A Hospital in Situ: Maternity Nursing Practice in Freetown Since 1892 by Tara Dosumu Diener
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A Hospital in situ: Maternity Nursing Practice in Freetown since 1892 by Tara Dosumu Diener A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Anthropology and History) in the University of Michigan 2016 Doctoral Committee: Professor Nancy Hunt, Chair Professor Joel D. Howell Professor Judith T. Irvine Professor Elisha P. Renne Professor Alexandra Stern Table of Contents List of Figures iii Abstract iv Introduction 1 Chapter One City Upside Down 13 Chapter Two A Cottage Hospital in a Creole City 60 Chapter Three A Differently Constituted Body: Clinical Racism and an Africanizing Medical Service 99 Chapter Four Where are the Nurses? 126 Chapter Five A Uniform Profession? Nursing since 1961 146 Chapter Six “These nurses today, they are strict-o!” Situating Clinical Violence 164 Chapter Seven Knowing about Not Seeing in a Freetown Hospital 179 Conclusion 207 Bibliography 212 ii List of Figures Figure 1: Central Freetown in 1815 Page 24 Figure 2: Postcard depicting Freetown in 1890 - View of Tower Hill Page 25 Figure 3: Imaginary traffic patterns from 1944 (top) and 1963 (bottom) Page 33 Figure 4: A map of the Sierra Leone coast Page 58 Figure 5: Pamphlet announcing the stone-laying ceremony at the Hospital Page 74 Figure 6: Dr. M.C.F. Easmon Page 122 Figure 7: Waiting for the Doctor Page 131 Figure 8: Patients and staff, PCMH Mission Hospital, c.1931 Page 135 Figure 9: Student Bendu doing microscopic work Page 140 Figure 10: Student Adi-Pratt is seen conducting an experiment Page 140 Figure 11: Miss Macauley, Senior Health Visitor Page 143 Figure 12: Fatmata, first year SECHN. Page 150 Figure 13: State registered nursing student. Page 151 Figure 14: As a fully trained state enrolled community health nurse Page 152 Figure 15: Agatha is a fully qualified state registered nurse. Page 153 Figure 16: The boss lady Matron Kamara. Page 154 Figure 17: Sister Mary Ward, c. 1898 Page 155 Figure 18: A nurse in Freetown Page 162 Figure 19: Student nurses tend to neonates on display at the Resuscitaire Page 183 Figure 20: A friend showing off in the Outpatient Department, 2011 Page 201 iii Abstract This study is an ethnographic history of nursing, midwifery, and childbirth in Sierra Leone. Combining rigorous attention to a historical longue durée as well as evidence collected via ethnographic immersion, this dissertation’s focus is on care, dress, and prestige in a single West African hospital. It was researched and written as a contribution to the history and anthropology of medicine in Africa; it also engages with the literatures on bioethics, nursing, science and technology studies, dress, and visuality. It explores colonial and postcolonial clinical practices, and situates these as knowledge, visuality, and embodied memory. Its focus is the Princess Christian Maternity Hospital (PCMH) founded in Freetown, Sierra Leone by British missionaries in 1892. Nursing and midwifery staff at this hospital practice today amidst crumbling infrastructure. The lack of basic necessities and socioeconomic circumstances often mean that the hospital only receives emergent, destitute cases. All the while its nurses wear 19th century-era uniforms that suggest complex, color-coded hierarchies. This study asks what is at stake and for whom in this sartorial work. It also asks how the clinical and the historical intersect on the wards. How have the perceptions of maternity nurses informed habits of giving and seeking maternity care in Freetown? The questions emerged during 15 months of historical research and ethnographic fieldwork, mining archives in Britain and Sierra Leone, and interviewing and coming to know childbearing women, nursing students, and hospital staff of all grades at maternity centers throughout Freetown, notably PCMH. There, in particular, six months of intensive participant observation and semi-structured, in-depth interviews enabled much data collection and analysis. The arguments of this dissertation are several: Nursing practice at PCMH iv emerged through decades with maternity care providers contending with varying degrees of scarcity, precarity, and inequality. The context is a sedimented one, requiring a sedimented, visual methodology. The practice of nursing, much like the city of Freetown, was established with British ideals on African soil; they have long been inflected by social and spatial practices. Practices of circulation, mobility, and nursing care have been translated across generations and also transformed. The seemingly anachronistic uniforms of PCMH nurses bear important evidence about intersecting logics revealing much about prestige, hierarchies, fame, humiliation, and implicit violence; consciously and unconsciously, these affective, material, and visual logics signify at multiple registers. v Introduction Hospital A has problems. Exterior security is heavy with electronic technology meant to restrict access, but behind the doors the image of order fades. Night shift is so under-staffed that an off duty EMT is recruited from the emergency department to initiate intravenous drips on children. Terribly lacking in human resources, this specialist referral hospital depends heavily on the labor of "techs": minimally trained all-purpose functionaries who fill in the spaces where doctors and nurses should be. The strain is showing. There are minor cracks, as rushed staff members administer medications without confirming patient identity. Simple supplies are lacking: a tube of petroleum jelly for a patient's chapped lips, a board to splint an arm with a temperamental IV. Abuses of the system proliferate, as patients are kept on narrow gurneys in the admitting department's holding bay overnight. While this practice often forces patients to pay a hefty deductible out of pocket (a charge that would be waived upon admission) it relieves the hospital from a full-fledged hospital admission, with its inherent record keeping and use of human resources. There are also larger problems, indicative of deeper fractures in the system. Following a traumatic IV start, a nurse insists on administering medication in its oral form, obviating the need for an IV. The capsule is scheduled for administration in the early morning hours, and the half- awake pediatric patient chokes on it. When the child becomes hysterical at the nurse's insistence, the nurse argues that the medication does not come in a liquid form and the child will not be released from the hospital until she swallows the capsule, which has by now melted into a bitter 1 paste in her mouth. A family member pleads with the nurse to petition the prescribing physician to consider a different medication. The nurse returns 30 minutes later and wakes the patient, who has just fallen back to sleep, to administer a liquid dose of the same medication, a form which supposedly had not existed 30 minutes earlier. Upon discharge home, the family learns that a crucial and obviously indicated blood test was never ordered and that the dose of medication the patient has been receiving was prescribed and delivered at half the indicated strength. The physician in charge mentions this casually while advising the family to continue the medication at home using the full recommended dose. Hospital B has problems, too. Security at the exterior gate is heavy: vehicles are stopped and their passengers interrogated prior to entry. Additional technologies such as patient registers and admission slips at the admitting department desk often restrict access, sometimes leaving patients waiting in pain while the correct documentation is compiled. Staffing is also a problem here. One particularly fraught day a single nurse is caught between shift changes, left to staff the entire admitting department herself as an ambulance approaches. This specialist referral hospital depends heavily on the labor of 'volunteers,' fully qualified but uncompensated nurses who often work for years at a time before being offered a paid position. These quasi-staff members may or may not be present on any given day. Hospital B's cracks are more obvious to even a casual observer: a common referral diagnosis is elevated blood pressure, yet there is only one blood pressure machine in the admitting department. The over-taxed machine works through the night shift but fails after the first three patients of the day shift. Abuses of the system are rampant, and staff members commonly charge patients money to purchase items that are provided free elsewhere in the hospital. 2 There are indications of deep systemic fault lines as well. One day nursing staff arrive to find that there are no physicians. After failed negotiations, the medical staff have gone on strike to protest wage and labor conditions. Nurses cope with patients seeking life-saving surgeries as best they can, but many women will suffer. A highly effective anti-hemorrhage medication is kept in a locked cabinet. The charge nurse knows the correct dose and route of administration, but she cannot access the medication because the resident physicians keep the keys in their pockets. The blood bank has the technology to instantly type and cross-match a sample, but the hospital supply is so critically low that patients' family members routinely solicit paid donors from the open-air vegetable market adjacent the parking lot. A young woman arrives in need of immediate attention, with birth imminent. After her information is painstakingly documented, two nurses transfer her to the hospital's only available wheelchair and rush up a steep concrete ramp through a guarded wrought-iron gate toward Ward 1. The ward supervisor turns them away: there are no beds available. Down the hallway, around the corner, down and up two more concrete ramps, they reach receiving Ward 2. Staff flatly refuse to admit the patient, arguing that her paperwork is not in order. One of the nurses sprints back to the admitting department, down and up, around the corner, down the hallway, through the gate, past the guard and down again to request the patient's chart.