Barbra Mann Wall, PhD, RN, FAAN. Thomas A. Saunders III Professor of Nursing, University of Virginia, Charlottesville, Virginia, USA The UKAHN Bulletin
Volume 8 (1) 2020

Introduction

In her essay entitled, ‘Seeing Images in History’, Anna Pegler-Gordon writes, ‘In the last few years, partly in response to what has been described by some as the “visual turn”, more historians have been paying attention to visual images in both their research and teaching’1. For the purposes of this article, images are used to depict how war and dislocation have been experienced by Catholic sister nurses, physicians and midwives and the Nigerian nurses who worked alongside them in Africa after World War II. The images used represent the efforts of Sister Doctor Pauline Dean, a Medical Missionary of Mary, taken within the context of her work during the Nigerian Civil War that lasted from 1967 to 1970.

I published similar photos earlier in my book, Into Africa: A Transnational History of Catholic Medical Missions and Social Change (Wall, 2015)2. In that publication, I argued that gender, religion and health care intersected in places like Nigeria, where transnational cooperation occurred at multiple levels during periods of conflict. Yet I did not ‘see’ the Nigerian nurses in the photos, who remained nameless. In this article, I emphasise how a shifting of the lens to focus on the ‘silenced,’ such as Nigerians themselves, might enhance a history of nursing and, in the process, provide a different way to think about conflict. How can photos be used as primary sources to analyse violent conflict and the roles played in wartime by many groups, religious and secular? How might a history of wartime look different if nurses and physicians are included in the story? At the same time, how do I rethink my earlier narrative that centered on white sisters only? The images chosen for this essay provide a more nuanced understanding of the complexities of war by revealing the intersection of gender, race, religion and health care hierarchies.

Janet Golden and Charles Rosenberg argue that photographs of health care often deal with social aspects and relationships among personnel in institutions as hospital leaders attempted to present their work to a larger audience3. Similarly, Rima Apple asserts that because historical photographs contribute to the study of people and relationships, they can provide details of a clinical environment that written and oral sources cannot4. She emphasises the importance of viewing photographs as more than simple illustrations; rather, they are complex primary source documents that are just as biased as written historical records. Thus, when choosing to use photographs as sources, the author must ask: ‘Whose reality is depicted? Whose eye selected what to photograph and what to exclude?’ How are subjects posing in the photographs? i.e., who takes center stage?5

Medical Missionaries of Mary, Nigeria

Marie Martin, a Catholic nurse, midwife and foundress of the Medical Missionaries of Mary from Drogheda, Ireland, went to Nigeria in 1937, where she and her fellow sisters opened St Luke’s Hospital in the town of Anua6. Eventually it became a 300-bed facility and boasted multiple departments in surgery, medicine, radiology, obstetrics, gynecology and ophthalmology. By 1960, the Medical Missionaries of Mary numbered four physicians, several nursing instructors, a radiographer, laboratory specialist and seven nurses7. At the same time, twenty-three Nigerian staff nurses, 125 student nurses and 146 staff were employed in various departments at St Luke’s. The work of Nigerians in sisters’ hospitals was possible because, in 1968, the government was paying for trained nurses’ salaries as well as those of student nurses8.

Sister Doctor Pauline Dean joined the Medical Missionaries of Mary in 1953 and went to Nigeria in 1961, where she worked first at St Luke’s Hospital9. She had obtained her medical degree from Liverpool University Medical School in 1945 and undertook post-graduate work in pediatrics at Children’s Hospital, Columbus, Ohio before joining the Medical Missionaries of Mary. When the Nigerian civil war broke out, in 1968, Sister Pauline’s superiors re-assigned her to St Mary’s Hospital in Urua Akpan, in the breakaway state of Biafra,southeastern Nigeria, where war was causing devastating famine. It was at this hospital where Sister Pauline wrote her diary. Along with many Irish priests, the Medical Missionaries of Mary made the crucial decision to stay with the Biafran people, to whom they provided nutrition, sustenance and medical and nursing care. The photographs shown in Figures 1 and 2 were taken between 1967 and 1968 in Nigeria.

Sister Ruth Carey, a member of the Medical Missionaries of Mary, took the photographs that appear in the diary10. To the sisters their work was a ministry and they published a magazine of which Sister Ruth was editor. Figure 1 was taken at St Luke’s Hospital, although the location of the second photograph is not noted. Nevertheless, the sisters used the picture at St Luke’s to represent their work at St Mary’s, which although smaller than St Luke’s, with 50 beds, had a large surgical clinic and a midwifery training school11. The sisters themselves chose the photographs for publication and both pictures show the intersection of religion and Western medicine. They emphasise technology and cure that Catholic sisters had accepted as part and parcel of their missionary work to relieve the suffering of others. Catholic religious orders used photographers, often women from their own congregations, to highlight their ministry for their sisters back home or for fundraising purposes. The photographs showed the sisters’ work to remind readers that, even in other lands, the organised church was reaching out to those needing help.

Although the diary features photographs, Sister Pauline said nothing about what they meant to her at the time. By contrast, when she published the diary forty years later, she commented on why she decided to distribute it. As she explained, she published it

[m]ostly because it has just come to light in a suitcase. I think because firstly I had forgotten how much the people suffered and secondly how many kind people helped us in caring for the sick and wounded. I also thought that some of the people mentioned in this diary might be interested to read it – as I was when I found it just recently12.

The written word, with chronological dates and commentary, take central stage for her. The diary detailed specific events for particular days and revealed Sister Pauline’s personal thoughts, anger, confusion, relief and sadness as she witnessed the horrors of war and dislocation. The photographs give shape to Sister Pauline’s words.

Photograph of Catholic nurses working in Nigeria
Fig. 1. Sister Doctor Pauline Dean and Sister Midwife Elizabeth Dooley, St Luke’s Hospital, Anua, before both were re-assigned to St Mary’s Hospital. Used with permission of the Medical Missionaries of Mary, Drogheda, Ireland.

Fig. 1 features Sister Pauline and Sister Elizabeth Dooley, a midwife, in their religious habits, before they went to St Mary’s. It is structured in a way that shows the centrality of the nuns and it confirms that this Catholic hospital was not only a medical institution but also a sacred space. Sister Pauline, the physician, has a stethoscope around her neck, which reinforces the medical hierarchy between nurses and physicians at that time. The stethoscope revealed that she had privileged access to the body that others did not have. The photo also reveals a vision of order, with a number of Nigerian women standing alongside hospital cribs. These were probably the mothers of child patients in the beds. In Nigeria, parents, too, worked with sisters to help care for their children while hospitalised.

Photographs such as these can be valuable for historical study in several ways. Just as context is significant to understanding a photograph, so is the intended audience. The photographs give the viewer a glimpse of what the sisters’ work was at the time, what their practice included, who they worked with and the achievements of Western-trained medicine.

Operating theatre in Nigeria
Fig 2: Sister Doctor Pauline Dean in operating room with two Nigerian assistant nurses. Used with permission of the Medical Missionaries of Mary, Drogheda, Ireland.

Fig. 2 shows Sister Pauline and two Nigerian nurses in an operating room scene, all wearing sterile gloves, gowns and masks. It was not unusual for any hospital publication to show such images to reassure viewers of the institutions’ technical capacities. The photograph reveals not only the promise of technology even in wartime conditions but also highlights the importance of the sister-physician/surgeons to the nuns’ missionary work. The two Nigerian nurses are not named, yet these likely are some of the people Sister Pauline refers to when she remembers ‘how many kind people helped us in caring for the sick and wounded’13.

My own interpretation of the operating room scene expands on this story. I see how the Catholic sister doctors, nurses and midwives worked with Nigerians in the Catholic hospital. While medical assistants, typically male, had been active in hospital work in other parts of Africa, that was not the case in Nigeria, where the bulk of the hospital work was done by Nigerian female nurses and nursing students who the sisters taught in their school of nursing. This photograph shows that Nigerians had an important presence – clearly in Figure 2, one Nigerian nurse is taking a direct role in the operation, not simply looking on – she looks very involved, thinking as to her next move, trying to anticipate Pauline’s next requirement. The care-giving staff in the hospital were closely integrated into the Biafran struggle. When, in her diary, Sister Pauline described doing an appendectomy during periods of bombing, the photograph of the operating room accompanied that description14.

Photographs can reveal much about the past by what is included in the frame, but also what is not included15. We do not see Nigerian doctors. This hospital was primarily a ‘female’ space. Indeed, it was the norm to find all-female spaces in Nigerian hospitals run by Catholic missionaries. At St Mary’s, for example, the Medical Missionaries of Mary included two nurse-midwives, two physicians and one administrator. The school of midwifery used female students to help staff the hospital. Furthermore, for financial reasons, sisters could not get government grants to cover the salaries for Nigerian physicians or medical students, who typically were men16. At times, Catholic priests assisted the sisters, but the Medical Missionaries of Mary were always in charge17.

In her diary, Sister Pauline repeatedly refers to a Nigerian midwife, a ‘Mrs. Hogan,’ who stayed with them during the war18. Mrs Hogan remains faceless; she is not among those photographed in the diary. Her picture would not have been the focal point; the diary was an exercise in public relations and its intended audience was the religious congregation, in which the sisters were central.

Historians of medicine and nursing provide histories of engagements of Western models of health care that are shaped within specific ethnic and religious environments19. Wartime, and the humanitarian efforts that result, complicate the interrelationship of secular and religious topics by blurring their specific boundaries. By examining photographic presentations of sisters’ mission work on the ground where health care actually took place, one sees how Irish and Nigerian women worked together to provide care during a period of conflict and dislocation. The pictures also defy gender stereotypes by showing heroic medical work, a masculine activity often done only by men, but not in this Catholic hospital run by women.

As well, in Nigeria, religious idealism collided with military goals and politics20. In 1970, when the war ended and the Biafrans had lost, the Nigerian government expelled many of the Irish sisters and priests from the country, including most of the Medical Missionaries of Mary (Report of St Luke’s Hospital, 11 September 1968). Officials accused them of prolonging the war by providing food and medical relief to the ‘enemy’21. Yet the Nigerianisation of the Catholic Church and its educational and hospital facilities had rapidly expanded and this included the institutional leadership of Nigerian sisters and nurses. For example, Nigerian sisters of the Medical Missionaries of Mary were active in reconstructing and upgrading Catholic hospitals after the war and they became a dominant part of the public face of Catholicism in Nigeria22. And we know two of their names: Sister Veronica Akpan and Sister Agnes Maria Essien. We also know from recent interviews that the Sisters of the Immaculate Heart of Mary also participated, although they remain nameless and faceless23.

Afterword

Photographs capture certain moments during wartime by revealing people involved in specific places and their interpretations vary. For Sister Pauline, re-examining her diary and its images forty years later evoked powerful memories about the suffering she witnessed. For others, photographs of sisters’ health care work in Nigeria can provide insights into the religion-specific features of conflicts and their broader historical, political and racial settings. Ultimately, however, images resist telling a single story.

Viewers have different interpretations of photos that may not always conform to the original intention of the photographer. Indeed, the same photo can be read and interpreted in different ways by different people24. My own interpretation is conditioned by the work I have done on the history of Catholic hospitals and I must be careful that this does not become a history of ‘great women’. As I re-examined these photographs four years after I wrote Into Africa, I asked myself, ‘Did I unconsciously reproduce a story of only white women making sacrifices during wartime?’ That was certainly not Sister Pauline’s reason for publishing her diary or Sister Ruth Carey’s intent when taking the photographs. My original interpretation, however, possibly presented this viewpoint to readers of my book. Today I provide a different interpretation. Catholic sisters responded to an event that was unplanned. They were moved by their Christian conscience, but their idealism clashed with military responses and they had to decide whether to stay or leave. They chose to stay after being convinced that any failure to act would be a dereliction of their duty. Thomas Haskell’s essay, ‘Capitalism and the Origins of the Humanitarian Sensibility’, is helpful here. He argues that one of the preconditions that influence people and societies’ humanitarian sensibilities is their sense of duty to humankind25. For the sisters, diminishing suffering through their medical and nursing care was paramount and their images reflect this care. Yet they were working in areas that had their own political interests and the sisters had to walk a tight line. These photographs also show that Nigerian nurses and others worked alongside the Irish sisters. They were fighting against an event that they did not see as random at all – a civil war for their rights and they could identify with the refugees in ways the Irish sisters could not. Perhaps Mrs. Hogan, the Nigerian midwife, fell into this group, along with the parents of the hospitalised children. Most importantly, Nigerians’ work was crucial to all hospitals in Nigeria, especially after the war when Nigerian nurses took the opportunity to keep Catholic institutions under their care. Any narrative must highlight their work as well. Indeed, a different story is seen when we include the ‘silenced’ from the past, which photographs can help identify.

The Situation Today

As Pegler-Gordon asserts, ‘We can build on our students’ interests, strengthen their engagement in history and help them to become more critically aware both about the world of the past and the world in which they live today’ by using images as primary sources26. As with written records, photographs that depict engagements of Western models of health care during periods of conflict are shaped within specific political, ethnic, racial and religious environments. Providing students with tools for interpreting photographs is important to facilitate understanding of the complex issues bestowed by colonial efforts and long intractable influences of politics, health, religion, race, gender and medicine, which continue to cause tensions when humanitarian responses operate during periods of militaristic nationalism27.

References

  1. Anna Pegler-Gordon, ‘Seeing Images in History’, Perspectives on History, 1 February 2006. Available at https://www.historians.org/publications-and-directories/perspectives-onhistory/february-2006/seeing-images-in-history [Accessed 27 July 2019].
  2. Barbra Mann Wall, Into Africa: A Transnational History of Catholic Medical Missions and Social Change (New Brunswick, NJ: Rutgers University Press, 2015)
  3. Janet Golden and Charles Rosenberg, Pictures of Health: A Photographic History of Health Care in Philadelphia, 1860-1945 (Philadelphia, PA: University of Pennsylvania Press, 1991), p. xxv.
  4. Rima Apple, ‘Picturing the Hospital: Photographs in the History of an Institution’ in The American General Hospital: Communities and Social Contexts, ed. by Diana E. Long and Janet L. Golden (Ithaca, NY: Cornell University Press, 1989), pp. 67-81.
  5. Barbra Mann Wall, ‘Looking Back: Celebrating Nursing History’, American Journal of Nursing 108/106 (June 2008), p. 28.
  6. This hospital was an extension of a dispensary founded earlier by Sister Mary Charles Walker, who had established the indigenous congregation, Handmaids of the Holy Child Jesus, in Nigeria.
  7. Wall, Into Africa.
  8. Ibid.
  9. Sister Pauline Dean, Biafran War Diary, Urua Akpan, 1968 (Medical Missionaries of Mary, 2008), p. 2. Available at https://mmmworldwide.org/images/stories/pdf2010/biafran_war_diary.pdf [Accessed 27 July 2019].
  10. Sister Carol Breslin (20 October 2019). Email communication with author.
  11. St Mary’s Hospital Report, 1962-1968. Archives of the Medical Missionaries of Mary, Drogheda, Ireland.
  12. Dean, Biafran War Diary, p. 1.
  13. Ibid.
  14. Ibid., 27 May 1968.
  15. Wall, ‘Looking Back’.
  16. Wall, Into Africa.
  17. Dean, Biafran War Diary, p. 8.
  18. Dean, Biafran War Diary, p. 9 and others.
  19. E. Fleischmann, S. Grypma, M. Marten, and I. Okkenhaug, eds., Transnational and Historical Perspectives on Global Health, Welfare, and Humanitarianism (Kristiansand, Norway: Portal Academic Publishers, 2013); Ann Digby and Helen Sweet, “Nurses as Culture Brokers in Twentieth Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. W. Ernst (London: Routledge, 2002), 113–129.
  20. Roger Cooter, ‘Medicine and the Goodness of War’, Canadian Bulletin of Medical History/Bulletin canadien d’Histoire de la medicine, 7 (1990), pp. 147-59.
  21. E A Ayendele, The Missionary Impact on Modern Nigeria (New York: Humanities Press, 1966); Ralph Schram, A History of the Nigerian Health Services (Ibadan: Ibadan University Press, 1971); Ndubisi Obiaga, The Politics of Humanitarian Organizations, 2004; Toyin Falola and Matthew W Heaton, A History of Nigeria (Cambridge, New York: Cambridge University Press, 2010).
  22. Wall, Into Africa.
  23. Sisters Maria Chinweze and Maria Nkiru, interviews by author, 29 August, 2012; and Sister Mary Nesta, interview by author, 30 August 2012.
  24. Po-Yi Hung and Stephen Laubach, ‘Learning to Do Historical Research: Sources Photographic Images’. Available at http://www.williamcronon.net/researching/images.htm [Accessed 21 October 2019].
  25. Thomas Haskell, ‘Capitalism and the Origins of the Humanitarian Sensibility’, American Historical Review, 90 (1985), pp. 339-361, 547-566.
  26. Pegler, ‘Seeing Images in History’.
  27. Cooter, ‘Medicine and the Goodness of War’; John F Hutchinson, ‘Rethinking the Origins of the Red Cross’, Bulletin for the History of Medicine, 63 (1989), pp. 557-578.