I set out for Ogbomoso, Nigeria, last summer with little more than a suitcase full of clothes, doxycycline for malaria prophylaxis, and a rudimentary knowledge of infectious diseases. Having never been to Nigeria, I had little idea of the conditions I would find on the ground. I soon found that even having grown up in one of America’s poorest counties in Eastern Kentucky ill-prepared me for what I saw. The four-hour drive into the city from the airport in Lagos was like no other that I have experienced. Rather than the savannahs and river valleys full of exotic animals and small villages, the Africa that I had been promised by television. I found the road lined with a never-ending sea of crowded shacks on either side, the breaks between them barren ground and piles of debris. In front of these dwellings, youth and women waited for vehicles to slow down to avoid the road’s enormous potholes so that they might sell passengers bottled water, bread, or palm oil. As vendors approached the van I rode in, they would invariably laugh, called out “oyibo” (meaning “Caucasian”) and try to strike up conversation. The affability of complete strangers convinced me that, though we came from two different worlds, I would have no trouble getting to know or learn from my Nigerian colleagues.

Brian Barnett standing in front of the entrance to the emergency room at BMCO.

Within days of my arrival, I had begun a research project at Baptist Medical Centre Ogbmoso (BMCO), assessing the burden of perforated typhoid cases at the hospital and their associated outcomes. Once prevalent in the US, typhoid – a gastrointestinal illness spread by fecal contamination of food or water – is now only found in the developing world. The lack of clean water or proper sanitation in some parts of Nigeria provides an extremely favorable environment for the bacteria that cause typhoid to thrive. Patients often present to BMCO, considered the area’s best hospital, with typhoid that has progressed for multiple weeks, long enough for the disease to have progressed to bowel necrosis, perforation, and subsequent infiltration of the abdominal cavity by feces.

With over-the-counter pharmaceuticals widely available, patients often choose the cheaper option of treating themselves rather than paying to see a physician. Unfortunately, the initial symptoms of typhoid often mimic those of malaria and patients frequently buy the wrong medication and delay proper treatment. A predictable series of events then ensues when they present at BMCO’s emergency room: Patients’ families scramble to pay a required surgical deposit fee at the hospital, a sort of hospital insurance fund. Blood, often in short supply, is solicited from whoever will give it so that the patient can be operated on as quickly as possible. Following an operation, for those that survive, recovery is long. Patients are often required to remain in bed for several weeks or even months, to the detriment of their families and their communities.

In addition to typhoid, a number of other infectious diseases burdened the patients of BCMO. With Dr. Adenike Adeniran, BMCO’s head of internal medicine, I traveled to a Hansen’s disease settlement – commonly referred to as a leprosy colony – outside of town. A small village of roughly-constructed dwellings provided residence for one hundred or so lepers, cast out from their families and the rest of society. Because of the stigma of the disease, most would never be able to return home, even after receiving treatment for a full year and being cured. Both those with active and cured leprosy lived permanently in the settlement. Men and women throughout the colony came to us with lesions of the skin and missing fingers, hands, toes, and feet from the nerve damage and festering infections that all too often lead to amputation. Amputation is especially devastating in the colony, as everyone must work in the fields each day in order to feed themselves.

On other days, sitting with Dr. Adeniran during her weekly HIV clinic back at BMCO, I was astonished to see patients presenting with all variations of symptoms. Some appeared completely unaffected, while those with infections that had progressed to AIDS looked like emaciated ghosts. My understanding of the destructive power of HIV was radically altered at that point; there was no longer a book of dry pathology to separate me from patients’ tired faces and protruding bones.

Electricity was only available in Obgomoso for a couple hours in the morning and from 4:00-9:00 PM every evening. When the lights went out at our house, another American student, Ravi Parikh, and I headed to the ER to assist the residents and nurses working by candle and lantern light. We learned from these individuals to make do with few resources in high-stress situations where lives were routinely at stake. Little equipment, few beds and even fewer medications were at the staff’s disposal. Without many strong analgesics on hand, screams sometimes resonated throughout the tiny ER during our visits.

Almost nightly, a group of people would run through the doorway carrying a loved one who had been involved in a traffic accident. Tanker trucks transporting gasoline across the country and helmetless riders on motorcycles (a prevalent form of affordable transportation) filled Ogbomoso’s main two lane thoroughfare each night. With high speeds, no street lights and unenforced traffic regulations, the road was surely the most dangerous place one could be at night. It was not at all uncommon that pedestrians, passengers and drivers presented with a serious leg wound or head trauma and eventually died in the course of a night shift at the hospital.

One evening, as Ravi and I walked to the ER, I glanced up and saw the thickest and highest plume of smoke I had ever seen. There were tanker trucks at a standstill on the road in front of the hospital and it appeared as if one had exploded on the outskirts of the city. Within minutes of our arrival to the ER, a group of frantic individuals rushed through the door into the darkened room carrying a man and laid him on one of the four beds. The staff gathered around, noting that a good deal of his skin had been burned off. What little remained was bunched up and charred, resembling burnt plastic. He was utterly quiet, gasping softly for air, as the on-call resident, Dr. Aroh, arrived. Soon all the beds in the hospital were full and patients were lying on the floor shaking, screaming, and moaning. Family members packed into the room fanning the injured with shirts and torn pieces of cardboard, doing anything they thought might reduce the pain from the burns that covered every patient.

Trying to help as Dr. Aroh began to give IVs, I placed blankets under those on the floor in a feeble attempt to stave off infection. Generators were activated – the ER would require more than lantern light. Nurses began cutting clothing off patients; I found a razor and started to follow suit. The injured groaned and jerked as I pulled the cloth tight against their limbs in order to slice it. Some clothes and skin had fused, making it impossible to know exactly what I was cutting. Within minutes there were at least 40 victims, family members, friends and medical personnel inside the ER. Cries for help filled the halls. The physicians and nurses remained calm and steadily moved around inserting IVs.

Still more victims came, many of them with faces or arms and legs completely devoid of skin. The unmistakable smell of burnt flesh permeated everything. With the fluid in their bodies rapidly evaporating without a skin barrier, patients went into hypovolemic shock. Without immediate correction by fluid supplementation, death might rapidly ensue. For some there was little we could do. They simply lay on the floor becoming quiet, still and beginning to breathe ever more slowly before finally closing their eyes. The hospital chaplain was soon walking around us to tend to patients’ spiritual needs.

In time, I found myself holding a flashlight in the still dimly lit room trying to find a patient’s vein for IV placement. With dehydration from rapid evaporation of fluids, burn victims’ veins often collapse, making the insertion of an IV line exceedingly difficult. For almost half an hour, a resident and I prodded this patient. In the shouting and commotion, he was eerily quiet, only calling out in pain when we inserted the IV needle. Finally it happened, the flash of blood in the cannula, signifying that we had struck a vein. The patient let out no triumphant call though. Perhaps he knew, like us, that there was only a minimal chance that he or most of the others would live through the next two days.

Soon, we began transporting patients to the OR for wound care. As I helped lift one man onto a stretcher, his skin came off into my gloves like tissue paper on a gift box. He gave no reaction. Looking back, with all of the patients and their beds finally transferred out, the floor of the ER served as a canvas on which the night’s horrific events had been captured in a paint of dirt and blood. The agony was overwhelming. In the OR, one patient called for water and I held a bottle to his lips to let him drink. I refilled it and he finished the entire bottle again.

Of the 22 patients with serious burns, only seven would still be alive when I left Nigeria a month later.

Now back in the US, it might seem all too easy to get swept into the daily stresses of my studies and other responsibilities, to forget as many have about a place so different than where I live now. But my experiences have changed me. And they have inspired me to improve health and healthcare in Ogbomoso. My study found 177 cases of perforated typhoid at BMCO during the five year period preceding my time there. Of those patients that made it to surgery, 10% died, nearly half the rate one would expect at a hospital in a similar setting. This is a testament to the skills of BMCO’s surgeons, but also an alarming reminder of the prevalence of late-stage typhoid. Prevention is the only way to reduce this number to zero. BMCO continues to grow and has expanded its services, although it still needs better imaging, surgical and anesthesia technologies, as well as basic medications such as analgesics and potent antibiotics. No matter how good the care is at BMCO, prevention is what is truly required to stem the tragedies that I witnessed during my time there. Without proper sanitation and clean water, most infectious diseases will never be contained. The enforcement of traffic laws and the use of helmets by motorcyclists would surely save many lives. Repairs of highway infrastructure would also greatly reduce accidents.

Most importantly, I believe that a constant source of electricity will improve the health of Ogbomoso’s people, improving visibility on the road as well as in the hospital. With a reliable electrical supply, hospital staff would not have to work in the dark during the night and delay care while waiting for generators to be activated to power lights and anesthetic equipment.

I await the day that these improvements occur, and with the skilled physicians of BCMO, I will work towards seeing that they do, so that we may rid the city of tragedies that have stalked its streets for far too long.