History of Nursing in Pacific Canada

[W.H.O Reports written by Lyle Creelman] Creelman, Lyle, 1908-2007 1968

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Igrlo Oreel»an, Ifesing Consultant
WHO Geneva
March 17# 1954
I have recently returned frosa a. trip which has taken me arouM -
the world and up and dosm on tho msgs, from Jasselton in North Borne%
lp about 6° north of the Equator* to .tho Aleutians, about. 12 south
Of the Arctic Circle* It 1* true that the latter stop was just to.
.^jftu& the aircraft on a cold, blustery night, and not to sec what kind
of nursing is-provided for those interesting people, tho Aleuts.
IZy starting point was" Geneva, the headquarters of the World Health .
Organisation, and my first visit was to Delhi, the $outh~isst Asian
headquarters for "WHO. Belhi., as you knest, is the capital of tho
great subcontinent of India which has nearly 400,000,000 people^ a
country rich in human interest, With high mountains and groat flat
djfy plains. India has a plan for the development of Improved health
Services for her people., Mew there are more doctors than, nurses*
There are two schools of nursing which grant a degree and thus attract
the young women, and there are. increasing numbers of theaa who are ■
seeking to enter a university* There are 20 nurses employed bgr tho
World Health Organisation helping the nurses of India in their great
task of preparing others who am  servo their country in publio^he&lth
services, in clinics, and in hospitals,
Then I went to Bacca, at the lie ad of the Bay of Bengal, Dacca,
not to be confused with Dakar In Africa, is the capital of Saot Pakistan.
East Pakistan has 43,000,000 people and there are less than 30® xwses.
That is, not one nurse for every 14,000,000 people, Just in comparisons
in the United States, there is one for less than J00. la East Pakistan
most of the women are in purdah, much means they do not go outaldo
their hmms unless they are colored froa head to foot with a takah or
long veil, The burkah may be black or white. Ton can imagine ho*
difficult it is to persuade parents to allow their daughter* to become
nurses when they will have to leave the home, live in a residence with
sessarily less supervision t
;ca helping the Pakistan les
LI be acceptable to parents
play their part in the deve
•m be given at home, &nd work side
mid doctors,   WHO nurses ere in
levelop the kind of school which
ing Pakistani women who really want
nt of their newly independent
Kangoon. tne
ttv of the 'Kest*-
starting on tneir course. M.
were graduate nurses and also
had his certificate in midwife
ixurse in charge of this progrt
I   83ff   th
have their field experience m
nurses in Rangoon wear a unif<
western nurse. The native Bm
around ikirt, called a Xcueal,
sewn as the most beautiful
# students, including one male, just
> these public-health nursing students
tduate midwives,    Xes, even the man
,    A WHO nurse is helping the Burmese
u    In | ee at little village -just
i centre where these students would
assisted by "WHO nurses♦    Public-health
but not like the uniform of the
;q dress is a blouse with a long wrap-
ea 'Burmese nurse is in fJuniformK when
her loungi is of the colour selected hy her hospital or her public-
f the East, It happened to be a
ag wae gay ®n&  colourful, I wont
sd in Thailand, and a Ion'-; with soe
mercnants with u.a?~.r coat© iul
And of course, rice, because (
countries of the world. Even
learn ft cm the WHO nurses how
preparing more midwives ®n& pu
kinds of vegetable s and fruits
is one of the few rice-surplus
Lth nurses,
i how to
give BOG- vaccine and other teams hm to control yaws which affect*
13 p®? cent of their people.
Bow many of Y€m have ever been to Cambodia, the smallest and
most southerly of the three countries of Indo-China? Urn? tourists
go to see the ancient ruins of AhkoswVat, but few goto its delightM
capital, Pnompenh, Will you stop a little longer in Cambodia with
me- while I tell you about their exciting nursing project? Cambodia
has about 4,000,000 people md it has never had a real school of
nursing. The government wanted one and asked ellO to help, Tib years
ago, two international nursing teachers went to ^nea-Penh, They found
a great mm! for nurses. They found also young imn mid women willing
to be nurses but handicap-;;*?d in their basic education* " And there was
no one to really teach them hor>  to nurse. True, they could, and did,
attend lectures given by busy French doctors, but there was no one
to help them apply this knowledge in the giving of nursing care. So,
with the assistance of two young Cambodians, a man and a woman,, the
WEKl nurse* began making plans for a nursing school. This meant helping
to improve the present' nursing services which we call the clinical Held,
so that students could have a better opportunity to carry out the
principles they would be taught, It aeant planning a teaching programme,
■ that is a complete curriculum, so that a nurse would be prepared -who
would be able to meet the needs of Cambodia imH  not necessarily those
I of -enother .country* It meant also .drawing up plans for a school
tulleley which right now is under construction and y^aT^  soon will be
open to the first students of the first school-of nursing in that country.
And newithe young Cambodian man and woman who have been workine on this
project from the start, are taking a correspondence course from Paris
in order to fill in some of the yaps in their education, They have
realised that a nurse is not someone who blindly carries out orders*
He, or she, must know, md understand, th® why, and the how,
Ihere could one spend a more delightful weekend than in Hong Kong
with its beautiful city of Victoria, its famous harbour and the lovely
 nurses will be ass
to give public-he5
if Hon?: Kong so tha
a has grown from a city of half
million people.    One of its
fint mortality, and very shortly
a'a demonstration health centre and
ling to the student doctors and *
111 be better able to control this
lanila, tha capital,
istmas season in the Philippineo.
be for  the Western Pacific
ft,   We left the city for a
tains of Luzon to see tho famous
g built over 2,000 years ago.
th its stocky people who plant,
reat toil and effort maintain
low, a ring-snap
ance, I thought
*rted in Janu
WHO to send a nurse-midwi.
fielp prepare lllippino nur|
sill be established for th<
bun tain areas.
Wm m
berth Borneo is a delightf
slue-green Atolls,   A q At|
id surrounding a. lagoon an&§ in -en
[•■Id be like red coral.    It is really
f North Borneo was ravaged by war
Ly re-established.    The. first school
[ wish you could have seen with me
Malayan, Chinese, Ceylonese, Be eon and Murut.    The latter are two
native North Borneo tribes.   A TOO nurse is teaching them - and the
language used - English.
From North Borneo md its lovely tropical climate to Taiwan or
Formosa, where the weather was cold and dmnpm    But it was only the
weather that w^s cold.    The warmth of hospitality was overwhelming
and the eagerness tc show th® many interesting developments in nursing
and to discuss the plans for the future left me breathless.    There
are 11,000,000 people on this island and so few nurses.    Here also,
WHO is assisting the Taiwanese .nurses with their teaching programs*
And hew many of you have experienced the delightful hospitali1$r
of the Japanese in their own beatttUEhl' country?    Ton take your shoes
off when you enter a J&pme&e home or restaurant.    Ton sit on a mat
and you eat with chopsticks their famous dishes of sukaiki and tamouri.
Japanese nurses mre enthusiastic m£ progressive - the difficulty is
there are just not enough hands to go round.    Their great shortage is
for nurses trained as teachers*    They are isaking plans to establish
courses and some luckv :• international nurse will have the opportunity
of planning and working with them to meet this need.    They have asked
WHO to find this International nurse for them.
After nearly three months packed full of interest ^nd learning,  I
crossed the broad expanse of Canada, jsy home country.    There I visited
a few hospitals and gradually realised what was missing in contrast to
those mmry hospitals I had recently observed,    Two things in particular.
The children fs wards seemed to be for children only.    There are notices
telling when the parents might visit » usually for an hour or so on each
of im days a week.    In my mind I saw those other hospitals, sadly
■ lacking in eqiipmsnt and staff it is true, but the mother was there
with the child providing that close link which we in the West are beginning
to realise is such an important factor in recovery and which I suspect the
people of the East htw® always instinctively known,   And maternity wards
r country seemed to be for mothers only. The babies were to be
., except at feeding time, in a separate nursery. And in my"
s eye again I saw the wards with mothers, and the little cots
le or at the foot of the beds* So much more natural and satis*
: for both mother' and baby. Then I realised more than ever how
the countries of the East have to offer the West, if only the -.
will learn.
1   ,
Jla\ jla~j-
M Seniinar on Casework3   Keuruu ISTF/Sein.6
by Lyle Crcelman,  Nursing Consultant,  77,H.O.
-"• * .f-fiAr_cdp-ction
I am taking a few liberties with the title of the assignment
which was given te ne., I feel that before we can discuss common
elements in in~s.orvice training- we need to have a common understanding of Yi'hat puhli-c health nursing is and of its functions, the preparation of its•workers and their relationships with, other workers in
quite evident that the principles which apply to in-service training
in social welfare apply also in the field of public health nursing,
With your permission I would, therefore, like to discuss first some
of the common elements in public health nursiny and social welfare
and in doing so to explain what we commonly mean by public health nursing.
H• Common elements 1n Public Health. Nursing and Social yelfare«
1o Both of these professions are concerned with people - with
■ helping people to nolo themselveso V'/KOTs definition, of health, is*
I am sure, well known to all of you* It is"Health is a state of
complete physical, mental and social well-being and not merely the
absence of disease or infinnity-" It is, therefore, concerned with
helping people to help themselves. This helping of people to holp
themselves has not in the past boon understood by others as so definitely a part of public health nursing. I shall try later to show
you how this concept, as a part of public health nursing, is g-rowing,
2. Both public health nursing and social work are new professionsc
The first fcubljB health nursing service started in England in 1859 •
It was concerned at first mainly with the nursing care of the poor
in their homes hut the opportunities for health teaching ^cre very
quiekly recognised.
The first visiting nursing service in the United States started
1885 • I.-'t is interesting to note that in some other countries a
different type of visiting service originated. For example in Germany
due to the high degree of hospitalization, there was not the same
need for bedside nursing care in tho home<» In this county as well
preparation is basically social work* In Prance we have the "assistant
social15 whose preparation is based on nursing hut who is trained also
in social work and who carried curt social work functions«,
The profession of social welfare is younger than public health
nursing., There has been some rivalry between the two professions. Some
it is not healthy and it can easily he prevented* We • cannot completely
separate the areas of responsibility and it is the lack of understanding
and renege-tion of this which has caused sor.n of t-b-e :nb^nl fhv rivalry a
 i au une   open
in such a wM
leal  although
monsiiip    with, un
1  on hin
Y S     /oJA^jl^x   (a     O^a^aJJAa^
ISO: /£etu 6
to recognise and remove from his "back those obstacles5 personal °r
material., Ivhicfl impede his recovery ana prevent; his full co-operation
with the docf oz'A X The nurse also has this type of function to per
form; in relation to health, she should not^|mpose her will or her
will 02? her goals on  the patient e T5is combined_ ro 1 e or good
Lll^XS^A^AAzA^A 3R<1  ?--"™^1S^-— X±1zlFXzX±:S8XAAAL  cans i.or gooa jUf-^hah
A well known nurse educator1 has defined the position the nurse
-nczu  occupies as followso--
sv?he nurse is the interpreter cf the bindings or medical science.
She acts as a "bridge between the sources of knowledge (the
physician or the health officer) and the people5"'. Her intimate
association with the patient and his family establishes a
relationship which affords many opportunities for teaching, There
is a direct relationship 'between the confidence she inspires.
the soundness of her preparetion  and the effectiveness of her
reaching'5 ;
The public health nurse is in this position in the public health
field. Apparently"'no" country has agreed on a definition of social
work but "certain specific areas within if have been defined. We
might say the same for public health nursing. The definition will
vary; in countries according to their understanding of public health;
according tc what the worker in public health is o.oing in that
country and how he or she is trained. Proba.bly public health .nursing? ,
like social work, can ^^e^lained better than defined.
As I indicated to you earlier5 less than a century ago public
health nursing was confined to the nursing care of the sick in their
homes *"To-day it is the additional responsibility of the public health
nurse to assist in analysing health problems and related social
problems of families and individuals; to hel£ theuu with the aid of
other community resources -  to formulate an"" acceptable plan for the
protection and promotion.-,of their own health; and to encourage them
. to carry out this planH*<,^
The public health nurse may do intensive work in one field* This
we refer to as suecializat1on. Or she may carry out all or most of
the public health nursing services in one specific area as a part
of a generalized programme. This latter is becoming more common and.
is felt Ao'he  nore~effective as it permits service to the patient as
a whole and to his family. It is also administratively sound. In this
type of service the activities ij§ the nurse may include as a pert
of the service to the family, any of the followingm-
£ health teaching during pregnancy, nursing care at delivery
ana tne care oY the mother and new born baby after delivery:;
- the bead tli jynpejrvtL si on of the infant and pre-school child?
-- the health supervision of the school child;;                   1
15 Oo Parrel -   Margaret -   30 Social Case Work in a Medical Setting,
cn AAyZ'Ay  App^l 285 195-1? p, 955
3) Manual of Public Health Fnueins:
 ~ the supervision of the health of ad.ults especially in regards
to the prevention ano retardation of those diseases common
f o a d-ult; 1 i f e;
- giving skilled noising care to the sick in their homes and
InstruerIng s'pm:eon-e in zrzz  home regarding the care of the
patients, Througjt. the giving of this direct and intimate
service the opportarulties for health teaching are revealj~«
| the nursing care and he al th supervision of industrial workers
and their families;
- teaching of home nursing5
~ teaching and demonstration of measures for the prevention med
dohtrbl of" communicable" diseases including tuberculosis and
venereal diseases;
- teaching and supervision of mid-wives?
•- the interpretation and priuciples of healthful living necessary for tne promotion of" physical and emotional health and
the prevention of disease,,
to mobilize capacities in the individual and resources in the
community appropriate for better adjustmentsbetween the client and
all or any part of his total environment"* _/
Public health nursing is just such an art in field of health
but we have tc add that It.is an art In which knowledge of the .
science of health is essential as well as the knowledge of fhe-
science of human relations. We have said earlier that the public
health nurse and the social case worker are both concerned with
helping people to help themselves,, There are two aspects to this In
both public health nursing and In social work* the preventive and
her ; so much a "door11« I am^sure that the young
lity of means to relieve pain and Illness or of seminary decent
housing just around the block- the client does not lift a hand to
IFJjSWi^urn Bowers, 0,1k An   "The nature and Definition of Social
Casework* P*x* Iir% Journal ot  Social Casework, vnl ATZ.- No. 10 (19-1-9) 5
her trainin
social worh
er also
which you x
things for
 better this situation." y The public health nurse has to face this
also and she frequently has the same: tremendous impulse to do so mouthing about it herself rather than help the family to fake the
responsibility for i5 doing-;,
It was indicated, previously that more and more emphasis on public
health nursing is being placed on'the y-reralized functions. The
objective is to understand the whole_ family v  ee all know that many
social problems arise becauso~~6T illness and vice versa. Many times
the social factor contributes to and nay often create the illness
itself. Therefore, the study and care of the patient^should be an
integrated whole. Because of the public health nurse's opportunity
to go to all homes she must be able to recognize the social problems
needing the attention of specialized workers/ A' study which was done
recently on the co-operation between the visiting nurse and the
social worker lists the following conclusions;-
1. That the public health nurse is in a very strategic position
to observe and. report family social disintegration.
^.Tliat it is very important for the nurse to recognize social
ills early and to refer them or to consult regarding them0
"3PIhat- the nurse,, as a health specialist and the social worker,
"as a social specialist, need to be- aware of each, others
as true in social work as in public health nui
a direct relationship between training and the
-. work* 'Per this* reason both prof ess I ens are ws
inuimate comc ae
of developing a
noun professions require a good, prenarawion in uhe social
sciences« These subjects are being intro'diiced in* tine curriculum for
nurses in more and. more schools and this additional knowledge will'
serve tc make nurses more co/nscious of the social and emotional needs
whigh patients have. They .will be able to deal with, some of these9   '
but will also recognize when more intensive case work service is  .~ •
The training for nursing is perhaps not as ?? independent" In most
countries as is the training for social work-, Thif ort urate ly9 it has
not in al.1 countries, become fully recognized that the preparation
for nursing should be on a sound educational basis. In too many
countries the student nurse is depended, on for service and the educational needs of the student are only secondary*
TJTIrginia L. Tannar^ : Student Problems ip. Pieldwork in a Public
Assistance Agency9', The Family,. Jan. 194-5/-'
 I 6
We have just "been talking about the services given by the public
something wjjich
ry good that this
sral the training
Ln nursing, which
5y9 mental hygiens,
Lthe is added a
tublic health
theory and field
ftin4aa4L there is
health nurse. Briefly, what is her trainin^v
varies in countries and wnicii "is changing,, X
is so and that experimentation is going on, I
nay "be of two sorts9  Pirstv to the "basic tra:
includes in addition to iteming subjects,, ps~
sociology and some field orientation to puol:
post-graduate course of about a. yveyz  duratii
nursing. This poist-graduafe course includes
practice. Secondly, in some countries, ae he:
the basic course in nursing with public health and social aspects
integrated throughout, and during the last six months or so those
who desire to work in'the field of public health nursing may specialize. This is usually a longer course associated with a university.
When the students complete their nursing course they will then be
prepared to work either in the hospital field or in the public health
nursing field. It is essential, however, that they work under good
supervision. It is recognized to-day that the preparation for any
field of nursing must include the health and social aspects.
As I indicated previously* there is a different type of preparation which is carried on in Prance, in Germany and in Austria.
5, Methods*
How does the public health nurse carry out her work?
Pirstsby home visits* This technique is possibly used more in
public health' nursihsf tfian it is in social work. It is essential that
the public health nurse see the home situation. In follow-up visits
it is frequently easier to teach and demonstrate in the home with
the actual equipment available and under the conditions there.
Secondly, through office visits. This is probably more developed
by the social worker and possibly should be used more in public
health nursing. One value
families aware of their needs
and taking the initiative in coming to the nurse rather than her
^oing to them.
A third method which is used by the
by the social worker is group teaching.
public health nurse, and
The fourth and important technique is interviewdng and of course
interviewing is an essential part of the three previous methods
mentioned. It is the basis of good health teaching and we have had
much assistance from sovial work in developing skills in interviewing , We have not alwayrs recognized the importance of it.
6, PieIds of close association of functions.
We referred previously to areas of overlapping. Perhaps the two
fields where this is most evident is in mental health and in tuberculosis .
ISTF/Sem,   6
ffl o
relieve also
work and that
who has  a
jxt2    fu„    --
ow 1
10 ste:
■^  ri r
bilif "
j.r c
par en-
CS o
u    3
prep a:
1   fc
in th:
LS ,
l c
rist •
i mi
1   01
.j assists the teacher
?. <^een b"^* the nsychi. at
Co   As was suave oi
tort they needed
where the
 greatest wocknessos were it was found that
out by thcf nurses contained only a minumum
social history
tides ed
nur ses werc
ilmselef with the
vi. dual conferences were held, Tne re
understanding of the functions of ea
that one of the greatest felt needs
assistance in interviewing, This res'
oh this" technique* Lastly, ""the secia
with a selected number of children a
not only from'the point of view of t
it demonstrated the skills and know!
nurses, who had been a littie soepti
luat.ed and it was found that the soo
treatment recommended and a better ie
the parents. There were fewer cases i
many of the nurses who had felt perse
reassurance. There was a greater' mim
of the public health nurse and the sc
skills and contributions of each pr-oi
tion on their part to
& mot followed up and
3elation on the part
 I give this just as an example of how public health nurses can
tho social case worker oan contribute to at and Is indeed an esseii-
B j. Ti ib e r cu 1 o s i s ,
Tuberculosis is another field in which there is e great area of
overlapping by the public health nurse and social worker. This is
probably because in tuberculosis there are so many social and emotional problems Involved. Tuberculosis has benn said to be a social
disease. It is quite generally accepted that the public health, nurse
is the worker responsible for visiting the homes in tuberculosis
cases and for teaching although in some countries a social worker
may have these resxaonsibilities. It seems to me that this is an area
where there must be the closest co-operation and understanding of
functions, T$q  tuberculosis patient who is the bread-winner has many
problems tc be solved before he is going to be content to remain in
hospital. You are well aware of these, In many places medical social
workers are associated with tuberculosis hospitals* "These workers
need an unci er s t an din g of the home situation in order to understand,
the patient in the hospital* This understanding they can get through
the public health nurse who has been and usually continues to be a
regular visitor to the heme., Just as in the mental health programme
the social worker contributes to the in-service training of the nurs^
so in tuberculosis work, the social worker can contribute in the same
III, In-seryice Training.
I would like to refer back to a statement made previously that
there is a direct relationship between training and the effectiveness
of performance. We all know that professional persons who are involved
continue to study and grow. The doctor who does not continue to
study soon becomes antiquated in his field. The man who was an expert mechanic on the model T* Pord can do little with a modern automobile unless he has continued to study the new developments„ So
with public health, nursinhg and I am sure with social work. The nurse
or the social worker who does not have the opportunity for some type
of in-service education will quite likely become antiquated.
It is important for the public health nurse to have' the opportunity of a good in-service training programme *
a. Due te the advances in scientific knowledge the nurse must
keep pace with the developments which affect health,
b. The public health nurse must have an tin dor standing of human
relationships, and keep informed on the modern concepts of
mental health, educational philosophy and methods, etc.
c. The public health nurse because of the great variety in her
work huJB be familiar with rhe work of many other disciplines.
 d. She must have a knowledge of the contribution of other
workers so that she can recognize the needs of families. An
we said previously* she is the one who usual lv has the first
to recognize early symptoms of social disease as well, as
physical illness. She needs to know when the advice of other
professional specialists are required.. Per example, the advice
of the nutritionist, or the social worker,
e. She like the social worker must be able to participate in
broad c ommunit y pro gramme s.
^ s Heeds and difficultieg^^
Both groups have similar needs - the need for personal and for
job satisfaction? the need for approval; the need for supervision
and for understanding leadership;  for assistance in the organization
of the work load; for supervised experience while in training^ for  .
orientation as a now worker; and finally the need for each other pet*****!!
Public health nurses and social workers are together on a team for
the community welfare, both health and social. In order to be
effective as team members they must meet and discuss together and
learn from each other.
Both professional groups have similar difficulties in establishing an in-service training programme. One of the first of these
difficulties frequently is lack of time and recognition that the
agency has a responsibility in relation to in-service-training.
Associated with this is the large case loads which have to be
There is also the difficulty ot he amount of individual readiness
for, and receptivity to, an in-service training programme. This is
sometimes closely linked with a lack of trained and understanding
leadership. Wo knew/ that if an in-service training programme is to
be effective and to meet real needs it must be well planned and it
must be planned with -and bj the group themselves.
Another factor, experienced in rural areas, is the distance that
one worker may be from another and that many workers may he from the
centre. How are they to get together for group discussions? Sometimes
the distances are so great that a meeting nay not be possible more
than once or twice a year. Other means of in-service training must
be established to make up for this lack of group contact. Finally not
all workers within the agency are at the same level or have the same
needs. Moreover, not all are professionally trained.
3»  Methods of in-service trainings
I think our metheds in public health nursing and in social work
are very similar. They include the following■;-
a. Sup eryisi.PQ,*
It is from social case work that public health nursing has drawn
on heavily in improving methods of sup^rvin-ion. Tn the past we have
 too frequently had the wrong kind of
period, I well remember in my own tr
a linen cupboard when   the  so-called
supervision during our training
'sis uar.oe.,   it was  sometime  beioro
here  age
Tne aeyej
conditions - 1
made case stuc
he alth nurses.
ording of th
.s a unit has
ning for pub
tha si zed ,
lssigns  cannot be  eve
rhe-Be  are part
se worming m une
This  is an area, of  in-service -braining which is  perhaps not
used extensively enough,  Too often it  is the  director  and possibly
the supervisor in an.  agency who represents the organization, on
committees.  One  director of public health nursing hold me  that at
one time  she had twenty-five  committees tc  attends   She  soon realized
how impossible it was for her and she realised also the  opportunity
committee meetings  is now shared with staff nurses  as well as
health nt
k ■' Respensibility f or__ suj
This is an excellent met!
brings to the nurse some of id
opportunity of le arning and t\
The s"ca.ii puDiic
auch to contribute to
of in-service training. The student
ewer lmiowl.ed.ge which she has had an
ublic health, nurse is kept on her
toes when she has to demonstrate procedures and teaching methods
to another professional worker who is usually very keen and very
i.  Responsibility for vis itors to, ther org^izatien^
This also helps to motivate the nurse to become' aware of
newer trends and to keep familiar with the total agency
This is newer and very  effective methods It is particularly
;  useful in promoting an understanding of human relationship.
We have many common elements in social welfare•and public
he alt la nur sing ?
We have much to learn from each other. The public health nurse
has learned from the social case worker how  to Improve her inter-
viewinh technique* She has learned more of the importance of human
relationships. She has drawn veyy much from the literature of the social w^rk profession.
The social worker learns from the public health nurse information which gives a more complete understanding of her client. She
can gain from the nurse*'s practical point of view in her approach
to family problems. She can secure frem the public health nurse a
more complete knowledge of community health resources. She can rely
on the public health nurse as an early detector of social ills.
In relatitn to in-service training I can. do no better than to
quote the final paragraph from the article by Catherine M, Manning.,
which received in your papers, She states stable part cf agency and staff development;  that if should be
broadly rather than narrowly defined.; that it must be continuous
that leadership must be strongs that staff participation in
planning and execution is essential; that method and. content
must be fluid and geared to'the movement of social work itself.
We might add that at least a part of the program should be
related to the needs and interests of the entire staff g
clerical as well as professional - and that it should offer
the kind of stimulation which, for some workers, will lead
on to professional, school? for others, will make their jobs
more understandable and challengingj and for the professionally
trained, will open avenues for iiacreased responsibility and
positions of leaders hi p,C"
Per the ?/erds "social workij you may substitute "public health
nursing.". The same principles apply, the same need exists.
 VISIT TO ms&s&L
11 to 14 March 1968
It had planned that we leave Kinshasa on Sunday 10 March.  However the
plane did not arrive from Dar-es-Salaam in time to leave Kinshasa and arrive
in M&i&obi before the air curfew at 7 P.m.  We had to return to Kinshasa and
come back to the airport on Monday morning.  We left at M. 9.50 a.m. and
arrived in Nari-petoi shortly after 11 a.m.  After lunch with Mrs Pratt at her
home, we drove with her to Ibadan arriving about 7 p.m.  This left us only
Tuesday until non on Wednesday to visit with the WHO team in Ibadan and meet
various cff/icials.  We returned to Lagos leaving Ibadan about 1 p.m. on
Wednesday.  In the evening on Wednesday Dr Nugent had a dinner party and on
Thursday morning we visited in the Ministry of Health, finishing with a luncheon
party given by the Ministry on Thursday.  On Friday morning we left for Accra.
In Ibadan in addition to discussions with the WHO nurses assigned to AFRO-87
we met the following:
Prof. Edington, Acting Dean, Faculty of Medicine
Mrs Ogunlana, Matron, University College Hospital
(Mrs Ogunlana was on sick leave and we met her at her home.)
She is a Nigerian matron, only the second to be appointed to
the University College Hospital.  Mrs Pratt was the first. However she was
followed by an expatriate for two years before Mrs Ogunlana's appointment.
 In addition as an official reception many university and government
officials were met.  About 150 were present.  Many with whom I spoke including
the Deputy Vice-Chancellor spoke in gloring terms of the WHO team and wished
to assure me that the programme was well established and there was no fear for
the future.  Dr Lambo who has been recently appointed as the Vice-Chancellor
unfortunately was not In Lagos at the time of our visit.
Our Tuesday morning visit began wiih a tour of the new building which has
been provided by the Rockefeller Foundation.  It is beautifully planned and
has ample classrooms and office space.  There are plans being made for the
opening of this building in June at the time of the graduation of the first class
of twelve students.  International nurses are being invited and it is also
hoped that WHO will support the participation of some nursds from African countries,
including both English and French speaking countries.  In the present group of
twelve students there are four from other countries; three in the first year and
one in the final year.  These students are from Lesotho, 1; Cameroon, 2;
Gambia, 1.
Later in the morning we met with the WED nurses and the four Nigerian
counterparts. Each of the counterparts told of the work which they were doing.
First was Mrs Adeho, who came to the Faculty from the School of Hygiene in Ibadan.
She sansa  acts as counterpart to Miss Clemence and teaches public health nursing.
Mrs Tubi acts as counterpart to Miss Mitchell and teaches medical surgical nursing.
She spoke of the methods of teaching and the emphasis on patient care, case
studies and problem solving.  Mrs Savate is the only one who already has a
master's degree; she gives nursing education to third year students.  She works
with Miss Saunders in regard to this.  She also works with Miss Saunders in
teaching psychiatric nursing, a subject in which she has not had a previous
experience.  Mrs Kaitell takes the final year students in administration and
 supervision.  I believe Miss Abbott teaches some to this group too.
Mrs Kaitell supervises their field work and she also teaches second year students
in maternal and child heath.
Miss Clemence teaches some research which is mainly an orientation to
research to some statistics and reading research studies and their interpretation.
The students are developing a statistical design for a research project.  This is
as far as they can go with this group of students.  There was considerable
discussion of where the programme needs to be strengthened.  This is especially
in regard to the clinical aspects.  All the students take the same programme
which include both public health nursing and psychiatric nursing as well as the
functional areas of administration and teaching.  Some of the students have not
had previous experience in psychiatric nursing or in public health nursing.
As to how experience in these fields can be arranged possibly during the long
summer holidays is a question to be studied; also the reconciliation of the
entrance requirements and experience required with the requirements of the
Nigerian Nursing Council.
At a breakfast meeting with Judy Saunders who specializes injpsychiatric
nursing, she discussed counterpart difficulties.  She mentioned that Mrs Savate
was not interested in this area.  This is not tea surprizing since Miss Saunders
uses quite difficult terminology in relation to psychiatric nursing and she is
rather abrupt.  Mrs Savate is rather recently married and her husband works in
Lagos.  It is therefore not surprizing that she is not demonstrating as much
interest in the programme and in psychiatric nursing in particular of s fields
in which she has had no experience.  Another difficulty in relation to the
programme is that three of the counterparts are planning to go abroad for stuoy
for their Master's degrees this year.  This has been a cause of some discussion
 between Mrs Pratt of the Ministry and Miss Abbott.  Miss Abbott feels very
keenly that these three must be replaced.  Mrs Pratt is finding this difficult
due to the emergency situation and' her need for qualified nurses elsewhere.
Mrs Pratt feels that three should not go this year.  These are difficulties
yet to be resolved.
School of Hygiene, Ibadan
This School was visited on Wednesday morning with Mrs Pratt.  Dr Thompson
and Mrs Aiola.  Five categories of health personnel are prepared:
- health inspectors
- sanitary overseers
- dispensers
- health sisters or public health nurses
- community nurses
There are 90 to 100 students at the School.  In the one year course for health
sisters there are l6 students, and in the two year course for community nurses
there are 55 students.
The health sisters' course accept a certain number of candidates, I think
three, from each of the Regions.  It is the only course for health sisters in
Nigeria.  The community nurse course also accept students from all the Regions.
There are two other courses for community nurses, one in the Northern Regjo n
and one in the Eastern Region, probably the latter is not continuing at the
There was some discussion of a possible link between the health sister's
course which is post-basic public health nursing and the university programmes.
It is hoped that some arrangements might be worked out whereby this one year
course might be considered for some credits if the student or the nurse wish
 - 5
to follow the university programme later.  There is no doubt that this
programme at the School of Hygiene needs strengthening. It is fulfilling
a need in Nigeria for public health nurses.  If it were strengthen better use
were made of the teaching faculty and classroom space, then it should be a very-
good programme.  There are very good clinical facilities including a clinic
at the School and also a district.  We did not see this.  The nursing staff
for the health sisters' course and the community nurses' course consists of
three health tutors and one health dister.  One of the health tutors
HAS Recently returned from McGill with a Matter's Degree.
On Thursday morning we visited the Ministry of Health where we had
discussions with Mrs Pratt and with three nurses whom she is given responsibilities
in the Ministry.   They are not yet directly appointed as members of the
Division of Nursing.  One is specialist in nursing education, another in
hospital nursing service and a third will be coming who will be responsible
for public health.  We also had a discussion with Mrs Bedsford-KaaiCole
who is in charge of domiciliary midwifery for the Lagos City Council. This
is a fairly largd staff with 18 UK-trained nurse-midwives, some of whom have
health visiting;  all must have district nursing.  39 community nurses and
39 locally-trained midwives.  I gather this latter differ in their midwifery
training from the community nurses, but I am not sure in what respect.  There
are 6 health centres in the city.  In 1967 there were 3*000 home deliveries.
However, this probably represents only ~Z>Z%    of the total deliveries In Lagos.
The Lagos City Council has three divisions.  First, a Maternal Health
which is a domiciliary midwifery; Child Health, which has 18 on the staff;
and School Health which has 10 on the staff.  Each of these three divisions
has a nurse-midwife ssqaffiasdasfsasjibu^ superintendent.  There is no overall
 - 6 -
nurse-superintendent as yet.  This is because of certain political
difficulties and the fact that the nurse who is the best qualified for it
would not receive the appointment.
Nigeria is being divided into 12 states.  The total papulation of the
country is some 55 million.  The difficulty now is that due to the
situation, people are going back to their own states.  The north-eastern
state, which is the largest from the point of view of population and area
and has 10 million people, has no doctor;  nor does it have any teaching
hospital.  There are 40 teaching hospitals in Nigeria.  A list of these
has been made available.  It will be noted that several of the states
have several;  others have only one, while Jthe north-eastern has none.
This new division into states is supposed to take effect on 1st April.
The nurse training is three and a half years.  There are two intakes
each year.  Mrs        stated that they are developing clinical teaching
and in-service education.  She has appointed a newly qualified male tutor,
newly qualified in that he has just returned with his degree for the co-ordination
of the in-service co-ordination.  There is a marked decrease in the number
of nurses going abroad for study.  It is very interesting that in the
Nigerian Nursing Council they do not register all-American nurses who apply
for registration.   This largely affects the missionaries.  They are also
considering the same policy in relation to United Kingdom nurses.  Some may
not be eligible for registration in Nigeria.  They hope very much that the
post-basic programme will be developed to fulfill the needs for teachers
of nursing and midwifery.
We met with the chief medical advisor, Dr Otolorin, and with the
permanent secretary Alajji Tatari Ali, The  commissioner of health left this
week for a trip to Canada, the United States and Manila.  It had been said
that he was going to Manila to recruit Philippino doctors for Nigeria.
 Miss Davis
To be
after the
Miss Davis who was assigned to the basic health services project in
West Central Region was stationed in       came into Lagos and we saw her
here.  She had bought a new car and was having a medical examination. This
climate apparently does not agree well with her and there is discussion of
assigning her to Kenya 16 to replace This would not
take place until October.  Her replacement here might be Mrs Banerjee who
was in Ghana and is now with her husband who is studying in England.
Miss Davis has had a pretty difficult time since arriving.  She was
brought into Lagos during the firsiipart of the emergency and spent two months
doing virtually nothing.  She then went to Ibadan and worked with the
post-basic team.  I gather she was helping in odd jobs but not doing much
teaching; at any rate, she gave them good moral support.   In -lilt!
she is trying to work at Ministry level to influence ^the basic nursing training
programme and as the project develops will undoubtedly be preparing auxiliary
personnel.  From discussion with her it seems that many of the schools of
nursing in Nigeria are still at a very low level.  They are trying to bring
them up to a level acceptable to the Nigerian Nursing Council, or as Miss Davis
says, acceptable or on a par with the S.R.N.
I asked about the medical officer in the basic health service team. She
said she felt he was really busy trying to be the senior officer. I have a
feeling that the functions of the medical officer in the basic health services
are not fully designed (???);  they know only that theyare "bearn leaders".
If Miss Davis cannot have a reassignment she will leave at the end of her
Visit to University College Hospital
A short visit was made to the Paediatric Wards of the University College
on Ibadan  Hospital.  There are a great variety of conditions ^represented in these
 wards - much malnutrition and and cases of very serious
conditions resulting from The wards seem to be well run
and well staffed.  Mothers visit at certain hours of the day - ft.  feeding
times for the younger children.  They are also housed on the hospital
It was not possible to see the Professor of Paediatrics.  However, I
discussed the possibility of the research on continuity of care with
Miss Abbot.  She thought it would be a very good exercise and would be
willing to consider it and work out some system whereby her students or the
faculty would co-operate with the medical people.
Following the visit to the Paediatric Ward, we called at the School of
Nursing and saw the acting Principal.  The Principal was not there.  Out
of the total of nine teaching staff, only three are qualified as tutors.
There is an establishment for eleven.  This results from the emergency.
In touring the hospital, Mrs commented that many of the
wards had been taken over by the military.  Apparently there has been a
great loss of medical staff and a great loss of students from the University.
No-one would say exactly what the student enrollment is now, but it is
probably almost a half less than before the emergency.
Comments on Project
Undoubtedly, this project has been well established within the University.
However, it seems to have had a very stomray beginning.  I think Mrs Howard
was probably a tragedy for it and I believe some of the criteria
21-25 March 1968
Arrived in Niamey Thursday afternoon after an overnight stop at Abidjan in
order to meet connections.  In Abidjan I had discussions with Dr Perabo and
Mile Sylvain.  This was unofficial.  I would gather that they are working
largely as staff people in maternal and child health trying to do a little
training and improving some of the MCH work in the dispensaries.
Shortly after arrival in Niamey made a tour of the School building and saw
some of the students before they left class for the day.  The School compound
has five buildings.  Details of this may be found in a special report prepared
19 March 1968.  There is a fairly good library and good demonstration equipment.
There is need of new desks as the ones they have in the classrooms are very old
fashioned and uncomfortable.  The buildings seems to be in fairly good condition
and are kept quite clean.  The report referred to contains proposals for extension
of buildings, equipment, etc. required to enlarge the School.
There are now xpcstudents in the School, 32 of these are in the one year
certificate course, these are auxiliaries, of these 13 are girls.  23 are in the
first year on the two year programme; 3 of  these are girls.  15 are in the second
year of the two year programme, none are girls.
Dr Wright gave a history of the School.  It started with auxiliaries in i960.
Courses were given by the doctors, there was no supervision.  The programme was
then two years old.   This carried on until 1965•  Since that time, the course
for the certificate group has been only one year in duration.  The present
School started ±&s 1 February 1965.  The School year is now October to September
with one admission for a year.  The interviews and examinations for entry are in
July.  17 is the minimum age and the students are all bonded for ten years.
 At the present time, the certificate groups have had primary education and the
diplBme d'Etat group (brevet) i.e. ten years of basic education.  In October,
it is planned to start the 3 year course and the first graduates will be available
in 1971.  Hopefully there will be 35•  Ten places in this course are reserved
for some of the older students who took their training several years ago and who
are permitted to ±%&m  repeat their nursing course and obtain the dipl6me d'Etat.
Further details of the development of the School to date may be found in a report
prepared by Dr Wright last year.
Last year a supplementary course or a third year was given to 8 students.
This/contained theory and practice in public health, administration, diagnosis, etc.
It was especially meant meant for preparation for those who will work in the bush
where there are no doctors.  Of the 8 who took the course, only one is actually
working in the bush.  The course has been suspended.  Some of the information
given will be included in the third of the three year course.
Dr Puyet, acting WHO Representative, requested that a course be prepared for
health inspectors.  However, this was going to prove too costly and- it has been
recommended that this not be given here in this School.  There are two other
courses, one in Lome and one in another adjacent country where such personnel can
be prepared.  Both Dr Wright and the personnel of the School including the WHO,
felt that it was not wise to prepare these people in the same institution as the
nursing personnel.
It is envisaged that the midwifery course will start in 1970.  The first year
will be in common with nursing and will be followed by two more years, in midwifery.
Dr Wright, who is officially the Director of the School and apparently is the
only one interested in that overall public health for the country, outlined the
 following which is yet to be done:
- preparation of a syllabus for thxe 3 year programme
- the passing of the decree for this programme
- a new building to be constructed
- the project for the midwife to be prepared
- and budget to be obtained for the enlargement of the School
- request for continuation for funds from UN (Special Fund)
In regard to the Special Fund Dr Wright would like someone to come to see
the project.  Mr Kurowski never visited the School.  He was in Niamey only once
two years ago.  Two Special Fund representatives were in Niamey last year.
Miss Beltzung saw them for five minutes, Dr Wright did not see them at all.
There has been no WHO representative for the past nine months.
Students have their practical work in the mornings and classes in the after-
noons.  Visits were made to/clinical areas.  These are in the hospital, PMI,
African maternity.
The Hospital has about 400 beds but 600 patierts.  Just now there is an
epidemic of meningitis and many patients are housed in straw tents on the ground.
There is also a large TB ward with very advanced cases.  There is a lot of tuberculosis in the country.  The Hospital is on the pavilion type.  It is directed
by a Mother Superior and there are 4 or 5 catholic sisters.  In addition to local
personnel and 5 young French nurses who are here as volunteers; one of these,
Mile Vaillant, was interviewed since she has applied for WHO.  She is a very
pleasant person, has completed her baccalaureat and will have a copy of her
certificate sent to Geneve.  She is 28 years old. Miss Beltzung says she has
given a lot of help to the students.  From all I can gather I would recommend her
for consideration for IR-110.  She has worked in Niger for 15 months.  Her
contract ends the end of November 1968 but she would extend it for a little while.
To continue with the Hospital it is very overcrowded with patients on mats
on the floors in the corridor and on the balconies.  In spite of all this it is
relatively clean and the patients seem as comfortable as they could be under the
circumstances.  There is a hospital kitchen but many of the patients receive
food from relatives.
Miss Morlock took me to visit the situations where the students have their
public health experience.  First we saw the African Maternity.  Mothers stay for
24 hours.  It looked as though the sheets on the beds were never changed.  There
are two Nigerian midwifes in charge, both of them seem very capable.  In the
labour room there were three mothers being delivered.  The PME centre is very
crowded, but everything is very orderly.  A French doctor has worked there for
about five years.  She is very devoted to the work and does a great deal for the
mothers and children.  I would think the experience for the students there would
be very good.  Miss Morlock accompanies them every morning.  There is no
domiciliary service anywhere in Niger.
We visited the Anti-tuberculosis clinic which has a WHO team now consisting
of a doctor and a newly recruited laboratory technician.  She had just set up her
small lab.  The building seems very adequate but I do not feel that a great deal of
work has been done.  The streets in Niamey for the large part are not named nor
the houses numbered.  A system has been established whereby the families can be
more easily located.  There is some sort of follow-up of defaulters who do not
return for their drug treatment.  I could not determine that any special visiting
personnel are prepared.  They are waiting for the arrival of the WHO nurse,
Mile Huber.
Mile Couillard is responsible for the clinical teaching in the Hospital.  She
is there every morning with the students, along with three Nigerian counterparts.
These three are:  Mr MSiii? Mr Mamadou and Mr Yaye.  These three are not yet
prepared as tutors.  They will be sent away on fellowships.
 - 5
Mile Beltzung's counterpart is Mr Camara.  He has had the Ecole de Cadres and
also the course at Rennes.  He takes pretty well full responsibility for the
certificate course.  He admits that this course is a little too theoretical.
It is envisaged that Mr Camara will one day take a course in Lyon and that he will
become the Director of the School.  Apparently Dr Wright would like to relinquish
responsibilities.  He is really prepared as a tuberculosis specialist and he
acts as the counterpart for the WHO TB Adviser.
I have had a very good impression of the Nigerian mate nurses who are working
in the Schcd.  It seems apparent that they work as a team with the WHO nurses
and that they are really interested in nursing.  It is quite true that nursing
is largely composed of techniques here but with the conditions as they are, it is
difficult to see how it could be different.
In reviewing the objectives of the Plan of Operations, the following may be
1. the quality of the teaching has been improved.  They are continuing
to review the programme and to make changes according to needs.
2. They have not yet reached 30 or 40 graduates from the School each year .
However, there are plans to augment the intake and gradually more and
more with the required qualifications are becoming available.  Before
too long, it will be possible to require a complete baccalaureate.
More girls are becoming available too.  Three in October of this year
the three year programme will be started.
4.  Nigerian monitors have been prepared.  However, more fellowships will be
needed and ±ka some of them will need to return in L$5on to take a more
advanced course.  It is doubted that the Nigerian personnel will be
ready to assume full responsibility without WHO assistance at the end of
the five year period.
 It is felt that very good programmes have been made and that these
programmes are really being adapted to the conditions and the needs of the
Two procedure manuals have been prepared, one for the first year and one
for the second year.  Apparently Mile Vacherof/sent photocopies of these
and used them at Pointe Noire.
The students have organized themselves and have prepared a School
bulletin.  The first was issued this month.  A number will come out about
every two months.  (See sample in file)
The final meeting was held on Monday morning with the three WHO nurses
and part of the time with Dr Wright.  Some questions which I still had in
mind were dscussed.
The reasons why the third year supplementary programme which was given
to eight students was discontinued were because of the great immediate need
for qualified nurses.  Also it was felt that to give a better training in
three years, would be preferable.  A third reason was for finances.  The
Ministry were not willing to give an increased salary to those who would
graduate on the third supplementary year.
In regard to the Plan of Operations, practically all the objectives have
been met, except to increase the candidates from 30 to 40 per year.  It is
hoped that in two or three years, they will have sufficient candidates with
the brevet to increase admissions and graduates to 30 or 40 per year; also
there will be more girls for training.
With regard to in-service education which is mentioned in 1.2.6. page 5
of the Plan Ops, a cours de perfectionnement has been organized by the
Faculty of Medicine of Lancy.  This seems to consist of written questions
and theory which are sent to the students by mail.  The students do the work
 - 7 -
and send the replies which are marked by the doctors in Lancy (?).  Out team
agree that this is not enough but it is a start.  It was stated in the Plan of
Operations that the personnel should be relieved from their professional responsibilities.  This is not possible at the time.  The Chief in-service education which
is given to service personnel is through the work of the WHO nurses presently
Mile Couillard and Mile Morlock with the service staff and with the moniteurs
who also work with the students. This is all in relation to the clinical teaching
of the School students in the Hospital and in the public health field.
They have had aprognamme prepared for in-service education of traditional
birth attendance but this was not started.  The reason for this seems to be that
the Ministry of Health was not keen.  Incidentally we have tried two times to see
the Minister of Health but he has been absent.  He will be at the Assembly in
Geneva as will Dr Wright.
In regard to supplies, they Jaaxa are pretty well supplied for the School and
the Library.  They did ask for more which they could use for clinical teaching
in the Hospital but Brazza objected.  I suggested that they should try again and
not to hesitate to request some extra materials which would be left in the Hosp ital.
They all realize that they should not have too muhh so that tha conditions of their
practice will not differ too much from the actual reality when they find themselves
in positions in hsospitals and public health.
We discussed fhe fourth position for a WHO nurse.  They would like very much
have a clinical instructor, not necessarily a midwife.  This person would work with
Mile Couillard and the three Nigerian counterparts in the clinical teaching in the
Hospital.  At the present time Mile Couillard takes responsibility for the
certificate group as well as a diplome d'Etat, i.e. 70 students;  it is too much.
 The item on the equivalence of this course with the diplome d'Etat and France
was explained.  The English translation is not correct.  It is equivalent to the
level only which means that when the students go from here they do not have to
take the examination.  They are not entitled to practise in France.  This is
also awarded to other countries of Africa.  Mile Beltzung will send us a paper
explaining all this.
I discussed at various times the need for more narrative in the report for
the Special Fund.  Apparently Mr Yahmin, the Assistant to the representative for
UNDP here, has always told her that they did not want narratives, just figures.
I suggested that if he continued to feel this way she attachs a narrative as an
annex.  She fully understands our need for this.
In regard to fellowship students, two are in Paris now and will return in June.
The three moniteurs who assist Mile Couillard will go to study this year.  All
Nigerian moniteurs have spoken to me about the opportunities for extra study and
this morning Mr Camara, who is destined to be the Director, spoke to me about the
need to see how things are done in other countries.  On the first day that I
talked with him I asked him if he felt that the programme given as in France was
good for here.  He had immediately replied yes.  However he has been thinking
about this since that time and had more discussions with me about it.  He also
feels that there may be too much theory.  He is willing to consider a better
integration of theory and practice.  Mile Couillard told me that he is very
intelligent.  He observes and he asks questions and he is willing to try new
things.  He should be given an opportunity to go to Lyon before taking over
responsibility for the School.
I think it has been fery fortunate that Dr Wright has continued to be the
Director and I told him I hoped he would do so for some time.  He does not interfere
the technical things and he forms an excellent IMson with the Ministry of Health.
In fact I think Dr Wright is the only one who does anything at the Minos try.
 He is genuinely interested in doing things for his country and regrets very much
having to spend so long in Geneva and be absent so long from Niger and his work here
when he goes to the Assembly.
I asked Dr Wright about what has been realized of the national health plan.
His immediate response was the School of Nursing.  He went on to indicate a few
other things.  They have established 4 mobile teams which act.jreallymas mobile
dispensaries.  Each of these teams are in four departments in the Eastern part of
the country.  There are seven departments in all and three teams are still to be
organized.  The health infractucture has not been established.  There are two
tuberculosis centres with beds, in addition to the pilot project in Niamey. This
pilot project is for research (I had previously asked Mile Morlock and Mile Beltzung
just what they did in this pilot project; neither ofj them feel that feel that very
much has been done since the nurse has left and they agree with me that it is somewhat of a mistery.)  Dr Wright said there is a plan for training and for home
visiting.  We discussed a little the need for integrating the domiciliary service
so that the same home visitorcould do the PMI work as well as the TB.  He agrees.
It would be well to discuss this project with Dr Mahler and Dr Piot in Geneva.
Further to the realization of the National Health Plan, there are no sixth health
centre as yet. There is a project with FED for small hospitals and the enlargement of
the hospitals in Niamey and Zinder and to establish 16 new dispensaries.  All of
this is yet on paper but it is hoped it will be completed by 1973.
There has been some training of first aide's in three places.  This training of
3 weeks to one month has been given by the doctors in these centres.  The first
aiders return to their villages.  They are employed by the village and the village
also pays for the medications.
In Niger there are in all 64 doctors of whom only 9 are Nigerians.  31 of the 64
are stationed in Niamey.  There are 15 away now studying medicine.  Most are in
France but one is in Abidjan, one in Poland and one in Russia.
 - 10 -
In Summary I told Dr Wright that I was very pleased with my visit and had
found it very profitable.  In particular, I felt it was very good that he was the
Director of the School and hoped that he continue.  I indicated that I found the
programme much better than I had expected and felt that a very good foundation has
been laid.  It is recognized that there are very many problems in the country and
that the health service coverage is indeed very scant.  He pointed out that there is
onxly one nurse for 7*000 people.
This morning I had a conference with Mile Couillard ai~i her request.  She
asked that those whom she saw in Geneva to give an indication of how much she
appreciated the reception there.  She likes the work very much.  She finds the
students more responsive this year.  There is more of a esprit ouvert.  She gave
each of the students the ICN Basic Principles of Nursing Care,  They asked for a
conference in regard to the role of the nurse.  She is not so sure of her three
counterparts moniteurs.  They did not come to the conference.  However, she feels
that their attitude is improving and they really want to learn.  I asked her if she
felt there was too much theory.  She feels that this has to be given and she is
doing all she can to integrate theory and practice.  I do not know how she gives
the clinical supervision to the whole group but it is bovious from visiting the
Hospital that they are very responsive.  Mile Couillard wants to return.  She
spoke about the spirit of the WHO team.  She and Miss Morlock work together and
they both seem to have a real appreciation of Mile Bel tzung.
During official visits which were made with Mile Beltzung, it would seem that
the Nigerians appreciate Ber also.  I think we must give her credit for a very fine
job and I doubt whether or not a year of study abroad would have been of much
Mile Beltzung is leaving on home leave today.  Her address at home is
27, rue Marechal Joffre, Guebwiller - 68 - France.  She will be there from
25 March to 30 April and 15-30 May.  She would like to come to Geneva and will
write to Brazzaville.  I said I would write a memo also to request their approval
 - 11
so that she can discuss reporting for the Special Fund.  She would like very much
to come to Geneva wh before Ted leaves and if possible we will arrange this.
Rose and Bell send their greetings to Ted.  She was a Peace Corps nurse
here last year and two months ago married a French chap, an instructor in a Lycee.
I met her at a cocktail party.  She is very charming and so is her husband who
does not as yet speak any English.
Of all the projects which I have visited so far, this one probably gives me
the most satisfaction.  WHO teams are working under the least favourable conditions
and yet they have national counterparts, although not all qualified who are working
with them.  This is much more than it can be said for Ghana.  Ibadan is much more
sophisticated but I doubt that It is adppted to the needs of the country any more
than this one is. There is probably also good hope that Kenya will develop well
as long as Miss Koinange remains.
Add list of people met:
Dr Wright
WHO team, their counterparts
Chef of Cabinet
Minister of Health has been absent
Mr Yahmin, Assistant to the Resident representative, UNDP
and at the Hospital, la Mere Superieure, the Director of the Hospital,
Mr Oumarou Ali, the Chief Doctor, ax Madras; Mr Galeazzi, Representative of
In the interview with Mr Galeazzi, I gather the UNICEF project for youth
leadership training still rather much on paper.  He indicated that UNICEF has
four projects in health and in nutrition.  They are preparing for the meeting in
May.  Niger has been chosen as the pilot country for Africa, out of four for the
world, for a UNESCO project called "Extra Scholastic Education for Youth".  Youth
 - 12 -
comprise the ages of 8 to 20.  The first step is that a consultant will be coming
very soon to survey the situation for six months and to prepare a programme for
There seems to be several beginning projects which involve wss.  and certainly
WHO, if they have the personnel, could be involved.
There is 10$ scholarization in Niger.  This apparently means that 10$ of the
children finish primary schcd.  All education is free right through the lycee.
There is no university education in Niger.  The population of the country is something over 3 million.
Dr Emmanuel, the new WHO representative arrives from Accra and Abidjan today,
on the same plane that Mile Beltzung leaves on for her home leave.  I hope very
much that he will give the support needed to E!kx]£ WHO projects here.


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