Garbage Bags and Tomato Cans: The History of Nurses Making Basic Equipment Out of Trash

In spring 2020, images of nurses treating patients while wearing garbage bags instead of standard disposable gowns symbolized both the bravery of frontline clinicians and a shocking lack of preparation for the emerging COVID-19 pandemic. This clever use of a trash bag as well as other everyday items and actual trash to create ad-hoc personal protective equipment (PPE) was a moment of nursing ingenuity sparked by the failure of our healthcare system to provide nurses and other clinicians with the equipment necessary for their work. As a historian of clinical technology and a nurse, I often use similar examples of nurses building equipment from scrap in the past as evidence of nursing’s unique combination of scientific, technological, and social knowledge – a practice that gives me pause in light of our current healthcare crisis.

There is a long history of nurses creating necessary clinical equipment out of trash, usually during military service, well-documented in professional nursing publications. During World War II, U.S. military hospitals in one often forgotten region, the so-called China Burma India theater (CBI), were particularly under-resourced due to logistical, social, and cultural circumstances, requiring personnel to scramble for supplies readily available at stateside hospitals and better-supplied areas of conflict. Nurses at work in the CBI regularly used trash to meet the complex medical needs of their patients and shared their ideas via letters to the American Journal of Nursing (AJN) and other publications.

Lt. Helen Poulson of the U.S. Army 20th General Hospital in Assam, India, wrote one such letter to the AJN in 1944, full of cheerful quips and exclamation marks and titled “Sterile Dressings in Tomato Cans.”^[1] Poulson employed tomato cans to contain wound dressings inside an autoclave during sterilization and baked bean cans as surgical tray components.^[2] Poulson noted that the obsolete autoclave “runs by gasoline, drinks water like a fish, and is very temperamental. Several times an hour we pump air into it like an old tire – very good for the figure!”^[3] To create sterile culture plates – a critical tool in the diagnosis of infectious disease – she developed a system using grape juice bottles, tablet cans, and an incubator built from a discarded ice chest.^[4] Similar articles written by U.S. Army nurses in the CBI described adapting packing crates for use as furniture and creating patient charts from a combination of scrap paper, spent x-ray film, and locally purchased office supplies. None of these accounts question the scarcity of supplies.

Other scarce equipment was more difficult to replicate, reuse, or do without, sometimes with deadly consequences. Many factors made blood transfusion risky in the CBI, including supply shortages unthinkable in the U.S. Standard blood donation kits, for example, were not available, requiring nurses to reuse glass IV solution flasks for blood collection, jamming empty glass procaine capsules into holes in the rubber stoppers to seal them.^[5] Semi-disposable rubber tubing was reused to the point of getting “pitted and sticky” from repeated heat sterilization.^[6] Substandard blood donation and transfusion equipment paired with inadequate cleaning and sterilizing facilities resulted in a high rate of dangerous and sometimes deadly transfusion reactions at the 20th until more suitable equipment arrived late in the war.^[7]

Global shortages of raw materials and logistical constraints certainly made it difficult to consistently get equipment to U.S. hospital units in the CBI. For example, the hospital where Lt. Poulson worked such wonders with her trash and temperamental autoclave, the 20th General, was at the end of a 12,000 mile supply line. However, supply-chain decisions made by Allied leadership also reflected deep-rooted racist beliefs about who was most worthy of resources, including weapons, support units, physicians, nurses, and the lifesaving clinical equipment necessary for their work.

The circumstances of the CBI were politically, medically, and culturally complex for the Allies after Japanese forces fully occupied Burma, previously controlled by the British by early May of 1942. Allied forces, consisting mainly of exhausted Chinese troops under U.S. military command, retreated into India on foot along with refugees. This resulted in thousands of malnourished Chinese soldiers arriving at U.S. military hospitals, many ill with infectious disease and suffering from untreated battle wounds. As part of a campaign to keep China in the war and limit deployment of Japanese troops to the Pacific theater, the U.S. took on the construction of an overland supply route from India through Burma into Southern China, the 1,072 mile long Ledo Road. Approximately 60–65% of the U.S. personnel at work on the Ledo Road were African American enlisted men working under white officers.^[8] Black soldiers were typically posted in remote rear support units and given grueling or unpleasant assignments white soldiers felt more entitled to refuse.^[9]

In addition to influencing the limited allocation of resources to the CBI, the institutionalized racism of the U.S. military also affected which hospital units were dispatched to the region. The entire staff of the 100-bed 335th Station Hospital – surgeons, physicians, medical corpsmen, and sixteen nurses – were African American.^[10] The U.S. Army appointed the 335th, one of two all-Black hospital units deployed overseas, to Tagap, Burma, 80 miles up the Ledo Road, with the intention that it would primarily serve Black engineering corpsmen.^[11] In official reports, 1st Lt. Daryle E. Foister and 1st Lt. Agnes B. Glass described how nurses divided their quarters with discarded corrugated board and decorated with hand-sewn surplus fabric curtains and furniture built from wooden crates.^[12] Glass, Principal Chief Nurse of the 335th Station Hospital, carefully framed hardship in her official reports in ways that emphasized the willingness of Black nurses to serve despite the discomforts of their remote station hospital. There is no discussion of inadequate clinical supplies, even though the 335th, 80 miles up the supply line from the 20th General, would have presumably experienced even more shortages. In an interview with a war correspondent from an African American newspaper, 1st Lt. Glass carefully listed all of the supplies prepared for surgery, perhaps implying that “bandages, syringes, sterile gloves, cotton dressings, tubes, needles, and novocaines” were in ample supply at the cliffside station hospital.^[13]

It’s unclear how much fear of reprisal from a military that only begrudgingly accepted the service of Black nurses influenced Glass’s choice not to discuss medical supply shortages.^[14] An inspection report from the Director of Nurses in the CBI complemented the appearance of the 335th’s nurses, the correctness of their uniform, and the cleanliness of their quarters, also noting that “very few complaints were offered.”^[15] Glass’s official reports and interviews suggest that she understood the power of stories that highlighted the professionalism of Black nurses to a government and public doubtful of their suitability to serve in the military and chose to center such narratives.

Black and white U.S. Army nurses crafted different stories of scarcity and hardship while serving in the same undersupplied theater of World War II for both official, confidential reports and the American public. White nurses felt free to complain publicly, though in an upbeat manner about clever trash-based solutions, while Black nurses, at least in the sources shared here, refrained from commenting on the lack of supplies available to their unit. Nurses at the front lines of the COVID-19 pandemic are similarly sharing their experiences through consciously shaped social media posts, newspaper op-eds, and professional journal articles. Some are stories of patient care victories and technical ingenuity despite scarce supplies, inadequate facilities, and personal hardship very similar to those shared by nurses of the 20th and 335th. I suspect that the racist disparities in the distribution of resources during the current COVID-19 crisis are reflected in these nurses’ narratives and that there are many nurses who aren’t sharing their need to use garbage as equipment publicly for fear of reprisal.

Ingenuity in the face of scarcity is a common theme in the celebratory history of nursing. Such anecdotes are told and retold by nurses (and nursing historians) as historical examples of nursing innovation, which continues to center white nurses and reinforce the categorization of nursing as a self-sacrificing women’s profession. Celebrating these moments of ingenuity without critiquing the circumstances that necessitated a solution pulled from the trashcan reinforces the harmful belief that nurses should “make do” under any circumstances. As I continue to witness my nursing colleagues “make do” with dirty, soggy respirators and garbage bag gowns nine months (and counting) into the COVID-19 pandemic, I struggle with the knowledge that my excitement over Lt. Poulson’s tomato cans and 1st Lt. Glass’s handmade curtains has reinforced the idea that it’s acceptable for nurses to risk their lives with inadequate equipment. Yes, the ability to craft PPE and other critical clinical equipment from trash or whatever is at hand is a feat of nursing ingenuity, but surely nurses (and other bedside clinicians) deserve better.

Amanda Mahoney

Amanda L. Mahoney is the Chief Curator of the Dittrick Museum of Medical History at Case Western Reserve University and a historian of medicine, technology, and nursing.

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