Saturday, September 8, 2007

A Small Safari

Three weeks ago Deputy (Senator) Grema returned to Maine-Soroa from Niamey. The National Assembly is taking its summer break and he has come back home for vacation and to spend some time with his constituency. He has been an important supporter of our work at the hospital and has been very helpful in smoothing out bureaucratic obstacles when they have occurred from time to time. A few days after he arrived here he dropped by the house to ask if Orietta and I would be interested in joining him on a small safari up north to the edge of the Sahara. We were of course delighted by the invitation.

We started out two weeks ago. We had three vehicles. The first vehicle, which went ahead by an alternate route, was a Toyota safari truck loaded with our supplies. The second vehicle was an aging Toyota Land Cruiser with our military escort, and we were in the third vehicle – the newer Kirker Foundation Land Cruiser with Deputy Grema, our driver, and a guard.

Our route was initially to the west on the paved road as far as Goudamarie. There, after a brief visit with the village chief, we headed directly north entirely off-road. At this point we were still in the Sahel, sandy savannah with a thin growth of trees and a fair growth of grass courtesy of the recent rains. We followed a marginally visible track up to the village of Boutti. We arrived there about noon for a scheduled rest. We were brought to a thatched shelter which provided shade. Mats and blankets had been spread over the sand for a place to sit or nap. During the heat of the day we rested and were served fresh water, roasted mutton with couscous and fresh yogurt. Everything was served “family style” with large communal bowls of food which is to be eaten with the right hand. The couscous and yogurt were mixed together and quite hot. It takes a little practice to learn to “roll” the couscous and yogurt into a small ball which can then be lifted to the mouth.

During the early afternoon Orietta and I explored the local market. In one of the market stalls we were surprised to see the daughter of one of our previous hospital patients – a woman with tuberculosis of the spine. She spoke some French and invited us to her house to see her mother. We were pleased to find her mother making good progress. She appeared elated to see us and the visit seemed to lift everyone’s spirits, our own as well. I am always amazed by the therapeutic and psychological value of a house call. Everyone benefits.

From Boutti we continued directly north until we reached the first of the large Saharan dunes.

At that point we turned back to the east and paralleled the line of dunes. There are a number of small villages along this route and we stopped a few minutes in each one. While Deputy Grema did a little politicking Orietta and I would go to visit the local dispensary and talk to the nurse running it. All of these dispensaries are supported by our hospital, so it was a nice opportunity for us to introduce ourselves and meet some of the other healthcare workers. I will have to say that in my mind these nurses are real heroes.

Most live with their families in these remote areas. The salary is about $40 US per month, when they get paid. Several had not been paid in a couple of months, yet there they were, on the job with clean and well organized dispensaries and clearly devoted to their work.

Our last stop for the day was a small unnamed village at the edge of the dune line. The village elder and about 15 men greeted our arrival. He told Orietta and me that we were the first Americans to ever visit. After handshakes and greeting we headed north into the desert about 5 or 6 miles. We found the tracks of our supply truck and followed them to the top of a large dune where camp had been set up. We had time to find our tents, get mosquito nets set up and wash up a bit before sunset. The dunes were incredible. The sand was absolutely pure white and completely clean – devoid of any organic matter, or anything for that matter. Walking around barefoot felt wonderful after a hard day in the Land Cruiser.

As night fell we heard people approaching. It was the men from the last village we had visited. They arrived by horse and camel bring freshly cooked mutton and fresh raw milk and yogurt.

A fire was started and they sat with us in a circle talking well into the night. It could have been a thousand years ago.

After their departure, and with the fire going out we were treated to our first night in the desert. The stillness was palpable and I have never seen the stars like this. The moon set early yet you could see by starlight – the Milky Way, constellations, nebulas, the Southern Cross, everything. Our sleep that desert night was the most restful I’ve had in years.

The next morning we were up at dawn. Breakfast was yogurt and bread. The fresh raw milk from the night before had soured. This is actually considered a delicacy here and was consumed by all except Orietta and me. We both tried it, but just couldn’t get it down in quantity.

After breakfast Orietta went back to the village and held a small clinic using some medications which we had brought with us. I was invited by our military escort to do a little exploring. We went back south to the edge of the savannah. We saw lots of animals – outard, a large crane-like bird, hawks, falcons, eagles, desert fox and antelope.

Following the morning activities, we broke camp and headed back into the savannah. We traveled through beautiful pastureland and saw enormous herds of long-horned cattle, sheep and goats tended by Fulani herdsmen all of whom use flutes to calm and call their animals. As well we saw several groups of Arabs with large camel herds moving south toward markets in Nigeria. Deputy Grema showed us the rather large system of wells put in by the Danish government to provide good water for the herdsmen and the small villages. By late afternoon we were back in Maine-Soroa.

It was a remarkable two days. We covered almost all of the Department of Maine-Soroa. We saw land and met people unimaginably remote from our Western world and culture, yet we felt welcome and secure and experienced a night of remarkable serenity.

Steve Humphrey
Maine-Soroa, Niger
8 September 2007

Monday, July 30, 2007

Pitfalls and Peculiarities

Traditional medicine is alive and well in this part of Niger. Here are three anecdotes about some of our early encounters with traditional healers and hexers.

Anti-scorpion medication
Some days ago a small, excited crowd gathered outside the gate to the guest house where we’re all staying. We went out to investigate. Usually the sick or injured are taken to the hospital and not brought here but we were asked to look at a young man in the center of the small crowd. As we approached we could see that there was something on his face. A closer look showed a large scorpion. One pincer covered the man’s left eye and the other rested on his right cheek. The stinger - tipped tail waved menacingly. I’ve never seen this problem described in any medical text and we were at a loss as to how we were going to proceed. I’m sure our quandary was apparent to the crowd as well. Suddenly laughter broke out. Our victim opened a small bag a pulled out another scorpion which he effortlessly, and without being stung, passed from hand to hand. It turns out that he is well known in these parts as a “scorpion handler”. His business is selling scorpion protection. For 200 Francs he’ll sell you a small amount of a specially formulated (by him) powder which will protect you from scorpion stings, and I guess let you walk around with a scorpion on your face as well.

Something missing
One of the local gendarmes brought a highly agitated and frightened young man of about 20 to the clinic shortly after we arrived here. The officer’s French, like mine, wasn’t particularly good and the young man spoke only Hausa so we struggled for a while, but finally the story was pieced together. The evening before the young man had encountered an old and apparently rather frightening man on one the dark streets here. Without warning the old man grasped the young man’s hands, uttered something and then disappeared into the gloom. The young fellow was uninjured but frightened. Later, to his horror, he learned that he had been “attacked” by an old man widely reputed to have the power to remove a young man’s testicles with a single touch of the hand. For a price however the testicles would be returned in the same way. My young patient had spent a sleepless night agonizing over his dismal future as a eunuch since he couldn’t afford the price of the ransom. The morning of his visit to the clinic he had “experimented” a bit and found that in fact “things” just wouldn’t work. He became so agitated that his friends summoned the police who brought him for a visit.

Well, I thought, this should be easy. A brief exam disclosed completely normal anatomy – everything was there and nothing had been taken. I put on the mantle of authority, the visiting consultant if you will, and explained to him that I had some experience with these things and that I could assure him that everything was alright. The old man, I continued, was just trying to trick him and steal his money. He shouldn’t give it another thought.

The next morning he was back. “Things” still weren’t working and he appeared morose. Authoritative reassurances were clearly not going to work. Bigger magic was needed. I told him to return in the afternoon and I would have something which would restore the testicles. I walked over to the pharmacy across the street and bought a 50 mg. sildenafil (Viagra) tablet and put it in a small box. When he returned I gave it to him and told him this would make everything right. He never came back for another clinic visit but I saw the gendarme a few days later. He told me that after taking the medication the young fellow had had a rather remarkable experience and now considered himself cured.

A Near Tragedy

This past weekend a 7 day old child was brought to the hospital. His parents reported that he had suddenly begun to vomit blood. He was terribly weak and anemic and required a blood transfusion. Fortunately no further bleeding occurred and he became stable. We began trying to figure out what had caused the bleeding. We have very little if any diagnostic equipment or laboratory here and we doubted that we could make a diagnosis. Fortunately one of our nursing students who speaks the local dialect well came up with the answer. There is a tradition among some of the Fulani tribes of clipping the uvula – the “flipflop” that hangs down from the soft palate in the back of the mouth. It is thought to promote growth and to prevent vomiting. We got a good look into the back of the throat, and sure enough, the uvula had been clipped. The child’s mother and older sister had had the same treatment as well. Fortunately all turned out well, but a tragedy was narrowly averted.

Steve Humphrey
Maine-Soroa, Niger
July 30, 2007

Sunday, July 8, 2007

A Death

Aissa, the younger sister of my good friend Mahamadou died yesterday. We first became acquainted with her a few weeks ago, shortly after we arrived here. Her problem was growing weakness, lack of appetite, weight loss, some fever and diarrhea from time to time and recently a persistent dry cough. One of us saw her in the clinic. She was thin, weak and had very abnormal breathing sounds. A screening test for the presence of HIV (the Human Immuno-deficiency Virus) was positive.

To its credit, Niger has a national program for the treatment of AIDS (Acquired Immuno-Deficiency Syndrome) which is caused by HIV. The program is vertically integrated which means it includes periodic clinic visits, appropriate lab tests and also free medication not only to treat the virus itself but also to treat some of the common infectious complications of AIDS such as tuberculosis, chronic pneumonias, and fungal and yeast infections. To enter the program a patient must travel to one of four centers in the country. The closest to us is in Zinder – about a six hour drive to the west.

As soon as the screening test results were available, Aissa was seen by the social worker here and referred to Zinder to enter the program. She and Mahamadou traveled there about three weeks ago. A more accurate test for HIV was performed and confirmed the results of the screening test. She then had some other blood tests and a chest x-ray. One of the most important blood tests, the CD4 count was not performed because the laboratory had insufficient money to purchase the reagents needed for the test. The CD4 test is basically a blood count which gives the number of a certain type of white blood cell. These cells are critical to the function of the immune system and are attacked by the HIV. As the infection worsens, the number of CD4 cells drops. When the count reaches a certain level, the immune system stops working well and all the chronic infections associated with AIDS begin. When the CD4 count reaches this threshold level, antiviral drugs are started in hopes of reducing the amount of HIV in the blood and improving the function of the immune system.

It’s at this point that Aissa’s problems worsen. AIDS treatment and many other health programs in countries such as Niger depend on foreign aid for funding. Assistance may be in the form of government grants or a myriad of other programs operated by non-governmental organizations (NGO’s). These programs usually operate under rather stringent protocols and protocol violations can result in the withdrawal of funds. For example, antiviral drugs for HIV cannot be given unless the CD4 count is at such and such level. Giving antiviral drugs to everyone who just has a positive HIV test is very expensive, and for people who still have a good CD4 count, it really doesn’t help. It may even help resistant forms of the virus emerge, so there’s a good reason for the rule. As a result, since no CD4 count could be done, no antiviral drugs were given to Aissa. Instead, she was instructed to return at a later date for the test and possibly medications. She never made the return trip to Zinder. Her condition worsened abruptly and she died suddenly, probably of an overwhelming pneumonia. In retrospect of course her CD4 count must have been very low. Would the antiviral drugs have made a difference? No one can say.

Her death points out many of the difficulties in administering health care in developing countries. Physicians and administrators have to juggle many different protocols and programs and even though a program is in place on paper, patients may still not benefit.

Many ironies exist in these schizophrenic systems. For example, last year a US based NGO came to this area with a very successful program aimed at eradicating trachoma, an infectious conjunctivitis which is highly contagious but which is also very readily treated by a single dose of an antibiotic called azithromycin. Over a period of thirty days, this well organized program gave the entire population of the region a dose of azithromycin and has essentially eradicated trachoma from the area. Azithromycin is also very effective for the treatment of a number of other infectious diseases including ear infections, venereal diseases, pneumonias and so on. There have been numerous occasions in which the antibiotic could have been used here; however, neither the hospital pharmacy nor any of the private pharmacies here have any. Here’s the irony. The warehouse of our hospital pharmacy contains several thousand doses of azithromycin, due to expire at the end of this calendar year; however it cannot be used because it belongs to the NGO. No one here knows if the NGO is planning to return or to use the medication for further trachoma eradication. The hospital administrator however is very clear that the medication cannot be used by the hospital. For physicians taking care of patients this is very frustrating. NGO’s take a macro view and physicians a micro or individual view. Of course the large programs do much good for many people. It’s just that I’d like a few doses of azithromycin.

Today I went to see Mahamadou. It was the day for visitation. In keeping with Muslim tradition Aissa was buried yesterday – before sunset on the day of her death. Outside the mud-brick wall of his house cloth awnings had been erected and rugs and mats placed on the sand. All the men sat together under the awnings. Inside the wall of the compound the women sat together in the same fashion. Small charcoal fires heated tea. Little was said. It was very peaceful and comforting just to sit together, quietly. Open displays of emotion are not the custom here. If there were recriminations, or anger, or frustration with “a system” I could not detect them. The air was one of acceptance.

Two houses away a wedding was underway with laughter and the sound of the griot’s horn. I made some mention of it.

“We are happy that life continues,” was Mahamadou's reply.

Steve Humphrey
Maine-Soroa, Niger
8 July 2007

Tuesday, June 19, 2007

Seeing Patients

We have now been seeing patients for a little more than three weeks. We usually start our hospital rounds at about 8 AM. Bill visits the surgical and obstetrical patients and Orietta and I check the pediatric and internal medicine patients. At 10 AM we start with the outpatients. We divide the outpatients along the same lines, with Bill doing surgery and obstetrics and Orietta and I handling pediatric, internal medicine and gynecology patients.
There is a wide gulf between hospital care in the western world and Niger. A major factor of course is the lack of money available for health care here. Hospital beds have mattresses covered with a rubberized plastic – often worn through to the foam inside. There are no bed sheets. Patients who are better off will bring a mat with a blanket or other cover from home. Others may have only a straw mat and some have nothing. Most patients prefer to be outside. After our hospital rounds are finished, most of the patients take their mats outside and spend the day on the sand in the shade of the few trees on the hospital grounds. Family members bring food and small charcoal burners and prepare tea or warm food for the patients. The hospital provides two meals a day, prepared over an open fire in the kitchen, . Many patients spend the night outdoors as well. In the dry season it is not a major problem, but when the rains come the risk of catching malaria at the hospital will become much higher.
A handful of drugs for things such as tuberculosis, HIV disease and leprosy are available free of charge to the patients through government programs. Recently we received a container load of medications from Atlanta – based MAP International (Medical Assistance Programs) and these medications are provided free of charge to the patients, but otherwise everything must be purchased by the patient before it can be used. For example, if one of us orders an intravenous antibiotic, the patient’s family must go to the pharmacy and purchase the antibiotic, the fluid used to dilute the drug, the administration set and even the needle, gauze and tape needed to set up the infusion. If there is no money, there is no antibiotic. If someone has to go home to get the money, then treatment is delayed. X-rays are a special problem. The x-ray here doesn’t work, so patients needing x-rays must be transported 35 miles to neighboring Diffa. There is an ambulance available but gas money must be paid in advance by the patient in addition to the charge for the x-ray. It’s the same story here – no money, no study. You might say, “Well, in the States patients have to pay for everything as well.” That’s true, but in the States accounts are settled after the fact. Treatment comes first and we figure out how to pay for it later using a mélange of private insurance, Medicare and Medicaid, cash and funds from other governmental or charitable organizations, or the hospital just absorbs the loss. Here the realities are much harsher.
Nursing care is provided almost entirely by the family. The hospital has a handful of nurses, but no nurses’ aides or other technical help. The nurses transcribe the doctors’ orders for medications or other treatments then communicate this to family members. Family members do all nursing care such as bathing, turning and feeding the patient. The nurses administer intravenous or intramuscular injections, draw blood for laboratory studies, help with bandage changes and check vital signs daily. All oral medications are administered by the patient’s family. The risk of medication administration errors is very high. We speak with the nurses in French and they then communicate the instructions to the patients in their native languages such as Hausa or Fulani. Not only do most of the patients not speak French, but most do not read or write so patients have to remember pills by shape or color. Then they must remember the schedule of administration as well. The nurses maintain that they don’t have enough time to give out the medications. They also point out that it is better for the patients to learn how to take their medications while we are supervising them. They may be right – we will have to give this some thought.
Teaching hygiene is a continuous problem. Many of the patients are from the bush and have had little or no exposure to showers, sinks, toilettes, etc. Showers and toilettes are located in an outbuilding. This is fine for ambulatory patients, but it poses a major problem for sicker patients or small children whose families have to figure out how to cope with bedpans. One enterprising family hit on the idea of putting sand in the bedpan – at least spills were easier to avoid. Again a major problem is personnel – there’s just not the money to have the personnel to help teach the patients.
None of these problems will be solved quickly or easily. It is hard to know where to begin. The four of us along with a local citizen have chipped in the salaries for four custodians so at least we can begin the process of cleaning and hopefully reduce the risk of hospital acquired infection. The shipment of medications from MAP International has been a major help to many patients but the supplies are being used rapidly. We hope that MAP will continue to send us medications but they have many requests from other deserving sites well. Funding, manpower, medications and hospital equipment will be ongoing issues requiring patience, persistence and innovation.
All of us here enjoy hearing from you. Please send a comment from time-to-time.

Steve Humphrey
Maine-Soroa, Niger
17 June 2007

Friday, June 8, 2007

First Visit to the Hospital

Today was our first look at the hospital we are to help resuscitate. There are four of us…three doctors and a nurse nutritionist.

Dr. Bill Kirker, a Michigan native, and his wife Barbara, the team’s nurse and nutritionist are heading up our team. I first met Bill and Barbara two decades ago in Columbia, SC. After leaving Niger and the Peace Corps in 1975, Bill built a large practice in urgent care. I was an internist and cardiologist in Columbia, so our paths crossed frequently. From time to time we talked about his work in Niger. When Bill talked about it I could sense that he had never wanted to leave Niger and that circumstances surrounding the coup d’etat in 1975 had taken him and Barbara away from their work before they considered it finished. Those conversations always reminded me that when I decided to go into medicine my thought had been that I would work in the third world.

Dr. Orietta Barquero is a native of Costa Rica and a tropical medicine specialist. We became acquainted with her through medical missions in Nicaragua two years ago. She teaches at the medical school of the University of Costa Rica. Since specializing in tropical medicine at the University of Barcelona some years ago, she had always wanted to work in Africa. The more we talked, the more all of us realized we shared a sense of unfinished business and the decision to come to Niger was made.

In the mid 1980’s, about 10 years after the Kirker’s departure, the Ministry of Health of Niger decided to reopen a hospital in Maine-Soroa. With the assistance of the French government a fifty bed hospital was built adjacent to the site of the old hospital. The hospital was equipped with two operating rooms, a delivery room, systems for equipment sterilization, a laboratory, x-ray, and separate buildings connected by covered walkways for maternity, surgery, and medical and pediatric patients. Unfortunately there were inadequate funds to fully staff the hospital with physicians and nurses and to provide for regular maintenance and upkeep. It became what is known as a “resource dump”, that is lots of money and labor poured into something which never functioned. Now it houses only a few patients and sees a handful of outpatients daily. Two physicians have been trying to keep things going here under very difficult conditions. One is a young general practitioner recently out of training at the medical school in Niamey and the other is a surgeon temporarily posted here by the U.N.

None of us were quite prepared for what we found on our first visit. The hospital with its multiple buildings is situated within a walled compound about four acres in size. The grounds are sand with the driveways marked by stones. There are a few scattered trees which provide some shade and part of one drive is bordered by mangos. Goats and guinea hens belonging to the guard who lives on the premises roam the grounds freely. Patients’family members are scattered around the grounds seated on mats in the shade, many preparing food or tea over small charcoal fires. Paper and plastic litter the grounds as do pieces of discarded hospital furniture and the carcasses of two trucks leftover from a previous aid program from Japan. A shed houses four vehicles – two old Land Rovers and two battered Toyota pickup trucks, all without tires and partially “parted out”.

The building which houses radiology and the lab is our first stop. It was designed to be air-conditioned but only one unit has any refrigerant in it, so the entire building is roasting. We get a look at the x-ray machine. It’s a nice French built unit like you might find in an urgent care or small emergency room in the US. It would be fine for taking x-rays of chests, abdomens, heads and broken bones. Incredibly we learn that it has never taken a single x-ray. At the time the hospital was built there was no physician staff, so a hospital in nearby Diffa appropriated all the film and the darkroom system used to develop the films. Later when physicians arrived here, there were no funds to re-purchase the darkroom system, so no x-rays were taken. Now after a decade and a half in the heat, the unit will not even turn on. We look into an adjacent room. There is a portable x-ray machine which could be used to take x-rays at the patient’s bedside – same story.

Down the hall there is a machine covered with a blanket. I pull the cover off and to my amazement I find myself looking at an echocardiogram – a device which allows a cardiologist to make an ultrasound picture of the heart. When I decided to come here I thought I would be doing primarily internal medicine and that all the cardiology would be done with a stethoscope alone. Now the possibility of doing something a little more sophisticated tantalizes me. It’s not a bad machine either – maybe 10 or 12 years old. I worked with machines like this in the States some years ago and they do just fine. I inquire if it works. No one seems to know so I plug it in and turn it on. Smoke immediately curls up from the underside of the machine - back to the stethoscope.

The laboratory is small. It can do simple blood counts, an analysis of the urine and microscopic examinations for parasites and malaria. Blood chemistries such as you might use to check kidney and liver function are out of the question although blood glucose can be checked. When the budget allows, quick-tests for HIV (the AIDS virus) can be performed. There is a small blood bank and when reagents are available the blood can be screened for HIV and hepatitis viruses. If reagents are not available, unscreened blood is sometimes used in emergencies.
There is a small emergency room. It contains two rusted stretchers which are coated in dust. Used bandages are on the floor and small surgical instruments, uncleaned after the last case, lie in the dust on a counter top. A basket containing used surgical gloves and old syringes and needles is near the open door through which family members and children wander.

Only one of the two operating rooms is functional. The electrical system in one doesn’t work and hasn’t for several years. The other room does work but is in need of a thorough cleaning. The sterilization equipment works and a couple of sets of old surgical instruments are available. There is an anesthetist on the staff, and basic anesthesia equipment is available. A few cases such as emergency appendectomies, caesarian sections, and some minor procedures are performed each week. Infection rates are high. Electrical power in Maine-Soroa comes from nearby Nigeria and is unreliable. There are numerous outages ranging from a few minutes to an hour or more each day, so surgery is frequently performed without lights. The hospital has an emergency generator which is said to work but often there is no diesel fuel available.
Next we tour the buildings which house maternity, medical, and pediatric cases. The hospital rooms are relatively small and contain anywhere from three to six beds. There is a skeleton crew of nurses. There are no nurses’ aides or janitors on a regular basis. There were no funds available to pay them, so most quit. A few still come around on a volunteer basis. Day to day patient care and cleaning are the job of each patient’s family. The rooms and beds are dusty and sandy. There are no sheets or towels, most patients lying on mats on bare mattresses with family members sleeping on the floor or on the ground outside the building. The rooms have no sinks or water and the bathrooms and showers are in an open building behind the hospital. Hand washing by the staff requires a trip to the nurses’ station. One meal a day is prepared for patients in the hospital kitchen where cooking is over an open fire. Meals are not delivered but must be picked up by family members. Special diets are out of the question. The feeding of infants is a special problem, especially if the mother is unable to nurse them.

As we walked back to our truck I think all of us shared a sense of being overwhelmed. There is so much to be done that it’s hard to know where to start. The problems are numerous and none will be solved easily. If ever any of us thought this hospital could be turned around quickly, today’s visit put that out of our minds forever. Tomorrow we will start to see patients.

Steve Humphrey
Maine-Soroa, Niger
May 20, 2007

Monday, June 4, 2007

Beyond the End of the World

For two days we pushed overland, eastward from Niamey, finally arriving in Maine-Soroa late in the afternoon of May 11th. Our route followed the main east-west road which parallels Niger’s southern frontier with Burkina Faso, Bénin and Nigeria.

About 60 miles out of Niamey the way passes through the village of Kouré where West Africa’s last wild giraffe herd, numbering about 150 animals, can be found. Often they are close to the road. We were lucky enough to catch sight of several and a few minutes of off-road driving and walking brought us very close to these elegant creatures. They have been protected for several decades. Although cautious, they will let you draw within 30 to 40 yards before they amble off.
From Kouré the route passes southeast towards Maradi. As we approach Maradi the terrain changes. The rocky orange hardpan of the Sahel gives way to sandy soil which supports larger stands of trees and sparse pasture resembling the savannahs usually found further south.

Leaving Maradi we reenter the Sahel and by the time we reach the city of Zinder we are really in the desert, seeing the first of large sand dunes. Zinder brings to mind all the history, romance, adventure, and cruelty of the Sahara. Originally a resting place for camels on the trans-Sahara route it later became the capital of the Damagaram state which profited from agriculture and the slave trade. Near the end of the 19th century the French arrived with their Foreign Legion. Zinder was at the center of bloody fighting for many years but eventually fell to the French. For the early part of the 20th century it served as the capital of Niger. If you remember the novel Beau Geste reread it for the flavor of Zinder in those days.

We stayed the night in Zinder at a government guest house. Our rooms were air conditioned but the rest of the house was not. The heat was stifling. Ceiling fans stirred hot air and fine dust over the dining table where couscous and mutton were served along with fresh mangoes. The bathroom was nicely tiled and fully equipped but there was no water because of low pressure in city mains – a common problem in the dry season. A five gallon bucket of water was provided for washing and flushing and there was bottled water for drinking and tooth brushing. Breakfast was yogurt, tea, and excellent local bread.

We continued on good quality paved road east to the village of Gouré. Here the Sahel loses its battle with the Sahara and is no longer able to hold it at bay. Despite attempts to stabilize the dunes with plantings of hardy grasses, the sand has marched steadily southward. The desertification of this area has ruined the road which in many areas is non-existent. Our trucks grind slowly in 4 wheel low through sometimes deep sand. We pass two or three of the big ten-wheel Algerian desert haulers being dug out of the sand. Vegetation is sparse to non-existent and the temperature reaches 120 degrees. We drive around the base of a large dune and downward into a depression in the desert. Suddenly the road reappears and everything is a deep cool green. It seems like a hallucination. Date palms are everywhere. Through the trees we can see blue water – a lake maybe 3-4 acres in size surrounded by fields planted with vegetables and fruit trees. It is an oasis produced by a spring fed lake which has created a small island of life in the midst of apparent desolation.

We endure about 60 miles of poor to non-existent road and at last good hard surfaced highway reappears. By late afternoon we are approaching our destination, the village of Maine-Soroa. In the distance we catch sight of something obstructing the road and cars and trucks are on the side of the road. As we draw closer we see that a group of twenty or thirty people is in the middle of the road. We are waved to a stop and as we get out we hear applause and cheering. In the distance drumming can be heard. The chief of the village and a large delegation have driven about a mile out of town to greet us and escort us to the village center. The men approach first with smiles, handshakes and fists held in the air. The fist in the air is not an invitation to leave town but rather the equivalent of a salute – it takes a little getting used to. The women stood to one side while we were greeted by the men, then we were introduced to the women.

As our entourage entered the village everyone stopped and waved or shook a friendly fist. The town center near the mosque and prefecture was completely filled. Our trucks stop and everyone crowds around. As we open the doors we are literally pulled out by friendly hands. Everyone thrusts a hand to be shaken. The sound and movement are almost disorienting…drums, the griot’s horn, clapping, cheering and dancing. We are pressed toward the center of the square by the crowd. The senator from the region along with the village chief offer us a traditional welcoming drink of cool goat’s milk laced with ginger. Introductions to the traditional and now largely ceremonial king and princes of the region and other local dignitaries are made and we are offered seats alongside the king. There are a few speeches of welcome and then a traditional dance. Bill and Barbara Kirker join in to great cheering from the crowd.

The reception we receive is very gratifying. It is a welcome to all of us, but more than that it is a great tribute to the work Bill and Barbara did here more than thirty years ago. From nothing, over a period of ten years, they built a hospital and dispensary system which eventually served thousands of patients in the region around Maine-Soroa. They trained nurses, midwives and technicians, organized vaccination and public health programs, and treated epidemic diseases such as cholera and meningitis. Bill performed hundreds of surgeries and handled complicated obstetrical cases. Almost everyone we talked to was either cared for by Bill and Barbara or had a close family member whom they had treated. In 1974 a coup d’etat in Niger forced the Kirker’s to leave the country. The military government decided to move hospital operations to nearby Diffa and a decade of work was rapidly dismantled. Bill and Barbara returned to the U.S. and Bill entered private practice. In addition he founded and still serves on the board of Africare, a Washington, D.C. based NGO providing assistance to Niger and other African nations. Bill retired from his medical practice in the late 90’s. While inspecting Africare projects in Niger last year he was invited by the Nigerien Ministry of Health to return with a team of physicians to reopen the hospital in Maine-Soroa. Now after months of planning we are here.

The reception ends and we are driven to our quarters at the government guest house. This will be home for the next two months while our housing in completed. All of us on the team are volunteering our time and paying our own living and travel expenses. In return the Ministry of Health is providing us with housing and two vehicles with a monthly fuel allowance. Tomorrow will be a day of rest. Then we will pay our first visit to the hospital.

#1 The village of Gouré
#2 The Griot and his horn

Steve Humphrey
Maine-Soroa, Niger 13 may 2007

Sunday, June 3, 2007

The World Ends at Gouré

Africa begins in terminal 2C at Paris’ Charles DeGaulle airport. Walk into this terminal and you leave behind the sleek, carpeted, calmly efficient world of modern Europe. Here the floors are concrete and the ceiling is best described as industrial. Noise, crowds, jostling, and an agreeable energy are abundant.

We four Americans form a pale island in an ocean of darker faces. At first it seems that finding our flight and checking in will be an impossibility. Surprisingly, the long lines move quickly and soon enough we are aboard our flight for Niamey, the capital of Niger.

Clouds cover southern France and the Mediterranean as we fly south. Over the Algerian coastline the clouds break up and we get our first view of the Sahara stretching below us. Except for the bright sand it could be an ocean. The stark blue Air Mountains, rich in uranium and other exotic elements, signal our passage over the northern border of Niger. During the descent into Niamey heat rising from the desert floor produces severe turbulence and as our plane turns west on final approach we are buffeted by heavy winds.

Descending from the door of the aircraft the view and the sensation are otherworldly. The afternoon temperature has reached 115 degrees with a relative humidity of 9 percent. We have arrived at the peak of dry season. The hot west wind has stirred a haze of fine dust which has reduced visibility to about a mile. As we step onto the tarmac our eyes sting from the grit and dust and the walk to the terminal is withering in the hot wind. We are in the Sahel, the flat, stony edge of the Sahara where orange soil, scattered trees, sparse grass and scrub vegetation defend the savannahs to the south from the desert.

The four of us make our way into the terminal where air conditioning has mercifully reduced the temperature to a bearable 90 degrees. The thump of an immigration officer’s passport stamp finally signals our arrival in Niger.

We have come here on a two year medical mission at the invitation of the Republic of Niger. We will be working as volunteers to help reopen and expand the services of the hospital in Maine-Soroa, a village which lies in the southeastern corner of the country, near Lake Chad. Our team is made up of three doctors, Bill Kirker, Orietta Barquero and I as well as Bill’s wife Barbara who is a nurse and nutritionist. In the early 1970’s Bill and Barbara headed the Peace Corps effort which originally built the hospital. Hard economic times in Niger later forced the near-closure of the facility. Now it is our job is to try to get it running again.

So, after months of planning we find ourselves walking from the Niamey terminal with a delegation from the Maine-Soroa hospital, to waiting Land Rovers. Driving from the airport into town we share the road with camels, donkeys, motorbikes, container trucks, old cars and a few shiny Mercedes and BMW’s, most bearing either diplomatic tags or plates from neighboring oil-rich Nigeria. Although downtown Niamey has broad boulevards and several handsome government buildings courtesy of the previously high price of uranium, it is clear that Niger is struggling. The markets are full and food and an array of consumer goods are available, but the desperately poor and sick are everywhere. Beggars congregate at the edge of the marketplace. Most of them are blind, crippled or disfigured by leprosy. Even before the drought and severe food shortage of 2005 the country ranked last on the UN’s Human Poverty Index. Life expectancy here is about 44 years. Before reaching the age of five, almost one of every five children will die, usually of malnutrition, diarrhea and dehydration, or malaria.

There is also cause for optimism here. In 1999 the country underwent peaceful transition from military to stable democratic rule. President Mamadou Tandja was reelected in 2004 with 65% of the vote. There is ongoing decentralization of government. Main roads are good quality, information technology and communication are progressing rapidly and public health is receiving new emphasis. In addition, there may be large oil reserves here and uranium is plentiful. There is interest in investment in Niger, especially by the Chinese, who along with the Americans, Cubans and European Union are also providing medical and other assistance to the country.

We have had much to do here in Niamey before heading 650 miles east to Maine-Soroa. Supplies have been purchased and equipment and medications shipped from the States have been cleared through customs and transported east to the hospital. We have visited the US Embassy and the Ministry of Health. We were also nicely received by President Mamadou Tandja who has taken a significant interest in the work we’ll be doing.

One of our final visits was to the Peace Corps headquarters here in Niamey. We hoped to interest the Peace Corps once again in the hospital at Maine-Soroa. The director was sympathetic to our request. Walking to a large map of Niger he traced out our overland route from Niamey east to Maine-Soroa. “You’ll be going this way… through Dosso, Tessaoua, Maradi, Zinder and Gouré,” he said, his finger coming to rest on the map over the village of Gouré. “The paved road stops here in Gouré, a hundred miles west of Maine-Soroa. We have volunteers working all the way out to this point, but as far as we’re concerned the world ends at Gouré. Not even the Cubans or the Chinese go out this far. I wish I could help you, but right now I can’t.”

The rains and cooler weather should arrive in a few weeks. Tomorrow morning we will leave for Maine-Soroa.

Photos top to bottom:

1. Niamey, sunset over the River Niger

2. Niamey market scene

Steve Humphrey, M.D.
Niamey, Republic of Niger
May 4, 2007