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International Child Health Section: Articles
Galmi, Niger
Submitted by Anita Cheng
University of Western Ontario
There were three of them that day. I was passing by the emergency room with dust covered cement floors, slowly rotating ceiling fans barely moving the thick haze of heat, certainly not dissipating the now familiar stench that defies disinfectants. The nurse informed me that there were three patients transferred from another hospital. Already exhausted from the busy morning, I tried to gather my dragging feet. Three children and their mothers had been piled into a bush taxi and arrived to Galmi Hospital—half alive.
I looked at them with wide eyes. Trying to triage the sickest, I saw three sets of sunken eyes, three wasted bodies, and gasping breaths, each threatening to be the last. The first boy was perhaps two years old. I talked to his mother in my limited Hausa as I quickly examined him. Sucking ribs, eyes closed and unresponsive, I looked over my shoulder to ask the nurse to start an IV immediately. I turned back to the boy, and he had stopped breathing, his heart stopped pulsing beneath his emaciated chest. He lay motionless in his mother’s arms.
Without time to realize the gravity of the life lost, I moved to the second child, another boy the same age. His gasping and his listless eyes heightened our sense of urgency. The nurse grabbed his arm to search for a vein. He stopped breathing. His eyes half opened, pupils were fixed and dilated, lifeless.
Unfortunately, stories like this occur every day at Galmi Hospital, Niger. As a third year paediatric resident training in Canada, I was unprepared for the severity of illness and suffering that was common to Nigeriens. One of the poorest countries in the world, Niger has a 12 per cent mortality rate in children under the age of one year. Located in rural sub-Saharan Africa, the 120 bed hospital serves over 100,000 patients per year in surgery, obstetrics, and medicine, at least half of which are paediatric patients.
With a in-patient mortality rate of 20 per cent, the national staff are accustomed to the “this is just the way it is” and “there’s nothing we can do about it” mentalities. With neither ventilators nor vancomycin, neither critical care nor CT scans, it was a challenge managing sick patients with renal failure, head trauma, encephalopathy, and tuberculosis. Being mosquito season, complicated cerebral malaria dominated in-patient rounds. Most children were severely malnourished and functionally immunocompromised, making malaria or pneumonia often fatal. Patients were admitted from our out-patient clinic with tetanus, Burkitt’s lymphoma, severe ascites, and marasmus. Greater than the challenge of extremely sick patients was the endless influx of extremely sick patients.
Fatima had watched everything that had happened. She had been at the other hospital with the other two mothers and their sons, and was piled into the same bush taxi to find hope in Galmi. She had never been to Galmi before. She didn’t understand the strange languages and strange white faces. Now she watched as the mothers wrapped their dead sons in cloths. The boys were just alive; she remembered the sound of their laboured breathing in that taxi—now they were gone. She gripped the flaccid hands of Mohammed, her grandson. His father had gone to Nigeria to find work. The drought this year had wreaked havoc on their tiny millet farm. His mother had reluctantly stayed behind to care for the younger children.
Fatima looked around in fear, she had to decide now. What was this place? Was Mohammed doomed to die too if they stayed here? She quickly stood up, and began to lift the boy to be carried away on her back. The nurses and the white doctor protested; the other two boys were already very sick, and that Mohammed was still breathing. She paused, stooped over, her grandson already lying limp on her back. The white doctor desperately said something in French. Fatima didn’t understand. He could get better; let him stay here for medicines, be patient, please. She hesitantly lowered the boy onto the bed, not knowing if this was the right decision. It wasn’t her decision to make anyway, but the men of the family were not here. She watched the nurses hang a bottle of water connected to Mohammed’s arm, as the white doctor listened to his shallow breathing and opened his lifeless eyes. Fatima looked intently at the doctor, wondering if there really was any hope behind the desperate efforts. As they exchanged glances, she thought perhaps the doctor was wondering the same thing.
Beyond the difficulties of severe illness and a lack of resources, working in Galmi was wrought with cultural challenges. Fatima’s story is a familiar one. Stricken with poverty, illiteracy, famine, and lack of opportunity, Nigeriens are too well acquainted with death, suffering, and loss of loved ones. Religious views, roles of men and women, values of the young and old, guided decisions and health outcomes. Mothers often refused admission to hospital for sick babies in fear that their husbands would not allow such usage of money. Boys go to school; girls are trained to be good wives. Even in the face of death, emotions are to be contained; tears, grief, sorrow are to be kept silent, lest the dead should not rest in peace. Planning for tomorrow is not applicable for those who are hungry today. Patient education and counseling were challenging when hinged on such different life perspectives.
 The differences were not only with patients, but also with the national nursing staff. If practicing medicine with broken French, charades, and a handful of Hausa words was not stretching enough, there was the added challenge of building rapport with the staff balanced with encouraging better standards of care. Significant patient morbidity and mortality could be improved with optimized nursing care. I organized the Neonatal Resuscitation Program for the midwives and nurses, who had been previously trained. There was a question of discrepancy between the protocol and actual practice. Through a questionnaire, together we explored some of the barriers to changing practice. Many differences in world views and culture were brought to light. After weeks of repeated mock resuscitations, there were marked improvements in performance, focusing on early bag mask ventilation. However, long term changes are yet to be observed.
As I entered the ward the next day, I expected not to find him there. Mohammed, unlike the countless other children who succumbed to cerebral malaria, was not waking up. But he was still alive. Fatima sat on a floor mat by his bed. She had been watching the ward room all day. The girl across the room was seizing. Her parents refused to let the doctors insert a tube in her stomach to feed her. Only people who were about to die had this tube, so she assumed the tube must be harmful. The baby in the next bed had been there for five days; his mother said they would go to the malnutrition rehabilitation center today.
I walked over to Mohammed’s bed. Against the grim statistics running through my mind, I mustered up any sliver of hope remaining, and smiled. We would continue anti-malarials and be patient. Fatima remained doubtful, as did I. The next day, Mohammed withdrew his hands to pain. I was still skeptical; life had proven itself frail in Galmi. But Mohammed proved himself as well. After a few days, I found Fatima sitting faithfully on his bed, “He drank water.” Mohammed had asked for water. After a week, he sat up in bed and asked me if he could go home. I looked at Fatima. She smiled.
 Each person I met in Niger had a story. Not every story was like that of Mohammed’s. It was in the stories where there was great loss that I was privileged to walk with families through some of the most difficult trials in their lives. It was in this walking that my life has been changed, and I believe the lives of these families will never be the same either. I do not agree that “there’s nothing we can do about it,” but firmly believe that the relationships built with the Nigerien staff and patients prove that there is yet hope.
In addition to learning about tropical medicine and exercising creativity in a resource limited place, my short time in Galmi has brought insight to how I would like to continue to be involved in international health. Thank you for your generous support and walking alongside me in this journey.
Despite the extreme poverty and gravity of illness, I was reminded that every patient who lived is a miracle to be celebrated.
There were three of them that day. And Mohammed went home with his grandmother, Fatima.
Posted: December 2009
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