“The first baby I held was the baby of my sister. It was during the 1994 Genocide against the Tutsi in Rwanda, and my sister gave birth in the forest. It was raining and cold, and I didn’t know what to do when I held the newborn covered in blood. We were saved by the loud sounds of my crying for help. From that moment, I wanted to be a nurse or midwife, someone who could help another in times of need.” 

His ambition was fulfilled. For 11 years Andre Ndayambaje worked as Senior Nurse-Midwife in Critical Care Units providing intensive neonatal care. He has since held executive and non-executive positions for organizations supporting nurses, including as President of the Rwanda Association of Neonatal Nurses (RANN). He is a 2019 graduate of UGHE’s MGHD program, a master trainer, an educator, activist, and project manager of evidence-based programs in maternal and newborn health. Now, as UGHE’s Health Services Coordinator, he currently provides mental and physical check-ups to the nearly-100 staff, students, faculty, and campus workers living on UGHE’s Butaro-based campus. 

But most of all, he is a passionate advocate. Passionate about the health of new mothers, passionate about neonatal care delivery, and passionate about changing the status quo in support of frontline health workers, with due focus on nurses and midwives. 

This month alone the world celebrated International Day of the Midwife, Mother’s Day, and now, International Nurses Week. The World Health Organization named 2020 the Year of the Nurse and Midwife to recognize the critical contributions both professions make to global health. The current COVID -19 pandemic has exposed both the extent of the work of nurses and midwives, and their personal sacrifices to keep us safe. “It has greatly added to the workload for nurses and midwives,” says Andre. “Mothers are still coming for care as the cycle of life continues, and nurses are still handling other conditions like routine health problems on top of caring for patients with COVID-19. It doesn’t go away in times like these.”

But whilst frontline health workers are now, deservedly, celebrated as heroes, their day-to-day commitment to care outside times of crisis is enduring; the world benefited from the dedication of nurses long before COVID-19 hit, and will continue to do so indefinitely in its wake. 

Celebrating the work of nurses is important, but it is not everything. To really value nurses, now and for the future, governments and supporting bodies must ensure they are protected in the workplace. “Nurses do not see themselves as heroes, they are just getting on with their jobs,” says Andre. “They don’t have the option to stay home – and yet, at work, they are often vulnerable – unable to protect themselves. “Their sacrifices are manifold; there are nurses in almost every country who have lost their lives at the hands of this pandemic, nurses suffering physical and mental hardship in the face of long hours and emotionally draining patient circumstances, and nurses’ families who will suffer either the absence of a mother or father, or else risk increased exposure to transmission at home.”

Their roles are manifold also. As often the first point of contact for patients, nurses are responsible for administering medicines, monitoring symptoms, feeding, washing, and caring for patients, amongst many other duties. “We need to remember that nurses and midwives are doing a large percentage of what is actually going on in care facilities,” explains Andre. “A doctor can prescribe drugs and give instruction, but after this, it will be a nurse who stays with the patient; they are the ones implementing the treatment.” Andre goes on to convey his surprise in watching nurses and midwives disinfecting ambulances themselves after transporting patients. They are informal educators and counselors also, often serving as the mouthpiece for government updates; “nurses tell patients how to put on masks, teach handwashing and provide information about how they can protect their families.”

They are also critical touchpoints with communities in many LMICs. In low-resource settings, nurses are often the only health professional a patient will see and, through a unique understanding of the patient’s contextual situation, they form a frontline defense against widespread illnesses such as malaria, pneumonia, and tuberculosis. Midwives often provide postpartum support to new mothers in their homes, when they cannot reach clinics due to living rurally, or responsibilities at home. Andre is no exception. Frustrated with the process of treating and then simply discharging new mothers and babies, Andre sought to diagnose the social determinants contributing to the pattern of newborn deaths outside the hospital, on top of the medicine he provided. “I never knew what happened to mother and baby after discharging them. I learned this needs to come with accompaniment, so I took the contacts of these mothers, and called them as a type of follow-up.” 

Yet despite their obvious responsibility, they are often undervalued and underused as health professionals. “My wife, a midwife, waited for a bus after a long shift. When it arrived, she was informed it was reserved for doctors only, and told to wait another 3 hours.” Andre also explains that, despite working as a nurse-midwife for 11 years in one hospital, he didn’t receive a pay rise, whilst his doctor contemporaries were moving vertically up the ladder every three years. He describes how, in some places, free food and travel allowances are afforded to doctors, but not nurses. Now, in the COVID-19 crisis, there is a distinct lack of disaggregated data and standardized reporting to show how many nurses have been infected and died at the hands of the virus, which serves to both devalue their lives, and limit critical understanding of potential safety problems in systems of infection prevention and control. 

Rwanda’s robust measures against COVID-19 have, so far, averted any deaths and kept cases low, a success Andre attributes to collaboration. “Nurses, midwives and community health workers have been an important part of the response,” he explains. “It’s a model of interprofessional work; when we value the work of nurses, it benefits the entire system.” Andre’s advocacy for collaboration of this kind was fostered through his MGHD degree. “We learned that to comprehensively treat and understand a problem, we need a common commitment from professions, sectors, and even countries,” he relates. The benefits of interprofessionalism were also instrumental in Rwanda’s milestones in maternal and childhood health; nurses and midwives were- alongside other health professionals – responsible for decreasing maternal mortality by 80% (2000-2017) and childhood mortality by 75% (1992-2015). “You can’t have good doctors, without good nurses and midwives,” Andre reflects. “Doctors alone are not enough to achieve effective health system delivery.” 

So what will the future hold for frontline workers after COVID-19? “I think the way we think about the role of nurses may change after this period,” reflects Andre. “They are making history before our eyes in demonstrating that our health systems can’t do without them. The next step is to have nurse and midwife representation in ministries, in policymaking and leadership. Why can’t a nurse or midwife become a minister of health?” 

UGHE’s new Center of Nursing & Midwifery intends to do just that; both equipping a nurse or midwife with advanced practice skills in various clinical disciplines as well as within leadership and governance, all in the realm of global health. “A nurse or midwife trained at UGHE will be able to manage the sickest and the poorest in our communities not only in Rwanda, but also beyond, to the rest of Africa,” explains the Center’s Chair Judy Khanyola. “Nurses and midwives are uniquely placed to understand the causes of patient inequities and thus, can fulfill UGHE’s vision of social justice and equity.” It will also focus on providing nurses and midwives the tools needed to deliver care safely, and responsibly – whether safe, hygienic environments to work in, and support systems such as counseling to help combat the mental and emotional strain sometimes experienced in roles like these. 

So whilst today marks a global recognition of nurses, we encourage the world to value these critical health workers beyond the confines of a single day, or even year – with the right resources and equipment to perform their nurturing role  “As a nurse-midwife, I feel so proud of my colleagues across the world who are reaching patients where others don’t dare to reach,” concludes Andre. “By fostering collaboration between health workers, investing in fragile health systems, and providing the right tools to nurses on the frontline, we will beat this virus, and outbreaks to come.”