” Maddox says. Nurses and other providers must figure out how to best interpret results of current and future studies so the message is crystal clear to patients. While pediatricians and OB/GYNs may be expected to educate their patients, information can get lost in translation. That’s where nurses come in. “They are able to communicate the message very substantially,” Maddox says.
Hispanic communities or Native American tribal groups may require a different set of tools than a predominantly African American community. Nurses of all ethnicities should understand these unique backgrounds and cultural sensibilities. Pregnant women, women with disabilities, and other special populations also require special targeted messaging. Even nurses in the trenches in these areas may not realize the importance of translating info for patients and the community at large.
With the SIDS campaigns of the 1990’s, colleges and universities teamed with health educators, faith communities, nursing organizations, and continuing education programs, working together to design a safe sleeping program. They produced literature describing proper infant dressings, approved cribs, and do’s and don’ts for new mothers and even other health care professionals. Nurses who completed the program then disseminated the materials.
“We found that the way to address these issues is to launch strong education campaigns,” Maddox says. Researchers also point to increased training of health care workers, like midwives and community clinic staffers, so there are enough caregivers to attend to these mothers and babies.
Government agencies like the NIH need to understand how communities interpret campaigns as well, Maddox says, making bolstering public trust another priority. As one of the most trusted professionals, nurses can hit the ground running.
Solutions for nurses
“Minority nurses bring a breadth of knowledge and experience to every aspect of health, contributing to excellence in health care for women and children,” van Dyck says. “Public health nurses, for example, are leading the effort for community-based approaches to resolve infant mortality disparities.”
There’s Healthy Start; the Healthy Mothers, Healthy Babies campain; and Lewis Lee’s A Healthy Baby Begins with You. Nurses can also use the Fetal and Infant Mortality Review (FIMR) process to coordinate community dialogue and address community-specific issues related to infant mortality, from bereavement and postpartum depression to barriers to care, SIDS risk reduction, and substance abuse. “Community-based FIMR is an action-oriented continuous quality improvement process with a significant role in building community partnerships, understanding community issues, and developing culturally sensitive interventions,” van Dyck says. There are roughly 200 such programs located throughout the country 40 and U.S. territories.
“Communities will address their health issues if given information and forum for resolution,” van Dyck says. “FIMR teams have learned that many health messages are not culturally and linguistically appropriate, are not reaching all of the varied ethnic groups in each community, and are not being delivered by a messenger specific to each group and whom the community trusts.” Consequently, FIMR has developed culturally appropriate educational materials and services.
Karla Damus, Ph.D., M.S.P.H., M.N., R.N., F.A.A.N., a clinical professor of nursing at Northeastern University in Boston and a member of the CDC’s preconception health expert panel and March of Dimes’ Nurse Advisory Council is looking for a paradigm shift in neonatal care.
People don’t understand, Damus says, that to fully understand infant mortality rates, they must also incorporate fetal mortality rates, including miscarriages. “Families are just as devastated” and women are just as likely to experience another negative outcome and increased risk with subsequent pregnancies. She encourages nurses and health care providers to widen their scope as well. It’s not just about infant mortality, but the “near-misses,” the sickly infants, the NICU. We don’t just want our babies surviving, but thriving, she says.
Damus says nurses and their patients can think of the uterus as a muscle subject to the same risk factors as the heart; just as with heart attacks and disease, health care providers should look at family history of preterm labor and pay attention to red flags. Doctors should also know the pregnant woman’s birth weight and whether she was born early or late. “We’re talking about these life course perspectives,” Damus says. “We’ve got to do everything we can for men and women”
Healthy start initiatives may be targeting pregnant women in black communities, but “you’ve got to make them healthier long before they conceive,” Damus says. “It’s all about wellness promotion.” Damus speaks with a tinge of annoyance, perhaps anger, about the lack of advocacy for folic acid. One of the simplest, most cost-effective solutions to curbing infant mortality rates seems to be an afterthought for many health care providers. All sexually active women should be encouraged to take folic acid once a day or more, she says. “Did you take your folic acid?” should be one of neonatal nurses’ first questions, Damus says. Social media can be used to disseminate daily folic acid reminders. She even wants to see scrub caps with that question emblazoned on it. But what seems like the most obvious solution—ensuring the health of the mother to protect health of her unborn child—just leads back to overarching health disparities nurses and health providers have been and must continue fighting.
“We still do lousy despite all our priorities, and that’s because families aren’t a priority,” Damus says. “This is science as well as social justice.” In addition to lackluster infant mortality rates, the racial and ethnic disparities don’t seem to budge. “We should be outraged that we’re not making progress,” Damus says. “Yet, there are places that do, that show it is possible.” Damus’ former home, the Bronx, had an infant mortality rate of 15/1,000. Now, it is lower than the U.S. average, a result of years concentrated efforts.
Damus also advocates full-term deliveries whenever possible, avoiding scheduled earlier births. She categorizes the phrase “near term” with the saying “you’re a little bit pregnant.” You either are or you aren’t, she says, and advocates allowing women to postpone delivering until they full term. And nurses must arm themselves with adequate information, like making themselves aware of any medications that can compromise pregnancies. They can even teach expecting mothers to count kicks later in their development (a practice now back in vogue, she says). She also advocates healthy intervals between pregnancies and making sure fathers are involved too. “All the other stuff is just wellness!”
“The nurse is key as the advocate,” Damus says. But she maintains: “we can do a much, much better job.”
Life goes on
At the end of the day, perhaps the solution isn’t so simple after all: we need healthier people—healthy from birth—to grow up and conceive the next generation of healthy babies. Quite the chicken-and-the-egg scenario, and one dependent on an embattled and changing health care system.
What might happen in the next 10–20 years? “I’m not sure,” Damus says. “I don’t expect big changes.”
“If we look at the trend of the past 15 years, we expect the infant mortality rate to decline further in the coming years,” van Dyck says. However, the rate of decline during those years was “modest,” even largely unchanged from 2000–2007. He says recent infant mortality rates have been influenced by increased births among women over age 35 and little improvement in smoking before and during pregnancy.
“We really have to involve all the stakeholders,” Maddox says: nurses and doctors, mothers and fathers, government and community leaders. With an issue as complex as infant mortality, there can never be enough resources and research.
“A country’s infant mortality rate is one of the most important indicators of health,” Maddox says. “We have a lot of work to do.”
Spong, Catherine Y. MD; Iams, Jay MD; Goldenberg, Robert MD; Hauck, Fern R. MD, MS; Willinger, Marian PhD. (2011.) “Disparities in Perinatal Medicine: Preterm Birth, Stillbirth, and Infant Mortality.” Obstetrics & Gynecology. April – Volume 117 – Issue 4 – pp 948-955.
Jessica Tomer is a former editor of Minority Nurse magazine.
A nurse is defined not simply by the medical knowledge he or she acquires. Personality traits—ambition, selflessness, courage—also characterize those in the field. Being a medical professional requires a level of giving that those in other occupations may not experience firsthand. There’s a sole focus on the health of others, and a drive to set aside all personal matters for the well-being of complete strangers. For some nurses, the selflessness has taken them to another world, one where they step outside the confines of a hospital setting and into an area devastated by a natural disaster.
Over the past decade, there has been no shortage of disasters: Hurricane Katrina, the earthquake in Haiti, and the tsunami in Japan, to name a few. But through all of these events, one thing has remained certain: nurses and medical professionals act as steadfast caretakers to help victims physically and mentally recover from such disasters. Nurses act as the liaison between the devastation and the happy, healthy life the victims had before—and strive to have again.
These are the stories of the nurses that helped make that happen.
Haiti Earthquake, 2010
Eugenia Millender, Ph.D.(c), M.S., R.N., P.M.H.N.P., C.C.R.N., experienced multiple hurricanes as a Florida resident and Panama native, and knew firsthand what it was like to have such a major natural disaster strike. But even after the earthquake in Haiti, she couldn’t begin to imagine how the quake could drastically change so many lives so quickly.
“As a human being, I couldn’t imagine how a person could one day have their whole family, friends, and neighbors, and the next day, lose them all,” she says. “Day after day, the stories I heard got worse to the point that I just couldn’t watch anymore. I wanted to do more than pray.”
Working full time as a critical care nurse, Millender was no stranger to sad situations. But she had experienced “nothing so massive,” until she traveled to Haiti. And from the moment she got off the plane, it was pure chaos, she says.
“There were thousands of people walking with nowhere to go. Children were walking alone because now they were orphans,” and on the way to the hospital, there were countless bodies on the side of the road, Millender says.
“Once I reached the hospital, there was no orientation, no introductions, no explanation of what to do, how to do it, or when to do it, because there were hundreds of people in the parking lot of the hospital waiting for care,” Millender says. She adds that in the following days, there were many aftershocks, including one that was as high as a 7.0 on the Richter scale.
Millender remembers one patient she had, a 21-year-old woman with an arm that was almost dead and covered with flies and maggots. They didn’t have the equipment for amputation, and even if they did surgery, she would likely die from infection. Millender made many phone calls to help the woman—even contacting hospitals in the United States—but ended up sending her to the Israeli Army on the island since they had more advanced medical equipment. Millender later received good news from the woman’s brother: they amputated her arm and were taking excellent care of her.
After her work in Haiti, Millender moved away from acute care, and into community care and prevention, saying that she wanted to be an agent of change, not of treatment.
“I want to prevent, educate, and empower,” she says. “I want to change policies to improve the health care of the underserved. This is a step I probably would not have taken before the earthquake.”
Millender noted the resilience, perseverance, and hospitality of the Haitian people, saying they cared as much for her as she did them.
“Even when they did not have food or a place to eat, they made sure that I was cared for,” she says. “Caring is a universal language. I did not have to speak French or Creole to show how much I cared.”
Norma Graciela Cuellar
Hurricane Katrina, 2005
For Norma Graciela Cuellar, D.S.N., R.N., F.A.A.N., her biggest moment of assurance for becoming a nurse was in her mother’s last days.
“She said, ‘I know what you do. You are a nurse. I know how much these nurses have done for me and I know what you do now. I am so proud of you,'” Cuellar says. “To this day, no one has ever reassured me that I made the right choice to go into nursing as those words from my mother did.”
Having spent so much of her life along the Gulf Coast, and with family still there when she joined the faculty of the University of Pennsylvania’s School of Nursing, her heart sank when she heard about the approach of Hurricane Katrina. Cuellar’s family was living in New Orleans and Hattiesburg, Mississippi, and her sister owned a condo in Long Beach, Mississippi.
“That Monday, I went to work when I knew the hurricane was hitting. I could not concentrate. People at work acted as if nothing was happening,” she says. “How could I be somewhere safe, being aware that people could actually be dying, fearful of survival?”
Feeling helpless, Cuellar volunteered with the Pennsylvania chapter of the American Red Cross. “I was sent to the Cajun Dome in Lafayette, Louisiana, for my assignment,” she says, adding that there were 1,100 people there—mostly from New Orleans—that had to leave their homes.
Cuellar was assigned to be the charge nurse for the medical unit. The volunteers worked 12-hour shifts, but any time nurses left, there was always a chance they wouldn’t come back. “Sometimes, I wanted to beg them to stay because we didn’t know if we would get replacements for them,” she says.
There was one story that stood out in her mind about a man who thought his life was coming to an end. “He was looking out his kitchen window and saw a wave of water coming towards him. This was when the levee broke,” she says. “He couldn’t get out fast enough, and the water was up to his waist.” In tears, the man described how he was trying to get to safety while dead bodies were floating in the water around him.
Cuellar and her staff were so busy, it was often difficult to take the time to hear the victims’ stories, but she says, “the most important thing is to listen. These people wanted to talk and they needed to talk. They needed reassurance.”
Although working with these victims was the hardest thing she had ever done, she recommends that everyone volunteer with disaster victims at least once in their lifetime.
“You will get a different perspective of what is in your community and what the needs of the people were before the disaster hit,” she says. “It is a challenge to yourself and it will make you more aware of who you are and how you will practice in the future.”
Haiti Earthquake, 2010
When Joyce Hyatt, R.N., M.S., M.S.N., C.N.M., D.N.P., heard about the earthquake in Haiti, she fell asleep with horrific images in her head from the disaster. She woke up the next morning and told her husband that she had to go to Haiti to help the victims.
Born in Jamaica, Hyatt works as an assistant professor at the University of Medicine and Dentistry of New Jersey (UMDNJ). The desire to become a nurse came at an early age for her.
“I was inspired to become a nurse after watching my grandmother, a lay midwife in Jamaica, diligently perform her duties: delivering babies in the community,” Hyatt says. “I knew she was doing something good. She was helping people, she was loved and respected, and I wanted to be like her.”
She had initially planned on becoming an operating room nurse, but when she inadvertently assisted with the birth of a baby in a hospital elevator, she knew that was her calling.
“The overwhelming joy I experienced when the baby cried led me to realize this was my true calling,” she says. The following week, she applied to the University of the West Indies School of Midwifery, where she received her degree in nursing and a certificate in midwifery.
Hyatt had the support of colleagues and her church when she decided to go to Haiti. She had also joined an organization called Midwives for Haiti, a group that was training traditional birth attendants to become skilled midwives and to offer compassionate care to women.
When she went to Haiti, Hyatt worked in a hospital in a village outside Port-au-Prince. Many of the patients, particularly women and children, went to the hospital to deliver their babies or to seek general medical care
She worked mostly with other volunteer midwives, resident nurses, doctors, and medical students from the area who had lost their medical school in the disaster. “Everyone was compassionate, kind, and caring, not only to the patients, but toward each other,” she says.
Many visions of the disaster in Haiti remain with her. Even a few weeks after the earthquake, the effects were still evident: collapsed buildings, tents that housed victims, and organizations providing donated food. “[There were] people with missing limbs, some with burns or other injuries from the earthquake,” she says, adding that there was “an air of sadness” in the affected areas.
Some of the challenges she encountered with patients were ambulating women in labor, promoting position change, and trying to provide comfort in the absence of pain medication. Hyatt also helped in an orphanage during her time in Haiti. And for the first time in over 30 years of being a nurse, she used her CPR/neonatal resuscitation skills.
Despite the challenges, Hyatt noted how volunteering time and resources can truly make a difference to victims of a natural disaster.
“Helping these patients was one of the most rewarding experiences of my life. The patients were very grateful for the help they received, and most were just grateful to be alive,” she says. “I have become more aware of and more appreciative of what I have.”
Cynthia J. Hickman
Hurricane Katrina, 2005
After hearing about the suffering caused by Hurricane Katrina, Cynthia J. Hickman, M.S.N./Ed., B.S.N., R.N., B.C.-C.V.N., C.M., broke into tears.
The news reported that buses were coming to Houston, Texas, with displaced families. After hearing requests for water, clothes, and other sustenance, Hickman wanted to do anything she could to help the victims. But local media outlets said to wait until “a true assessment could be made” of the situation.
“I thought to myself, what kind of assessment was needed with so much human suffering?” she says. “I was scared, afraid, and sad. The worst emotion of all was an overwhelming feeling of helplessness. It was at that point I cried.”
For Hickman, a case manager at St. Luke’s Episcopal Hospital in Houston, this was her first time helping victims of a natural disaster. She had always wanted to train, but just never had the time. “When Hurricane Katrina hit, I learned a lot of things fast. I knew I was not going to face people just within my specialty,” she says.
The list of suffering was long: diabetics without insulin, infant dehydration, depression, and more. “The [hospital’s] expectation of available staff and the roles we were to play would change based on instructions from the command station,” Hickman says. “My role as a non-direct care member of the staff was more of ensuring that patient and family needs were met and to assist with medical equipment or community services if patients were hospitalized.”
The stories of the victims brought back distressing memories for Hickman. The faces of the people and children wondering: What just happened? What do I do? Have I lost everything?
“I spoke to a lady who could not find her son, who was with a family member while…the levee collapsed,” she says. “Still today, I don’t know if she ever did.”
Hickman says food hoarding was a frequent occurrence among the victims brought to the George R. Brown Convention Center. “Many had no idea what the following days would hold. Survival by any means possible was the behaviors of many,” she says.
Most of the evacuees she worked with were African American (New Orleans’ population is roughly 67% black). But Hickman notes that the hurricane didn’t show any regard for ethnicity. “Disasters are unplanned and unwanted, but occur,” she adds.
Hickman quickly realized there were lessons to learn before, during, and after a natural disaster. Though she often thinks about what she could have done differently, she believes that anyone in a community can help during a time of disaster.
“The natural disaster reminded me why I became a nurse: to mentor, teach, care, and support those needing a hand,” she says. “My reason for volunteering was very simple. There was a need, and I wanted to meet the need to the best of my ability.”
Marie O. Etienne
Haiti Earthquake, 2010
For Marie O. Etienne, D.N.P., A.R.N.P., P.L.N.C., the earthquake in Haiti was personal.
A native of Port-au-Prince, Etienne was in her office grading papers when a fellow professor came in and asked if she had heard about the quake.
“I was in a state of shock, feeling a sense of urgency to call my family to find out if everyone was safe,” she says. Her family members in Port-au-Prince lost their homes. Another family member had a broken leg. And her cousin, who was attending medical school at the time, died as a result of the earthquake.
Currently a professor at Miami Dade College School of Nursing, Etienne traveled to Haiti a few days after the earthquake struck. There, she served as a nurse practitioner with Project Medishare, where she cared for amputees, children, and families who “felt powerless,” she says.
“I felt so guilty that I was able to walk, breathe, and feel okay while so many people were crying in pain and suffering with either one or two limbs amputated,” Etienne says. “I did everything I could to help the patients and families…giving them hope, hugs, and a little smile to keep them going.”
One patient that stands out in her mind was a 26-year-old woman who was brought in with a GI bleed and elevated blood sugar, barely conscious. She held on to Etienne saying, “Please don’t let me die.” Although they did everything they could, the woman didn’t make it.
“I could not control my tears and emotions, yet we had to remain focused to handle and care for other victims,” she says.
One major lesson that stood out during her time in Haiti was Maslow’s Hierarchy of Needs to prioritize patients’ survival: airway, breathing, circulation (A, B, C). Etienne adds that providing culturally sensitive and compassionate care was essential.
“I had to remain strong, calm, and ready to serve at any given moment,” she says. “During the recovery phase, I learned to appreciate the smallest things in life, because the victims were optimistic even when they had no reason to be hopeful.”
Etienne speaks proudly of Miami Dade, saying that students took part in several vigils and helped raise funds for the victims. She also speaks highly of her colleagues who volunteered in Haiti, having worked with the Haitian American Professionals Coalition (HAPC) and members of the Black Nurses Association (BNA) Miami Chapter both before and after the earthquake. She also worked with the Haitian American Nurses Association (HANA), noting that 30 HANA volunteers, under the leadership of former President Guerna Blot, R.N., M.S.N., M.B.A./H.C.M., O.C.N., arrived to assist with the shortage of Creole translators and provide culturally competent care.
“The medical and nursing team were outstanding in terms of handling the pressure of saving lives,” Etienne says. “When giving care, give it all you’ve got by being caring, compassionate, skillful, and a dedicated nurse.”
In July 2010, Etienne received an Unsung Hero Award in recognition of her efforts in Haiti’s earthquake recovery by the Haitian American Leadership Coalition. She continues to coordinate medical missions to Haiti with the HANA team.
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