Three years ago we began our first class for the training of hospital assistants at Malamulo Mission training school in Africa. This November our second class will begin. Our new students will have had Standard 6, which is equivalent to our eighth grade, or as nearly equivalent as is possible, considering the difference in background. We call a graduate of this course a "hospital assistant," for the ultimate product of our training is not the same as a graduate nurse at home, but must fit into the different circumstances demanded by this country. First of all, our students cannot take as much advanced work because of their lack of preliminary education. Then, there are some phases of nursing that are impossible here.
But lack of training in some phases is partly made up by knowledge of elementary laboratory technique, for every assistant must know how to diagnose microscopically, hookworm, roundworm, Bilharzia, malaria, etc. Hospital assistants may take government examinations and thus become recognized, the same as nurses in the homeland. Their professional activities are outlined and regulated by the government.
Our next pupils will come to us with more preparation than our first class had, for when we began our first class we took just what was available—the boys already working at the hospital. ("Boys" are natives of the male sex anywhere from fifteen to fifty years of age.) These boys varied much in preliminary education and experience and thus complicated the teaching problem. But it has been the Lord's good pleasure to bless the efforts made, and now the course has proved its value and is attracting young men of higher educational qualifications.
Little has been done in training women to work in the hospital, as they are far behind the men in education and must be handled in a separate group. As yet, there has not been enough teaching help to handle two classes.
I
To fully understand the problems in the education of native nurses, it is necessary to have a glimpse at their background. So, let us leave the mission and go to a near-by village where one of the hospital boys now in training was born and grew up. When I first saw it, I noticed that the houses had been well built, of mud-and-pole construction, but they were now in varying stages of disrepair. Efforts had been made to beautify the surroundings, and there were foliage plants, roses, and other flowers about—some following an indefinite line that was supposed to mark a path. There were many very large mango trees, some old papaws, and bananas everywhere. These dense growths near the house fostered hordes of flies, and each banana plant was a hiding place for myriads of mosquitoes.
The detached kitchen that I entered was black from the smoke of many fires made in the middle of the floor. Sometimes fires are built on the floors of the living quarters, too. Three articles of furniture graced the dwelling —a crude bed and two tables of even more crude construction made from native timber. Everything accumulated during the last ten years had been saved, regardless of its utility; such as bits of old tin, bicycle parts, bottles, useless dirty rags. Throwing away useless things and cleaning house seemed to be foreign to the nature of this village, and it was in no way different from the others.
The children grew to the age of nine or ten years before entering school, if they entered at all, and—they just grew. Very little restraint was placed upon them. They learned the three R's in a village school, taught in the vernacular by a teacher who made the most of his teaching aids. This school functioned quite effectively without desks, pencils, paper, etc. Writing was learned on a slate or a piece of slate, and the knees served for a desk. The training in the village school consumed four years.
Next comes the central school, which begins with Sub-Standard and goes on to Standard 4. Pupils living nearby attend the Malamulo central school, and here they are gradually introduced to English, besides more vernacular grammar, arithmetic, hygiene, etc. When they have at last finished Standard 4, they enter the teacher's training school. Then after two years of study, they may either enter the hospital course, or finish their teacher's course. Many of our first class never finished the central school, although three had had one or two years in the teacher's training school. This made our first class one of much variation in preliminary education.
II
Like many in other countries who take a course in any type of medical work, these pupils had little idea what they would actually learn, and they found new worlds constantly opening before them. As the educational process went on, they themselves began to contrast and compare what they learned with the erroneous beliefs which they held before and which their friends and relatives still held. Come with me to a few classes and see how they work.
It is time for the nursing procedures class, and the lesson is on fomentations. The reasons for giving fomentations have been fully discussed. The demonstration has been finished. The pupils are engaged in an interesting discussion on how fomentations can be given in the villages. One pupil volunteered the information that corn husks may be boiled, then wrung out of the boiling water and applied hot to the aching part—a really sound procedure. Sad to relate, not all their ideas are so sound. This became evident in a later class, on "pushing fluids."
Opportunely, a child had been admitted who had eaten practically nothing for a week or more. He had been sick, with a consequent loss of appetite, and just because he didn't want anything, nothing was given to him. According to native practice, food is not good unless it is desired. Medicine of crude native manufacture is pushed down, regardless of whether the patient wants it or not. But not so with food or fluid. In other words, food and fluid are merely incidental, but medicine is absolutely essential, to their way of thinking. Consequently, many die in the villages from lack of food and water, when a different procedure might have conserved their body forces and tided them over a serious illness. This was forcibly demonstrated by the child admitted, since he came just at the time when our lesson was on that subject. The use of fluids by the body was explained fully; and then we proceeded to put the lesson into practice.
The ignorant relatives interfered and threatened to take the patient home if food and water were forced upon him. We persuaded them to let him stay, however, and the students, under supervision, persevered. The child began to pick up strength, was treated for worms, and made a good recovery. The object lesson was so striking that there has never since been any question on the part of the students as to the value of forcing fluids in all dehydrated and fever cases. Many of our procedures have been aptly illustrated by patients who have arrived with an ailment requiring the particular treatment we happened to be studying at the time. With these native people, seeing is believing; and too often, not seeing is not believing, even though they may be able to recite the lesson perfectly from text or notes.
In the second-year physiology class, the process of digestion had been thoroughly discussed, and every class member could recite perfectly that ptyalin in saliva begins the digestion of starch, and that it is finished in the small intestines by the secretions from the pancreas. They could give the correct answer to the question, "Why should we chew our food well?" For this class. I had brought small amounts of honey, milk, potato, egg, cornmeal, and bread. We tested each with Benedict's solution, and of course, obtained positive reactions from the milk and honey. The other products were negative, and the solution remained a deep blue. We next tested each product with iodine solution. Each food containing starch turned a dark blue, but the iodine color remained in the milk and honey, as they were negative. The results were obvious.
Then, I asked them if potato is starch or sugar, and having just seen the test, they were all positive that it was starch. So, I asked one boy to chew some potato well, mixing it thoroughly with saliva. This done, I had him spit it back into a beaker. We tested that solution, and it gave a marked reaction for sugar, to the amazement of the boys. They wanted to know why. I reminded them of what they had studied about digestion beginning in the mouth, and of the work of ptyalin. Thus the lesson was made clear, and they will never forget it.
This principle of actual demonstration I have incorporated into every class possible. If it can be shown by chart, blackboard drawing, skeleton, experiment, or project, that is done. Every lesson in diseases or hygiene is practically demonstrated by displaying the actual condition, since Africa is so amply provided with all kinds of diseases. This has been one of the easiest of all the classes to teach, because of the abundance of clinical teaching material. Our leper colony supplies every type of leprosy. Pneumonia has given endless examples of typical symptoms and of how cases respond to hydrotherapy. Tropical ulcers, ulcers of yaws, and just plain ulcers resulting from sepsis, abound.
Classwork is recorded by periods of instruction, but every patient coming in is a source of clinical teaching material. There is much questioning regarding the different cases, in order to help the students apply what is learned in class. An endeavor is also made to ascertain what the student is teaching the patient with regard to health and hygiene. There is no end to the need for health education among both the inpatients and the dispensary patients.
III
It was a continual surprise to the native pupils to see that our sources of supply for medicines were many times the same as those of the native "doctors." They were much interested in quinine when they learned that it was used by the natives of South America. Caroid, used as a digestant and obtained from the native papaw tree, increased their respect for the papaw as a food. Medicinal foods, such as cod-liver oil, which supply necessary vitamins and other essentials without any of the harmful effects of drugs, were also of interest to them.
From the first we have tried to show why our bodies function as they do, how medicines and hydrotherapy affect us, etc. We have also tried to create a desire for honest practice in treatment, and to influence the students not to yield to the native idea that there is a medicine for everything, and that nothing but medicine will do. Instead, we have impressed them in the classroom and out, with the thought that good hygienic habits, wholesome food, and hydrotherapy when needed, are ;usually more effective than any amount of medicine. All this teaching is given in the simplest language at first, but gradually a medical vocabulary is built up until common medical terms become familiar.
The lesson on snake bite and its treatment was interesting and illuminating. In order for the pupils to understand why a tourniquet should be applied promptly, an explanation was first given as to how the snake poisons circulate through the body. The teeth of nonpoisonous snakes were described, then those of poisonous snakes. To illustrate the poison sacs and fangs, I used a hypodermic- syringe to demonstrate the poison sac, and pushed the fluid through the needle to show how the poison goes through the fangs into the victim. They were surprised, for it seems that the natives believe all snakes are harmful, varying only in degree.
When someone has been bitten, a native medicine man is immediately called, and he begins a diligent search for the snake's teeth, which they all believe to be the cause of the poison. They apparently know nothing of the poison sacs and the hollow fangs. Our discussion brought about a request for snake heads, and now we have excellent specimens, preserved in formaldehyde, of a puff adder with fangs a half inch long, also other poisonous snakes, and a nonpoisonous snake for comparison. From the study of physiology, and the procedure of giving intravenous injections, the method whereby snake poison enters the body and circulates rapidly was made plain. The pupils were most eager for such knowledge and had occasion to use it a few times.
One of the most useful pieces of teaching equipment is the microscope. Since the boys do all the routine microscopic work, such as examining slides for lepra and tuberculosis bacilli, Bilharzia, etc., they became acquainted with this instrument early in their training. They actually saw germs and realized how small they were. They saw Bilharzia eggs hatch on the slide, and the enclosed miracidium escape and swim about in the fluid under the coverglass. During physiology class, they saw blood cells flowing through the capillaries of a frog's foot. They saw the wonders and beauty of the cells of flowers and other plants. Perhaps this, more than anything else, has established their faith in the European style of medicine and broken their faith in the old, dirty, ignorant medicine men of the villages. The use of the microscope is introduced by a short history of bacteriology. After this there follows the study of the marvelous things this instrument unfolds to us.
The student nurses take their Bible work with the student teachers at the training school. This year, the boys have gone out with pastors and teachers in evangelistic work, filling much the same place here as our nurses do at home in giving health talks and caring for the sick at our camp meetings and tent meetings. It is proving an invaluable experience for them.
IV
These pupils possess keen minds. Perhaps their greatest handicap is their background of superstition, filth, and ignorance, ingrown for generations. It takes more than just teaching by words to change it. Practical applications over and over again are necessary, using every teaching help it is possible to find, together with untiring supervision. Their first impressionable years have been filled with intimate knowledge of plant and animal life, of close contact with birth,- disease, and death, and all manner of superstitions. Their contact with this mechanized age is practically nil, and this lack, together with their old beliefs, greatly complicates the teaching problem.
This first class, to graduate this year, convinces us that these native students are capable of learning to be faithful to the third angel's message and to adhere to professional ethics, and that they are qualified to join the great army of medical missionaries. Their joy in learning and their rapid progress make a very satisfactory compensation to those who teach them.
