Article begins
Bedsiders support under-staffed and under-resourced hospitals within power dynamics and policies that often do not reciprocate that support.
Introduction
“You know what? When you have 44 patients, and you only have maybe two nurses on duty, you find that you cannot manage to do the basic things, the basic procedures. And so, the bedsiders now come in, like, to help out on those small, you know, procedures like bathing the patient, changing the linen, and sometimes even feeding.”
– Sister Kampole, Senior nursing officer via a WhatsApp call with author in 2022
Bedsiders are unpaid family caregivers who work alongside nurses and other hospital staff to provide care to patients in the crowded and under-resourced hospital environment. As Sister Kampole told me, bedsiders are integral to the structure of hospital care. This has a history. In this article, I explore this history and the series of political and economic processes that have made bedsiding in Zambia into what it is today. Bedsiders, I will show, keep afloat under-staffed and under-resourced hospitals. Yet they do so within power dynamics and policies that do not value their labor and do not provide necessary material support.
Through archival research at the Melville J. Herskovits Library of African Studies and interviews with 13 retired and senior hospital staff at Arthur Davison Children’s Hospital, I learned that bedsiding was not always standard practice in Zambian hospitals. During the colonial period, the almost exclusively white settler medical staff kept kin of African patients out of the wards as much as possible. After gaining independence from Britain in 1964, rapid economic growth and investment in the healthcare sector allowed hospital staff to maintain most of the care work responsibilities, meaning parents and other relatives were usually only allowed on the wards during a small window for visiting hours. However, the fall of copper prices in 1973 and high inflation of the kwacha in the concurrent global recession changed the hospital environment and required a new reliance on family caregivers, a reliance that would become normalized over time. The international aid community took advantage of the opportunity to push Zambia, and other African countries, further towards neoliberal ideals. Through structural adjustment policies, the World Bank and International Monetary Fund required slashing funding to public spending.
Public healthcare in Zambia suffered budget reductions that led to understaffing, drug and equipment shortages, and a halt in health infrastructure development. In 1995, the Zambian Minister of Health used the following analogy to describe the precarious state of Zambia’s health system and the government’s need to resort to a cheaper and more efficient option given their financial crisis:
“The Health System of Zambia has been likened to a Cadillac which was maintained by a relatively wealthy family for years. The family’s economic situation has changed, and it can no longer afford to maintain this expensive vehicle without seeking assistance from cousins and relatives, to help fuel, repair, and maintain the gas-guzzling vehicle. The alternative is to design and construct a more efficient vehicle that can meet the family’s changing health care needs given its limited means.”
Informal care, done by families, then became more necessary, and hospitals relied more upon family caregivers to share the work of formal healthcare staff, thus reshaping relationships and roles in Zambian hospitals.
Integrating Informal Care Work into Zambian Hospitals
Sister Kampole’s more than 30 years of experience in the healthcare field gave her first-hand insight into the rise of bedsiding and its connections with the economic turns of the country. When structural adjustment hit, Zambian hospitals experienced the outward migration of hospital staff for better opportunities in other countries. Sister Kampole explained, “We have always operated here with the minimal number of staff. We were badly hit when Europe opened up their doors, so a lot of nurses from Zambia migrated to the UK. So, they created the gap… Since then, we have not recovered.” National incentive programs, referred to as voluntary separation, also encouraged healthcare workers to leave the public sector in exchange for a one-time payout. While the country’s payroll was reduced, hospitals became further understaffed and became more reliant on bedsiders to replace that labor. Sister Chisenga remembered, “In the many, many years ago, bedsiders were not allowed [on the wards]. Maybe even the time before I started my nursing, they were not allowed because the nurses were adequate.”
Today, bedsiders supplement hospital staff and make up for resource shortages, and bedsiders are expected to stay with patients in the hospital for the duration of their hospital care. With high levels of under-staffing, nurses negotiate their time and responsibilities through relying on bedsiders. As Doctor Mwangu phrased it, bedsiders have “become part of the healthcare system.” A bedsider not only keeps a patient company at the bedside, they also feed, clean, reposition, and monitor the patient. They clean wounds, change bandages, ensure medicine is taken, and facilitate patient-provider interactions. Hospital staff have also adapted to bedsiders’ integration in the hospital and shifted their role, relying on informal care work to carry out their jobs.
Bedsiders within the Healthcare System
While bedsiders and healthcare staff share many similarities in their care, the healthcare workers I spoke with identified unique qualities that differentiate informal bedside care, making it essential even in the possibility of sufficient hospital staffing. Sister Musawa put it this way: bedsiders are “a necessary component in the hospital. We cannot avoid them…Do[ing] away with the supports-the caregivers completely, it’s not possible… because the psychological part is on the mother.” The hospital staff I spoke with often described this emotional care in terms of closeness, both symbolically, in the relationship between bedsider and patient, and physically, in reference to the close proximity that bedsiders maintain to their patients. They viewed these two meanings of closeness, put together, as defining features of bedsiding that showed how bedsiders held different capacities to care than they did.
Mr. Gondwe, a radiologist, homed in on this difference and explained, “[Bedsiding] is so encouraging to the patient. You know? The nurses will not have time to… But when they are with a bedsider, this bedsider will always be with them, talk to them, encourage them.” The encouragement Mr. Gondwe describes facilitates biomedical treatment for the patient and supports the public healthcare system. For example, bedsiders comfort patients during and after painful procedures and injections. Note, however, that in making this distinction, Mr. Gondwe also hinted at the constraints on time and other resources.
The history of hospital care has also created a situation where bedsiders and patients may not trust hospital staff. Bedsiders are mediators between the patient and hospital staff. They monitor the activities of hospital staff and do not allow care to happen when they are not present. As Sister Lubemba described, “They don’t trust nurses. They will think maybe, we will drown their children, so they would want to be just near their child. There are myths and misconceptions around, you know, these places, so they… would want to be just there to see their child. Whatever you do on the child, they would ask you. Whatever you do on the child, they would want to find out.” Bedsiders, then, play a role in mitigating the slow violence that has shaped hospitals and the violence in care, both real and imagined.
Conclusion: An Incomplete Integration
As I have shown, informal family care has been integrated into hospitals in Zambia, largely due to the gaps created by limited funding allocated to the healthcare sector and also to poverty in the country. This integration has melded formal and informal care in the same space and required coordination between hospital staff and bedsiders. Their roles overlap but have taken on distinctions as well, with bedsiders providing more emotional support and being responsible for the physical and medical tasks that nurses deem require less training and expertise. Hospital staff, on the other hand, spend less time with individual patients and delegate what they can to bedsiders, ensuring they are able to complete their rounds and not neglect any of the patients, even with the high ratio of patients to staff.
Despite the extent of bedside care in Zambia today and the normalization of that care, bedsiders’ integration in hospitals is still incomplete. While bedsiders are part of the healthcare system, they are not recognized in terms of resource allocation, perpetuated by the national government and international organizations that have pushed Zambia towards reducing public sector spending. While the needs of staff and patients are considered an inherent part of the hospital’s functioning and responsibility, bedsiders’ needs are considered a burden. Bedsiding is an around-the-clock, unpaid role with little material support in food, medicine, soap, and other basic necessities. This is further complicated by gender inequities that reinforce the role of a “good mother” who sacrifices herself to provide bedside care. Without adequate space, time, and rest, bedsiders become patients. Bedsiders do not have dedicated space at the bedside and generally sleep in a hard chair at the bedside. They rarely get breaks to take care of themselves, and often develop their own health ailments while caregiving in the hospital and/or leave the hospital before doctors advise in order to take care of themselves.
For the health system to rely on bedside care, bedsiders must be supported in their role. What such support looks like must be identified locally and in partnership with bedsiders, clinicians, hospital administrators, and policymakers. Bedsiding has provided a tremendous source of support and strength to the Zambian health system over the past few decades, and it’s necessary to look critically at who maximally benefits from that care work. Outsourcing labor to informal family caregivers requires integrating support for them into the healthcare system and health initiatives.
I use pseudonyms in this article for all participants.
Jean Hunleth and Samar Al-Bulushi are the section contributing editors for the Association for Africanist Anthropology.