In Nigeria with MSF – Médecins Sans Frontières
Tuesday, 20 August 2024My travels in Nigeria included time as a typical tourist – particularly in Lagos and Kano – even though tourists are very few and far between in Africa’s largest country in terms of population. Nigeria already has more than 200 million people and it appears to be heading towards 400 million. There was also plenty to see on the roads of Nigeria and I made several flights.
▲ But most of my time in Nigeria was with MSF (Médecins Sans Frontières) starting in Abuja, the capital of Nigeria since 1991. The city’s development is all relatively recent and it’s intended to be sited at a mid-point in the country, more Christian to the south, more Muslim to the north.
▲ Although it’s certainly Christianity that you notice, all over Abuja there are giant billboard proclaiming preachers ready to bring the message to you, particularly on Sundays. Driving into Abuja from the airport you pass the huge orange 100,000 seat capacity Glory Dome (AKA the Dunamis International Gospel Centre) looking a bit like London’s Millenium Dome.
My MSF education started as soon as I arrived in Abuja – ‘are you OCB or OCP?’ I was asked by the MSF drivers. I’d not realised there are assorted different MSF branches under the one French umbrella although I was visiting Nigeria under another MSF umbrella, the Australian one. In fact I was OCP – Operation Centre Paris – not OCB – Operation Centre Belgium.
Having learnt that there are assorted different MSFs (6 of them in fact) I next discovered that it’s not just Europeans fanning out to the developing world. Overwhelmingly the staff I met were African and not just Nigerians. Going around the table in the common room at one MSF Guest House I counted 9 different nationalities in the 10 people there – plus Rhys and myself – the 2 Australians. The only nationality double counted in that guest house were the 2 Ugandans. Amusingly at one station one woman may have looked African, but in fact she was from Jamaica.
▲ Once I left the Abuja office my travels with MSF were all in the troubled north of Nigeria, the states crowding up against troubled Niger in the north and troubled Chad and Cameroon to the east. This area has always teetered on the edge of seasonal malnutrition, food is stored after the wet season and harvest, but stocks gradually run down through the dry season until eventually you get to the ‘lean season.’ It can get really bad and it’s all made much worse by the insurgency, farmers are unable to get to their fields or if they do their production is stolen when harvested. Or people are kidnapped and the money they get from the harvest ends up as a ransom. This Islamic terrorism is best known for the Boko Haram group and their schoolgirl kidnapping, particularly around Maiduguri in Borno State, directly west of N’Djamena the capital of Chad which I visited in 2022.
▲ I was amused that the MSF Guest House in Maiduguri had a ‘Safe Area’ where we could retreat if Boko Haram broke into the compound and started looking for infidels to kidnap. They never have, but if they did presumably that would be the first place they’d start looking.
▲ The safe room in Katsina featured cement bags piled up around the edge of the room, presumably in case the terrorists started shelling the place? Again it’s never happened.
▲ All the MSF Guest Houses looked somewhat armoured with metal gates which were only slid open after they’d checked who wanted to enter and decorated with signs warning you not to bring automatic weapons with you. In fact we were not riding around in armoured cars and we were often able to look around the towns – as long as we stuck to the ‘green areas’ and never went out alone. This was not like being with the UN, whose personnel are often never allowed out of their secure compounds.
In fact the problems across northern Nigeria varied from state to state, in Borno it might be Boko Haram and Islamist terrorism, but in other states it was simple ‘banditry,’ they’d discovered that pointing an AK47 at people was a pretty good way of making money. We drove from the MSF projects in Katsina 50km to Jibia, pretty much on the Niger border. All the way the traffic flow was constantly interrupted by road blocks, traffic stops, most of which just wave us through – they included the Nigerian Army, local police, border patrols, customs stops, vigilantes of various colours and no doubt others. Sometimes there’s a stop and a hundred metres later another stop from some other group. They’re often standing right in the middle of the road, with guns or at least big sticks. Often there are little traffic slaloms of big boulders and/or tyres. One of the army stops asks if we can give their vehicle a tow! All these guys standing around are clearly a source of employment, or at least activity if they’re volunteers, but wouldn’t it be good if some of them could be working on their farms? Keeping malnutrition at bay. They all stop work at 4pm I’m told, that’s when trouble could start and you don’t want to be stopping somebody who really needs stopping?
I had real trouble getting a feel for how rich or poor Nigeria is. The straightforward GDP (Gross Domestic Product) per capita figure ranks Nigeria at 21 amongst Africa’s 54 countries at US$5,459, a bit behind Kenya at 17 with US$6,178, but well ahead of Tanzania 30 US$2,932, Ethiopia 33 US$2,599 or Uganda 39 US$2,397. The gini coefficient, the standard measure of income inequality indicates that Nigeria is not that bad, certainly far better than South Africa where the inequality is severe. Nevertheless on the street Nigeria didn’t feel so good.
▲ There were always many water carriers around, this was in Jibia. In other countries in the region, Uganda most recently, collecting water seems to be purely a female occupation and the jugs or jerry cans are always carried. Here it’s more business than family, strictly male and usually with push carts designed to carry a dozen 20 or 25 litre yellow jerry cans. So that could be 300litres, 300kg of water. Which they sell at 50 to 100 NGN a jerry can, say 5c to 10c US. That’s very little money for a lot of hard work.
▲ On the other hand there are lots of private jets, this is the apron at Abuja Airport.
▲ RUTF – Ready to Use Therapeutic Food – commercially know as Plumpy’Nut
The big problem MSF is fighting in Nigeria is children with malnutrition. The ‘lean season’ rolls around every year, but the terrorism, banditry and unrest across the northern states mean the food supplies are never really secure. I’ll soon get used to seeing cartons of RUTF, Ready to Use Therapeutic Food, a French invention by Nutriset commercially known as Plumpy’Nut. It costs US$0.35 for a sachet, which is expensive for what is essentially peanuts with assorted magic ingredients. In Nigeria Nutriset is Nutrik and that’s owned by Alhaji Aliko Dangote, the richest man in west Africa. Somehow this seems symbolic of everything that bothers me about Nigeria, there are really two Nigerias, the one where MSF has to come in to save children from death by starvation and the one with the oil money, the private jets lined up at the airport and the ‘wealthiest black man in the world’ making money from supplying Plumpy’Nut to starving children.
I was particularly impressed with how the MSF medical centres handled incoming patients, at the Jibia centre for example:
• The children, most of them really babies, are measured and weighed. There’s an upper arm circumference measurement which is a marker for malnutrition.
• Their appetite is then checked, they should be hungry and sure enough a couples of rows of babies are tearing in to their RUTF sachets. Last week they got through 18,588 sachets. There’s a place where out-patient mothers are handed RUTF sachets, but they have to return an empty sachet for every fresh one. They don’t want them to become a commodity bought and sold.
• The children are tested for malaria, the figures skyrocket during the about to arrive wet season, the ‘malaria season.’
• They’re vaccinated for measles, all of them, 100%.
• They’re registered and lined up again for another appetite check, by this time a long time will have passed and they should have built up an appetite again. More RUTF sachets are passed around.
◄ Second go at a RUTF sachet
Malnutrition is always a problem, but it’s much worse if the child has some other problem – malaria, whooping cough, measles are all big problems. Of course measles is an easy one, just make sure everybody gets vaccinated, but in Nigeria poverty and remote communities makes that difficult and, amazingly, there’s some vaccine resistance – it’s a Western plot, our religion doesn’t approve. Late one evening at the MSF Guest House in Maiduguri the head nurse and the hospital director wearily trudged in, they’d had a sudden rush of 28 measles cases turn up, overwhelming them. The nurse said she expected some mortality and they both seemed exhausted. We discussed vaccines and vaccine reluctance because of course they would not be suffering this if everybody was vaccinated. It’s not just here I insisted, we have anti-vax idiots in the West.
Wherever I went it was noticeable that the parents with the children were 100% female. In fact I read an MSF story in the Daily Post Nigeria which ran ‘It’s truly worrisome to witness the prevailing absence of fathers here.’
▲ An almost-fully-loaded car about to depart Jahun
Malnutrition was a primary focus at every MSF post I visited – Maiduguri, Katsina, Jibia, Jahun – but in Jahun maternal care was also important, but even more important this hospital was a focus for fistula or VVF. Long before Planet Wheeler, the foundation Maureen and I started after we departed Lonely Planet, the Lonely Planet Foundation had encountered Catherine Hamlin’s pioneering fistula work in Ethiopia. She died in Addis Ababa in 2020 at 96 years of age. ‘Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence.’ Or vagina to rectum and then you’re shitting yourself.
OK this is a horrible problem – which first got real western world attention from Ethiopia – but why does it happen? Simple answers: poverty, lack of education, remote locations, stupid sexual practices, all of which go together. The stupid sexual practice is men wanting absurdly young wives so they can be certain they’re virgins. That means women who are really too young to be having children, very possibly their pelvises are simply not mature enough, they haven’t got ‘child-bearing hips’. So they go into labour and the child does not deliver, the labour goes on and on, usually the baby dies and the woman is basically torn apart, she suffers terrible vaginal, rectal, bladder injuries with a result that she is now an outcast, incontinent for urine and/or feces, dumped by her husband, disowned by her family and neighbours, her life wrecked.
▲ Antenatal Clinic at the Jahun General Hospital
Today this simply does not happen in the west – 13 year olds are not having children, women are getting good antenatal care and if, despite all that, things did go seriously wrong – ie the labour just went on and on and on – they’d be whipped into hospital and the baby delivered by cesarean. In Nigeria (and Ethiopia and other related locations) lots of women do end up with fistula and MSF can – very often – sort it out.
It’s not a quick process, generally they have to be looked after for a couple of months before surgery, they’re probably suffering from malnutrition for all the usual reasons now made even worse by their unwanted position in village society. They’re probably dehydrated because if you’re wetting yourself all the time you try to drink less. Plus they are often terribly depressed – who wouldn’t be – there’s a room labelled ‘Counselling’ and that’s part of the preparation process. Often these poor women don’t even realise that they are not unique, that they’re not the only woman who has failed to pop a child out.
Then there’s the operation – which is not guaranteed to be 100% successful, but generally is – and then a long rehabilitation process, healing, getting fit, learning some useful skills, getting lessons on childbirth (unbelievably some women have a second fistula disaster). So it can be three months or more from arrival to departure, heading back to their village where they’re accepted back into society and unbelievably some men who have divorced their useless wives now decide they’re not so bad after all and offer to take them back! I’m told, some men do support their injured spouses, but they’re a minority.
▲ Tony dances
So we tour the facility, pre-op, post-op and observe that the lessons are not just the practical ones which you’d expect: there’s also learning some useful skills, cooking lessons, exercises, but also a lot of emphasis on getting their lives back together, feeling they can be appreciated and loved again, putting rejection behind them. And being happy, as we walked through the centre there was music playing and a group of women were dancing around in a circle. Before you know it I’m in dancing with them, to wild applause not only from my fellow dancers but from the general circle. ‘You’ve made their day,’ one of the hospital staff insisted. ‘No,’ I say, ‘they’re all agreeing it’s true, white men can’t dance.’
▲ Divine Intervention – a shop near the airport in Lagos
▲ And there’s always ‘419’ – it’s a general Nigerian law against scams and in the western world we got used to 419s in the form of email offers to transfer large sums of money to you for no good reason. Somehow millions of dollars, often oil money, had mysteriously left the country, could you please help find a good home for it? Within the country the best known 419 scam is to fall for buying land or a house from someone who doesn’t actually own it. Any vacant or abandoned-looking house or plot of land could end up as a 419.
▲ Sign in the gated community on Banana Island in Lagos – at the end of my Nigeria visit I was driven around Banana Island in Lagos, a private, locked-away community for wealthy Nigerians. You needed a passcode to get in and then a password to stay there. The sign said it all, we want those domestic staff to come in and work for us, but get them out after 8pm. So what did you think of Nigeria I was asked on that last day? Well there isn’t a single Nigeria I replied, there’s the gated island-private jet Nigeria and the malnutrition-poverty Nigeria, one beside the other.
My Médecins Sans Frontières experiences started with the discovery that there was more than one of them. Then I was repeatedly reminded of what an international crew the MSF people were. But over and over again I was impressed by how committed they were, how strongly they believed that what they were doing was vitally important and how proud they were to be working with MSF.
