Death Comes Quietly in Mali

DJENNÉ, Mali — Last Saturday, Albert Ganou, an unemployed tour guide with an ailing heart, prostrated on a thin cotton blanket in his musty room and refused to eat. His limbs swelled. His breath grew shallow. When his pregnant wife and four daughters spoke to him he could barely whisper back.

Friends pooled money and helped Ganou through the sewage-sluiced snarl of narrow adobe alleys to Djenné district hospital, which employs a handful of general practitioners and some nurses. The doctor prescribed painkillers and a salt-free diet. Then night fell and the spongy, low sky dribbled a billion stars over the millennial town, and Ganou died. Men buried him quietly at daybreak in the town’s walled cemetery by the Bani River, where tamarind trees contort their baroque trunks over generations of the dead, and Djenné’s world-celebrated Sudanic skyline gives way to the immense pale horizons of thorny and flat Sahelian wilderness.

Ganou was in his early forties. In the postmortem the doctors stated the cause of his death as "heart failure." They should have written "neglect."

From time to time, humanitarian crises push Mali into the world’s distracted eye. The latest example is the French intervention to force out of Mali’s north a hodgepodge of radical Salafis, Tuareg rebels, and drug traffickers linked to al Qaeda, who had established there a punitive and grotesque theocracy reminiscent of Hieronymous Bosch paintings, keeping order through amputations and lashings. The day Ganou died, French and Malian troops wrested free of the Islamists’ control Kidal, the last insurgent-held city in Mali’s north. Months earlier, three successive coups and counter-coups in Bamako and the simultaneous insurgent expansion in the north briefly grabbed international attention. The year before, drought and famine throttled Mali, and networks broadcast the stereotypical images of Sahel’s dying, bloat-bellied babies — a painful echo of the famines of the mid-1980s, when a million skeletal people wasted away on this hardscrabble, laterite savanna.

The creeping systemic healthcare crisis that allows Malians like Ganou to perish daily is harder to capture in made-for-TV snippets. Aid workers agree: War notwithstanding, the country is in no outward emergency. There are no throngs of matchstick-limbed children with protruding stomachs, no AIDS victims scooped into shallow graves. Simple poverty makes the problem as endemic as it is routine.

Most Malians cannot afford to seek even perfunctory healthcare in the country’s limited medical facilities, which, like so much infrastructure in this impoverished country, are propped up by international development organizations and relief groups whose budgets now are stretched extra-thin by the needs of more than 300,000 people who have fled the fighting in the north. Even in peacetime, the country has the second-highest infant mortality rate in the world, after Afghanistan, and thirteenth-highest death rate overall. One in three children under five suffer from chronic malnutrition. Relief workers in Bamako, Mali’s capital, told me this is normal, a habitual, unabating catastrophe.

The calamities fold onto one another, double and triple up, mostly unexamined and unassisted, invisible to the rest of the world. For example, no one can guess how many people will be hungrier, sicker, and more destitute than usual because they have welcomed into their homes families of relatives who have run away from the war in the north. Aid organizations expect 660,000 children under five to suffer from acute malnutrition this year, one of the aftershocks of last year’s severe food crisis. Since Mali’s impoverished, putschist government is bogged down in its own stalled political process, the burden of providing healthcare for them will fall on international NGOs. And what about men like Ganou, who could not afford even an electrocardiogram, because the clinic in Djenné has no EKG machines and to reach the nearest one that does, in Mopti, would have cost an unaffordable $150?

Of course, the people of the Sahel have been navigating attenuated resources forever. The 15 million Malians are persevering, chaffing in the shade of mosques, watching the Africa Cup of Nations on television sets outside shabby mercantiles at dusk. In Djenné, they share dinner leftovers with neighbors. They parcel out their children among various relatives to avoid starvation. My host here has taken in two.

After Ganou’s widow and children complete the 40 days of mourning, she probably will move into her parents’ crowded and beggared house, and my host probably will take in two of Ganou’s daughters, as well. But doctors haven’t been able to tell him why his own 22-month-old son has been cranky and feverish for more than a week now, despite the malaria medicine and painkillers prescribed by the same district hospital that could offer no succor to Albert Ganou.

Ganou had been ill for a year. His friends say he had a weak heart, but how weak exactly no one can say. It is possible that last February he had a heart attack; but then he got slightly better, even got his wife pregnant. It is possible he had a second heart attack last month, when he suddenly became too frail to move. There was no one in Djenné to diagnose him, no one to recommend treatment, let alone perform surgery.

For the last week of his life, Ganou lay in the stuffy room of his oblique clay house. When friends visited he whispered, sometimes in the English he had learned to guide Western tourists: "I really don’t want to eat," and "God knows best."

The day Ganou died, I sat with a primary school teacher of French under a thatch awning in the square before the Grande Mosque of Djenné. The awning belonged to a goldsmith who, like many men here, has been unemployed for two years. Once, Djenné was a center of trade and Islamic learning, and an important resting point for trans-Saharan caravans of salt, slaves, and gold. After the great famine of the 1980s, UNESCO designated it a World Heritage Site. Since then, much of the town’s economy has depended on tourism. But tourists stopped coming two years ago,  kept away by the combination of the global financial crisis and the fear of kidnappings by Mali’s Islamists. Now much of adult Djenné sits under thatch awnings, stringing together beaded necklaces no one will buy, smoking cigarettes, drinking tea, and waiting for better times. They are the parents of perpetually hungry children. They are the adults wasting away invisibly from sickness, like Ganou. "Everybody here," said the town mayor, Bomoye Traoré, "is very, very poor."

The teacher and I drank hot hibiscus tea from shot glasses. His name was Cheik Kanitoo. He was 32 years old. From time to time, children in tatters flitted just under the shade of the pleated awning and stood there, mucoid and stunted and coughing the terrible cough of the condemned. Kanitoo told me that at least a third of his class of 120 seven-year-olds is always sick.

"They have rheumy eyes. They are malnourished. They have respiratory problems. They have malaria," Kanitoo said. "Parents don’t have the opportunity to take them to the doctor. They have a choice, either to buy food or medicine — sometimes they can’t afford either."

Since this school year started in September, one of Kanitoo’s students died, a girl. He doesn’t know of what, but suggests a combination of malaria and malnutrition. He doesn’t remember the student’s name, or what she looked like. Nor does he remember the five or six of his students who died last year, or the five or six who died the year before.

"I have a giant class, how can I remember?" he said. "But every morning before class I take attendance…. If someone doesn’t respond for one, two, three days in a row I ask the class what happened. Sometimes the classmates say, ‘he’s dead,’ or ‘she’s sick.’"

How does a teacher cope, emotionally, with such a loss? Kanitoo couldn’t say. How does he explain it to the rest of his class? He doesn’t. Instead, he told me that after school some of the boys he teaches come to his house asking for sugar.

"You know what they do with the sugar? They have one meal a day, millet, for breakfast. So in the afternoon if they get some sugar they just eat it. Out of a plastic bag. They dip their fingers into it and lick it off." 

One of Kanitoo’s friends tipped a tin cup full of water, and a lizard sidled up to the drip and with a quick tongue caught the drops before they fell and curdled like mercury balls in the dust. The loudspeaker at the Grande Mosque crackled like distant bursts of gunfire and a muezzin began his summons to the afternoon prayer. The Harmattan, the dry northeasterly wind of winter, blew particles of straw, the smell of manure and motorcycle exhaust, cigarette smoke, wisps of prayer, dreams of food. A small boy in a ripped orange shirt stood at the edge of the awning and looked at us awhile. He said nothing. Then he left.