Notes from the Southern Heartland 19 November, 2017

In the introduction to this Column, in July, I mentioned that I would travel with Médecins sans Frontières (MSF, Doctors without Borders) to Africa in early October; that time has arrived. Initially the deployment was to South Sudan, but this was changed at the last minute to a hospital in the Northeastern Nigerian town of Jahun. The next couple of columns will be written from this location. This is of interest to us for several reasons, the most important of which is that the example of Nigeria shows what happens when a rich country is ruled by oligarchic, corrupt, and kleptocratic leaders who use religion as a tool to divide the people. Of course, you might say, It Can’t Happen Here; I beg to differ. Please read on; I welcome you on this journey with me.

Nigeria is the most populous country on the African continent with, in 2015, about 182 million citizens, 44% are under 15 years of age and 95% are 59 or less. While Nigeria has the continent’s largest economy and a per capita income is about US $ 2,700, and not-withstanding significant oil wealth, 61% of the population subsists on less than US $ 1 per day. In the Northern part of the country – where Jahun is situated – 72% of the population live in poverty; this figure is 27% in the South and 35% in the Niger Delta. To understand the implications of this level of poverty, look at these basic statistics: In 2015 only 69% of the population had access to clean drinking water. Even in urban areas, people are obliged to buy water from vendors rather than accessing it from municipal sources; in the countryside, only about 42% of people have access to clean water. Less than one-third of the population has access to basic sanitation, such as latrines. The result, in public health terms, is life expectancy at birth of 55 years (compared to Europe 76 years, the Americas 77 years); maternal mortality rate of 814 per 100,000 births (Europe 16, the Americas 41); an infant mortality rate of 69 deaths per 1,000 live births (Europe 9.8, Americas 12.5), and an under 5 years of age mortality of 109 deaths per 1,000 live births (Europe 11.3, Americas 15). All data come from the UN/World Health Organization 2016 Report from the African Health Observatory and 2017 Global Health Observatory data.

The political result of the Nigerian North-South economic divide has been the rise of violent organizations challenging the national government. The elites – be they from the North or South – have divided the oil riches, leaving the people of the country in poverty. One of the violent organizations that has arisen is Boko Haram, the name meaning “western education is forbidden”. Violence related to this group has taken the lives of some 10,000 people, and 1.5 million have been displaced. Whether the group is in armed revolt because of government corruption, abusive security forces, and/or economic problems, or because it is allied to ISIS or al-Qaeda matters overall – certainly in the sense of initiating a strategy to come to grips with them – but for our purposes is of little consequence.

Boko Haram is responsible for multiple acts of terror against civilians: the 2013 murder of 65 agricultural students as they slept; beheadings of truck drivers; the killings of travelers on the roads of northern Nigeria; the 2014 kidnapping of more than 200 school girls from Northeastern Nigeria. Whatever the articulated reasons, these acts are those of terrorists.

It is in this context that the MSF hospital came to be in Jahun in 2008, where some 60% of the women treated are aged between 15 and 19 years; there are up to 1,000 admissions per month. This is primarily a women’s and children’s institution as, due to the lack of prenatal care, giving birth is high risk – as noted in the above statistics – and the mothers do not otherwise have access to care. Again, due to the lack of both prenatal care and that during delivery, the mothers are at risk of prolonged and/or obstructed labor, putting her at risk of complications including vesiculo-vaginal and colo-vaginal fistulae.

Vesiculo-vaginal and colo-vaginal fistulae are pathologic connections between the urinary bladder and the vagina, and the colon and vagina. When either of these occur, the injured woman is unable to control the flow of urine or stool, and these exit from the vagina, often – but not always – leading to shunning by family and friends. Obstructed labor is not the only cause of these fistulae – trauma from rape is another, hence the focus on Boko Haram – but it is a major one. In these cases, the child is often still-born.

Fistulae are not the only complications seen in the MSF hospital. Because of the lack of prenatal care, heart failure, preeclampsia (severe, complicated hypertension) and eclampsia (hypertension with seizures and/or coma) are seen and the mortality rate is disturbingly high.

The institution is staffed by about 10 international staff and some 150 Nigerian colleagues. MSF ensures that the appropriate medications, and supplies are available, and manages the clinical staff. Because of the security situation, MSF demands very rigid adherence to their security protocols; ignore them only one time and you are removed from the country. This is the seriousness of the situation.

MSF send its volunteers into some of the most dangerous areas in the world: West Africa during the Ebola epidemic; the Syrian-Turkish border area, and so forth. MSF wants technical expertise in their clinicians, an understanding that we are there to assist the national staff, and a profound respect for the people of the country. These stringent requirements result in an acceptance rate of 2 in 10 applicants.

What is happening in Nigeria should matter to us, as that country is a striking example of the consequences of a corrupt and collapsed political system.