Ikara and beyond
We were ready to go at 7am today, to an area northwest of Zaria (called Ikara) where there are recent outbreaks of measles in more than one village. We met Amina in the parking lot of our hotel and set off.
Today her driver had overslept, so she drove us herself. This gave me a chance to sit in the front with her, which made for more optimal conversation. Normally she sits in the front and we in the back, so we don’t converse as deeply as today. The 90 minute (or more?) drive to Ikara afforded a lot of time for us to discuss our Nigerian and American cultures and their similarities and differences. America and Nigeria are large from both a geographic and population standpoint, so I think the two have more commonalities than most people might realize.
We saw several cold stores today, and it is interesting to see how they scale downward in size as we approach smaller cities and villages, but they are all mostly the same: freezers; generator(s); lots of handmade posters on the wall with catchment maps, population data, focal person cellular phone numbers, and so forth.
The village we’d heard had an outbreak was a small (by Nigerian standards) place called Sia Sia (also spelled Saya Saya). We made an appearance at the community gathering area, met the focal/ward person for the area, and he set off to show us the cases he knew about, we saw families with five or six children who all had just recovered or are now recovering from measles. Most of these cases were fairly straight forward and there weren’t major complications other than anemia or some minor malnutrition. The very first case we saw though, I wasn’t allowed to enter because I am male (something about Muslim tradition that I didn’t quite grasp the intracacies of but was willing to accept), was a girl of two who was extremely malnourished. The mother was flippant about her condition, ascribing her fate to the “hands of God.” This is hard enough to hear for a normal meales case, but a lot harder when a plump, nearly obese mother sits in front of you ignoring her skeleton of a child. I wasn’t present for this, but reviewed the footage Miranda shot, and am pretty horrified. We both spent some time talking with Amina trying to figure out what we could do — giving money to the mother for medical treatment (which is free here anyway), Amina was certain, would only be pocketed by the mother. Short of bringing a nurse with PlumpyNut directly to the house, there’s little we could do, and even if we could somehow do that (nevermind it takes weeks to fully recuperate a malnourished child), that wouldn’t much protect the child from the next time she is on the precipice of death and her mother decides to let fate or God decide.
I am sad to say, but it’s possible the child will die, and there is little we can do. Amina is going to return to try to make further interventions for the child, but it may be too little, too late.
One of the last cases we saw was a little more promising, but still heartbreaking. The mother had heard we were in the village and sought us out. Again, there is a free clinic she can go to that is not far, but at least she made some effort, even if only to see us. She hadn’t taken her child to the clinic because the father is away and she needs his consent. It was explained to me that this ‘father consenting for any treatment’ is semi-official — I get the sense that if she was empowered and demanded treatment for the child she would get it, but there may be reprecussions later from the father for disobedience on her part.
The child was maybe a year-and-a-half old, bleeding from the nose and mouth, with both eyes stuck shut and literally crying puss. The rasp of the child crying was closer to stridor* than normal crying. This is a child that will almost certainly be blind if she doesn’t receive immediate treatment, and even with immediate treatment it may already be too late. This is the first time in my life I have even conceived of, let alone seen first hand, tears of puss.
There was another village not too far away having an outbreak as well, but after seeing dozens of cases in Sia Sia in just a short period Amina felt it would be more-of-the-same to go to the second village, and we should focus on doing what we could for the first with the limited time we had.
We spent about an hour meeting with the chief of the village, imploring him to do whatever he could to motivate the members of the community to avail themselves of the clinic. After suggestions from his council and from us and Amina it was settled that he would speak to the village members and that Amina would come on her own time with other nurses to give informational seminars, and that a few other avenues of educating and pursuading the members of the village would be pursued (trying to get the local clinic to do outreach, etc).
After the meeting with the chief, we tracked down the immunization teams of the area and Amina inspected their paperwork to see how many children they’d jabbed today … one team had done only 27, which is probably about the same number of cases we saw in less than an hour of just going to a few houses. The other team had fared better, and Amina lauded of their efforts.
Today is, for me, a perfect example of where more funding is needed, although it’s not needed in the most straight forward way — which is to say that this village already has access to free nurse-staffed-clinic care for under-fives and free drugs for most conditions, as well as free immunizations, so the funding isn’t for drugs or nurses, but for more outreach, for education and trust-building within the community (which may also include hiring better nurses or other clinic staff). Likewise, an ounce of prevention is worth a pound of cure — whatever the cost of trying to save this child’s eyesight, or nourish the other case we saw, it is certainly more than the twenty-six cents of a measles vaccine.
Having a free clinic means nothing is the community won’t use it. We saw this in Rigasa and again today in Sia Sia. Having community health volunteers works well for Ghana (something this village wasn’t doing), and in general involving the community in the quality of their treatments is a way of giving ownership over their own outcomes. When the poorest people of Nigeria will go to a pharmacist and pay money rather than go to a free clinic, you know that something in this picture needs fixing.
I am by no means an expert at this, but I look at Partners In Health (Zanmi Lasante) and their successes in Haiti by involving members of the community in outreach and education, and I would wager this model could be nicely imported to Nigeria. In the same way Voodoo can sometimes be seemingly at odds with medical science, so too can religious leaders in Nigeria … and in the case of Voodoo, it’s integration of the community and an open-minded approach that doesn’t denigrate religious beliefs that has led to ZL being so successful in Haiti. If local religious leaders and community elders were brought on board, and if a couple of community volunteers were designated and given training to do early interventions by way of referrals and patient followup I suspect the prevalence of vaccination and incidence of morbidity in Sia Sia would both take turns for the better.
As it was, we were on the ground and surveilling measles cases better than the actual officer assigned to this area. We made a point later not only for Amina to apprise the district surveillance officer (who was about 10 minutes away, and is a doctor) of this situation, but to show him photographs of the two worst cases, and try to draw his interest. He glanced at one photo for a second and then went back to his work. I am not blaming him for their outcome, but of anyone he is in the best position to make an intervention on their behalf: he’s a doctor, he is working and living in the area, and it’s his job to respond to this outbreak; yet from what I have seen he will probably do nothing. Amina is going to do what she can, both officially and on her own.
When we apprised him we had seen a couple dozen cases, he simply remarked to indicate this jived with the 20 or so he’d had reported to him. If someone were to go door to door within Sia Sia, I suspect they would find many multiples of that number — but no one will go door too door, because no one has the time, no one is being paid to, and no one cares enough to do so.
When we left the Cold Store, one of the health workers there said he hoped we had a “meaningful trip” in Nigeria, and I think that is the best way to characterize what I have seen. I have experienced things that have saddened and angered me, and things that have filled me with hope for the future. If anything, my experience here has been meaningful.
I have more to write, more to say, but at this point I think I still need to process everything I’ve seen. I hadn’t even come close to really forming concrete conclusions about all of the things we saw in Ghana, and now we’re in the north of Nigeria having so many strikingly dissimilar yet thought-provoking experiences. The last three months of my life have been quite meaningful, but I think it will take me some time yet to fully process and synthesize all of that meaning.
*Stridor is a labored breathing condition children can develop for various reasons. It is characterized by a rasp or high pitch when breathing and intercostal retraction. You can find some videos of it on YouTube I suspect, but I warn you it may be disturbing to watch (although it’s more disturbing to see than it is necessarily damaging to the child).
