Leprosy Eliminated? Togo

MAHAMADOU KEFAS

Mahamadou was 20 when he got leprosy. I spoke to him at Koloware’s Centre de Sante, formally Centre de Lepreserie, a Catholic Mission near Sokode in Togo, West Africa. He was born in neighbouring Benin, and was working on a farm in Anie with his father when he noticed a cut on his arm that he hadn’t felt. He realised that his entire body was going numb. I spoke to him as he sat in his wheelchair outside the wound care room where Tchedre the nurse was doing dressing changes for several patients at 7.30am on a Friday morning. Most of the patients who were due to have their wounds looked at had not turned up due to heavy rains that morning. This is not uncommon, but unchecked wounds do get worse. Stones often turn up in foot wounds and infection sets in very quickly. It is these infections that result in rotting flesh that drops off or requires amputation, leading to loss of digits and limbs.

Mahamadou told his father about the symptoms and was taken to a hospital where a doctor correctly diagnosed it as leprosy. He was due to go into the local clinic near where he lived in southern Togo three times a week for injections. However continuing to work on the farm he suffered more cuts which started to get infected. Word spread that he had leprosy. No-one would hang around with him anymore. If he went out people would shy away from him. He told me that his friends would see him then simply turn around and run away. He lived with his father who stuck by him, but the rest of his relatives did not visit or speak to him. Eventually he stopped going out completely. The only people he spoke to for several years were his father and the doctor. His Uncle heard about Koloware and his father brought him up to the Leprosy Centre. His father visited him every Saturday for 4 years before he died.

He now lives in a small room in a compound with a total of five rooms, each housing a patient. He is the only one of them that does not have family. The leprosy bacterium (Mycobacterium leprae – closely related to tuberculosis) that causes the numbness is no longer active in him. He has no right foot, no digits on his left hand, cannot feel any part of his body, is blind and according to the World Health Organisation does not have leprosy. He has lived in Koloware like this, relying on food and support from the sisters of the Catholic Mission since the 1960’s.

Above and below: Mahamadou eats alone in his room. He is blind and can’t feel what he’s touching, so makes sure his food bowl is always in the same place between his legs so he knows he’s picking up food. He has no fingers on his left hand, mainly from burning his fingers while cooking during early years at Koloware.

Above: Mahamadou gets a check up every few days at the health post about 40 metres from his house. Missed appointments in the past have lead to the types of infections that took his right leg away from him.

Above: Mahamadou is numb over almost his entire body.

TCHEDRE WALLAKASONA AND THE KOLOWARE LEPROSY CENTRE

Tchedre’s Uncle was a nurse at the Leprosy Centre and encouraged him at 17 to come and work here. He soon learned that despite much help being needed for the 300 ‘lepers’ (at the time) at Koloware there were very few doctors who would even go near them for fear of contracting the disease. The sister who was in charge of the mission at the time saw potential in him and with the private funding that the centre gets from European (primarily German these days) individuals sent him to the nearest town, Sokode to get trained as a nurse.

Despite retiring 5 years ago, he still comes in three times a week to check and clean the wounds on many of the patients. He described the attitude of many of his patients as like that of children: “Every day you must bring them in to take their medicine, or get dressing changes. But they can’t feel the pain, and I see them handle red hot pans with their hands. If they have work to be doing at home (such as cooking, or even farming for the few that are able) they choose that over coming in for their check-up. When they do come in I sometimes see stones lodged in their wounds (causing infections) because they haven’t been checked in several days. I even tell them not to go into the field to work after I’ve changed their dressings, yet they do and get dirt all over them”.

He is dealing for the most part with the very poorest people that have received no education. Sometimes it is hard to have sympathy for those that don’t seem to want to help themselves, but in the cases of these men and women their priorities are always going to be food, water and whatever family is still around them above a cut that does not affect them at present and that does not feel painful. Such is their way of life. Tchedre obviously cares enough to carry on having retired.

He told me that in the central region (where Koloware is located) about 50 people get diagnosed with leprosy each year. It’s not exactly a ground breaking figure, but such a feared disease also means that many will be hiding their symptoms – like almost all of those that attend Koloware Health Centre once did. Women especially suffer from this – if the husband doesn’t throw them out outright they’ll almost certainly be hidden away for fear of bringing shame on the family. Leprosy is not a fast acting disease, developing over many years. But with most of the people that get it ignoring the patches and numbness out of ignorance or fear, the later stages are often reached even in these current days when the Multi-Drug Therapy (MDT) cure is readily available worldwide.

They are able to take the drugs at home, only coming in to Sokode (where the central region’s leprosy advisor is) to pick them up and for the occasional check up. But too many times have professional, trained nurses in Sokode hospital refused to touch those with the disease, helping fuel the stigma. Many patients are sent to Koloware for these dressing changes. With the exception of the foreign missionaries (like the director – Sister Antonietta from Italy), all the staff in the health post have been born in Koloware and grown up around those with leprosy. However even in Koloware there’s fear about the disease, despite being educated in how easy it is to cure if caught early.

Just a few weeks before I arrived some farm-hands had seen patches on a sixteen year old co-worker. They suggested it was leprosy, but the boy covered them up with his shirt insisting it was from a voodoo curse that was put on him – the more bearable burden. Fortunately they confronted him later and he agreed to go for a diagnosis at the health post, where they confirmed it was leprosy. Within two weeks he was no longer contagious; however he will need to make sure he continues taking the MDT for at least a year before the bacteria has completely been eliminated. His colleagues had caught the disease before any nerves had been killed, but if they hadn’t the numbness would remain for the rest of his life, and he would have to be extremely careful as a farmer that those areas of anaesthetised skin don’t get damaged.

There are only a couple of the ‘lepers’ that attend the markets – when people from all around the village come to sell, buy and trade in Koloware. They fear being shunned and rejected. Those that have small businesses rarely attend their own stalls, knowing people will not buy from them. They instead get family to sell for them. Others have little choice, hoping the busyness of the market will pull attention away from them they go about buying the food they must have to survive. Since the leprosy post was founded here 63 years ago there has been only one marriage between a ‘leper’ and a ‘non-leper’. Social mixing is relatively uncommon.

Above: Patients wait outside the Health Centre for dressing changes and check-ups.

Above: Assistants from Koloware help patients clean out infected wounds under the tap before they are looked at by the nurse.

Above: When you can’t feel your feet you can’t tell when your feet get too big for your shoes or when they are crushed. Permanent disfigurement can make walking extremely difficult.

Above: Tchedre Wallakasona, who has worked at Koloware since 1967 and despite retiring five years ago still comes in three times a week.

Above: Tchedre examines a regular patient while a child looks through the curtain from the room next door. The Health Centre now attends other diseases and injuries as well as leprosy, it’s main purpose when it was founded over 60 years ago.

Above: A ‘leper’ makes twine to sell to bind straw onto roofs. I saw a few patients doing this job even though few have fingers, and some are entirely blind.

Above: A patient passes the time with a rolled up cigarette.

Above: This man has been blind for over thirty years. He also spends much of his time making twine for roofs.

Above: Leprosy affects the eyes in a number of ways that can result in blindness. In this case it has prevented the eyelids from closing and protecting her eyes from dust and dirt. Tchedre is reaching out to her and berating her for missing her dressing change the previous morning due to the rain.

Above: A ‘leper’ buys vegetables from the Saturday market.

Above: Outside the Mosque at lunchtime on market day, a faithful patient must remove his prosthesis as well as his footwear before entering.

AISSATOU ASSOUMANOU

Aissa was brought up in Sokode, red patches started appearing on her face and she was diagnosed with leprosy. She was 12 at the time. She started the treatment, but stopped going when she was married at 13. Her husband told her it brought shame to the family, so she pretended she had never had it. In the next few years she gave birth to a boy and girl by him, but patches started to appear again in her late teens and her husband left her. “I was sad” she recounted wistfully, “but not because he left me, because the leprosy had come back again”.

Her parents took her to Koloware where treatment began. After four years of living in Koloware and taking the treatment she got married again, to a fellow ‘leper’.

“While I was with my second husband, my first one came to visit me. He saw I had built a life around me and was happy. He was jealous and angry. But I wasn’t going to go back to him, even after my second husband died from leprosy.” Her second husband had built a home for her and their two new children, but after his death a storm destroyed it while they were sleeping. She managed to get her children out before the roof collapsed in on them. The director at the time helped rebuild her house with the funds from private donors. Of her four children three are living in Cotonou in Benin, and one in Sokode. She sees them once a year after the Islamic festival of Tabasci.

She is lucky in that her leprosy injuries are easier to hide than others, and she sells a few things on market day; ground nuts, cigarettes etc. “I used to sell much more, biscuits and sweet snacks. However over the years my custom has got worse. If the director didn’t provide me with ingredients to cook with I wouldn’t have enough to feed myself”. Last week the patient living in the room next to her died. She will use the room to house her chickens until somebody comes to fill it up.

Above: Aissa thinks back through her life as my questions brought up past memories.

Above: The courtyard where Aissa lives. Her room is one of those on the block on the right.

Above: Aissa cooks in the light of her doorway, away from the spitting rain outside.

Above: Aissa emerges from the doorway of the room next to hers. It was vacated last week by its owner who died of infections from leprosy. She keeps chickens in it now.

Above: The infection on the bottom of Aissa’s foot. She is glad that it is easily concealable.

Above: Aissa sells groundnuts and other snacks at her stall outside the yard where her room is. She used to sell much more, but business has not been good in recent years.

I only had two days to photograph in this small village. I wish I had been able to spend more time and properly got to know the lives of these social outcasts. I am trying to document leprosy in several different countries worldwide, to show that such an ancient, well-known and easily curable disease has not been eradicated because of the vastly disproportionate wealth distribution across the globe. It can only survive in people with poorest immune systems where poverty is rife, and will continue to destroy the lives of those it inhabits due to the lack of education and stigma that surrounds it. The project is entirely self-funded, and I plan to fund my own exhibition to raise awareness. If you can help in any way, with finance or advice, then please do not hesitate to contact me – info@tom-bradley.com. My leprosy work from Nepal and Nigeria is on my website – www.tom-bradley.com.

Central Togo: The Koloware Health Post

The trip up to Sokode went as far as I was concerned pretty smoothly. Dodji and I left the house at 6 in the morning and went straight to the bus station where I bought us tickets up north to Sokode. I’d travelled on plenty of local buses in various part of Africa before, so wasn’t surprised that we had to wait for over an hour for the bus to leave at 7.30am. I also wasn’t surprised that it didn’t in fact leave until 8.30am. In fact I was pretty happy it was only delayed an hour. In Zambia I once had to wait 8 hours for a bus to leave after its scheduled departure. Naturally we were crammed into the bus, 20 in a 14-seater bus. Raymond (having lived in Sokode for three years) had promised the journey would be about three hours. I remember smiling to him as he said this and suggesting that perhaps it would be therefore more like five or six hours. I received a hurt look in return and bit my tongue from explaining the western take on time in Africa.

Regretting my smugness we arrived in Sokode at 4pm. There weren’t even long delays, we stopped every now and then for travellers to answer nature’s call and satisfy their snack cravings as well as allowing a poor young mother on the bench behind me to clean her vomit from her and her baby’s clothes. Malaria apparently.

After directions from a pastor-friend of Raymond’s to Koloware, where the Catholic Mission Leprosy Centre-turned Health Centre is located, we hopped on zimis for the pleasant journey through beautiful lush-green Togolese countryside. The villages were beautiful, with noticeably less rubbish than near the cities and stop-off points on the journey up. The wind blowing in my face was warm but not to humid, the clouds ranging from bright white to thick black, divided with crackled lines, a sky that had Ride of the Valkyries as its soundtrack. Raindrops fell lightly and sporadically bringing the temperature down perfectly.

Koloware Catholic Mission

A cyclist scoots through Koloware village among houses for the 'lepers'

Approaching Koloware

We arrived at a Health Centre that looked luxurious – spacious, clean simple buildings that were not nearly as old as I had expected from a leprosy mission that had no ties with NGO or government funding.

We briefly saw the director, Sister Antonietta, who was extremely busy, but greeted us with a beaming, surprised smile. It was through a friend of Raymond’s who worked in Health that I had heard about Koloware. When I asked for the number to call ahead and ask if we could stay, he said it was not a problem – it was run by Catholic sisters and they had a dormitory. We could turn up, explain my project and stay there with no problem at all. I’m not sure the frightfully busy Sister Antonietta quite appreciated his casual attitude. Explaining that she’d been given no warning, she informed us of the lack of beds they had at Koloware – even all the hospital ones were full. We’d have to put ourselves up in hotel in Sokode. Well I was not able to afford the daily commute to Koloware for the next couple of days let alone accommodation at a hotel – even basic accommodation was not within my budget for the trip.

With nowhere to stay, Dodji and I stood crestfallen at the side of the road – the formerly pleasant light rain now soaking through our clothes and spirits. He explained our situation to two passing elderly gentlemen. They sympathised and led us two minutes walk away into a little hamlet of huts. There we were introduced to Reda, who immediately with the fussiness of a grandmother who had just had the Queen turn up on her doorstep took my extremely heavy camera bag and sped across a courtyard over to a room while excitedly beckoning us to follow. In less than five minutes, with barely a word from Dodji or I she had cleared the room, put in a hefty mattress made with rice bags for myself, a mat for Dodji (he insisted on sleeping on that rather than the mattress), clean sheets and a table for all our things. We thanked her constantly, but she just said ‘non non non non non’ waving it away.

This is Reda's courtyard. Our room is the centre one with the door open. The man on the right is brewing beer.

Mine and Dodji's room.

Reda cooks our Akume and Soup by torchlight. Electricty went down 3 months ago in this area from a lightning strike. It hasn't been fixed since. Only the hospital has it's own generator.

Half an hour later, we were clean (I’m surprised at how I’m now so used to washing with cold water from a bucket) and sitting down in the dark to akume (a mashed pulp of cassava and flour) and kodoro (a northern Togolese soup made with leaves from baobab trees). I really couldn’t have asked for more.

Sister Antonietta in her office. She has lived in Koloware as a missionary for eight years.

A patient waits for dressing changes at 7.30 in the morning.

A 6.40am rise and we went straight to the health centre where Sister Antonietta pointed us in the direction of the leprosy clinic. There were already 15 gathered together, ready and waiting for wound care and dressing changes by the nurse Tchedre Wallakosona. It took a little while to find someone who spoke French well enough to translate into the local language of Kotokoli.

Kufou, the thirteen year old pharmacists son and our translator form French to Kotokoli.

Eventually it was Kufou, the pharmacist’s son who was shyly pushed forward. With two translators, especially when one is 13 and only speaks the French he’s learned from school, it’s not always easy to get the answers to the questions you asked originally. Still, I managed to talk to a couple of patients for a while, gathering their stories.

Dodji speaks to Mahammoud, a blind Beninoise leprosy patient that has lived here for over forty years.

The rain was thick in the morning, getting to torrential-standard for the UK, but simply averagely-heavy rain for here.

Patients crowd under the porch away from the heavy rains at Koloware Health Centre.

Rain in Koloware.

A decent rest at lunch time and a quick charge of my laptop at Tchedre’s house made for a relaxing afternoon before more photography. I got a chance to chat with the spritely, enthusiatic Tchedre, who proved to be extremely helpful and informative about the health centre and the area. He’s worked here since 1967, and despite the fact that he officially stopped working 5 years ago, still works with the leprosy patients in the hospital three days a week. I’ll follow up more on this in my next blog, specifically about the leprosy work being done here.

A leprosy patient sitting in his doorway in Koloware village.

The Togolese people further north in the country are, like many western African countries, predominantly Muslim, and I attended my first ever Islamic event in the evening. The Imam allowed me to go into the Mosque and photograph. Embarrassingly I know very little about the religion, so I was cautious and hovered at the back, photographing in the spacious, well-used room, the light blues and drab browns lit by just a couple of bulbs. It lasted just a few intense minutes, with the Imam praying out loud at the front. Each time they bowed in silent worship I’d take a photo, aware of the echo of my near silent shutter in the holy temple.

Muslim men pray in the Mosque.

Muslim women pray in a separate section at the back of the Mosque.

I nipped round the back to photograph the women’s entrance. They have a separate area at the back where they pray. I’ve always wanted to find out more about Islam, preferably not from reading the Daily Mail, so if anyone has any recommendations for a book about it I’m all ears.

Koloware Mosque.

Dodji and I got back to our room in the dark to find a mouse in my mosquito net and droppings all over my bed. I’m not particularly bothered about such things, but Dodji had a little fit trying to stamp on the mouse which promptly disappeared into the corner of the concrete room without a trace. A half kalabasse bowl was posted outside Reda’s, informing passers-by her homebrew was for sale. I tried a bit with my Akume, it smelt like rotten vegetables, but tasted more like very yeasty liquid bread dowsed in something strong and tesco-value. I declined a second bowl.

The half-kalabasse outside Reda's indicating her home brew is ready for consumption.

Reda and her daughter make her homebrew.

My wash in the square walled drainage area across from the little courtyard was shared with a spider the size of my palm, pulling itself up into the tree above on its slivery thread, glinting in the light of my headtorch, and unwavering in the warm still air. The yellow markings on its back glared at me, just daring me to have a reaction. I’ve barely seen the stars since being in Togo, a result of spending most of my time among city lights, but they are clear up here deeper into the country, peaking through the branches above my head. Venus shone out like a pearl among salt granules, with the dim orange hue of mars not too far. I saw several shooting stars, and not a single satellite. For the first time in three weeks, I wished I could stay here a bit longer. This is the Africa I’d like to live in. We went to bed early, to the laughs of men outside drinking Reda’s homemade beer.

Tchedre shows us the numerous leprosy patients in the village, translating from Kotokoli to French.

A leprosy patient relaxes in the afternoon out of the sun.

Tchedre introduced us to the chief and his two wives. He did have three, but one died recently.

Saturday was market day. The market only started to get under way at about midday so Tchedre showed us around several houses in the morning, asking many of the leprosy patients if I could photograph them. I spent two hours with them, as well as photographing a few around the market. I’d already established from Tchedre that despite Koloware having a large concentration of leprosy since the late forties, and the town also being educated in the fact that none of them can pass on the disease (as none of them are carrying the bacterium) there was still a large stigma attached to having leprosy. Almost all the ‘lepers’ get children or relatives to sell their produce in the market to avoid being seen; it is only a few that venture out to brave shuns and revilement.

Vendors outside the Mosque.

Selling pork at the market.

I had the idea in the afternoon of photographing Mahammoud, one of the patients I had spoken to the previous morning. He agreed to stand without his sunglasses or prosthetic limb wearing just his shorts. I photographed different parts of his body in sections. I’ve exhibited my leprosy work before, and am always looking for new exhibition ideas, and a montage of close ups of this man’s frail, weathered body, numb from leprosy, still healing from wounds well over a decade after he went blind I’m sure will provoke a response from the audience.

Myself and Mahammoud in his room.

He was more than compliant about posing, and I helped him put his prosthetic limb back on afterwards. He’d mentioned the day before that of the five people living in the housing block, he was the only one who had no relatives or friends to visit him. Usually I don’t give money to those I photograph, especially just one person, but since it was beer season, I gave him 200CFA (40 cents) to get a bowl from where everyone else was on this swelteringly hot market day. A big grin broke out on his face, one that you might expect from an old man at the end of his years who’s just been given the opportunity to spend a hot afternoon with a kalabasse of strong yeasty-red beer. Who can blame him? Being blind, disabled, very forgetful, going deaf and with no relatives to visit him, there’s little else left in this world for him.

On my last night there it rained. This time the rain was torrential. It started around midnight and carried on through the morning. For about half an hour it was truly deafening. I was awake anyway when it started, and heard the first few dull thuds like small balls of putty falling from a great height. This developed in a matter of seconds into a barrage of paintballs fired from the heavens targeting Dodji and myself. Within ten minutes it seemed like waves were hitting the house, the Atlantic Ocean emptying itself onto our doorstep. The corrugated iron roof amplifies the sound five-fold and I spoke just to see if Dodji could hear me. I could barely hear me. With the exception of slight cracks around the wooden door and window shutter, the room was sealed, yet I could feel the spray through my mosquito net. I’ve always loved storms, but this one never subsided, and when my alarm went off seven hours later I realised it may be a wet journey to Sokode.

Tchedre with his wife and granddaughter. Tchedre has worked in Koloware since he was 17.

I’d planned to say goodbye to Tchedre, but with the rain like it was I’m sure he’d understand that we’d have got drenched going to his house. Luckily there was a car by the bar down the road that said it had two spaces. It’s not so much hitch-hiking, as anyone can be a taxi, so we agreed about $2 for the both of us to Sokode and hopped in a car that was in poor condition even by African standards. The windscreen resembling a crazy-paved patio is a norm and not something to write home about (he says writing home about it). The front seats looked like they had been attacked by a starved Rottweiler on crack and the back of the rear bench looked half melted. Dodji’s door had to be tied and untied in order to get in and out of it, and mine kept swinging open. Luckily this wasn’t too dangerous as we couldn’t go much faster than 20 mph, partly due to the 100kg of charcoal propping up the back seats, and partly to do with the ancient engine that had a break to smoke every 20 minutes (the driver kept pouring something into the bonnet to put out whatever fires lurked underneath). It had taken us 25 minutes to get to Koloware, but over an hour to get back to Sokode.

The trip home was lengthy (we had to wait 4 hours for the bus to show up this time), but being on a large (prebooked) coach, it was much more comfortable. I got home at 8.30pm to Raymond welcoming me with open arms, like I was the prodigal son. After Koloware, Raymond’s house seems very modern and comfortable. Just goes to show everything in this life is relative.

This year’s adventures in Africa have come to a close now. Raymond, his family and Dodji and the other people who have introduced me to life in Togo have been extremely kind to me and I will make every effort to stay in touch with them in years to come. The last three weeks will stay with me for the rest of my life as very strange but essential time in getting to understand a bit more about how most of the world lives. Yet I don’t consider the wildly poor (compared to back in England) houses I’ve stayed at as places of poverty in terms of the other things I’ve seen here. Perhaps next time I’ll have a go sleeping on the streets.

The barber in Koloware asked if he could shave off my beard. I allowed a quick trim.