"Swaziland is dying. Will the last nurse on duty please turn off the lights?" reads a handwritten note at a clinic in Manzini, the country's AIDS-hit commercial centre, 35km southeast of the capital, Mbabane.
The wry note disguises the pain of Swaziland's diminishing number of nurses and hints at the reason why their colleagues have fled the country to offer their services elsewhere.
"The working conditions, the lack of basic necessities to treat people and all the dying: it is demoralising," said a nurse, 28, who asked that her name not be used. "It's not just the money - it is hard to watch people die and you are helpless to do anything about it because there are no drugs or other things [to treat them]."
Working in a poorly lit, aging ward, with scant equipment and a chronic shortage of drugs after the government failed to award tenders this year, are as much a motivation to leave the country as any promise of greater financial reward in Europe, the United States or neighbouring South Africa.
In the emergency room of Manzini's Raleigh Fitkin Memorial Hospital, a child screams in pain as a nurse removes sutures from a stitched finger wound. "I haven't got the proper cutter -they have such scissors in the paediatric ward," said the nurse as she gouged the tender skin around the wound with large scissors not intended for this procedure.
In a recent report, 'Public sector nurses in Swaziland: can the downturn be reversed?' released by Human Resources for Health, an online medical journal published in collaboration with the World Health Organization, authors Katharina Kober and Wim Van Damme noted, "The public health sector in Swaziland faces a serious shortage of health workers: 44 percent of posts for physicians, 19 percent of posts for nurses and 17 percent of nursing assistant posts are unfilled. We identified emigration and attrition due to HIV/AIDS as major factors depleting the health workforce."
UNAIDS estimates the national HIV infection rate of people aged 15 to 49 at 33.4 percent, the highest in the world. Two-thirds of Swaziland's roughly one million people, ruled by sub-Saharan Africa's last executive monarch, live on US$2 or less per day.
The report concluded, "Our projections show that both emigration and attrition due to HIV/AIDS pose a serious double threat for Swaziland's health system, which, if not effectively tackled, would mean the loss of 44 percent of the nursing workforce in the public sector up to 2010."
Nurses at St Theresa's, a clinic on the outskirts of Manzini run by the Roman Catholic Church with financial support from government, last week held a crisis meeting after two months of erratic salary payments or none at all.
"It is too hard doing what we do, under these conditions that you see," a nurse at the clinic told IRIN/PlusNews. The waiting room contains a few wooden benches, with little ventilation to combat the stifling summer heat.
As a result of the government's policy of zero growth, no new posts were created in over 20 years, even with the onset of the HIV/AIDS pandemic, which began to bite in the mid 1990s. The World Health Organisation has put the total number of health workers posts at 3,726.
"Some 758 of the 944 established nursing posts in the public and mission sectors are filled. The nurse-to-population ratio in the public and mission sectors is therefore around 70 per 100,000. The official number of nursing posts was widely regarded as inadequate for the actual workload in the health sector," the Kober and Van Damme report commented.
The researchers estimated that 288 of the 758 nurses, about 38 percent, employed in the public and mission sectors were probably HIV positive, of whom 29, or 10 percent of the HIV-positive nurses, might have died during 2005. They projected that 3 percent to 4 percent of the entire nursing workforce would succumb to AIDS-linked illnesses each year.
HIV/AIDS is a lesser contributor to the country's nursing shortage than emigration. Researchers found that 100 of the national nursing workforce of about 800 leave the country annually. Swaziland's two nursing colleges produce about 80 to 90 graduates per year, while a school for nursing assistants delivers around 20 graduates.
Although the two training sites receive hundreds of applicants annually, too few student bursaries from the health and social welfare ministry, a lack of teaching staff and student accommodation, and insufficient opportunities for practical training have kept enrolment low.
A basic nursing course last three years, but most students do either one additional year to obtain a qualification in midwifery or a five-year course to obtain a Bachelor in Nursing Sciences degree.
"I left nursing school and went right to work, like all my classmates. I worked at the Mbabane Government Hospital [the country's largest health facility], and right away I saw someone die because they couldn't get the medicines they needed. This is why Swaziland loses more nurses to 'greener pastures', in my opinion. And AIDS is making our work so much harder," the nurse said.
The Kober and van Damme report said 80 percent of bed occupancy in the medical and paediatric wards of government hospitals nationwide was HIV/AIDS-related.
"Doctors from a mission hospital estimated that five years ago they would spend an average of five minutes per patient on a ward round, while presently this was more likely to be 20 to 30 minutes. This was seen as a consequence of the increasing number of terminally ill patients needing time-intensive care. There is an increased demand for health services, and health workers speak of feeling overwhelmed and burned out," the authors said.
Nurses were granted a salary increase in 2005, but little could be done about the poor working conditions; 21 nurses resigned from the Mbabane Government Hospital in the same month that the salary increment came into effect.
On a previous visit to Swaziland, Kober and Van Damme found that public and mission health facilities had 1,481 posts, but only 1,184 staff were reported as actually working at the facilities, leaving 297, or 20 percent, of the posts vacant.
To increase the number of nurses, the Ministry of Health has requested the Ministry of Public Service to lift a ban on the recruitment of foreign nurses, whose salaries would be paid by the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Another solution to the shortage of nurses might come from government's rollout of antiretroviral drugs for people living with HIV. Though hampered by teething problems this year, the rollout could reduce the number of chronic HIV/AIDS patients, as well as throwing a lifeline to HIV-positive nurses.
"No one wants to talk about it, but Swaziland's AIDS problem is frightening nurses. We are on the frontline of this battle, and it is easy for some to run away from the danger," the nurse commented. "It takes real patriotism and a dedication to your calling as a nurse to work as a nurse in Swaziland today."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions