This article is taken from Dispatches, MSF UK's supporter newsletter.
How do you improve healthcare when there’s no land for a clinic and your patients live on water? In Makoko, a densely packed slum on the outskirts of Lagos, MSF has found the answer
It’s 6am, the sun is already beating down and a crowd is gathering. There are mothers with children, pregnant women, old men and teenagers. For weeks now, word has been spreading that free medical services will be offered at the new building with the white walls, and nobody wants to miss out. By eight o’clock, there are scores of people on the veranda, on the steps and out the front.
Queuing here, however, requires more than just patience. What’s also needed is sure footing, a touch of ingenuity and possibly a boat. For this is not just any medical clinic: this is a floating MSF clinic opening in the Makoko lagoon, a densely packed slum that sits on a large body of water on the outskirts of Lagos, Africa’s fastest-growing city.
Here, wooden shacks perch on stilts over the brown water, linked by precarious wooden walkways. Men paddle by in handmade canoes, while children poke their heads out of windows, clamber up poles and shout to each other across the waterways.
In a city of 18 million people, the settlement on the lagoon is where some of the 2,000 daily arrivals from rural Nigeria and neighbouring countries end up. And it’s here, where poverty and overcrowding are commonplace, and where some people have never even set foot on dry land, that MSF has opened its unique floating clinic.
The new floating clinic is on one of the main waterways in the Makoko lagoon. The lagoon has shops, churches and schools but had little in the way of healthcare. Photo by Silvia Fernandez/MSF
“It is an exciting challenge running a project in this huge megalopolis,” says Daniele Cangemi, MSF’s head of mission in Nigeria. “Here we’re surrounded by so many different cultures and ethnic groups and by people who don’t have access to free healthcare. The challenge for us was finding a way to work effectively in an environment like this.”
Finding a way meant first acknowledging that most of these waterdwellers would be unable, realistically, to reach the clinic that MSF operates on land in a nearby slum. Many live so far out on the lagoon that it can take a long time to reach solid ground. Instead of expecting them to go to the clinic, MSF brought the clinic to them.
Since opening in January, the floating clinic, which sits on stilts and juts out onto one of the lagoon’s main waterways, has already become a focal point for the community. This, despite the fact it almost sank the day it opened.
“We were overwhelmed with patients on the first day,” says Pamela Bernard Sawyer, the MSF nurse in charge of the clinic. “Before we arrived we thought there would be a few patients and the numbers would grow as the weeks progressed. We were so shocked when we came up the canal on the boat and saw so many people.”
With two rooms for consultations, a small pharmacy and a veranda, the clinic can only safely hold 40 people and eight staff at a time. “At one point there were so many people crowding onto the clinic we were really worried we would collapse into the water,” says Pamela. “We had to stop everything and ask a group of people to leave and come back later.”
With the clinic stabilised, the task of treating patients could begin. Many of those living on the Makoko lagoon are immigrants from neighbouring Benin. “Every year more people arrive here
and they build on the lagoon because it is the only place they can settle,” says Pamela. “In this area conditions are unsanitary. The river is very polluted. It’s contaminated with human waste, animal waste, and every other type of waste.”
Despite these difficulties, schools, shops, churches and a functioning community have been established. Healthcare, however, is virtually nonexistent.
“People are coming to us with a whole range of conditions,” says Pamela. “Infected wounds, malaria, respiratory tract infections, diarrhoea – everything.” For serious emergency cases, there is a rapid referral service to larger clinics on land.
Sorting this out, however, was not straightforward. “First of all we had to work out what was the quickest exit off the lagoon, as there aren’t many and it’s like a maze out here,” adds Pamela.
With the rapid exit route established, the team had to establish how they would get patients out. “It’s just a boat with an engine, but we like to call it our ambulance,” she says.
Maternal healthcare has been a particular focus for the clinic. Nigeria has one of the world’s highest maternal mortality rates, as even women with difficult pregnancies usually give birth at home due to the high cost or unavailability of medical treatment. Out here on the lagoon, those problems are magnified.
“I have pregnant women turning up who are eight or even nine months pregnant and they have never had any antenatal care,” says Pamela. “Many of them have lived on the water their whole life and come to us with urinary tract infections, malaria and other complications. It’s great to be able to help them.”
She laughs. “We haven’t had a birth on the clinic yet. But it’s coming. I can feel it.”
Working in such a unique urban environment has thrown up new challenges for MSF. But with the majority of the world’s population now residing in cities, innovative projects like the floating clinic in Lagos are an increasingly important part of MSF’s work.
For the MSF team, it has meant forging a close relationship with the local community. “The first contacts we made on the lagoon were with the traditional leaders,” says Manfred Murillo, the field logistician for the project. “It was the community that came up with the workers and it was the construction of the clinic that really helped us enter the community and be accepted.
“The local crew were experts. They solidly lodged the wooden posts seven feet under ground and stabilised them with cross beams for a foundation. It’s a simple structure, but it was amazing to see these guys work so skilfully in such difficult and wet conditions.”
At the floating clinic, the day is drawing to a close and the team is loading up the boat ready to depart for dry land. A group of boys are kicking a ball to each other as they jump from boat to boat, oblivious of the water beneath them. This unstable, watery world is their natural environment, and they move as if on dry land.
“When I first came here, I was amazed that anybody could actually live here,” says Pamela. “But I soon became so impressed with the way people have adapted. I really wanted to work somewhere where there was need, and as soon as I arrived here, I knew that this was the place. “These people really need health services and MSF is providing those services.” She looks around at the watery surroundings. “I’m glad we’re here.”
Dispatches is a print publication written by people working for MSF, sent out every three months to our supporters and volunteers in the field, edited in London by Marcus Dunk. It costs 8p per copy to produce and 22.5p to send, using Mailsort Three, the cheapest form of post. We send it to keep you informed about our latest activities and how your money is spent. Dispatches also gives our patients, staff and volunteers a voice to speak out about the conflicts, emergencies, and epidemics in which MSF works and about the plight of those we strive to help.