There are many images that will haunt me when I leave Niger. The groups of children roaming the streets holding bowls, begging for left-over food; the sheer numbers of those blinded by Rubella or paralysed by Polio, diseases that are preventable with a cheap and simple vaccination; and of course the faces of many of the children that died in the hospital despite our efforts.

As I reread the above paragraph I realise I probably sound tired, or guilty, or in need of another holiday. It’s clear that the constant awareness of suffering can leave us feeling emotionally exhausted. Yet I don’t feel that I should have done more. Of course there is always more we can do, but we strive to find this sacred balance between seeking happiness for ourselves, and trying to help others to do so (and of course the two are not mutually exclusive). And guilt? I think it’s okay to feel a bit guilty – we feel guilty because we are living, sentimental beings, and we can’t abide the idea of other beings suffering while we are living comfortably.

Paradoxically this guilt allows us to live better, to be happier. Just as we feel guilty as we observe the injustice around us, we feel liberated and lucky to be free (relatively) of suffering. Guilt can quickly metamorphose into celebration of our health, our liberty and our autonomy.

In my mind’s eye I see those images of hardship metamorphosing into more light-hearted views of this exuberant country, a few of which can be seen below. The beautiful Hausa architecture; the huge, life affirming Baobab trees; the children who get better and their mothers who dance with joy when you agree that their baby is ready to go home. I think I’ll leave here feeling lucky, and happy, and a bit guilty, but also a bit proud that I have done a good job.

It’s 43° outside but malnourished children still manage to get hypothermic. Often it reflects severe infection with low blood sugar, which needs to be treated by covering the children in space blankets and piling them on top of each other in a small warm room as seen here. I guess we don’t tend to see this in Europe, where shared body heat is a resource that only James Bond tends to employ.

Remarkably they (usually) pull through and start sitting up, and then putting on weight, and then running around….and then they go home. But for every 10 children who progress from intensive care to the open ward, 10 more arrive in an equally fragile state. When one is tired, the task can seem Sisyphean. It’s at these moments that I relieve my tension by chasing the cats out of the intensive care unit.

Unfortunately cats seem to adore the unit, and particularly the warm room. One day I realised that the staff hide in the warm room to eat their breakfast, which explains the lingering aroma of food (and may also explain the cats’ attraction to the room). Sadly, prohibiting this practice does not seem to have made a difference. I have tried everything to get rid of the cats – locking the doors, setting up a committee of hygiene, unleashing the health educator on the mothers….but the irresistible charms of the warm room always lure them back. Unfortunately they have a frustrating habit of jumping from bed to bed, from one puddle of diarrhoea to another, which belittles the introduction of sinks and detergent bottles which we were so proud of at first.

So…it was with some surprise today that I realised that there was not a single cat in the feeding centre. It took me some time to find the explanation. An enterprising nurse who had previously worked in the national hospital remembered that there was a similar structure at the hospital, near a kitchen which produces an aroma of food that extends to a radius of 50 metres. Apparently our cats have taken to their new home with no regrets.

I guess this means it will be breakfast in the warm room as usual tomorrow.

It is the season for reflection; in the midst of the meningitis outbreak and the training week –and or course the malnutrition, which is always present – we try to find the time and space to debate the future of MSF. These ‘Associative Debates’ are intended to allow everyone in the association a chance to have their say, to play a part in shaping the organisation. At the very least, they represent a tentative step towards the ideal of an organisation in which the employees are members, rather than just workers.

Of course at the end of the debate one is left with the impression of having been here before. The same grand ideals are invoked, the same platitudes echoed about sustainability and responsibility to the beneficiaries and the community. A call to arms is issued regarding the twin notions of empowerment and participation at all levels. And the participants depart with the sense that things will be better in the future. And then they quickly forget all about it until next year.

If I sound a little cynical it is probably just the fatigue. After several intense weeks of vaccination campaigns and staff training programmes, to facilitate debates on questions that noone understands or really cares much about saps what remains of ones energy. Occasionally someone has something of value to express, but their voice is quickly drowned out by the mass that use the debates as an excuse for a holiday. We shouldn’t be surprised at this failure of forced democracy. The idea that the leaders of an institution wish to lay the plan of action on the table for the members to rewrite is no doubt counter-intuitive for many, and likely to be greeted with suspicion.

Nevertheless, I don’t think we should give up on the idea of empowerment. It was the awareness of inequity, and the inability of many to participate in society, that drew me into this field of work. But I realise that genuine participation requires a lot more than just being invited along to a debate and given free coca cola. Participation is the result of a long process of emancipation, in which literacy and freedom from financial and physical insecurity have first to be obtained. I don’t have the recipe for this; but patience and more debates and a lot more free coca cola are probably amongst the ingredients.

Sometimes there is little traditional doctoring in the work I am doing here. Often I start the ward rounds at 730 in the morning, and then have to stop to see a cleaner who has passed out, or to give a visiting official an impromptu tour of the Creni (the French acronym for the therapeutic feeding centre). The ward round which could be carried out in 2 hours lasts until 1pm as a result of these diversionary activities. Then there are the staff vaccinations to be carried out, and the field debates, and the occasional marriage that I have to attend (in my capacity as supervisor), and that I try to fit into the lunch break In between all this I make my daily visit to Abdou and Harira and the children in phase 2 who have recovered from their illnesses, and now offer me their hand whenever I visit. We are all conscious that they are doing this for my benefit, but we all pretend not to know.

All of this makes for quite a varied lifestyle – rarely a day passes without a new (and often bizarre) challenge to be faced. At 6pm on Saturday afternoon I was preparing to leave for the weekend when someone alerted me to the fact that there was a snake in the woodpile near the kitchen. I asked what type, and they said an Anaconda. My response that this was unlikely served to aggravate the situation, because my interlocutor then demanded I come to have a look. We searched the pile for 20 minutes but could not entice the anaconda out of its lair. Unfortunately the kitchen staff had all seen it, and used this opportunity to inform me that they were not willing to work until a snake charmer was called and the snake was caught.

Now this presented me with two dilemmas. Firstly, I had had a hard couple of weeks and desperately wanted to rest; yet a therapeutic feeding centre without a kitchen is like a hospital without nurses – more of a risk than a benefit. Secondly, I was unconvinced that the snake charmer was the solution – I guess my medical training encourages me to steer clear of interventions that are not evidence based – and yet I could not come up with a better suggestion now that the sun was already setting. So, I bravely called the nursing supervisor and the logistic assistant and arranged for them to meet at once, and then got on my bike.

This may seem like an avoidance of responsibility, and I think it probably was. I rationalised my action in terms of the fact that I was too tired to function well, and that I needed to find a solution that was fair to everyone, including myself. It just so happened that the chosen solution was a bit more fair to myself than to everyone else. And at other times I think that sifting through a pile of mouldy wood looking for an anaconda in the company of a wizened mendicant playing a pipe and burning some herbs could be an excellent way to spend a Saturday night.

At least I followed up on the situation the next morning. No snake was found in the pile of wood. The charmer has been called and will arrive today. The staff have somehow been placated. By Monday this will all be forgotten; and there will be something new, and no less bizarre, to deal with.

I don’t tend to get out much these days. The days run from 730 in the morning to 730 in the evening, and combined with the intense heat this regime leaves me with little energy to do anything but eat and read. Sunday is our day off;  occasionally I go in to the hospital if we have any patients in a particularly fragile state; but otherwise I spend the day pottering around, preparing the weekly team lunch, examining the cat for worms and pretending to learn the local language.

From time to time I do cycle out of town though, and briefly I reconnect with a life and a society outside of the hospital. Without these brief moments of respite, I would know Nigeriens only as patients or nurses. These trips allow me a glimpse of the lives of people in their villages – the women working, the men mending their bicycles, and the children climbing the baobab trees. It’s immediately noticeable just how many children there are relative to the number of adults. The moment I enter a village I am surrounded by at least 40 children, smiling and snotty and (generally) not at all malnourished. I guess it’s not the hunger season yet, but all the same it’s reassuring to remember that malnutrition is not the default state here – it is still an aberration, and something we need not accept.

Quantity is undeniably important when it comes to children. My colleague Abdi plans to have 20 – mercifully for his current wife, he plans to have the second 10 with a second wife. When I ask him if he will be able to remember all their names he says that generally speaking the father doesn’t have that much contact with the children in his culture. 20 is a good number because some will die but he will still be left with a generous handful. I ask him how he would pay for their education and health care, but from his perspective this is a ungenerously pragmatic question – one does not deny life to a child for fear of not having enough cash.

Moments like this bring my own risk-averse attitude into context – I am terrified by the idea of having a mass of children that I can’t afford. Yet when I perceive the pleasure with which A talks about his future flock, I am left with the overwhelming urge to procreate, in abundance!

Nothing brings more of a smile to peoples faces here than the sight of a fat child. A round beaming boy always has a crowd around him – everyone wants to pick him up, squeeze his cheeks, and give him a snack to eat. The concept of obesity is absent here – being round is seen as a sign of exceptional well-being, in a country where the default state is emaciation.

The easiest place to find one of these chubby children is at the TB follow up visits. Once they are cured of their TB they still have to return for regular visits as the therapy continues for several months. At each visit they are fatter than at the one before. The mothers are generally ecstatic, and display their obese infant like a trophy for successful motherhood. . I have never decided whether the children’s new found fatness reflects the persistence of the increased appetite induced by the “Consumption” (as TB was once called), or whether the mother now favours her miracle child and somehow finds additional food for him.

Interestingly the pursuit of obesity extends to adulthood. I always thought that the notion that fatness is seen as attractive in Africa was a western cliché. But every few days a nurse approaches me to ask if I can provide her with nutritional supplements (even the therapeutic foods we give to the children) as her husband wants her to be fatter. I ask them why they don’t just get pregnant like everyone else, but they are searching for a more sustainable solution to their weight problem. There aren’t really any references on this subject – I found plenty on the internet about regimes to reduce ones weight, and a few about muscle building programmes, but little that I could use to advise these women. I also find myself facing an ethical dilemma, since they are asking me to help them achieve something that I believe to be (in some ways) bad for them, even if it may bring enormous psychological benefits.

Ultimately I suppose if the husband wants his wife to put on weight he should do some of the housework himself. I’m not sure how well this treatment plan will go down though.

After recent weddings, and invitations to the houses of staff members, people have said to me that they are really happy to see the foreign staff interacting like this. I suppose we are benefiting from this period of relatively lower activity at the hospital. But comments like these remind me that, no matter how much we may doubt or question the effectiveness of our work, we have the chance to interact and share with the people here, to make them happy and to be made happy in the process. Perhaps this should be our primary aim in any humanitarian mission.

The photo here shows the afternoon part of a marriage ceremony. A large tent is erected in the middle of a road, such that the traffic quickly comes to a stop. The band sets up and the audience (consisting of those invited, as well as those trying to use the road) gathers. The dancing begins, the highlight of which is the somewhat irreverent “Dance des fesses”, sadly not shown here, in which two or three women in the centre point their backsides in the air and gyrate their hips for 5 or 6 minutes. It’s a remarkable spectacle, and I’ve yet to understand its connection to marriage.

At the end of this ceremony I was asked if I had any last minute advice to offer to the young bride, before she was whisked off to the house of her new husband. I couldn’t decide what was expected of me at this moment – was I really supposed to advice her on first-night behaviour? Or is it the tradition that each guest offers their tips for a successful marriage? I didn’t think it would be appropriate to tell her to get drunk and not worry about things (the advice we tend to offer back home), so I just told her not to be late for work the following week. She smiled, and I was off the hook. No cultural blunders that day, as far as I know!

It can be incredibly invigorating to depart from an intense working environment for a while. Once you set out you feel immediately liberated, you stop shaving, you walk for hours and you can eat street food 6 times a day because set meal times no longer have any hold over you.  After 3 months of staying in one place, freedom is achieved in small gestures of this kind.  I carried my friend’s new baby through the Gambian bush, helped a hoteliers daughter with her history homework, and swam in the river before a dinner of barbecued fish and beer.

The return from holiday can conversely be tough. People express their pleasure at seeing you again by recounting all the problems and stresses that occurred during your absence, for which you (momentarily) feel culpable. But you also quickly realise that everything worked at least as well as normal when you were not there. So perhaps part of the benefit of being away is to help you contextualise the work you do, to realise that life goes on just fine without you, but somehow the people still want you to be there.

I’m back now in the swing of things. And perhaps something has changed – for yesterday, for the first time a child talked to me. (Admittedly, it’s not often that we have a child over the age of 3). He said good morning, said he was feeling better, and that he would like to eat some fish. I told his mother that all this was a good sign, but of course I refused his request for fish. I’m a doctor after all; it’s my job to deny people what they want (even if I’m in a magnanimous mood after my holiday). He can have a disposable glove blown up into a balloon, and will have to make do with that!

It creeps up on you, doesn’t it? You swing from task to task – one minute examining a child with severe malaria, then settling a dispute between staff, then trying to check someone’s ability to convert a dose in milligrams to millilitres, then throwing the cat out of the Intensive Care Unit. You feel you are in control; perhaps you are vaguely aware that you have worked every day for the last 15 days, but you think to yourself that this was a one-off and wont happen again. But then finally on your rest day you get called in to the hospital to deal with a staffing issue, and all of a sudden you realise you are dreaming of malnourished children and waking up with work on your mind.

One of the curious features of psychological stress is how ridiculous it feels. You remind yourself that there are far more stressful situations than this, and perhaps you yourself have been in more stressful situations, so to be stressed now is inexplicable. What’s more, it reflects an unsustainable short-term outlook. The stress is linked to the fact that you have been overworking, and whilst it may be that lives are being saved as a result, you know full well that relaxing and pacing yourself is ultimately more effective in terms of impact on the patients, and in terms of ensuring your own quality of life. Stress feels ridiculous because you know you have been here before, and you should know better by now.

Well, after (a) feeling stressed and (b) criticising yourself for feeling stressed, you are only left with one more option – (c) to accept it, and to express it, and then to make an enormous cup of coffee and get on your Hero and cycle into the dusty Harmattan wind.

I might just stop off at the hospital en route to check everything’s alright…

The discharge area is definitely the most fun place to be in the hospital. Discharges take place in Phase 2 – the section of the centre dedicated to those children who are ‘cured’ of whatever medical problem they came in with, and are now gaining weight on a high calorie diet before being set free. So when the mother finds out she is about to be liberated, she becomes ecstatically happy (as this means not only that her child is cured, but also that she can now go home to her other 7 children to make sure they have a chance of survival too!). The child usually becomes aware of the change in his mother’s behaviour, but interprets this with caution. On the day of discharge, he senses that something dramatic is going to happen, and bursts into uncontrollable tears when you enter the room to carry out the final examination.

Now, if we follow this child’s progress back in time, we pass first to the phase of transition, where he is recovering from his medical condition and is trying to get used to the taste of plumpy nut for the first time. Prior to this is phase 1, where children are often sick, limp, horizontal and moaning, with metabolisms that are not yet working properly and infections that their weakened immune systems are fighting to control. This is the entry stage for most children. But any child that is in a really bad condition is sent directly to the intensive care unit. This is where I spend most of my days. If you get admitted here, you have an 80% chance of getting out alive. The children get injections and incisions and tubes put in, and if they make it through all that there’s the psychological trauma to deal with. So when I sit with a child at the time of his exit from Phase 2, and I start to feel hurt by his disdainful tears, I have to remind myself that my relationship with him began in the intensive care unit, and that I am a face he would rather forget.

Do I sound pessimistic? I don’t believe I am! I’ve learnt to love the sound of tears! That uncontrollable expression of life force that indicates a strong pair of lungs and a child that is on the mend! And when occasionally it is followed by a little laughter, or more miraculously, by a child who reaches out to you to hold him (whilst he quietly pisses on your trousers), then I get a taste of the euphoria the mother feels when she finally arrives home to display this bouncing smiling child, in place of the bundle of bones she set out with.