Introduction

Starting in Upper Egypt, one of the poorest areas of the country, Tandier is professionalizing nursing and, in doing so, improving health care and creating jobs.

Having practiced medicine for fifteen years, Tandier sees that the national health care system fails to deliver consistently high-quality care to patients.  In fact, egregious errors are not uncommon: routine procedures may result in protracted illness, infection, or death.  Recovering patients are tended to by downtrodden nurses who are not trained to dress a wound, monitor for infection, or ease the emotional strain hospitalization brings to patients and their families.  To improve healthcare in Egypt, Tandier focuses on nurses, a tier of medical personnel absolutely critical to the delivery of care.  She offers an accessible curriculum, provides on-the-job training and mentorship from seasoned nurses, and improves—transforms, really—the profession’s negative image to draw in the right people.  Starting in one of the most challenged regions of the country, Tandier has begun to show important results: smart, dedicated recruits now seek training because they see in nursing a respectable career opportunity.  Building on this initial success, Tandier works with citizen groups, doctors, and the Ministry of Health to institute important changes in national and regional practice.

The first dimension of the problem is one of numbers.  Yes, there are nurses here in Egypt, but far too few to handle the task at hand, with some areas of the countries severely understaffed.  To meet the national demand for roughly thirteen thousand five hundred nurses, six thousand more nurses are needed now.  And as Egypt’s population soars—it’s estimated to jump from seventy to nearly one hundred million in the next twenty years—health care providers must organize themselves to deliver effective, high-quality care to a growing population.

The second dimension of the problem relates to the quality of training for nurses.  The nursing curriculum is neither accessible nor especially relevant.  In some places, it’s offered not in Arabic but in English, a language few nurse trainees can read or speak.  The result is that newly-certified nurses, many of whom are teenagers, find themselves tasked with caring for very sick people without the benefit of relevant instruction or the guidance they need from seasoned nurses and doctors.  In most hospital settings, nurses perform a function closer to that of a maid—they change bed-sheets, deliver meals, and sweep the floor.  Further, it is common practice for nurses to beg patients for tips.

The third dimension of the problem, which feeds the other two, is rooted in societal norms linked to gender, to expectations of women, who comprise the nurse workforce. In Egypt and in much of the Arab world, a woman is expected to support and care for her husband.  Helping other men—nurses routinely do this—is socially unacceptable; it arouses suspicion of sexual promiscuity and taints family honor.  Spending nights in hospitals and paying house calls to male patients—nurses routinely do these things, too—further supports the suspicion. History and lore link the professions of nursing and prostitution, an association which may have roots in an incident in which sex workers were sent to care for quarantined soldiers with polio, with the tortured logic that the loss was less, should the women contract the virus. Portrayals of nurses in popular culture, including in the movies, reinforce the link.  In some areas of the country, girls or women who choose nursing as a career cannot find men to marry them.  The stigma is severe and prevents many very capable—in fact, the most capable—women from considering a career in nursing.

A doctor with a wide range of experiences in community health, Tandier is improving how nursing is taught.  The curriculum she has designed, and is introducing in nursing schools in Upper Egypt, is comprehensive and offers a holistic perspective on health care.  The first of three modules teaches nurses the techniques they will need to perform their daily work—bandaging wounds, taking blood, giving injections, administering prescription drugs, and so on.

The second module covers in detail much of the science behind the practice of medicine, and helps nurses to understand why they do what they do.  The material covered allows trainees to see the whole picture of care, and shows them the importance of their role in relation to doctors and other health care providers. Tandier has arranged for doctors to teach this course component, a strategy that has two important results: first, the topics covered are covered by experts; second, doctors feel some stake in training nurses, and begin to see the profession, and its professionals, in an improved light. Improvements in the doctor-nurse relationship mean improvements in the health care delivery system: doctors and nurses grow to value and rely on their professional competencies. Such advances forecast a big step forward in care.

The third module of Tandier’s curriculum deals with nurses’ relationships to those patients in their care.  There are a few important highlights.  First, trainees learn that all patients are human beings and that regardless of differences among them relating to religious affiliation or any other factor, each deserves careful, professional attention by medical personnel.  Trainees, especially young trainees, may not have had a great deal of exposure to people who have specialized needs and who behave in predictable ways according to their needs.  Take the example of psychiatric patients.  To know how to handle a patient who is hospitalized due to schizophrenia, for example, the nurse needs information and exposure.  Without preparation, the possibility of patient abuse by the nurse, or of nurse abuse by the patient, is very real.  The introduction to people provided in this section of the course is invaluable in setting a professional tone to the delivery of care.

To change attitudes among the public and reach families and their teenage girls with the message that nursing is a respectable profession, Tandier makes several other seemingly small, but important, adjustments in how nurses are taught.  For example, she has built a dormitory and nursing college separate from the hospital to avoid the problematic link in the minds of many of nursing and prostitution.  Importantly, she collaborates with existing citizen groups and networks to encourage young women to consider entering the profession; in Aswan district, she works with ten local groups, two in every city.  She has begun to see her efforts pay off, as more and better recruits come knocking.  In one of her schools, the student size has more than doubled—from a capacity of one hundred seventy to three hundred fifty students.  To provide on-the-job training for newly-certified nurses, Tandier has arranged partnerships with thirty-four hospitals and established mentorships with seasoned nurses.

Having begun in the small city of Edfo, in Aswan, in 1998, Tandier has expanded to five nursing schools, and has started to see remarkable success both in the quality of training and in the public’s attitudes toward nurses. She has hired thirty-one newly-certified nurses and ten experienced teachers who are not trained nurses to cover the work and aid her expansion efforts, which she hopes to see progress along two parallel tracks.  Geographically, she hopes to expand from Aswan to Quena, a neighboring governorate, which is also very poor.  In addition, she is working to reach the Ministry of Health, and expects that her initial success will, based on its evaluation by the Ministry, inspire changes to the national curriculum and, eventually, create incentives such as increased salaries for nurses.

Tandier was born in Upper Egypt, one of the poorest areas of the country, into a middle class family with no sons.  She remembers wondering at an early age why everyone pitied her father for having only daughters.  As a young girl and teenager, she dreamed of becoming a law or political science teacher; however, she succumbed to her family’s preference that she study medicine.  In 1990, she graduated from medical school in Assuit University at a time of great difficulty for Christians such as herself, as the university was heavily influenced by the Islamic movement.

Tandier’s career as a doctor has been unconventional in many regards.  She has moved around a good bit, gaining a comparative overview of health care from region to region, and she has straddled medicine and public health, working initially in a village in Quena, a very poor and difficult region of Upper Egypt.  During her work there, and in many subsequent assignments, she learned of the great difference between textbook medicine and on-the-ground practice.  She learned of the importance of many actors—nurses being a critical group—in the delivery of proper care.  She designed and ran health awareness classes for the women who visited the clinics to address many issues from a preventive standpoint.

In what she would later see as a pivotal experience, Tandier was asked to join a training program, sponsored by UNICEF and the Institution for Cultural Affairs and aimed at teachers doctors in rural, poor locations to be teachers as well as care providers.  She began to see how she might turn the clinical experience of helping a small number of patients through treatment into helping whole communities through education and preventive care.  This experience led to a job offer to in another governorate, which she accepted, although accepting meant convincing her new husband that she would need to live apart from him during the week.  She later returned to Quena to live full-time, and began offering awareness classes to village women, most of them illiterate, on issues ranging from reproductive health to water quality and its link to disease.  She helped the three hundred villagers with whom she worked most closely to form an association for women, the first of its kind in the region.  Tandier and her team taught the women administrative skills and helped them secure a small fund to cover operational costs.  The association continues, aided by trained staff.

These experiences, part medicine, part community health, drew Tandier’s attention to the dire situation of nurses and allowed her to see the problem not only from the clinical side, but also from the perspective of village women’s lives and opportunities.  The stigma of pursuing a career as a nurse was ever-present, she observed, and the training provided to nurses wholly inadequate in preparing them to assume responsibilities in a health care setting.  To fix Egypt’s health care system, she saw, she would need to fix the stigma, fix the training, and route talented young women into careers as nurses. She began her work with nurses in earnest in 1998.

Tandier lives in Cairo with her husband and their new daughter.