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.

Bad days

15th August
For the last 24 hours, my pleasant life in Niamey has been teetering on the brink of oblivion in a variety of ways, only one literal. First, I woke up with a cold on monday, probably caught from one of the bronchiolitic kids. This is not fun in any situation, and especially not so when there are very few toilets and certainly no toilet paper in the hospital. In a climate where the average temperature this week has been 23-26 degrees at night and 32-35 during the day, with humidity anywhere from 60-90%, it's absolutely absurd to be sneezing and sniffling.

In additiion, on sunday night my gas cylinder ran out as I was trying to boil a few day's worth of eggs, so on monday evening I lugged it down to the nearest roadside purveyor of rusty metal canisters full of butane - here, those Laurel & Hardy Glasgow terrorists might have been able to blow something up other than themselves - and swapped it for a full one. I then carted the full one (which was heavier) all the way back...and couldn't get the regulator which connects it to the oven to screw onto the cylinder. So monday's dinner was cold potatoes from the previous night and tomatoes.

Even worse, now that I had a cold I couldn't boil water for tea in the morning, so I decided to make up for this by having a mango for breakfast instead. It had black bits in and I had to throw two-thirds of it out. Then on the way to hospital on tuesday morning I got caught in a torrential downpour which laughed at my waterproof as it drenched me and the contents of my bag, including my British National Formulary, my French dictionary, and my Hausa notebook (which is admittedly in its infancy). Only the leather-bound notebook Al Walmsley gave me, which I'm writing in now, survived relatively unscathed.

The rain continued in more or less half-hearted fashion until the afternoon, and meant that there were no new patients on the wards (as most won't walk in if it's raining, and can't get in from the villages if the roads are flooded). I therefore devoted the afternoon to getting the gas working - so I carried the new cylinder back to the stall to swap it...but they'd run out of full cylinders, so instead I forked out for a whole new regulator. Back at the apartment, I enlisted the help of the guard from across the street to install it, and we got it working.

So I decided to celebrate by making tea, and found that I couldn't get the valve on the tank open - he'd closed it too tightly. Swallowing my pride, therefore, I went and found him again and explained that I was too puny to open it. Laughingly, he came to open it again, and gratifyingly completely failed to, even with the teatowel I'd already tried. So he took it off, inflicted untold brutality on it elsewhere, and came back with it openable. Now, however, there was an unsettling hissing noise from around the new regulator - so before I made tea (to celebrate), I did as he'd suggested and held a match near the regulator to check for leaks.

It caught fire.

Happily, after one attempt to blow it out which I can only describe as - well - a bit Laurel & Hardy - I remembered that turning the gas off at the valve would probably be a better idea. The unpleasant realisation that I'd just been in a room with a burning canister of explosive gas was bad enough - and the plastics stuff I saw on burns victims in Addis Ababa, for all that they were mostly due to kerosene stoves, meant I was fully aware of how nasty it could have been. However, the overriding emotion was despondency - I'd thrown basically two whole afternoons and about 10,000CFA at something as simple as being able to boil water, and had got closer to blowing myself up than making a cup of tea. Back home if I can't boil water in an electric kettle, I boil it in a pan on the hob; if I can't boil it there someone needs to pay the gas bill. It's a much simpler, and markedly less explosive, equation.

Anyway, I explained this to the bloke at the gas stall who, having been a bit intolerant of the useless whiteboy previously, softened somewhat, and told me to bring the whole thing back. "I myself have seen two of these new regulators do this - bring the whole thing tomorrow; there is a man here who is very good at setting these up, and we'll sort it out. But you mustn't use it in the meantime!" Encouraged by his newfound graciousness if not by the fact that he was selling the gas canister equivalent of driver's side ejector seats for cars, I came home and have just had part of a baguette with tomato, cucumber, and a meat pâté which smelt slightly like dogfood, and a cold beer, all of which have improved the situation enormously.

But if the fridge packs up, I will officially have Had Enough.

Niamey, offal, nicknames, and banditry

So I'm arrived on Monday morning, a little under two hours late, after an impromptu three-and-a-half hour wait for my flight out of Casablanca, which was two hours late. The only good thing about this was that I got talking to a Peace Corps volunteer called Tina who was heading back to Niamey after her holiday, so I had some insider info on the place when I got in, and thanks to her fluency in Hausa, I didn't get fleeced for the taxi into town.

It was 27 degrees when I landed at 5am and got progressively hotter from there, so I went to bed until just after noon under the AC, then headed down to the hospital to try to find my contact there. The third doctor I tried had heard of her and sent me off to a clinic up the road; I arrived just after she'd left, so then had to wait around for a Dr. Cheikh so I could get her phone number.

My slight unease at the absence of any central admin type office and my near-total reliance on one person was allayed by the fact everyone was so helpful - Dr. Cheikh was chatty, kept saying he was sure there would be no problems in a way which suggested pasty white people turned up in his clinic wanting to do electives roughly every second monday, and even lied about the quality of my French on several occasions.


So I left to wander around the city, which is quite pleasant. Although there's almost no grass, meaning that underfoot is either bitty tarmac or a reddish-orange dirt. The buildings are mainly concrete, although from the taxi ride in it looks like there are mud-brick and thatch areas on the outskirts. None of them are particularly attractive, however, and there's no Sheraton hotel here to dazzle among the shanty-towns and to allow Brangelina to stay in it while picking some poor orphan who will, over time, realise that they've traded the squalor of poverty for the degradations of a brief movie/musical/famous-for-being-famous career followed by a succession of stints in rehab and the front pages of most newspapers, culminating in a death from overdose or in a carcrash which may even be younger than they'd have got had they stayed put. There are some quite bizarrely attractive government buildings like the Ministry for Energy, which I will attempt to photograph later. Generally, though, it's a city plonked down in a bit of desert which happens to have a river nearby - so it's dry, dusty, and seriously, seriously hot. I got tanned yesterday wearing factor 40 - it's that hot.

Last night involved calling Dr. Marianne, and then heading out for dinner and drinks with a bunch of the Peace Corps lot (Tina, Noah, Emily, Whitney, and someone else). I say "someone else" because one of the first bits of info I got was that they are only all in Niamey every couple of months - normally they're out in villages (<1000 people, no electricity or running water, etc) where they work with the local people doing health education and so on. Part of the deal is that their host families give them names in the local language, i.e. which they can pronounce (apparently "Whitney" is impossible). The guy whose name I can't remember was given the nickname "Rashid", and although he is never called that by the other yanks, it removed any possibility I would remember his actual name. We went to a bar out west of the hospital (marked on the map above above the last R of 'river') and drank 60p giant bottles of beer; as ever, I fell asleep for about 20 mins in the middle of the evening, but woke up in time to head outside and find some street food. The others ordered rice and potatoes which the woman fished from the cauldron of meat sauce; thinking this a really poor option, I went for rice-and-meat. The sauce was great, but the meat was basically tubes - I couldn't decide if they were aorta or windpipe, but probably the former - so I think I'm going to stick to the potatoes next time...

This morning I checked out of the expensive hotel I'd been in the first night (28 quid a night!) and into the Catholic mission (7 quid a night) which is central, clean, and looks good. I also met Dr. Marianne in person, although this also involved running around with her while she helps Dr. Borreima organise a UNICEF conference on maternal and paediatric health. This will I'm sure be pretty interesting (and I may get to go), but meetings about it are not so interesting, and I battled manfully to stay awake. However, everything looks set for the elective, and I've decided to split it between paediatrics and internal medicine...so we shall see how that pans out.

The only other thing I must add is that if any of you are thinking of going on holiday, don't take traveller's cheques. Amex charge a flat fee of ten quid however much you exchange, and the bank takes another 2%; so if you try to change 100 euros, you end up paying 20% in fees. When you then try to change 400 euros, you get told you can only change a maximum of 200 a week. The fees on this mean that the bank gets 2%, Amex get just over 9%, and you get shafted. Had I taken it all in cash and been robbed, I'd have paid less for the excess on my insurance than I would in fees to Amex on the traveller's cheques I've brought...

I'm off to find something for dinner that isn't mostly offal. Bye for now.