1. Miller, Lisa A. CNM, JD

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I am devoting this column to the work of Pauline Hill, a friend and fellow nurse who is spending time in Rwanda working to improve neonatal and obstetric care at a hospital responsible for more than 700 births each month. The following is an excerpt from one of Pauline's letters home, to friends and family. It gave me pause in so many ways, causing me to think about the disparities of care for women and children throughout the world, the challenges of working with limited resources, and the rewards of what all of us do on a regular basis, care for mothers and babies. Her letter made me cry, it made me laugh, and it made me proud to know Pauline. I think you will feel the same.


Here are just some of Pauline's challenges and accomplishments, in her own words:


Transitions are a time for personal and professional growth, and I have had the opportunity to experience a few. The transition of loss of familiar support, from something as simple as a traffic light or the flow of traffic in the US. It is hard to find reliable transportation here, and to rent a car with brakes is more then to rent a car with brakes sometimes. Most of us would find brakes a requirement in a vehicle, but here, not so much, and the loss of the familiar support systems can be overwhelming. The flow of traffic is chaotic, and just the loss of a familiar landmark is challenging. With Rwanda, a land of 10,000 hills, and the weather overcast, I have no sense of direction of where I am or what direction I am going. Around the next hill, or up the next hill, that's about the best I can do on the cloudy days. Loss of identity, as I am not in my country of birth, but a consultant and guest in an African country. The changes Rwanda has been through in the past 20 years have been well documented, but for the people, there are many things that are not really understood unless you live with the people. The loss of familiar references, the loss of reliable services, the loss of the value of currency. When I exchange money, the exchange rate changes daily, and each for-ex has a different exchange rate, and to navigate where you get the best rate can be an hour adventure. My experiences are minimal when I think of the Rwandese and the loss of their country in 1994. I have nothing to complain about, I know that.


I am still the one who looks different on my walk to work, out and about in Kigali, and at my hospital. All the hospital staff know me and interact with me as a regular worker, but the visitors to the hospital are the ones who look at me. Little kids in pediatrics are petrified of me, and I do not go to assist with blood draws, to start IV's or to give nebulizer treatments. The mothers say the crying kids "fear I have lost my color," and become too upset for me to get near them. I understand, and since malaria is not a disease I have had a lot of experience with in the states, I stand back and learn from the Rwandan nurses and mothers. The darn little mosquito can cause so much sickness. The high fever of malaria kills children, and I feel helpless and frustrated. I do not pay much attention to the stares and awkward glances anymore as I am out and about in the city; it is just a part of my every day. The street kids find me especially different, but these are the kids from poor areas of town where they do not have the opportunity to go to school. Many of the primary school children want to say something to me in English, and Good Morning is said at any time of the day, even in the evening.


My work in the neonatal intensive care unit (NICU) has been slow, but we have improved kangaroo care (where mother's hold their babies to provide warmth all the time) and we have worked on breast feeding schedules. There are infant incubators, but with no power the babies lie in the unplugged incubators, get cold and lose weight. Once the infant is off oxygen, I work with the nurses to move the babies with their mothers. One thing that slipped under my radar was the breast feeding schedule. I had thought that the babies were fed during the night, but many of the babies were gaining weight slowly. When I asked about the night feeding, the nurse told me the babies did not breast feed at night because the mothers slept. I asked why the nurse did not wake the mothers up every 3 hours to feed their babies, and the nurse said she did not know. I developed a parent information sheet, and each new mom has the sheet read to her so she understands that her baby needs to breast feed every 3 hours, day and night. The night nurse now wakes the mothers if they sleep too soundly. The increase in feeding frequency has made a very big difference in the weights and growth of the premature babies. Sadly, that took me 6 months to find out.


Maternity continues to be a challenge, from a huge volume and no resource perspective. I have been successful in obtaining 3 new industrial washing machines from the Minister of Health, now my problem is no plumber to attach them to the water source at Muhima. I simply cannot believe it, and I am at a loss for what to do about this. I will find a way to get these machines up and working, I just have to. Dirty linen continues to be a big problem, and the rats continue to enjoy the ample supply of rotting blood clots in the dirty linen. It was pointed out to me that maybe the rats would listen to me if I asked them to leave in French, since it was only 2 years ago that Rwanda adopted English as the official country language. I am trying to speak some French, but the locals would think I was crazy if I spoke French to the rats. I just walk through the linen room with a big broom, and boots!


Cultural baggage is something to be aware of, and I pause daily to recognize that the Western way of doing something is not the only way to accomplish a shared goal. I can change myself, and I can change my attitude toward the situation, and I can recognize the attitudes of others, and together, if a small change is accomplished, there is a ripple effect of positive changes and outcomes. What I view through my personal lens is not the view of others, and we all have a unique filter, past memories, past histories, past pain, past fears. The country of Rwanda has come a long way since 1994, and is still on the painful road to a full recovery. Today I was helping the staff in the NICU give a mother information about the death of her infant, and when we talked to the mother, she is a 21-year-old orphan, all of her family had been killed in the genocide. There are many days when I am at a loss to find the words for anything.


In closing, let me say that I think Pauline has found the words to make it clear to me that she is the right person for the job, and I know I am not the only one amazed by her compassion and dedication. Since writing the letter I have shared with you, Pauline has been able to get the washers hooked up and the rat population has gone elsewhere to find food; mothers and infants have clean linen; and the hospital has a functional laundry. Pauline has also just informed me that she is signing on for another year, and I hope to bring you more news of her success in future columns. For those of you who are moved to share a few words with Pauline, her email is She tells me that she would love to hear from anyone interested in doing global work similar to hers, and she welcomes correspondence of all types, as it keeps her connected and provides welcome relief from daily stress. I hope that when she reads this column, she will feel the admiration and gratitude that I have for her and all she is doing, and my ongoing amazement at her strength and commitment. Pauline and her work are wonderful reminders of what makes nursing so vital, so important, and so rewarding.


-Lisa A. Miller, CNM, JD




Perinatal Risk Management and Education Services


Portland, Oregon