It is a cold January morning and I am sitting in a cafe on a busy London street. Looking out of the window, I watch people bustle determinedly along the pavement. I remember how my English friends used to complain that I walked too slowly when I first arrived in London. I thought they walked too fast, but now, in the chill of winter, I find myself quickening my own pace and lengthening my strides, eager to get back to warmth. I unfold the newspaper that I’ve found lying on the table and struggle to keep the still-unfamiliar, outsized pages from encroaching upon the space of the people seated at the tables next to me. I open the newspaper and the word ‘Nigeria’ catches my eye. It is funny how my mind always, almost unconsciously, seems to seek that word out whenever I am reading a paper. Sometimes I am fooled and the reference is to Nicaragua, but this time my eyes have found a worthy target. It’s a feature on the young British Nigerian novelist Helen Oyeyemi in which she speaks of her struggle with depression in her teenage years and the difficulty her parents faced with understanding it. ‘Because people don’t get depressed in Nigeria,’ she says. ‘They were like, “Cheer up, get on with it.”’
The black words sliding over the page carry me back in time to another place, where I too, like Helen’s parents, believed that people don’t get depressed in Nigeria.
It has been a hot night; much of it spent rolling away from the concrete against which my bed is pushed. The walls, retaining the fiery, dry heat from the sun of the previous day, burn with an intensity that seems to scorch my skin when, in my fitful sleep, I roll to the edge of the bed closest to them. I have woken up with a start several times, finally dozing off in the early hours of the morning.
I wake up to a clucking sound outside my bedroom window. It is guttural, low-pitched, and there is a rustling in the fields of guinea corn that stand sentry immediately outside our low-eaved modern bungalow. I walk to the window and peer through the grimy glass louvres, past the hole-ridden metal mosquito netting, and see a herd of cattle making its gentle, almost silent way through the fields. In a distant corner, I can see the Fulani herdsman, a boy really – he is the source of the clucking noise. Whenever a particularly adventurous cow threatens to stray too far, he clucks, softly, almost under his breath, yet loudly enough for the sound to carry into my bedroom, and the cow wanders back to the fold. I remember the stories I have heard about Fulani being able to ‘talk’ to their cattle, and from what I can see, it seems that the tales told by an old driver of my father’s who had once lived in the North are true.
I walk out into the living room that I share with the other occupant of the small two-bedroomed house set on the edge of the hospital compound and head for the bathroom. There I retrieve my battered metal bucket and head out to draw the water for my morning ablutions. At the well, there is a gaggle of young children, chattering rhythmically in Hausa as they deftly throw the black rubber guga into the well, hauling it up to fill the buckets and jerry cans surrounding it. As they see me make my way along the path lined with bowing neem trees, they shriek their greetings, laughing, excited
‘Sannu, Likita, sannu.’
I am likita – Hausa for doctor – and I am twenty-seven years old, freshly qualified from medical school in southern Nigeria and posted to this small northern village for my national service.
One of the children rushes to grab my bucket and, despite my protestations, runs to the well to fill it up and deposit it back at my feet. I thank him and head back to the house, leaving the children to continue their chatting and fetching. I walk past the fields planted with cotton, where the first white balls of fluff on the ripened, splitting pods are only just beginning to show. It will be harvest time soon and the village will flourish in the brief prosperity conferred by the sale of their auduga to the merchants who send their agents from Kano, the nearest big city.
Back in the house, my housemate Wilson is awake and already dressed. As usual he has chosen to wear the khaki trousers and jacket that is the uniform of the ‘corpers’, as those of us on national service are called. Like me, he is another fresh graduate – of medical laboratory science – and is in charge of the fledgling hospital laboratory which, in reality, consists of a couple of microscopes, some dusty slides and, in a slight acknowledgement of contemporary times, a handful of HIV rapid-test kits. Coming from a large teaching hospital in Lagos, with a whole plethora of medical equipment, I am struggling to adjust to the austere realities of rural medical practice.
I brush my teeth, using water that we have boiled and cooled in a large pot in the kitchen, and have a quick bath. I dress in my uniform – short-sleeved cotton shirt, blue jeans tucked into the sturdy brown khaki boots that we were issued in camp – my only concession to my corper status. Carefully hanging my sunglasses (bought in more stylish times in a traffic jam in Lagos) round my neck, I walk to Wilson’s room. Sitting in our single armchair, its cushions worn and holey, I tuck into the plate of hot rice and beef stew that Wilson has conjured up on the small kerosene stove that sits just outside his room. Beef is plentiful, thanks to the Fulani herdsmen. As I go to wash the plates, Wilson bids me farewell and heads out to work. The clinic starts later so I have a bit more time.
I walk down the tree-lined mud path that leads from the grandly named staff quarters to the hospital, pausing on the way as I meet colourfully dressed and veiled women heading for the market in the next village, who greet me in the elaborate formal ritual of the Hausa culture.
Ina kwana... ina kwana, I echo as they enquire after my wellbeing, my work, my family.
We finish off with a madalla and I make my way along the lowceilinged corridors to the clinic where, as usual, there is a large mass of people of all ages and sexes already gathered. Looking into the distance, I notice that work seems to have started again on the wall that is being built around the hospital by the Petroleum Trust Fund. It isn’t clear who has decided that this is what we need most – a generator to stop us doing surgery by lantern light might have been good, as would some equipment for Wilson’s fledging laboratory – but the contracts have been awarded in faraway Abuja and Kano, and so I suppose we must be grateful that the contractor at least seems to be making a good fist of building the wall, which is supposed to provide us with additional security. And he has employed local labourers to do it, so we must be grateful for that as well.
Muttering angrily to myself, I settle into my chair and ask Sani, the cheerful youth who, with his smattering of English, has bagged the role of interpreter, to summon the first patient. I hear him calling out a woman’s name, having first, with an air of self-importance, bid the crowd to be quiet and to listen well. I have soon learned that everyone who works in the hospital is highly revered in the village. We all, apparently, are called likita and there are rumours that the theatre cleaner, the hulking Kaka, runs a thriving sideline in low-price hernia surgeries performed after hours in his living room. Considering how bare the theatre itself is, his living room may perhaps not be that much more under-equipped for the purpose.
A bearded young man, perhaps twenty-five years old, dressed in a blue riga, walks into the room, carrying a toddler in one arm and with the other solicitously leading a young woman, a girl really, dressed in the simple wax-print wrapper and blouse with a loosely tied headscarf that is the common dress of all the female folk here. He greets me respectfully but with an air of distraction as Sani ushers the girl into the seat. The young man stands guard beside her, holding the baby and focusing on my face. She sits listlessly, head bowed, silent.
I look at the blank sheet of paper, torn out of an exercise book, that lies before me and serves as a consultation sheet. I ask her name, her age and what has brought her to the hospital. I do not bother to ask for an address, swiftly amending the history-taking technique learned at my medical school in Enugu. Her husband answers as she continues to look down, despondent. He says her name and volunteers that she is perhaps fifteen years old. Having by now spent over a month in the village, I can already pick out his answers from the rapid-fire Hausa without Sani having to interpret and am not surprised that a girl that young is already married with a baby. It is the way here and one of the nurses has explained to me that in their culture a woman is not supposed to see her second menstrual period in her father’s house. He cites the Quran as his source and I tell him of the many Muslim northern Nigerian girls that I knew while at secondary school, many of whom remain unmarried and are pursuing careers. He is silent but I sense that he refrains from challenging me out of respect rather than out of any acceptance of my counter-argument. Returning to the patient before me, I ask again what has brought them to the hospital. My question, once Sani has translated, elicits a burst of animated utterance from the man, his wife remaining silent, her head still bowed.
Her problems started, Sani translates, perhaps a year or so ago, soon after the birth of the little boy, their firstborn. She would spend almost the whole day lying on the mat asleep, she had stopped smiling or singing while she cooked, she now cried a lot, and had ceased doing all of her household chores. I can see the concern on the husband’s face as he recounts the many ways in which the girl has changed from the cheerful industrious woman he married, to this lifeless bundle of misery draped floppily on the chair beside me. He swears that he has been good to her, that he does not beat her, even though he is only a poor farmer, and I can see it in the newness of her cheap wax-print outfit and in the rows of bangles that adorn her wrists. They have taken her to see a number of traditional healers but the maganin gargajiya has failed to work its magic and so, against the advice of his family and hers, he has brought her here to try Western medicine.
My first thought is of post-partum depression and yet my doubts remain. In spite of our psychiatry lectures and placements, the hours spent in the wards and outpatient clinics at the psychiatric hospital in Enugu, many of my classmates, myself included, still look at depression as a largely Western illness. The few cases that we have seen in the clinics in Nigeria have been mostly among the relatively affluent, and so we imagine that it is a luxury for those who can afford to ignore their more pressing immediate problems – what to eat and how to keep a roof over their heads – to indulge in afflictions of the mood.
And so I probe a little more, asking more questions, trying to disprove the evidence of my own eyes. How, I wonder, can a young woman who has grown up in this harsh environment, waking up early to fetch water, cook, clean, farm till late in the day, be suffering from depression?
And yet, the more I probe, the more the husband, through Sani, proffers evidence to confound my theory. I am conscious that time is passing and that there are still a slew of patients to see on the morning ward round and so I embark on more rapid-fire questioning. Is she eating? No, she has had a poor appetite since the illness began and has consequently lost a lot of weight. She has also stopped visiting her friends and family and takes little or no interest in her child or, indeed, in anything.
The more I try to discount it, the more conscious I am that this is looking more and more like a classic case of post-partum depression. I look up from my scribbling on the page and meet the eyes of her husband, staring, his gaze almost boring into my face, his countenance steady, earnest and hopeful. He has come to us against the wishes of his family and the village and I feel that I owe him something. I must not let him down.
Finally, with an inward sigh, I reach for a pile of neat slips of paper, which Sani has meticulously cut up before I arrive, to serve as prescription forms. The recommended treatment for depression is either therapy or medication. Looking out at the fields of guinea corn and the array of young girls squatting on mats selling food just outside the hospital, there is no question that I only have one option. I look through my formulary, flicking through the well-thumbed antiinfective agent section to the pristine antidepressant section, trying to decide which antidepressant might be most easily available in this remote place. The question of going to the hospital pharmacy does not arise as they have struggled in the past to fill prescriptions for simple antibiotics. The few drugs that they now have in stock are courtesy of the Petroleum Trust Fund, set up by our military president, the goggle-wearing Abacha, to ensure that the benefits of petroleum, our country’s main export, trickle down to the masses. Knowing the limitations of the pharmacy, I opt for Amitriptyline, the cheapest and most basic of the antidepressants, and ask her if she is still breastfeeding.
‘No,’ her husband says, she has not really breastfed at all and the baby is being suckled by his brother’s wife who has a toddler of her own.
I scribble quickly and hand the paper to the husband, explaining through Sani how the medication is to be taken. I know that he will probably have to send someone to Kano, a good hour’s bus ride away, to buy the medicine. I wonder what it will cost him – this is the lean time between harvests. Perhaps he will need to draw on the last few naira saved from the previous year’s cotton crop, reserved for the ram meat for the impending Sallah festivities. Or perhaps he will join the throng of supplicants squatting outside the Hakimi, the village head’s palace each morning, bringing their needs and concerns.
Whatever the cost, I sense that he is determined to do whatever it will take to restore his wife to him. I pray that I am not sending this young man on a wild goose chase. I ask them to come back in two weeks, fearful of giving a later appointment, just in case I have got the diagnosis wrong. I do not want to leave her for too long on medication she does not need. They leave the room the same way they came in, a ragged chain of three, her battered plastic slippers dragging on the rough concrete floor.
Two weeks later, I am sitting in the clinic again and my head is reeling. Sani is mopping the floor with disinfectant and bleach where the last patient I have seen, diagnosed with HIV, has vomited. This patient also has tuberculosis and has been admitted into the isolation ward on the far side of the hospital compound. A village boy made good in the city of Lagos, he has come home to die of the mysterious illness that has drained his body and inflicted a hacking, bloody phlegm-producing cough upon him. He is emaciated and I know that his chances are poor.
Perhaps we will be able to treat the TB and buy him a little more time. But the virus that is so evidently rampaging through his body will leave him little time or hope. I know that abroad they now have medicines to treat HIV, and my colleagues say you can even get them in Kano, but they cost far more than even this success story can afford and so I have prescribed TB medicine, some Septrin, vitamins and intravenous fluids and sent him to the isolation ward.
I return to my desk and stare out into the distance, marvelling again at how flat the land around is. I imagine that if my eyes were more powerful I could see right across to Kano, for here, unlike southern Nigeria where I grew up, there are no hills or forests to circumscribe your view.
Sani calls the next patient and she marches forward, her gauzy headscarf tied at a jaunty angle. She carries her toddler in her arms, cooing soothingly to him. Behind her is the bearded husband, a broad smile splitting his expansive face. As she takes her seat beside the consulting desk, he falls to the ground, wanting to grasp my feet in gratitude. I ask him to get up and laughingly begin to scribble on her sheet. I do not need to ask if the medicine has worked.
That afternoon, at the end of the clinic and the ward round, I make a futile dash to the children’s ward, summoned by a panting attendant – himself dispatched by the nurses – to resuscitate a dying child. Pronouncing the infant dead, I watch as the mother straps her lifeless baby to her back, gathers their belongings and prepares for the long walk home. Her stoicism contrasts so much with the hospitals where I have trained, where often the sudden sharp wailing of a bereft mother marks the location of the children’s ward.
Drained, I make my way to Mama Olu’s zinc-walled shack, take my place on the wooden benches and order pounded yam and chicken in okra soup.
As I mould the balls of yam and swirl them around the soup, I hear again bushy-haired Dr Chikwendu, one of my favourite lecturers from medical school, intoning by a patient’s bedside on a ward round: ‘You must always keep an open mind, in this business. Always be ready to be challenged.’
Nearly a decade later, I sit in a white-panelled meeting room, beneath harsh, bright fluorescent lighting. I look out to the rooftops of west London, the arch of Wembley Stadium barely visible in the distance. My colleague responsible for mental-health provision is explaining the challenge of getting more people to use the new ‘talking therapy’ service for those with low-level mental-health problems. We have invested hundreds of thousands of pounds, but uptake has been slow.
As we debate how to address this, my mind wanders back to a small, bare consulting room, in a hospital in the northern Nigerian savannah, and I wonder how my patient is faring.