“When I had the test yesterday I told the guy, ‘God forbid, if you find HIV in me, please, don’t give me the news, just give my parents the news…because if you tell me I might just go straight and commit suicide.’”
Abraham,[i] a small time real-estate agent and sometimes used-car salesman, was recounting what he called “the dark stage of my life.”
He had been feeling under the weather for a few weeks; his body ached and his energy dipped. The week before, his back began to nag him and he developed a burning sensation in his legs. Then he came down with typhoid and malaria, a dizzying, feverish combination of diseases. “Another crazy sickness,” Abraham said, but “that’s like the general sickness here.” Malaria is so common, Nigerians brush it off like the flu. There are an estimated 100 million malaria cases annually here. Any illness or general malaise is immediately assumed to be the parasite. But as quotidian as it is, it is also lethal: there are 300,000 related deaths every year.[ii] For Abraham, though, his typhoid-malaria cocktail was the entry into another horror.
“When I went for the result and they told me ‘oh you’re HIV negative,’ I was all calmed down, relieved,” he said. He drew his last syllable out to a sigh.
But the same blood tests revealed he had hepatitis B, along with malaria and typhoid.
Hepatitis is called a “silent killer” because most people don’t find out they have it until too late. The disease is largely asymptomatic until it is so far advanced to be mostly untreatable. Abraham was lucky to find it in the slew of blood tests he took when he fell ill. More than 780,000 people die of complications of the disease, mostly liver cancer and a type of liver damage called cirrhosis. According to the World Health Organization, 240 million people in the world are chronically infected with hepatitis B, which spreads through blood and other bodily fluids. Eleven percent of Nigerians have hepatitis B, and 2.2 percent have hepatitis C. In a country of 177 million, that means there are 20 million people with hepatitis.
Across sub-Saharan Africa an estimated 5 to 10 percent of the population is infected. In North America and Western Europe, on the other hand, less than 1 percent of people are.[iii] In the US, the 1 percent that has hepatitis is mostly a high-risk group that includes sex workers and injecting drug users. In Nigeria, though, hepatitis is endemic. In addition to the 13 percent that currently has hepatitis, 30 percent of the population has had it and recovered. This means nearly half of Nigerians have had hepatitis at some point. It spreads through many activities that mix bodily fluids. During vaccination campaigns health workers used to use a single, large syringe, pricking children one after another with the same needle. Many health workers and informal health workers reuse syringes. Barbers reuse razors without properly sanitizing them, and people cut tribal marks into skin with unclean sharps. Mothers pass the virus to their babies during childbirth. It is only rarely spread through sex.
A vaccine for hepatitis B has been available since the early 80s and is 95 percent effective. American schoolchildren are required to get the vaccine in all but three states.[iv] It was only in 2012 that Nigeria began promoting the hepatitis B vaccine in a combination of five free vaccines for children. Even with the free vaccination policy, Dr. Omede Ogu, the hepatitis desk officer at the federal ministry of health, noted that 64 percent of mothers are not delivering in health facilities and are likely missing the vaccine.
Nigeria developed a hepatitis policy just last year. The five-year plan costs 131 million US dollars, and it is not yet funded. But Nigeria is actually a leader in the hepatitis response. Around the world, hepatitis has been largely neglected. The World Health Organization made its first declaration on hepatitis in 2010. “Other countries are coming to learn from us; many countries don’t even know how to start to establish a structure. In Africa I think Nigeria is taking the lead,” Dr. Omede said.
But, he said, most Nigerians know nothing about the disease, and the little they know is often shrouded in misconception and taboo.
“Awareness is biggest challenge we have,” Dr. Omede said.
When Abraham received his results he didn’t know any of that. All he had heard was that hepatitis was “a disease that’s contagious and a sexually related kind of thing.”
In so being, his diagnosis came not only with fat medical bills, but also with stigma and shame. “It’s like you saying I have syphilis… for the society it’s not something people would really want to hear you having,” he said. “And you know we Nigerians have a jump mentality. When they hear you have a STD related kind of sickness…they take it to another level entirely. ‘Oh are you sure its just the hepatitis? Are you sure he doesn’t have AIDS or HIV or something?’ You know, these are the things they ask.”
To Abraham, an HIV infection was one of the worst things imaginable. “HIV is like the death sentence of all illness as far as the human mind is concerned,” he said. He recalled images of late stage AIDS victims, people shriveling from a full, muscular physique to complete emaciation. Finding out he had hepatitis was “the horror of my life,” he said. But at least it wasn’t HIV.
“It’s just a dangerous disease, it’s not a dreaded disease,” he said.
Lagos, a city of 20 million, can often feel like a small town rife with gossip, known colloquially as “gist”. Notorious local gangsters called area boys are normally described as an urban scourge, or alternative security guards, but they also illustrate the subdivisions to the sprawling metropolis. Everyone, not just the boys, refers to their area. Inside their pocket of the city, residents expect a certain level of recognition, familiarity and rights. During a fuel shortage, Abraham drove to the gas station down the road. Boys had shut the gates and were demanding 200 naira ($1) from drivers to enter. Abraham exploded “In my area?” He pointed to one of the thugs inside, said he knew him, and the gate boys waved him in.
Abraham spends most of his time driving around his area. His real estate deals are mostly local. His parents live on the top floor of a white concrete building in Yaba. Abraham rents an apartment he shares with his sister in neighboring Akoka. He mostly drives between the two homes or hangs around Moleye Street, a small road in between the two. There he helps a friend flip used cars, or chills and gists with members of his parents’ church or his “bad boy” friends.
He drives a small, dated Mazda sedan. He washes it almost every day before setting out on his errands, especially during Harmattan. In Nigeria’s dusty, windy version of winter his car is coated in fine red powder each night. He pays one of the street boys to polish it away. The fuel gauge is broken, so he follows his “intuition” to know when to top up. The car is not the model he would like, but it is precious. Inside he is independent and free to daydream.
Abraham is 35 years old and single, but he is doggedly optimistic. Nigeria was named the “happiest country in the world” in a 2011 Gallup poll[v] and there is a striking joie de vivre here, seemingly incongruous with the quotidian challenges. A cash-strapped, single fashionista, Abraham is not only certain that he will get married, but plans to wear an Armani suit and Louboutin shoes when he does.
One afternoon he drove his mother and niece through thick midafternoon traffic to the bank. As he waited to turn into a clogged intersection, a shiny black Mercedes sedan inched past.
“That’s my car right there,” he said.
Jola, his 4-year-old niece pointed at a bright yellow tricycle taxi called a “keke”.
“Daddy is that your car?” she asked.
“No, no, this is my car” he replied, pointing back at the Mercedes.
He was driving his mom to the bank both out of family obligation, but also with the hope of borrowing money for a medical test. In addition to the stigma of contracting what he thought was an STD, Abraham’s biggest problem was that he was broke.
Youth unemployment in Nigeria is as high as 50 percent. Most young people, like Abraham, hustle for a living. He lives a regular boom and bust cycle, albeit a small scale one.
“You know two months ago I had 200,000 naira ($1,000). Now I barely have 2,000 naira ($10).” He said. “I think the problems in Nigeria are made worse by us not being a cashless society.” He wondered if his trials would be lightened if he could use a credit card.
Instead, when there is money, he catches up on the things he has been craving. “When I don’t have money everything is just a scarcity. Like right now, I don’t have money. I’m not bothered with stuff that I lack that I think I need, like cologne…When I need a good cologne like maybe a Givenchy cologne or Hermes or Christian Dior…I try to just take my mind off it until I have the money. As soon as I have the money I’ll go for it.”
In the meantime, when there are big expenses or emergencies, people mostly borrow. The month before his surprise hepatitis problem, he paid back a 70,000 naira (US$350) loan. He had borrowed from a friend of a friend to secure his apartment a few months before. He was lucky that he only had to pay one year up front. Most landlords in his neighborhood demand two years rent, cash, in advance. Lagos state has outlawed this practice, but the rule is not enforced. Landlords know their tenants scramble to pay most expenses. Monthly rent could easily lead to monthly conflict or months of delay.
Abraham’s parents were also struggling. They are both national leaders, called prophets, in the Cherubim and Seraphim church. The church is one of a handful of Aladura churches—indigenous Nigerian denominations that emphasize spiritualism and mysticism. His parents lead a small congregation called the Sanctuary of Healing in Lagos. It is a tin-roofed, cinderblock structure adorned with flowing mesh fabrics and twinkle lights. His mother is a Yoruba princess from one of the royal families in Kwara state and has traditional tattoos across her forearms befitting her rank. His father, a retired army engineer and national boxing coach, heads the church’s national disciplinary committee. He was invited on a state-sponsored pilgrimage to Jerusalem the week Abraham fell sick.
But their status and position earned them respect, not money. Of seven children, only one had a white-collar job. Abraham’s older sister worked as civilian staff for the armed forces. Her salary was small and she hustled most weekends as a juju music singer at weddings and birthday parties. One of his brothers had moved to Malawi seeking a better life. Another sister trekked back and forth to Ghana importing small shipments of trinkets and sandals.
“In Nigeria it’s a normal thing, especially when you don’t belong to the political class or the professional classes. When you find yourself in just the normal average class, not the lowest class but probably the low class in the society…being broke is totally normal,” Abraham said.
Over 62 percent of Nigerians live in extreme poverty. Abraham’s family was, as he described, totally normal. Having $10 in his bank account was also normal. Financial anxiety was an immediate and debilitating side effect to his diagnosis.
“Funds is my enemy right now,” he said. “I hope it won’t be something that will cost me my car.”
Nigeria’s formal, fee-for-service health system is largely unforgiving of financial hardship. It is standard at hospitals to pay in advance for each service rendered, and most Nigerians don’t have insurance. A patient pays first to be admitted and for a consultation. Once seen, the doctor writes a prescription for any necessary test, scan or procedure. The patient then brings the slip to the appropriate department, where the staff writes an invoice. The patient goes to the cashier and settles the bills. Only when they return with a receipt can they receive care. That’s in the smoothest possible instance, where the patient has money and is seeking services from a single source. That is rarely the case here, and certainly not for Abraham.
His healing process was akin to a road trip, though he stayed within three neighborhoods. Hours were spent in the car jamming to the same, repetitive 90’s RnB playlist and driving between a hospital, a pharmacy, an independent laboratory, a traditionalist and a church, interspersed with frustrating, lengthy trips to the bank. Each location offered its own solution to his health crisis, as independent from the others as spokes on a bicycle wheel. Abraham was the only commonality between the diffuse, concurrent health systems.
First stop: the hospital
Abraham pulled into the railway compound in Ebute Metta. The federal buildings are beautifully archaic. Many of the architectural relics in Lagos are government owned. Caught up in land feuds or overdue for maintenance, they stand for decades. Colonial style white shutters and broad verandas line the railway offices. Just past, the hospital has blue and white geometric detailing. An angular ramp connects the floors. Four men in scrubs painstakingly guided a stretcher down the rutted surface. When they came to the base we could see a woman with her leg in a cast wincing with every jar. Old buildings are more photogenic than functional.
“Man, look at that, man I hope my case won’t be like this. I pray,” Abraham said, nervously.
We climbed one level of the ramp and Abraham called a friend who works in the hospital. He met us on the landing and pointed Abraham to the diagnostic center. It was a dingy room the size of a closet. There were five stools in the room, which took up most of the space. The center stool served as a makeshift desk. Vials of blood with purple and green caps were propped in a white plastic stand. The stagnant blood had separated into a thick red base and a translucent upper layer.
Abraham sat and handed over a pile of paperwork to the lab technician. Dressed in a brown hooded tee-shirt he did not look like hospital staff. But he was deft and confident as he drew the blood.
The technician looked through the colorful stack of referrals for tests and scans. One ordered a viral load test to verify the advancement of the hepatitis.
“This thing will cost a lot,” he told Abraham.
“Like how much?” Abraham asked.
“Just program 30k ($150),” he answered.
At the moment Abraham had 5,000 naira ($25) in his bank account. For now, he took one of the cheapest tests on referral, a 3,000 naira ($15) test to confirm the hepatitis.
The viral load is the essential test that determines whether the hepatitis is latent or advancing. Most people who have hepatitis are simply carriers, but there are one to two out of ten cases that will advance to deadly liver damage. The viral load test, along with a liver scan are the medically necessary tests that would determine whether Abraham needed to treat the hepatitis and if so, how. But Abraham did not know that. The doctor had prescribed numerous tests but had not explained how to prioritize them. And Abraham could not afford the most pressing and expensive tests.
Because the lab technician was a friend of a friend, he took his blood before Abraham paid. After, Abraham walked down the dusty street to the bank. A dozen people were queued, sweating stickily in bright synthetic blouses and wax print ensembles. Abraham ran off to buy a hankie for 100 naira (50 cents).
I waited next to a massive generator while he used the ATM. He returned looking dejected. He had an error with his Bank Verification Number (BVN). The BVN is Nigeria’s attempt to implement a single numeric ID for each citizen, like a social security number. It is meant to link all of a person’s bank accounts and combat identity theft. But the implementation process has been clunky. Abraham made a clerical error on his application so his bank account was locked down.
I lent him 1,000 naira ($5). He promised to reimburse me later that day, after he visited his other bank. I had explained to him the ethics of reporting; that I could not both write about him and help fund his treatment. He assented, but we talked about it repeatedly. It was a sore spot, a cultural rift, both because of the confusing one-directional intimacy of reporting on poverty and trauma, but especially because in Lagos relationships are deeply transactional.
Abraham was clearly still working through his concept of good friendship.
“The Nigerian situation has really made people too money conscious. They put money first before any other thing, especially in a relationship,” he said. He had broken up with his girlfriend a couple of months prior. “She was being demanding, she was expecting more me taking care of her kind of relationship, me footing every of her bills… I’m not signed up for such a relationship. I want genuity, I want love, I want a confidante.”
Monetized relationships are standard here. Pop music affirms the value. Wizkid, a hit singer has a single called “show you the money.” He sings, “are you gonna dance o/if I show you my money…are you gonna dance o/if I show you my pocket/are you gonna dance o/if I show you my wallet.” People dance, flex and sing along without batting an eye.
Another dancehall jam from Patoranking brings a more romantic spin to patronage dating. “My woman my woman, my everything/my woman, I go fi buy you anytin,” he croons. Music site 360musicng analyzes the lyrics as “Self-explanatory; ‘my woman, my everything’ is as it reads and sounds — a tribute to the woman after his heart and every woman keeping it real out there.” It takes as standard that affection is demonstrated through gifts.
“All the girls…they just want to know, is he rich? Is he rich? Is he rich?” Abraham complained.
Friendships are similarly knotted in layers of responsibility. “They don’t choose friendship based on mutual understanding, affection, passion and the likes, all the elements that make the friendship worth it. They choose it on yeah he has money he will be able to foot my bills or something, I can run to him for help every now and then. I don’t believe it should be all about that. I believe it has to do with friends helping each other not money wise…but moral support.”
Most of Abraham’s “friends” were people he was afraid to speak to. “I have the kind of friends that will make it the news everywhere,” he said. He had a few friends he really trusted, friends that perhaps fit his concept of moral support. They were also the ones he called in his hour of financial need. “I have very few nice ones maybe two or three I can call real friends. But I wish they were mega rich, you know then I can say yes I have friends that can help me out,” he said, snapping his fingers, “and get this thing over with ASAP.”
Even as he wished for a simpler relationship, he participated in the cycle of obligation and expectation.
After leaving the hospital, he called on one such friend. As normal and as necessary as asking for money is, it still filled him with shame.
“I hope he will be able to help…you know the problem is I don’t like when I call up someone for help and I get turned down. I feel sad…so its always very difficult for me to pick up my phone and make calls because now you know my situation and now there is nothing that can be done about it.”
He toyed with his phone in his cramped but meticulously arranged room. A framed Picasso poster hung on one wall, an oil painting on another. The light from his single window glowed through an ice blue curtain decorated with polar bears. His walls were painted royal blue. He told me that a spiritual man had told him once that his colors were blue for blessings, yellow for courage, and white.
Sighing, he called. Snaking fluidly from Pidgin English to Yoruba he recounted the ordeal from the beginning.
When he hung up the phone he told me, “He’s broke for now but by Friday he’ll be able to give me something small, however small it is.”
The family lab man
Back on the road again, the same circular beats on the stereo, Abraham was looking for phone credit and a snack. In the afternoon, vendors sell fresh crudités from wheelbarrows on the side of the road.
“I’m trying to look for cucumber and carrot,” he said, “I don’t even know what to eat. I have to be very mindful of what I’m going to put in my mouth.”
Before we set off he had been researching hepatitis on his iPhone. “I think one of the major contributing factors to the whole hepatitis thing is what one eats,” he said. But the advice he found was foreign to him.
“‘There is some controversy over whether you should take distilled water in moderation,’” he read. “‘Try these recipes for gluten free all purpose flour and gluten free whole grain flour. Avoid hydrogenated oils, you have a different choice, the better choice is virgin olive oil.’”
He interrupted himself, “I have no idea what all these things mean…I will go and buy credit and I will call my lab man. I want to ask him what I can eat.”
Phones are pre-paid in Nigeria. Abraham has two, an iPhone 4 and a Samsung. He took a detour and stopped by one of the small colonial bungalows that still stand in his neighborhood. A slim, middle age woman hurried out when he honked his horn. She wore a side slung nylon bag, the de facto uniform of phone vendors. He bought 200 naira ($1) each for his Etisalat and Airtel lines.
Abraham was trying to call the lab man “because the man has a long experience of medical whatever, you know he knows a bit about this,” Abraham explained. “He told me I have to stop eating…liver and intestines, and palm oil, and what was it again, of course I have to stop alcohol and I drink Guinness a lot, I’m crazy for Guinness.”
They had discussed this before, but after looking online Abraham had more questions. He called the man to ask if he could stop by his office.
I thought that he was referring to the man who took his blood earlier at the hospital, but Abraham said, “no I want to speak to the family lab man…he’s a lab scientist we go to for tests and we’ve been using him for so many years…he was the one who did the first test for me, he was who made me aware of the situation.”
Since he was a trusted and longtime contact, I wondered if he would do the expensive, 30,000 naira viral load test for Abraham on credit.
“I think he might not have the facility…and even if he does, most of all those hospitals, they prefer to get the result from a reputable institution, not just any company.”
I imagined that this could be true in the Nigerian context, that a hospital would only take the test results from its own lab. It was only when I arrived at the lab that I realized it was a completely different genre of health facility.
Abraham parked in front of another bungalow. Inside, a single long hallway was paved in uneven concrete. A dog cooled its belly on the floor and kids peeked out from the single-room “face me, I face you” apartments.
The office was the last door on the left. A small waiting area was lined with two plywood benches. Posters from the hugely popular Redeemed Christian Church of God (RCCG) Pentecostal church were affixed to the walls. The 2013 “signs and wonders prophecies” calendar was pasted next to the 2015 “all sufficient god” one. The expired premonitions still seemed applicable: “The reasons for your stagnation will be known, addressed and eliminated, therefore progress will follow.”
When we walked in, Goye, the lab man hurried out. From the backyard he “onned the gen”, e.g. fired up the small individual generator known colloquially as “I pass my neighbor”. Soon the overhead fan started its slow whir and the weak light illuminated. Fumes from the motor poured in through the two windows and the air inside grew thick.
Behind a thin plywood partition was the lab. A rusty centrifuge and an ancient looking microscope were the primary instruments. Vials of blood were stacked on neatly piled papers.
“We are checking his electrolytes, we are checking his creatinine, that has to do for kidney and his liver as well, for cramps and numbness in the hands,” Goye explained. He spoke assuredly as he broke down the medicine but he had a tendency to tease. Decades older than Abraham, he had a solidity to his stature. He had quick fingers but a heavy gait.
“This was part of what I complained to the doctor that’s why she wrote that…I should do the electrolytes. But I told her I was having a stinging sensation on my finger tips and at times numbness on my finger tips.”
Goye tied Abraham’s wrist with plastic tubing then inserted a syringe, beginning to extract blood. The flow was slow, he said. He couldn’t seem to get a vacuum. As he pulled, only a splash of blood came into the syringe. He pressed the plunger back in, then pulled again; then again and again. Abraham began to writhe and scream in pain. Goye gave up and switched to the other hand. Again, he pushed and pulled while Abraham screamed.
“It’s not flowing o,” he said.
Goye held an esteemed and deeply trusted position for Abraham and his family. Goye allowed him to pay partial fees (3,000 naira for the tests that day). And Abraham respected him, referring to him constantly as a medical professional. “Goye said you can’t come and see his work while he’s doing everything; that’s just the way most of these professional people are especially when it comes to the medical field,” Abraham said later.
However, his unlabeled practice, his privacy, and his poor skills with the syringe are all signs that Goye may be a “quack doctor”. Quacks are individuals with little or no qualification who pose as doctors or health workers. In the context of overpriced private clinics and state run health facilities that are often understaffed, under furnished or suffering from strikes, these cheaper independent options proliferate.
Sometimes quacks worsen the problem, or cause it. A third of new hepatitis patients in Nigeria are infected by “the use of unsafe injections due to the negligence of some medical practitioners and quacks,” according to Professor Funmi Lesi, one of Nigeria’s top hepatologists at the Lagos University Teaching Hospital (LUTH).[vi] About 2 million people contract hepatitis from unsafe injections in Nigeria, according to the Society for Gastroenterology and Hepatology in Nigeria.
Goye could have been reusing syringes, spreading hepatitis among his patients. I did not see him do so, but it is quack doctors that administer many of the unsafe injections that spread the virus in the first place. It is possible that Abraham had contracted hepatitis from the very place he went for treatment.
Informal health practitioners in Nigeria are often working with the same equipment, if not the same principles as Western—what Abraham called “orthodox”—medicine. They just don’t always know how to use the equipment. “They know a little bit more than [Abraham],” Dr. Lesi said. I met with her at LUTH much later and she analyzed the many steps of Abraham’s journey. Quacks, she explained, “haven’t been trained. They don’t have that much knowledge themselves.” But they have a lot of trust and they are more accessible and affordable than the hospital
In addition to the lab man, Abraham called his “family nurse.” He described the family nurse as an independent medical practitioner who works on her own, unconnected to an official institution and managing her own caseload. His own family nurse also worshipped at his parents’ church.
He tried to schedule an appointment for her to give him an IV antibiotic for his typhoid. He stopped taking the oral medication because he complained it was “draining me up.”
“Antibiotics dry out your blood, that’s what they do,” he told me, “I wanted the family nurse to come and do the transfusion to fully flush it out of my system.”
In addition to the danger of inadequately sterilized needles, 8 billion injections are unnecessarily administered globally every year, another important factor in the spread of the disease.
But he couldn’t reach the nurse. “She’s a very busy woman,” he said. He estimated she managed at least 100 patients.
The pharmacist
The day I met Abraham to visit the pharmacy, he was in particularly low spirits. He said he had slept “terribly” because “the pain is still there.” He was picking at a bland, boiled sweet potato in the living room for lunch. He seemed disheartened and indecisive. “Once I see the pharmacist then whatever he says, he will tell me what to do.”
After he showered and changed we walked downstairs to the car. As we were about to climb in he decided it needed another wash before we could go. We sat on a bench and watched a soccer game that had taken over the dead end street. Sweating, nimble players tussled over the ball in a cloud of dust as another teen wiped down the Mazda.
The pharmacy Abraham visited was the farthest flung stop on the road trip. We drove past Jibowu, the overpass where long distance buses park before splintering off across the country. We skirted Palm Grove where buildings with 1930’s art deco accents still stand. Finally Abraham pulled up next to the “Drug Consult Pharmacy” on a side street off Ikorodu road. A friend had seen signs about hepatitis on the pharmacy’s windows and suggested Abraham check it out. He figured the ads meant the pharmacist was a specialist. When Abraham visited, he was convinced.
The front windows were indeed plastered with PSAs. A small sign advertised HIV testing and counseling beneath the accolade “heart to heart…we listen, we care.” Next to it a lengthy green sign listed prevention tips beneath bold lettering: “Think you’re not at risk for Hepatitis? THINK AGAIN.”
Inside the pharmacy, shelves were packed with lotions, vitamins and stomach aids. The owner, Charles, set plastic chairs in one of the aisles and invited us to sit. He apologized for the cramped, makeshift arrangement. He said he was remodeling to construct a consultation room and pointed to black plastic sheeting covering the back half of the pharmacy. Over the top of the barrier were visible Redeemed Christian Church Posters, like the ones at the lab man’s office. One showed the smiling face of the head of the church, Pastor Enoch Adeboye overlaid with the quote “if you think of impossibility you don’t think with god.”
Abraham had been to see Charles once already since his hepatitis diagnosis. Charles had prescribed a drug called Essentiale Forte. Abraham’s parents had given him the 3,000 naira ($15) for the dose. Its product description on Amazon promises: “this originally formulated complex saved many lives and is nothing short of a medical miracle.”
“Essentiale Forte is a good multivitamin for the liver,” Dr. Lesi said. When I asked if it would wipe out his hepatitis as the pharmacist promised, she pursed her lips and shook her head.
After additional blood tests, Abraham returned to check in with Charles. The meeting with Charles was like a meeting with a doctor, not a pharmacist. It was Charles who looked over test results and suggested what medicines Abraham should try. He was not solely filling prescriptions from the hospital. This was why he was building a consultation room in his pharmacy.
Quacks in Nigeria are not as straightforward as they look in the movies (they are a common antagonist in Nollywood films). Many of them have some skills, but they do not stay in their role. The lab man clearly had some chemistry skills, which he extrapolated into a full on testing facility. The pharmacist probably studied pharmacology, but he mutates into a frontline health worker.
Charles oozed charisma and warmth. His concerned face honed in on Abraham as he asked how he was feeling. Abraham worriedly stood and opened his eyes wide to show Charles. His sister that morning had told them they looked yellowish, one of the symptoms of acute hepatitis.
Charles peered beneath his lower lids and said, “They’re not yellow.”
Abraham laughed with relief. “I was so worried! She had me so scared this morning!”
Abraham handed him the rest of his test results, the third health professional he had shown the rainbow stack of papers to.
The latest tests showed he had mildly high cholesterol, just above the normal range. Charles suggested this might be causing his leg pain. He explained that cholesterol in the body is like grease; when it’s cool it solidifies, like cooking oil in a chilly kitchen. That, he said, was why Abraham was having worse body pains at night, and also why it was important to exercise to keep the blood flowing. He prescribed him a cholesterol medication, a painkiller and a sleeping pill.
The total was more than Abraham could afford, so Charles took out the sleeping pill. He said that since it was the pains keeping Abraham awake, he should be fine just with the one. Abraham still emptied his wallet of all of the 6,000 naira ($30) he brought.
By the next day he said he was feeling much better. “Slept like a newborn!” he texted. “Think it’s because of the cholesterol medicine. Remember it’s the bad cholesterol that’s giving me pain?”
Dr. Lesi said Charles’ diagnosis of leg pain from high cholesterol was medically baseless. More broadly, she said Abraham’s competing medical authorities were “an aberration. It’s not the pharmacist that is supposed to be treating the patient, alright? But [it is] his default option because he obviously doesn’t trust the hospital and he couldn’t afford it. Meanwhile the pharmacist will see him because he’s going to buy drugs,” she said.
“Unfortunately there are not many people like me either that have more knowledge on hepatitis b. In Nigeria we are about less than a hundred hepatologists. It is like a drop of water in the ocean… insufficient health personnel is a huge issue,” she said.
Interlude for love
A few days later, Abraham was feeling much more stable. He was confident his hepatitis was not in “the danger zone” and he was sleeping better with the drugs Charles had prescribed. He was still broke, though, and still fighting to fix the clerical error that had shut down his bank accounts. This was particularly bothersome because he had a date that night.
“I just met a chick,” he said.
We were parked, waiting through yet another car wash.
I was surprised, as I knew he had broken up with his girlfriend shortly before falling sick. But this was a new potential.
He tried to play cool, recounting how he needed to take an “okada” motorcycle taxi down a small road to meet a house-hunting client. He had parked his car and was waiting for a bike when he saw this woman walking by.
“I’m like oh who’s this? She’s old, not old, old, old, but from my own belief I just think she’s pretty old…I’m certain she would be in her thirties. So but she looks ok, she looks cute and all that,” he recalled.
They greeted as she passed, then when he caught his motorcycle he slowed to chat her up again. He offered her a ride, which she declined, saying she was nearly at her office. But she did give Abraham her number. He stopped by later that afternoon. She worked as a civil engineer at the railway. “At least I know she won’t ask me for money,” Abraham said.
He invited her out for dinner after work. The only problem was he had 500 naira ($2.50) in his wallet. His plan was to take her to a little restaurant on Moleye Street, his regular haunt. He knew the owner so he was sure she would let him put the meal on his tab. “I would have loved to take her somewhere else,” he said.
In the meantime he headed back to Goye for his test results. Goye found that he was on the verge of hypertension, but not yet out of the normal range. Still he blamed Abraham’s high sodium levels for his insomnia.
“He needs frequent fruit, a lot of water, by the time he drinks water, the sweat is coming out, urinating it away, it will balance out,” Goye said.
The tests cost 7,000 naira ($35) but Abraham gave him 1,000 for now, leaving the rest to debt. Abraham still owed Goye 9,000 naira ($45) overall. But he hurried out of the office for his date with Zainab.
“I just want to make myself happy you know, I don’t want to stay depressed…while I wait for the next thing that happens in my life.”
Even though Zainab had a good job, and even though he was still too broke to keep up with his medical bills, he was spending money on her.
One afternoon he stopped for a quick trim at his corner barber shop. Many barbers set up shop directly on the side of the road. They hang a single bulb from a tree branch, lean a mirror against a wall and arrange a table and chair. Abraham’s barber was one step up. The tiny two-seat shop was set up inside a shipping container.
After Abraham sat, the youthful barber pulled the brushes and clippers out of a plastic box that opened forward like a toaster oven. “Sanitizer” was written in white on the front, though the device was not plugged in and was packed to the brim with instruments. The sharing of razors and improper cleaning of barbing equipment is another common way hepatitis spreads.
As the barber buzzed his scalp, Abraham called Zainab. She complained that she hadn’t eaten yet that day. He offered to pick up food for her and sent one of the barbers out to pick up swallow and sauce for 600 naira ($3).
“A relationship in Nigeria comes along with responsibility, bills, you know they are attached together…there’s no way you can detach yourself except if you just don’t want to win a woman’s heart,” he said.
The herbalist
Throughout his process, Abraham had been speaking with an herb specialist. He was loath to call the man an “herbalist” which has the connotation of a witch doctor. At first he hesitated to mention the traditional medical practitioner at all.
“I think maybe he got the whole herbal thing from his parents, I don’t know…but he’s not really a herbalist,” Abraham said. He pointed out that herbalism is not the man’s full time job, though he didn’t know what other work he did.
Years earlier, a church member introduced Abraham to the traditionalist. She attested that after eight years fighting high cholesterol with conventional medicine, he had cured her for good.
The traditionalist told Abraham that he could “wipe out” his hepatitis and cholesterol for 37,000 naira ($185). Abraham needed to prepay so the traditionalist could procure the necessary herbs, then wait seven to ten days for the “herbal potion” to brew.
“It’s not a lot [of money], because you know if I’m to go through the hospital way, the medical way, it’s going to cost more than that,” Abraham said. He also preferred herbs, which he took regularly for various ailments.
“I like to take herbs, I think they work faster, it’s more potent than the modern medicine.” He felt that herbs were the original, functional treatment for illnesses. “Humans has been in existence long before orthodox medicine came into place and also people obviously have been treating themselves via the herbs you know long before we had the orthodox practitioners.”
He worried about the side effects of the conventional medicines he was taking. “I don’t want to keep using these synthetic drugs…these chemicals, they treat one thing and deposit something into your system as well so at the end of the day you get more complications.”
Despite his preferences and beliefs, so far he had not told any of his medical practitioners about the others. He had not told the traditionalist about the drugs he was taking, or the pharmacist about his plan to use the herbs. He was nervous about the opinions of his providers and about the stigma around different modalities. “One thing is for sure, if I ever mention the traditional to the orthodox medical practitioner, they don’t really support using it and they tend to speak against alternative medicine, they tend to discard it. Only very few among them agree that alternative medicine is good.”
Abraham, though, was convinced herbs were not only his best option; he saw them as his only choice. “According to what I’m being told, in the professional medicine way they say it can only be controlled but it can’t be completely eliminated from the system. Every one of them, that’s what they’re saying: it can be reduced to a very minimal point, a very harmless point. It will not be active but it will be in the body system,” he said. “But the other man is saying he can eliminate it out of the system completely…so I don’t want people to scare me that you can only control it, that’s bull crap. I don’t believe in such words.”
Medically, without knowing when he contracted Hepatitis B, he could not know whether it was chronic as he assumed, or if it would go away on its own. If he got the hepatitis from his mother at birth, he had an 80 to 90 percent chance of having the chronic disease. But if he contracted it as an adult, in 90 percent of cases the infection goes away on its own within a year.[vii] In that case, all the liver detox supplements and herbal concoctions he could buy could never be proven effective. Since he had never been tested before, there was no way to know for sure. He would simply need to be tested twice a year to monitor the disease. But the semi-annual testing would cost him 100,000 naira ($500). Since Abraham believes in all of the systems equally, it made sense to him to stick to the cheaper, supposedly more potent herbs.
Dr. Lesi, of course, had a different analysis “rather than him spending the 30k on that native guy, let him just get the viral load test. Because we see people like him, after he goes and does the herbal treatment, he goes away happy, next year the hep b is still there.”
The Church
Abraham’s parents were less enthusiastic about the herbs. A generation older, less educated, and deeply religious, their own constellation of health systems primarily consisted of the lab man and God.
“It’s not that they are against [herbs] in any way, they are not, but they just feel they are comfortable with praying. They feel very comfortable with prayer and praying.”
Spirituality was key both to Abraham’s healing and to his understanding of what befell him. “Every sickness has their own spiritual forces,” he said. “Yes we take drugs and all that, these are just the physical part of the process. In actual truth and reality sicknesses comes with demonic attacks. Sickness is not something of god; it’s from the devil. Just as blessings, good health, are gifts from the Lord Jesus Christ, so our sicknesses, fear, diseases, sorrow, anguish, all these things are also gifts from the devil.”
He said his hepatitis had spiritual causes. He felt he had dropped his guard against dark forces, “by being careless, having multiple sex partners,” and also by missing church. “Let’s say most of the time I don’t go to church. Like in every month we have about four Sundays, at times I don’t even go for the four Sundays. It’s bad, it’s really bad.”
The week after his diagnosis, though, he made it back to church. He arrived late, sporting his favorite Alexander McQueen glasses—which he insisted were real—and the floor length white robe worn by Cherubim and Seraphim adherents. The church, started 90 years ago, is the precursor to contemporary Pentecostalism. The language of good and evil, demons and miracles was omnipresent in the service. The seeds of his personal exegesis were clear.
He stood in the back as the preacher bellowed, “Every serpent shall be set on fire in the name of Jesus!… Every serpent swallowed, you should vomit it by fire. Vomit it by fire in the name of Jesus!… Fire! Fire! Fire!”
Abraham shook his fists and prayed viscerally, mouthing his own private supplication in response to the pastor’s prompts. In the center row a woman squirmed to the ground. Her seatmates stood and shoved plastic chairs aside to make space for her flailing. The pastor prayed over her, sprayed her with holy water and exorcised her. When she stilled, acolytes immediately came to mop up the area and rearrange the chairs. Abraham continued praying from the sidelines.
One of the distinct characteristics of many contemporary Nigerian Christian churches is miraculous healing.
Anthony Umoren, a theologian at the Catholic Institute of West Africa in Port Harcourt wrote a book called “Jesus and Miracle Healing Today.” He told me of the links between traditional African religions, the omnipresence of spirituality in all matters of life and how that has manifested in newer religious movements. “Christian religion in a way answers the yearning of the African for a better life at the material level but also answers the yearning of the African at a spiritual level because of the fear…and respect and love for mystical forces and spiritual and supernatural powers. People want to harness their spiritual powers against their enemies for good health, for safe journeys, for safe life, for success—they want to harness these forces for good.”
Christianity, he said, is “largely misunderstood because of its miracles, largely misunderstood because of its larger than life approach, because of this superhuman idea where [Jesus] comes and heals and nice things happen. So, in a way, Jesus then becomes the answer to the African’s yearning.”
Abraham’s church was called “The Sanctuary of Healing” and for him praying was the essential way to address the spiritual aspect to his illness.
Three hours later, the service drew to a close. Afterward, the congregation mingled and snacked on sausage rolls and oily, spicy jollof rice. Abraham, still committed to his diet, reluctantly passed.
As he drove away he mused on the importance of prayer. For him it was beneficial whether or not it offered a miraculous cure. The action itself was a crucial part of moving through his tribulation.
“It makes me feel refreshed. You know the thing is most of us humans are being too nonchalant about the word called prayer…you derive so much spiritual energy just from kneeling down and praying. When you pray fervently, whatever it is that you are going through, even if it’s not being solved physically, you will feel better inwardly. If you are downcasted, [if] you feel something is unsavory; all you have to do is just kneel down and pray. By the time you get up you’ll feel better.”
A silent killer
In the following weeks, Abraham told me he was feeling “great” and “super strong.” But when I explained his healing journey to Dr. Lesi, she worried. From the church to the lab man to the traditionalist to the pharmacist, nothing he had done had medically addressed the hepatitis. Because the disease is asymptomatic until its very late stages, there is ample time for people to take ineffective treatments and feel relieved, even while the virus flourishes in the body.
“When hep b rears its head it’s late,” Dr. Lesi said. She was intrigued to hear of Abraham’s saga she said, “because I sit down in my office far away from the patient and I will not get to see your patient for like ten years. When he develops liver disease I get to see him.” At that point she mostly offers palliative care. The patients she sees at LUTH, she said are “nearly dying.”
[i] Abraham’s name has been changed at his request.
[ii] http://photos.state.gov/libraries/nigeria/231771/Public/December-MalariaFactSheet2.pdf
[iii] http://www.who.int/mediacentre/factsheets/fs204/en/
[iv] http://www.immunize.org/laws/hepb.asp
[v] http://www.theguardian.com/global/2011/jan/04/nigerians-top-optimism-poll
[vi] http://www.thisdaylive.com/articles/hepatitis-b-the-silent-epidemic/168361/
[vii] http://www.who.int/mediacentre/factsheets/fs204/en/