Soviet Nightingales

Front matter

COMMUNISM —

SOVIET NIGHTINGALES

SOVIET NIGHTINGALES

Contents

Acknowledgments ix Abbreviations and Glossary xiii

Note on Translation and Transliteration xvii

Introduction 1 . War and Revolution 17 . Creating Order out of Chaos 35

Introduction

In 1922 an interesting exchange took place in Moscow’s Botkin hospital concerning a “delicate and even shy” patient who had just had a bullet extracted from his neck and was recovering in ward no. 44.' The patient wanted to know all about his nurse, the other patients, and the medical personnel. He even asked the nurse why she looked so “bad” and questioned the professor tending to him about why this nurse was “working day and night, without rest.” He noticed the physical toll nursing work took on people. Finally, he wanted to know how he could thank this nurse who had been taking care of him. The inquisitive patient was none other than the leader of the world communist revolution, Vladimir I. Lenin. Within a few days the nurse who had tirelessly taken care of Lenin received a resort pass to the Crimea, issued by Commissar of Health Nikolai Semashko on the direct instruction of her thoughtful patient.” The busy leader, it seemed, cared about nurses. The account was in a 1980 book on Lenin and Soviet public health, and the moral of the story was that the Soviet state cared about its nurses. Lenin’s nurse—Ekaterina Alekseevna Nechkina—was later featured in the journal Nurse. By the time her story appeared in a 1948 issue of the publication, Nechkina had already accumulated some thirty-seven years’ work experience. Born into a working-class family, she had the right class credentials, but life was far from easy. Orphaned at just fifteen years old, Nechkina moved from the provinces to Moscow to be under the guardianship of her uncle, a doctor in the Staro-Ekaterinskaia (Old Catherine) hospital. She joined the Sisters of Mercy school attached to the Aleksandrovskaia nursing community and graduated in 1911.’ After that she entered the Soldatenkovskaia hospital’s surgical department (later the Botkin hospital), where she remained for fifteen years. A “thoughtful, dedicated” worker, she was promoted from ward nurse to senior nurse in 1916. As testament to her high standing, she had the “great honor” of caring for Vladimir Ilyich Lenin in April 1922. In the mid-1920s the hospital appointed her head nurse of its new surgical building.*

Nechkina was valued as a “highly cultured” worker who had good relations with her patients. She possessed the typical attributes of other Soviet workers— she constantly “worked on herself” to improve her education and was an example to others.’ We do not know what exactly happened to Nechkina during the revolution, but like so many other nurses who had trained prior to the revolution she continued her hospital work. Her sound working-class background no doubt helped in shielding her from dismissal or arrest. The fact that she had trained in a tsarist nursing community did not negatively affect her career; if anything, she was valued more because of the training and discipline she acquired before the revolution.

Cold War histories tell us that a totalitarian system cowed and repressed Soviet citizens. And while that is true to an extent—the Soviet Union was an illiberal society, after all—people, nurses included, found ways of existing and sometimes thriving in this world. When the Bolsheviks initially set about constructing a socialist society and a New Soviet Person, they were venturing forth into the unknown. They were torn between the old and the new: How would vast numbers of people, predominantly peasants, accustomed to the “old” tsarist ways, help the Bolsheviks build a shiny new world based on Marxist-Leninist principles? They desperately needed healthcare workers to address the public health crisis, but oftentimes these nurses were from the “old” imperial world. If there were nurses and other medical workers who disagreed with the Bolshevik system, they nonetheless continued to work within that system.

Although we might associate the Stalinist years with terror, violence, and repression, and assume that people tolerated these conditions out of fear, we overlook the fact that alternative narratives ran alongside the hunt for enemies. The historian Karl Schlégel’s tome on the year 1937 shows us that Soviet citizens continued to go to work, parks, theaters, and concerts and basically got on with their lives as the terror unfolded.° The state, while unleashing mechanisms of terror, reminded Soviet citizens that the authorities were constructing metro stations and stadiums and creating a cultured way of life for them. People were told that Stalin and the Soviet government cared about them and that nurses and other medical workers would provide them with the best possible care. But state promises to the people depended on caregivers meeting these expectations. As I show in Soviet Nightingales, that was not always the case. The Bolsheviks were too slow to convey sufficient prestige and respect on nursing, and it suffered as a result. Lack of funding and organization undermined standards of nursing care and left medical workers in the hopeless position of working for low salaries in terrible conditions. This situation worsened after the war and only began to improve in the 1950s and 1960s.

For Soviet citizens, good care was, forgive the pun, a game of Russian roulette. The ideological nature of the Soviet system placed nurses in an unusual position. As representatives of the new, socialist order, nurses in the Soviet Union had the vitally important task of caring for future communists. They had to be more than competent: they had to be politically loyal, ideologically literate, and, at varying times, maternal. Yet, nurses inhabited a unique place in Soviet society: as part of a caring profession with roots in charity and the aristocracy, they sat somewhat uncomfortably in the revolutionary world of the Bolsheviks. This book addresses that discomfort by exploring the habitat of Soviet nurses and their colleagues. How did nurses regard the new socialist society? Was it everything they feared or hoped?

At the heart of this book, I show that nurses were crucial symbols of the new Soviet state. The whole ethos and nature of nursing, as the socialist state eventually came to realize, was paramount to the socialist ideological mission. Soviet Nightingales analyzes the Bolshevik effort to define the “Soviet” nurse and organize a new system of socialist care for the masses. The process of molding the Soviet nurse was challenging, and I examine the immense educational and organizational tasks that confronted the state as it attempted to identify the kind of nurse that most suited the country’s medical, material, and moral needs. Telling the story of nursing necessarily engages with Soviet politics, culture, and society, as well as nursing literature. Nursing ebbed and flowed with the social and political currents, the daily lives of medical professionals and patients shaped by the revolution, the Great Terror, war, “thaw,” and glasnost (openness). I analyze living and working conditions, nurse-patient relations, international contact, and education to piece together a holistic picture of the Soviet nurse. Nurses in the Soviet Union have hitherto received insufficient scholarly attention: their history is little known, yet it tells us much about Soviet society.”

Defining Soviet Medical Workers

This book deals with a broad typology of medical personnel. Physicians, surgeons, and other medical specialists sat atop the Russian and Soviet healthcare pyramid. The next tier comprised “middle” (srednyi) medical workers, a long list of personnel that included, among others, nurses, midwives, feldshers (paramedics), feldsheritsas (female feldshers), dentists, pharmacists, and laboratory workers. Pilloried and praised, the new Bolshevik authorities loathed the feldshers for their lack of scientific background, and they endeavored to completely eliminate this stratum of medical worker.’ Finally, “junior” (mladshii) medical personnel occupied the lowest tier, and included among them were orderlies, sidelki, and nannies. The sidelka—literally, someone who “sits,” such as a nursing aide or caregiver—was a curious figure in Russian and Soviet history. But the sidelki often horrified Soviet healthcare authorities, as they were usually uneducated and did not meet the lofty ideals of the revolution and its “New Soviet Person.” Although the nurse is the main protagonist of this story, the wider cast of medical workers play important roles too.

The function of middle and junior medical workers was largely seen as facilitating the work of the doctor, and these were not considered particularly prestigious positions. None of the medical professions were especially well remunerated. When researching this book, I quickly realized that a history of Soviet nursing would also have to be a history of a broad spectrum of medical workers. To tell the story of Soviet nursing is also to tell the story of middle and junior medical workers who often shared the same grievances, hardship, suffering, and rewards. And it proved almost impossible to separate them, for two reasons: (1) they were usually lumped together in the source material, and (2) they worked together and interacted every day—care in a socialist society was a team effort. Doctors drift in and out of the book for this same reason: they provided care alongside nurses and orderlies and worked in similar conditions.

The Soviet case is set apart from other international histories of healthcare because the Soviet Union was a worker state: the Bolsheviks quickly set about putting in place structures and policies allowing its citizens to access education so that they could become important contributors to the new socialist society through their labor. It was not uncommon for doctors and nurses in the Soviet Union to have entered the medical profession at the lowest rung as orderlies or middle medical workers and then worked their way up through the healthcare hierarchy and Soviet society.’ But their journeys reflected the turbulence and uncertainty of a state in flux or in crisis. In the early revolutionary years the state performed a kind of juggling act between the “old” and

“new” way of life when it came to establishing a class-based society. Healthcare is a prime example. Nurses, in the form of Sisters of Mercy, and especially feldshers, bore the brunt of campaigns to rid socialist society of its prerevolutionary past. These were not the typical “proletarian” figures deemed worthy of representing the new Soviet state.

Uncertainty about the role and even existence of certain forms of medical worker led to ambiguities in how people perceived nurses and even doctors. In contrast to other countries with a clearly defined system based on the doctor and nurse, the Russian and later Soviet system struggled to work out the best way of delivering care through its three-level system, in place for much of the Soviet period. In this system the orderly and junior medical workers often spent a great deal of time with patients. The Soviet state was built on Marxist-Leninist ideology that strongly influenced healthcare. A prophylactic orientation shaped medical work in theory and in practice. As Soviet healthcare officials examined public health and current social needs, including looking abroad to see how other healthcare systems fared, middle and junior medical workers saw their role and function change over time. Healthcare was subject to seemingly constant review and modification as part of the socialist experiment. New types of nurses in the 1920s tackled mother and child health, military training notched up many hours on nursing curricula in the late 1930s, and attestation arrived in the late Soviet period. Consequently, one of the basic issues for nurses lay in understanding their professional territory. While textbooks outlined their role and function, in practice personnel shortages and labor turnover could result in nurses taking on the work of orderlies. For this reason, issues around workload and salaries receive a good deal of attention in this book.

There are many parallels between the Soviet and contemporary international experience of nursing, none more so than the nursing crisis we so often read about today. Shortages of qualified nurses have led to greater demands for healthcare assistants. In Soviet parlance, these would be “junior” medical workers. Their role was to relieve nurses of their housekeeping work so they could focus on patient care. Much of the discussion in the book centers on debates about these kinds of responsibilities. And such debates continue. In the United Kingdom the Royal College of Nursing (RCN) recommends a skill-mix ratio of 65 percent registered nurses to 35 percent healthcare assistants.'° The RCN recognizes that healthcare assistants can support registered nurses and assume some of the administrative and housekeeping work to allow nurses to spend more time with patients, but it acknowledges that this “has not been widely enacted upon.”"! In the Soviet Union a skill-mix ratio was already in place, albeit as a necessary consequence of the absence of trained nurses.

The struggle of Soviet medical authorities to increase the quantity of nurses is a problem now faced in many countries, especially in the United Kingdom, where, for the first time in ten years, more nurses left the profession in 2017 than joined the register.'* Similar conversations about safe staffing levels are taking place in the United States. Even though increasing the number of registered nurses can yield a cost saving of about $3 billion, hospitals in the United States are “feeling pressure to reduce labor costs by eliminating or understaffing registered nurse positions.” 1° These problems characterize nursing in Canada, Australia, France, Germany, and many other countries." In the Russian Federation there was a shortage of 130,000 nurses in 2019, while that same year there was a shortage of 137,000 junior medical workers, compared to 2018.” In 2019 Russian junior medical worker positions were subject to drastic cuts in hospitals and clinics and their jobs recategorized to “janitors.”'® The reduction in the number of junior medical personnel led to increased workloads for nurses. International nurse staffing standards and conditions for medical workers are still below optimum levels some eighty to ninety years after debates on the same issue in the Soviet Union.

Professional Autonomy, Gender, and Medicine

For nurses the lines between “the duty to care for others and the right to control their own activities in the name of caring” are often blurred.!’ For Soviet nurses the duty to care usually took precedence. Altruism characterized the profession, while autonomy took a backseat.'* That said, while Soviet nurses may not have had many rights to control their own activities on a macro level, in the micro context of a hospital department they might have had more opportunities for professional autonomy.”’ Soviet Nightingales shows that nurses working in a range of healthcare institutions had quite different experiences depending on relationships with head doctors and colleagues and on local politics. And although Soviet nurses did not have a specific nursing union or association with easily identifiable nursing leaders to advance their cause, they nonetheless spoke out when they felt that their rights were infringed on.

As Soviet nurses navigated their professional course, they did so within a healthcare system that suffered from lack of funding, the struggle to modernize, an informal economy, and other shortcomings. Toiling in a vastly bureaucratic system, and often having to do physically and emotionally exhausting work, nurses and middle medical workers were frequently let down by the Soviet system. As the “faces” of healthcare, they saw their situation sometimes worsen because they acted as a buffer between the system and its patients. In an ideological and political context where “cadres” decided everything, nurses and other middle medical workers were often at the receiving end of much criticism. Many of the book’s chapters assess the changing positions and fortunes of these workers.

The Russian and Soviet healthcare system overwhelmingly consisted of women workers. Unlike in Western countries, this feminization did not apply just to nursing and auxiliary support: in the Soviet Union large numbers of doctors were women. For that reason, the Soviet case is interesting because many of the developments around gender dynamics arising from increasing numbers of women in medicine were already present in the Soviet Union.” Consequently, workplace relations in Soviet healthcare were not strictly delineated along traditional male/doctor or female/nurse lines. Still, men often held senior positions within a medical setting.” Male doctors both supported and looked down on nurses, for various reasons explored in Soviet Nightingales. In some cases strained professional relationships with male doctors eroded nurses’ self-esteem.” The relationship between women doctors and female nurses is less clear, although nurses sometimes characterized relationships with senior nurses or women doctors as being supportive. The complexities of the Soviet social and political context, combined with a dearth of source material, make it difficult to draw neat conclusions about complex workplace dynamics and gender relations among healthcare professionals.

Emotions, Identity, and Professionalization

Soviet Nightingales is laden with emotion. This relates to the language of care and the physical act of caring and how both play out in medical and political contexts. “Care” and “compassion” are terms we frequently encounter in the Soviet literature on nursing. Compassion is a feeling but also an action that involves helping others.” In the Soviet context mercy and compassion were part of a nurse’s tool kit: these were fundamental to providing a high standard of care. In Russian there are two words for care: zabota (care, as in concern) and ukhod (the act of caring for someone).”* We see both terms in the sources. Often zabota refers to the general delivery of care and can seem more abstract than the personal or individual ukhod. Whichever term is used, “care” is seen as intrinsic to nursing. But when nursing shifts from caring to administrative work, we move away from the realm of emotion and feeling and into a world that raises questions about authenticity and “real” nursing work.

In their work on nursing care, nursing scholars Sioban Nelson and Suzanne Gordon push back against connotations of “real nurses” and “emotional work”

and the view that those nurses who work in administrative or highly technical roles are not considered authentic.” In the Soviet case the “authentic” nurse was often involved in doing emotion work, suggesting that “real” nurses did not spend most of their time doing administrative or technical work. Emotionbased narratives of care and compassion make it all too easy to overlook a nurse’s hard-earned skills and knowledge.” Such associations belittle the nurse in a myriad ways, on both a professional and a personal level. Stereotyping nurses as kindly caregivers can marginalize them within the broader healthcare profession, affecting their self-esteem and sense of identity. The self, after all, does not exist in a vacuum but interacts with other individuals and communities who shape identity.” These are problems that confront nursing, past and present, but they often assumed different levels of intensity in the Soviet Union, usually according to a topical propaganda campaign. Ironically, the altruistic and philanthropic roots of Russian and international nursing were anathema to the young Soviet state, and yet it too ended up characterizing nurses in a similarly simplistic way.78

I argue that over the course of the 1930s—1950s nurses in the Soviet Union became increasingly professionalized, although there is a lack of consensus today about what “professionalization” constitutes. Sociologists and some healthcare experts have considered this term problematic and unhelpful.” Before the rise of sociological definitions of the professions from the mid-1950s to the 1980s, nursing was a legitimate form of profession or occupation.” One nursing textbook published in 2001 examines the following characteristics of Use of the Scientific Education Within institutes of

2 ee the profession: “A body of Specialized Knowledge, Method to Enlarge the Body of Knowledge,

2 66

Higher Education,”

33 ee

Control of Professional Policy and Professional Activity,” “A Code of Ethics, “Nursing as a Lifetime Commitment,” and “Service to the Public” .??

The term “professionalism” can connote striving for “excellence in performance” and a “sense of ethics and responsibility in relationship to [nurses’] careers.”** My use of terms such as “professional” and “professionalization” denote recognition and prestige afforded to nurses and nursing. This might entail higher levels of training and education, growing authority within a healthcare setting, or access to knowledge through conferences and publications. Professionalization terminology acts as a foil to simplistic portrayals of nurses as kind, caring workers, a reminder that nurses are also skilled workers engaged in complex tasks.” It helps move us away from the kind of “sentimentalized caring rhetoric” that we see today and that the Soviet state and nurses also deployed.*4

Marginalization and Morality

In a 2001 US nursing textbook first published in 1980, students learn that their work is hard to define, straddling the borders of art and science, profession and occupation.” Prospective nurses are informed that their work is about caring for a person’s health, whereas medicine is “concerned with the diagnosis and treatment (and cure) of disease.”*° The authors of a review of nurse theorists provide a “widely accepted definition” of nursing from Virginia Henderson for the International Council of Nurses (ICN) in 1958: “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to the health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”*”

A definition from nurse theorist Martha E. Rogers in 1984 defines nursing as “an art and a science that is humanistic and humanitarian directed toward the unitary human, and concerned with the nature and direction of human development.”?* In addition to the many definitions of nursing from figures such as Florence Nightingale, Hildegard Peplau, and Myra Levine, US-based nurses could also look to the American Nurses Association and the National Council of State Boards of Nursing for further guidance on how to define and understand their role.” The limitless interpretations suggest that nursing escapes easy definition. This was similarly the case in the Soviet Union.

A 1979 Soviet textbook for junior nurses defined care work as “assisting in satisfying basic life functions: ingesting food, bowel and bladder emptying, personal hygiene, helping the nurse or doctor during manipulations with acute patients—vomiting, phlegmatic cough, incontinence [involuntary defecation, or neproizvol'naia defekatsiia], and also supporting the sanitary-hygiene conditions of a patient’s bed, wards and departments, etc.”*° In a section on general patient care and the “moral character and norms of behavior for the junior nurse,” students learn that they are the “first aide to the ward nurse and doctor” and that “in communist society the basic medical morality is humanism.” ^ Although there was no specific equivalent to the code of ethics introduced in the United States in 1950, the ICN Code of Ethics of 1953, or even the Florence Nightingale Pledge of 1893, Soviet discussions about the “moral character” of the nurse infused Soviet nursing in the 1950s and 1960s. By the early 1980s Leonid Brezhnev had inspired concern about humanity, fueling discussion on deontology and ethics in nursing.” As the 1979 Soviet textbook indicates, an entanglement between love and duty prevailed. Junior nurses “[were to] have defined medical knowledge and professional skills to help the patient,” while “successful treatment” often depended on her “skill, attention and love.” # They were to be sensitive and disciplined workers who also had practical personal hygiene rules to follow, such as bathing once a week and showering after every shift.“ A sense of humanity imbued nursing work in the Soviet Union, a fact that allowed nurses to be cast as clean heroes and moral leaders.

Paradoxically, nurses were also marginal figures or people marginalized by the Soviet project. To be sure, many engaged with processes of transformation and constructed identities that fit into a broader socialist story (Nechkina, Lenin’s nurse, perhaps being one such example), but this book is more an examination of nursing work, that is to say, the public and professional face of Soviet care. How did nurses adapt to Bolshevik ideas about nursing and care? What did care mean under socialism—was it not a time of incessant repression and misery? The following case of a middle medical worker is illustrative of some of these issues.

Six years after the revolution a feldsheritsa wrote to Medical Worker (Meditsinskii rabotnik) about the May 1 holiday. Her family was excited about attending the festivities, but she was too physically exhausted to take her place among them.” This woman made known her support for the revolution and regime but did not conceal her dissatisfaction with her job. She worked a twenty-four-hour shift without a break and returned home at ten in the morning to find that her daughter had already left for the holiday celebrations. At work she had spent “every hour, every minute” caring for patients without time to eat or drink. When she finally returned home, she could not even summon the energy to prepare breakfast. Yet this tired feldsheritsa had to “find the strength to go back to the hospital the following day.” She wrote about how she would meet people the next day and hear them say that everyone participated in the May 1 celebrations except “backward” medical workers. “Is this fair?” she asked and suggested that people help medical workers out of their awful predicament rather than “judge” them.*° The revolution had done nothing for these workers, and the suspicious, critical attitude of others only made them feel more aggrieved. The lingering dissatisfaction medical workers felt was an ominous sign of things to come.

The sense of marginalization manifested in different forms over the entire Soviet period. To be sure, nursing was stripped of its religious associations, but care, ethics, and notions of the good nurse made their way into socialist discourse. We can understand that much of this had to do with a compulsion to “conceptualize nursing as a fundamentally moral act.”*” But morality in the Soviet context was not quite the same as the “moral agency” found in more modern conceptions of nursing—the “agency” part was problematic.“ Soviet nurses were to be doctors’ assistants, and their moral role was often more closely connected to being “good” communists.” In the Soviet Union morality was frequently politicized and relocated from the private to the public sphere: ideology consequently forms the “background picture” for the “moral and spiritual intuitions” of Soviet citizens.” Nurses and indeed other medical workers navigated ideological and professional codes or scripts that characterized their relations to the patient.

As the Bolsheviks attempted to move away from religion, they imparted a strict moral and ethical code on the behavior of nurses and other medical workers. Comprising a mix of revolutionary trained Sisters of Mercy and newly trained Soviet nurses, nursing inhabited a somewhat awkward position in the new worker-peasant state. The state elevated science and medicine as rational and objective pursuits during the entire Soviet period—they were ideologically sound fields of expertise to lead the revolution forward—but nursing lagged behind as a shadowy occupation that the new authorities at first seemed unable to fathom. The Bolshevik conception of nursing came to reflect ethical and moral ideas around “the good life” and the sense of “the importance of the everyday in human life” and “the importance of suffering.”*! While these ideas might seem to go against the grain of an authoritarian society such as the Soviet Union, nursing and, more broadly, healthcare became spheres defined by a dialogue about care of the person.

While it is clear that later narratives of kind and caring nurses produced predominantly in Soviet nursing literature reflected official ideological lines, especially after the 1961 Moral Code of the Builder of Communism, the work of contemporary authors on nursing care suggests that nurses can be complicit in the construction of such a narrative.’ Some nurses describe their work as caregiving and humanistic rather than medical or technical—this is the role and function they see themselves inhabiting.” Soviet nurses saw themselves occupying a similar kind of caregiving space and conceived of their work as a type of moral duty to support the emotional and mental well-being of the patient. But that did not mean that they were not also hungry for knowledge and professional recognition. Attendance at advanced training courses required every three years offered them a chance to improve their skills and knowledge. As others working on nursing have argued, nurses themselves often foreground their role as caregivers: to use a modern expression, they see this as their “unique selling point.”** The compulsion to constantly redefine their role suggests an ongoing sense of alienation and marginalization born of a lack of public and perhaps official understanding of what nursing work means and entails. This is something that affects nurses past and present, Soviet and non-Soviet.

Chapters

This book’s nine chapters span the nineteenth and twentieth centuries. Our story starts with the origins of organized nursing care in Russia and goes full circle to the end of the Soviet Union. The Crimean War (1854-1856), perhaps best known in medical history for the work of Florence Nightingale, was also fundamental to the establishment of Russian nursing. After Crimea, Sisters of Mercy cared for wounded soldiers at times of war and during epidemics and continued their work during peacetime in hospitals and nursing communities across the empire. In chapter 1, I contend that Russian nursing developed along similar, though not identical, lines to European nursing. I show that the experience of the First World War changed Russian nursing when the old imperial system began to fragment under the pressure of increasing conflict and chaos. Nursing organizations felt this fragmentation. The establishment of professional nursing unions, the most prominent being the All-Russian Union of the Society of the Sisters of Mercy, established in August 1917, signified a drive for greater independence and professionalization within nursing. The impetus for change gained pace during the February and October Revolutions when Bolsheviks and leading Sisters of Mercy worked together to shape nursing care through the development of a new education and training program.

In chapter 2, I focus on the period of transition during the civil war years, 1918-1921, and the effort to establish a Soviet system of nursing in the early 1920s. Revolutionary tensions did not dissipate but continued to shape attitudes to nurses and nursing reform well into the 1920s and even the 1930s. While the Soviet public health authorities pushed for a new type of socialist nurse, divested of any former religious associations, many Sisters of Mercy remained working as before. In fact, despite resistance from “new” cadres, prerevolutionary nurses formed the backbone of the nursing service during the early Soviet period. The civil war years were also marked by battles between various Soviet authorities—inter alia, public health, the Red Army, and the medical union—all trying to seize and reclaim nursing infrastructure and assets from the Red Cross. The fraught transition process receives attention in this chapter, as do the complicated conditions on the ground. Lack of resources, personnel, medicines, and food affected the treatment and care of patients as well as working conditions for medical staff.