The final furlong

Monday 10th September
Well, I have 7 days left, or slightly under, as by this time next week I will probably be touching down in Bamako on the first of the four stops before London. They are the aforementioned Bamako for "technical reasons", as my e-ticket prophetically informs me (I'm still torn between being reassured that problems have been predicted and unsettled by their predictability). The second is Dakar some two hours later, where I'm meeting Toyin and Liz; the third, on the 29th September, is Casablanca, where if the outbound flight is any indication I will spend several more than the two hours I'm scheduled to spend there and will meet someone who will be central to my social life for the next two months, and finally London itself.

To answer the question you would ask if you were here: yes, I am ready to leave. Caitlin (Nigérien name: Yakalu), who's a Canadian Boston University student doing premed there who's in Niamey for four months of language and cultural studies, and who I showed round the hospital this morning, asked at lunch whether I'd stay if I could, which I thought was much harder-to-answer and therefore better way of putting the question. I said 'no' with a speed that surprised me. I could do another couple of weeks in paeds - but even there, where they make an effort, my education would suffer from the overall lack of teaching, and I miss UK *standards*. They have standards here, of course, and I am about to go right ahead and judge them, as ultimately I'm out here and while I may only be a medical student and only essentially a tourist and blah, I believe that not only does that mean I am entitled to judge them, but that it also means that in some ways I must. The "you shouldn't travel to the developing world and *judge* them" is crap - if you come out to the third world and have standards of your own, you have to judge what you find here by those standards. If you can look at the 1 in 4 children who die before age 5 here and call that unacceptable, so too can you look at, for instance, the standards of care in hospitals and call them unacceptable. Of course, in terms of writing elective portfolios, doing one gets you marks and doing the other attracts accusations of arrogant colonialist medical students from a failed sociology student who has never heard of post-colonialism and who would cast my use of 'the third world' in the same light despite the fact that Niger, at least, is not developing in any meaningful way, so 'developing' is at best a lie and at worst an attempt to gloss over this fact. Anyway, I will say that the standards of care here in paediatrics are, given the resources available to them, excellent, and that's largely due to Dr. Roubanatou taking no shit and running a phenomenally tight ship. Having spent many a morning in internal medicine sitting around doing nothing while the head of service there sees his private patients until 11am, that lack of organisation is not acceptable. I never thought I'd say this - but I'm actually looking forward to handover meetings when I get back...

Interestingly, in Pédiatrie A, where the highest standards of care are, all treatment is free because the service covers children up to age 2, and until age 5 all medical treatment is free. By contrast in internal medicine, all the patients are paying and are often regulars at the private clinics of the same doctors treating them in hospital - but standards are catastrophically low. Electrolyte levels go unheeded for whole weekends, cardiac arrests are viewed by many as an inconvenience, and too much is treated as "not cardiological" despite this nominally being a general medical service. It's then not properly investigated, worse yet no attempt is made to diagnose it, and they're just referred on to pay a different kind of doctor. Here, a paying service is not only not a better service, it's exponentially worse.

The NHS must not be privatised, ladies and gentlemen. Those say it would mean better care are liars and idiots, and probably have shares in BUPA.

This morning was interesting. Caitlin had expressed an interest in seeing stuff in the hospital when some of the Peace Corps guys and I ran into her and a bunch of other Boston Uni students in a bar, so she came along to ward rounds; we broke from the round part-way through because I thought it'd be good to get her to examine a 10-year-old girl who'd had heart surgery. So she did, and that was great - as you'd perhaps expect, the kid had more signs than you would find in 20 patients back home (central sternotomy scar, 6cm raised jugular venous pressure, heave, ascites, 8cm hepatomegaly, Graham-Steele murmur which I did have to look up) and is a smiley girl. As we went through the exam, mum not unreasonably took the opportunity to ask questions, which was fine, except that they were the sort of questions someone should already have answered. I told her I'd check her daughter's folder more to verify the diagnosis than in any expectation that there'd be any notes in there, and would come back afterwards. She'd had a valve replacement 2 years previously for a congenital mitral stenosis which had gone unnoticed until she'd developed pulmonary hypertension and right heart failure. The op in France was useful in that it had halted the progression of the disease, but none of the existing damage was going to get better.

Entirely reasonably, mother and daughter both wanted to know if she'll be able to go back to school, or if she'll be able to walk 20 metres without getting breathless, or if she's going to *get better*. This is difficult to handle sensitively in a second language without resorting to the short answer to each question, which is "non". I told her that the drugs, we hoped, would improve things, but that the problems with the heart were not going to get better; that the damage there had been done; that there was nothing really that could be done even in France. I didn't dangle the imaginary carrot of a heart-lung transplantation, because it's in practical terms impossible.

Then there was the man who'd been moved to the high dependency unit (four beds within touching distance of one another) when his sodium hit quatre-vingts-treize (93), the woman who died as we did CPR on her waiting for a defibrillator which never came ("there isn't one" "yes there is, it's in A&E" "we can't use that one - it's theirs" etc) and one of the doctors said "it's hardly worth it" as the woman gasped occasionally, and then asked if she could continue the ward round. There was the Bell's palsy which fell between the "cardiology" and the "everything else" chairs, and was sent for a totally pointless CT scan despite the doctor agreeing it was a lower motor neuron lesion, and so on. There have been bright spots: one was the woman who claimed to have met the queen ("she speaks perfect French, Queen Elizabeth"), and Diana, and who shortly after I'd decided she was barking and allowed just a note of sarcasm to creep into my "oh, really?"s turned out to be telling the truth as she was the Belgian ambassador's wife. There there was Ali's wife, who was the first of several friends-of-friends who I was asked to see, and who sweetly but very rapidly irritatingly called me at least twice a day once she got home after I'd seen her to say "I'm in the best of health now". Hadjara, a friend of Alex and Bri's who came in hardly conscious with a raging fever and quite Seriously Unwell, and who I had a short and unsuccessful battle to get checked out for any cause of post-partum abdominal pain bar endometritis, which she in fact had. She got better over a week or so, and I stopped in five or six times to see her and the three or four family members who'd come with her and were sleeping, as she was, on mats, although where she was in a covered corridor, they were under a tree in the yard. All the kids at Hope House were another, that being an orthopaedic rehabilitation centre whose rather cloying name belies the fantastic work they do. I met Jen, the American who runs the care side of things, and her husband Will through Alex and Bri (again) and went out to see what goes on there a couple of times. They have a network of people around the country who identify kids who might benefit from orthopaedic surgery; they then get an assessment and if suitable are offered part-funded surgery. The family have to stump up I think 30,000 CFA (30 quid), with the remaining 90,000CFA+ coming from PRAHN's budget (PRAHN is the organisation which runs Hope House). After the op they then get physio, accommodation, any orthoses they need and general rehab until they're ready to go home and continue exercises independently. THe kids had the usual glee at seeing themselves on a digital camera, and were mostly working hard to get themselves able to walk again or whatever it was. They see a lot of cases of club foot, equinus deformities, windswept and knock-knees, consequences of polio, even one boy whose problems were probably due to sickle cell disease but who was pretty close to a contortionist, so bizarre were his legs, which sloped slowly outwards from lumpy, barely identifiable knees.

Deciding to drink to drink the tap water and to eat food cooked all morning in fire-charred and sun-baked cauldrons which stand in lines at the edges of the huts and which worm-bellied children with thorny sticks beat the goats away from has also been a positive. For 200CFA - 20p - you can get a plate of rice-and-potatoes with a meat and vegetable sauce which is often enough to see you through the day - although I've mixed in some 150CFA brochettes. These are hot, juicy, salty skewers of meat with deceptively spicy 'pimen' which are excellent for keeping your protein levels up without eating the tube-meat. I have eaten other good food here - wonderful thin-crust, crispy pizzas at Caterina's house, vegetarian peanut sauce at Jen and Will's - but stupid though it may sound, I quite like eating on the street. I know I'm still basically a tourist, and so do they - but the first time you order it amuses the women selling it, and the subsequent times they seem genuinely pleased you liked it enough to come back, tourist or no.

Another reason I've enjoyed doing it is that it reveals what nonsense the scare stories are. Yes, you can get terrible bacterial / amoebic / parasitic / etc. illnesses here - but basically only by drinking water straight from the river. An expat who worked at the water purification service reckoned the tests showed it was safer than in the UK, and even when the goats manage to dip their heads into the cauldrons for a second or two, it always has another hour or so's boiling ahead of it. Similarly, before I came out I rather foolishly heeded the tales of how people here will steal anything because they have nothing which I heard and which were repeated in the crappy, ill-informed Bradt guide to Niger. Not once here have I worried about people stealing things. I have been careful who I've told where I'm living when, on a couple of occasions, I haven't wanted impromptu home visits (as when the Man Whose Moto Wasn't Broken basically tailed me back from the hospital asking about my salary), but equally I've left Nigériens alone in the main room of the flat with umpteen small, pocketable objects in view without worrying about it. It seems so absurd that, in a country where everyone, even the man who runs the computer room in the hospital, tells you that you must come and eat when they are eating and you enter the room, and where people you've just met bend over backwards to help you, and where even knowing how to say hello, goodbye and thank you in Djerma or Hausa provokes grins and approving noises - that we Westerners, the poorest of whom is rich beyond most of their imagining, paint them as thieves. Even though I'm six-two and pretty careful, people have tried to steal my phone before in London; my home was broken into twice in four years, and people famously refrain from eye contact on the tube. No stranger has ever offered me food, and our food problems are not those of protein and calorie deficiencies, with famines which cull great swathes of the population every few years and leave the rest emaciated, aching-bellied, but probably still sharing what they have.

I think I will ignore the stories from now on.

The people, then, are the final thing I will miss. TO give perhaps the best example, one of the guys who plays rugby offered to pick me up and take me to training on his motorcycle, so we swapped numbers and sure enough, Djibo did. Even given the lack of helmets, moto is really the only sensible way to get around Niamey - you can manoeuvre more easily around the rain-dug pits in the roads, you stay cool, and you don't get caught in traffic. He then offered to show me the grande mosquée and the grand marché, and called me up to arrange a time, taking his whole saturday to do it and having me round to his one-room home for lunch. Then the following day we rode out to Kouré, an hour or so from Niamey, and home to the last giraffes in West Africa, which it is otherwise impossible to see without a 4x4 hired for tens of thousands of CFA. I had to fight to get him to let me pay for petrol. There are annoying people here, like anywhere - but overwhelmingly - and from what little I've seen it's the case across Africa - the people, who have nothing, don't therefore want to steal from those who do. Instead, they want to talk to you, to find out what you're doing in their country, to show you the country they live in, to share their food and their culture with you, and they do so by and large while asking nothing in return. So while I perhaps won't miss the medicine, I will miss the people and their generosity both.

Barring something spectacular happening (or my flight being cancelled) I plan to spend my time in Senegal setting Africa to rights with Toyin and Liz, largely on the beach and hopefully with a cocktail of some sort, so I don't anticipate writing any more from there. I will finish one rather dry post of facts and figures which will appear before this chronologically, and may add one with links to photo albums, but this is the last of the genuine missives from Niger.

Normal service will shortly be resumed.