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Niger: "We will continue doing our best as long as there are lives to save"
May 2019. It’s already past the end of the working day. I want to go home after a heavy day in the sweltering heat of the Sahel. It’s 45 degrees in the shade; there’s some ceiling fans to move the air around and that's it.
The Phase 1B tent, where I’ve been assigned for the last month, is filled to capacity: 30 children, all suffering from severe malnutrition. I’ve been circulating, moving from bed to bed, examining each child, asking each mother the same questions: "Did s/he have diarrhoea at home? Yes? Since when? Did s/he vomit? Have a fever? Convulsions?” In Magaria, time can quickly become our enemy, so we must act swiftly. You have to see all the patients.
It’s almost 6pm when I reach the bed of a child of two years, three at most. The child, Aisha, has been diagnosed with acute febrile gastroenteritis and profound dehydration, as well as severe malnutrition. I have seen hundreds of patients with this diagnosis during my six-month mission in Niger? It can be too easy to fall into automatic responses, redoing the same diagnoses, the same prescriptions. But no, my medical training taught me the rigor and professional ethics that makes me, I believe, a good doctor today. Every child has their own peculiarities, is a unique life that counts as much as any other.
The greatest fears
I lean over little Aisha’s bed and see her lying there, in her loincloth, so weakened. She does not open her eyes. She cannot talk or sit up. Her mother tells me that she was doing very well five days ago. We try to rehydrate her using an IV drip. Two hours pass and Aisha’s condition is still not good. Her heart is beating too softly, too slowly. I tell myself that we might lose her. “Hang in there,” I whisper to her. “It will be fine.” Aisha gets the most energy that her five kilos of body weigh can provide. Before leaving the ward, I advise the nurses to keep renewing her drip until morning. We have catching-up to do.
"One of the greatest fears for a doctor is to make a medical mistake, to have given the wrong treatment or missed something. We get angry at the idea that we could not do everything to save someone's life."
I go home. I eat. I talk a little with friends and I go to bed. In my dreams I see the fuzzy face of a very thin little Aisha, her features drawn back like that those of an old man at the end of his life.
The next morning, I return to my post in the 1B tent. To my dismay, Aisha's bed is empty. My first thought is "She’s dead.” There is no mat, no loincloth, no mother, no child; only a white mattress shining from the cleaning product that our hospital hygienist has taken the time to apply, knowing the next patient will soon arrive. I immediately ask the nurse what happened. She tells me: “I do not know. When I arrived this morning, the bed was empty.”
One of the greatest fears for a doctor is to make a medical mistake, to have given the wrong treatment or missed something. We get angry at the idea that we could not do everything to save someone's life. That's what I feel in this moment.
"But she’s still with us. She’s fighting with all her strength, and it shows."
Luckily, with the help of an interpreter, I talk with the mother of the child in the next bed. She tells me, no, little Aisha did not die last night. But in the quiet hours of the morning her condition worsened and she was transferred to the intensive care unit. I say to myself: “Not dead then, but it looks bad.”
I continue my day in the Phase 1B tent. When dusk arrives and the ambient temperature has cooled slightly – it’s 35 degrees maybe – I take the time to go for a quick visit to the intensive care unit. There are just over 20 patients in the unit. I'm desperately looking for Aisha. Did she survive her day? Which bed is she in? I can’t find her. Anguish and sadness rise in me.
Do not lose hope
And then, I see her. Hidden behind the panels of the ‘white bed’. In Magaria, this is the name we’ve given to the resuscitation table – quite simply because it is white. Aisha is here. She breathes laboriously; when she looks at me, her eyes are empty, without expression. But she’s still with us. She’s fighting with all her strength, and it shows. If a child ends up on the ‘white bed’, it is usually because they had a cardiac arrest and we had to resuscitate them. According to the duty nurse, Aisha had stopped breathing for a bit and would have returned to her after brief maneuvers.
That night, I arrive home late, still thinking of Aisha. And feeling guilty. Is there anything I could have done differently during her first day tent 1B? Should I have rehydrated her more aggressively? I sleep badly. I dream of Aisha inert, carried in the arms of her mother. I have lost hope.
Days follow without me hearing about Aisha.
Before the seasonal peak of malnutrition and malaria, the paediatric unit of the Magaria District Hospital cares for an average of 200 hospitalised patients each day. Many of these are transferred from one ward to another until they are eventually healthy enough to leave the hospital (most of them) or do not recover (a minimum proportion of the hospitalised children). It is impossible for me to stop and search for information on the progress of each patient that I no longer see.
Two weeks pass. We receive a visit of the Médecins Sans Frontières/Doctors Without Borders (MSF) communications manager in Niger. I show her the different services; intensive care, Phase 1, Phase T. We call it Phase T for Transition. This is the final step before a child can be discharged from the hospital. All their acute medical conditions have been treated and the focus now is on diet and weight recovery or stability. The majority of that follow-up will be done externally, in the ambulatory therapeutic feeding centre.
"Please, do not lose hope. When death threatens, when we have really done everything in our power and used all our resources, there will be happy endings."
That's when I suddenly see a woman with a big smile on her face, dancing happily with her child in her arms. She looks familiar to me. It is when I see the body and the face of the little Aisha that I understand where that sensation of déjà vu came from. She is there, alive, in the arms of her mother, her big eyes watching me. I feel a lump in my throat and tears in my eyes. Does she recognise me? I cannot believe it, but her mother confirms that it’s her, the same child I had seen in Phase 1B tent. She is alive!
To all those who have worked here or who may one day go through Magaria: please, do not lose hope. When death threatens, when we have really done everything in our power and used all our resources, there will be happy endings. There will always be stories that deserve to be told. And that pushes us not to give up. You will often say: “Today I made a difference.”
In 2018, nearly 18,000 children were successfully treated at the Magaria District Hospital thanks to the collaboration between MSF and the Ministry of Public Health. Our teams made ‘a difference’ nearly 18,000 times, for nearly 18,000 families. I hope that with these words and results in mind, we will be determined to continue doing our best as long as there are lives to save.
Voices from the field
Our project in Zinder region
MAGARIA DISTRICT HOSPITAL:
Aisha, unknown age, mother of 11 (2 deceased), from the village of Angualaia in Niger
“I got married at the age of 15. I have had 11 children, but 2 were stillborn.”
“Mohammed Sani is the youngest of my kids. He is normally playing with his sisters and brothers, but we are struggling economically, and he has fallen sick twice. Last time he was all swollen: the face, the body… He could barely open his eyes. I brought him to the nearest health post, 10 kilometres away from our village, and then to another one. On foot. Unfortunately nothing worked, so they advised me to bring him here [Magaria district hospital]. At the beginning his father refused to get him transferred, but later on he gave his permission. He has improved a lot since he arrived at the hospital.”
“Our main concern is food. Harvests are never enough. Sometimes they go well and we can eat, but when they are bad some children die. This year it’s not good; our stocks are already empty. When that happens, some families do off-season cultivation, others earn money by cutting wood, and others cross to Nigeria for business. My husband is a trader and goes regularly there, but he is not selling nor buying anything lately. Difficult times for us.”
Aiva, 30 years old, mother of 9 (2 deceased), from the village of S/broum in Niger
“My son is 4 years old [sick of malnutrition and measles]. He started having fever and red spots over his body. We live near the border with Nigeria, so we first brought him to the Zongo health centre across the border. They treated him, but after 9 days his condition hadn’t improved. My neighbours in the village told me the best thing was to bring him to the [MSF-supported] CRENAS [ambulatory therapeutic feeding centre] of S/broum.”
“The doctor told me he had ‘tamoa’ [he was suffering from malnutrition] and measles. I have eight children more. Two are now dead. One passed away 15 years ago, when he was just a few months old; I don’t know why, because he was in good health. Severe malaria killed the other one, 7 years ago. I was afraid I would lose this one too, because he was seriously ill at the beginning [in a septic shock, hypoglycaemic and with dysentery].”
“Life is not easy. We have some cows, and we are farmers. Money is always a concern.”
“When one of my children falls sick I don’t go to traditional healers anymore. They [MSF teams] taught us how to identify signs of danger like high fever or oedemas, when it is important to rush our kids to a health centre. We try to do the best for them.”
“Seeing that my child is getting better makes me happy, but I know recovery will take a while.”
Our project in Maradi region
MADAROUNFA DISTRICT HOSPITAL:
Suadi Abdou, 43 years old, mother of 9 (all alive), from the village of Unkulego in Niger
“My child was born suffering. He is weak and doesn’t eat much. It’s the third time he falls sick this year. I first brought him to the health centre of Maraka, and as he was in a critical state we brought him here by motorbike.”
“We have been at the [Madarounfa] hospital for 2 weeks. At the beginning he couldn’t open his eyes due to oedemas. For 4 days he would not even urinate. It was hard to see him like that. Now he is doing much better, eager to go home and play with his siblings again.”
“I prepare and sell ‘beignets’. My husband is a farmer, but he cannot do all he wants because he doesn’t have the means for off-season cultivation. Sometimes we don’t have money, and just wait. We don’t always have enough to eat. That depends on each year’s harvest. If it’s good, no problem. If it’s bad, there is nothing to do but to rely on others.”
“There have not been killings or abductions in our area, but as we are afraid of this happening, we often sleep in the bush. We also fear people armed men will come to steal our cattle. Nobody is 100% safe. Last year all was calmer, we were not that worried about violence. Now it’s a bit tense even if authorities and security forces have intervened.”
“My priority is our 9 children’s health. I want them to be strong and protected against diseases. So far I haven’t lost any of them, but one never knows.”
DAN ISSA HEALTH CENTRE:
Aicha, 30 years old, mother of 7 (3 deceased), from the neighbouring village of Gurbi in NIGERIA, Katsina State
“Two of my children passed away suddenly. One was 27 days old; the other one, 2 months old. Later on I lost a third kid at home: diarrhoea, vomits… nothing could be done.”
“When my daughter fell sick [of malnutrition] I decided to bring her to the health centre of Dan Issa immediately even if we are a bit far [about 50 km away from the health centre]. Now she is gaining weight.”
“Back in Nigeria, where we live, violence is tough: killings, abductions… Our village, Gurbi, has been attacked 4 times. Nine months ago, a large group of gunmen arrived out of the blue. They began shooting at anything that moved. There were many victims. We buried the dead, and got help for the injured. Four months later there was another attack, and we all fled to other areas within the region. I went to my hometown, with my children. My husband stayed in Gurbi, but he would sleep in the bush as nights are usually more dangerous: that’s when attacks happen. About 3 weeks ago I decided to return with him because everything was calm, but I’m nervous.
“It’s not easy to get food. Insecurity has affected agriculture. Some people don’t dare to go cultivate their lands as they used to do, so there are fewer products available and more expensive.”
“I just hope my other kids will not fall sick. Or me… [she is pregnant].”
 Patient’s name has been changed