The first time I approached the new General Referral Hospital in Niamey in June 2018, I thought it looked like a prison building, huge and isolated in the landscape. After leaving the center of Niger’s capital, my colleague and I drove for 15–20 minutes, then turned left after the Gendarmerie Nationale; we found ourselves on an arid, dusty and bumpy tarred road. A series of enclosed but undeveloped plots of land, brick sellers and several tiny grocery shops reflected the rapid transformation of the Tchangarey neighborhood since it had been selected as the location for the new hospital (Aboubacar & Detemple 2019). The former village, where just a few years ago donkeys and goats were still grazing, is now the site of speculation surrounding the new hospital constructed by the People’s Republic of China as a donation between 2014 and 2016, and inaugurated in August 2016.

In recent years, land has become very expensive – unaffordable for most of Niamey’s inhabitants. Speculation is not limited to this new building and the promise that it will bring water and road infrastructure to the neighborhood. The hospital is expected to create a new referral level and provide highly specialized medical services. The aim of Nigerien officials – the President in particular – is to avoid the high costs of sending Nigerien citizens abroad for treatment, and serve as a reference for the entire health system. The giant building fits the “politics of Emergence” that many African States have developed over the last two decades (Péclard, Kernen & Khan-Mohammad 2020). The “Emergence” of African economies might in many ways be fictitious – revolving around the notion of Africa Rising, the Eldorado continent for foreign investment; however, the narrative is productive in creating big infrastructural projects, financed by China, India and others. These enormous achievements are piloted by States, and open new markets and new national imaginaries.

Military personnel at the gate monitored the flow of visitors through entrances and exits, and patrolled inside the hospital, as we could note when we first spoke with the hospital authorities in June 2018. We have been granted permission to conduct a rapid collective investigation[1] in December 2018 with colleagues of Niamey research institute Laboratoire d’Etudes et de Recherche sur les Dynamiques Sociales et le Développement Local (LASDEL). By the end of 2018, the hospital had already opened various medical and surgical services: accident and emergency, traumatology, cardiology, internal medicine, neurology, nephrology, visceral surgery and acupuncture consultations. During the course of this inquiry we interviewed a number of medical professionals, technicians and administrators working in the hospital. Through these exploratory interviews and observations, I came to realize that this hospital is a sensitive topic. It touches upon the State. In a sense, I really experienced and came to understand how productive and disruptive this hospital could be.

This also gave me the opportunity to grasp the hospital’s materiality, its impressive architecture. I was attracted by the multiple and urgent questions raised by the opening of a new hospital, its significance as a medical institution and the intensity of the non-medical aspects, particularly with relation to the public resources allocated to the building. As recent anthropological scholoarship on infrastructures has made clear, they are truly multiple; they are technical but never purely technical. Infrastructures are spatiotemporal projects that “convey different visions of the future, different aspirations for one’s own life, and for the future of the community or nation” (Anand, Gupta & Appel 2018, 19); they “signal the desires, hopes, and aspirations of a society, or of its leaders” and they are biopolitical in that they wish to organize a society differently (Larkin 2013, 333).

The newly built hospital is huge. In order to make it work, the government had to start hiring a number of qualified medical, administrative and technical personnel. Once fully functional, by the end of 2021, it will be staffed by more than 1,000 people. These professionals are responsible for guaranteeing the functioning of medical services and equipment, and the steady provision of water, power and waste management to name just a few challenges. The government has committed to ongoing investment in its maintenance. That could make it a disproportionate infrastructural project for a country that, according to the United Nations Development Programme, is the poorest in the world.[2] Existing public hospitals in Niamey are struggling and require massive investment to achieve their missions at the district, regional and national levels. But there is no doubt that the population needs access to, for example, tertiary care like neurosurgery or interventional cardiology, as well as treatment for chronic diseases and emergency trauma care. Those medical needs are concrete, and are often associated with the imaginary of a middle class that corresponds to the narrative of African Emergent economies. Through the provision of specialized tertiary care, big hospital projects like this one target a new clientele: wealthy cosmopolitans, businessmen people and the political elites. Costs of care are greater here than in public hospitals. What do people in Niamey think of these new medical services? What do they expect? How will it work?

A Benchmark for the Broader Health System Reform and State Reforms

One of the most common ways this hospital is described is simply that it should be different. In the words of the hospital director, a young member of the armed forces and cardiologist by training: “A different mission, a new hospital with fresh ideas” (June 2018). During a conversation with the director of health services in the Ministry of Health (October 2019), she recalled: “As far as the referral hospital is concerned, it is true that at the beginning, the mission was that it should be different from other hospitals”. Citizens often criticize Niger’s public hospitals and describe the “behavior” of health staff as the most visible of a series of structural constraints as described by famous anthropological studies (Jaffré & Olivier de Sardan 2003): chronic shortages of staff and low salaries, lack of drugs, basic equipment and beds, and high healthcare fees are among the many issues that are unfortunately common to various West or Central African states (Chabrol 2018). Furthermore, patients are often turned away when they seek care. Given the deep, shared feelings of sadness and anger evoked by hospitals, that a hospital might be different from existing ones is of great significance. For many citizens, it’s an urgent matter: it’s about dignity. Niameans refer to health professionals’ “unacceptable behavior”; they also denounce the lack of transparency, and a general dysfunction and messiness in the healthcare system.

This national project has a historical context. L’Hôpital Géneral de Réference or the General Referral Hospital is expected to bring to fruition a long-term Nigerien project whose planning dates back to the military transition under Colonel Salou Djibo (February 2010-April 2011): a “500-bed hospital” whose main mission is to provide highly specialized care for conditions that could not be treated domestically and for which the State was sending patients to foreign countries for costly treatments. Thus, saving public money and developing an infrastructure for highly specialized tertiary hospital care are the raison d’être of this new hospital.

Aspirations to medical modernity are manifested physically. The hospital architecture is singular: not the kind of pavilion-style colonial hospital one encounters in West African cities. Neither does it comprise just one block; instead it is an assemblage of two- to three-storey buildings, surrounded by gardens, all tended by dozens of cleaners and workers. The buildings are made of sand and its Chinese architects have claimed “sahelian architecture” as their inspiration.^[3] The atrium is monumental (see Figure 4), and opens onto paths that lead towards the main medical building and to various other buildings, parking lots and a helicopter base. Less easy to see at first sight: a water-drilling system and pump, an oxygen station and an incinerator for hospital waste. The equipment is requires intense and constant work by Nigerien and Chinese technicians because it frequently breaks down. Since the hospital is a donation, the gift came with Chinese proposals, contractors and equipment. Technicians struggle with different norms, the manuals in Chinese and maintenance agreements with companies in China to supply spare parts when they break down. Much of the equipment was designed for a different context – in most cases, China – and requires major adaptation work, both material and technical as well as cognitive, linguistic, social and cultural, to ensure its successful implementation. With regard to the infrastructure and equipment, tropes of innovation and excellence are omnipresent in official statements and press releases are aligned with the objective of excellence and the desire to “make something exceptional”, something that stands out, or even the desire to physically and normatively “separate” oneself from the outside world, from what exists and what is the norm in Niger.

Recruitment of staff also falls under the rubric of excellence. At the beginning, the Ministry of Health transferred medical specialists and nurses from existing hospitals. However, the hospital management and the President have started to recruit medical, administrative, technical and cleaning agents from outside the civil service through an autonomous recruitment process. This is supported by a new vision of recruiting “only the best”: excellent and promising young doctors and nurses with “exemplary behavior”. Health officials want to attract relatively young doctors who are just coming back from specialized training abroad to lead new medical and surgical services. This strategy was questioned in conversations and interviews by several observers who asked: “Why would a professor of medicine refer their patients to a younger doctor to whom they taught medicine?” This is seen as potentially threatening, as one older Nigerien told me: “the young people have the fangs; they want to push out those in front of them, their elders”.[4] The new hospital with its excellent young doctors risks destabilizing the organization of the medical profession and hierarchies in Niger.

The current director claims to be instilling a new hospital culture in which order and discipline are ensured in the provision of medical care. The hospital has to make an excellent impression on visitors by means of its beauty and amenity. Cleanliness is elevated to a cardinal virtue. Dressed in his military uniform, the director often makes surprise visits to the building and the wards, thus performing authority, surveillance and control over professionals, patients and visitors. Control is especially directed toward visitors and family members as in the long run the administrators wish to achieve a “European-style hospital”, meaning one without family care-givers (“hôpital sans accompagnant”). Newly appointed medical staff we talked to said that the presence of care-givers is annoying for medical workers. At the same time, most of them acknowledged that getting rid of family members accompanying patients would be painful. A technician recalled: “it’s part our culture. Even me, if I have to look after my brother in hospital, I’ll stay with him”. However, even more than being heartbreaking for everyone, banning family care-givers is not feasible, because no provision has been made for taking over the care family members currently provide: the hospital would need more staff to look after patients, especially when it comes to food – which is not provided – and paying hospital bills – one of the main responsibilities for the companions.

The socio-technical system comes from China. The model of a “modern hospital” comes from Europe. But Nigerien managers have made it their duty to help this hospital achieve its “very particular mission”, “with an entirely new organizational blueprint”.[5] The government seized an important opportunity to help the hospital develop its organization: the Haut Commissariat à la Modernisation de l’Etat (HCME). At stake is the reform of State practices, and HCME helps by producing new legislation and regulations that promote performance-based management practices and the desire to facilitate public contracting and secure new markets.

The referral hospital becomes a reference point not only in terms of medicine, but also in terms of the kind of society that is imagined and desired by some: more ordered, transparent, where familial ties or other more informal relations are sidelined and where a top-down, highly organized, structured form of care and social relations comes into being. The hospital is desirable in that it materializes the promise of better care and is inscribed in the landscape of infrastructural projects that signal new interventionism, the return of the State as one of the main organizer of development and, at the same time, the increasing amounts of funding available through new bilateral loans and new types of private capital flows.

Referral Hospitals in the Sahel as New Geopolitical Terrains

The hospital as a project is inscribed in time and space: it exists in the short and long term; it revives past dreams and creates multiple expectations of future societal change. Located in Niamey, it is nevertheless to a great extent transnationalized, beyond the long-standing diplomatic relationship and friendship between China and Niger that made it possible. In order to provide medical and surgical services, the hospital administration currently relies on a galaxy of short-term foreign medical missions from such bilateral partners as Morocco, Turkey, India, China or Gulf countries. Like other hospitals recently built in Niger it is part of the politics of emergence that combine recentralization of the role of States in planning and development particularly because these strategies attract new funding sources and massive investment by countries such as China, Turkey, India and Morocco in big infrastructural projects (Péclard, Kernen & Khan-Mohammad 2020).

For China, the funder and builder of the hospital, this donation was strategic, aimed at maintaining Niger as a diplomatic ally and major commercial partner. China established its relationship with Niger in 1974 and has since participated in cooperation and infrastructure projects (bridges, roads, hotels). In 1996, China began investing in uranium exploitation and since 2008 the China National Petroleum Corporation (CNPC) has been exploiting an oil deposit at Agadem, constructed an Agadem-Niamey oil pipeline, and built and operates the Zinder refinery (Cabestan 2018). The new referral hospital is not just a construction project: it’s part of the expansion of relationships and health cooperation between China and Africa in the continent.

Within this health cooperation each African country is paired with a Chinese province – Guangxi province for Niger – which sends teams (once called “barefoot doctors”) often to remote and underserved areas. These medical missions remain the backbone of Chinese health diplomacy in Africa and South Asia (Chen et al. 2019), but the health cooperation is continuously expanding. At the Forum on China–Africa Cooperation of 2015, for example, the Chinese government announced that it will build dozens of hospitals throughout the continent, together with increasing donations of medical equipment and drugs.

Building referral hospitals is also meant to provide attractive working conditions for Chinese doctors who wish to practice medicine to their usual standard, and appreciate living in the secure environment of the capital city. In a referral center Chinese doctors can practice specialized medicine within a context of centralized medical cooperation in which drug donations and medical training are made available through pairing this hospital with a web of hospitals in Guangxi province, a relatively poor province situated in the South, next to the Vietnamese border. China is a medical partner that offers specialized training on site and in China, during which doctors stay for several months in Guangxi. Nigeriens are not comfortable discussing their social and professional relations with their Chinese counterparts. However, they acknowledge nascent working exchanges with their Chinese colleagues, despite the language barrier and cultural distance they rarely fail to mention.

The newly constructed referral hospital in Niamey has begun to attract various other foreign medical interventions. In fact, since the start-up of the few services mentioned above, most surgical operations are organized as part of short-term medical campaigns proposed by Morocco, Saudi Arabia, Turkey, Lebanon, India and other countries, who offer to deploy humanitarian medical missions for periods of one or two weeks. For example in 2018, India conducted a hip- and knee-replacement surgery campaign, while Morocco organized cardiac operations. Thus, in the new referral hospital, medical and surgical care is mostly provided on an ad hoc basis, according to foreign countries’ interests and willingness to send professionals to Niamey. These countries propose their participation through humanitarian or more remunerative arrangements. It is then up to the Ministry of Health and the hospital administrators to organize operations by recruiting patients who will benefit from these actions.

The hospital is not only an attractive site for medical campaigns and private investment, but it is also a model currently replicated in other regions in Niger. Maradi, the third-largest city in Niger, is located 665 km east of Niamey and very close to the Nigerian border and the city of Kano. This desert area is a commercial hub in a region destabilized by the presence of armed groups. Two big new hospitals have been built in Maradi: the Makkah ophthalmic hospital, funded by a Saudi foundation and constructed by a Nigerian company, and a referral hospital built by Turkey. Like the new hospital in Niamey, the latter has a similarly gigantic architectural structure and is also a 500-bed referral hospital, but Maradi’s referral hospital is a public-private partnership with the Turkish company Commodore: Turkey met 35 percent of the costs through donations to the Niger State, who took out long-term loans to finance the other 65 percent.[6] These hospital projects fit into the landscape in a grandiose way: they promise to fill medical vacuums in vast environments with dispersed populations, and they target a new clientele, ranging from merchants who can pay for healthcare, villagers benefiting from charity or soldiers from foreign military interventions such as the French Operation Barkhane in the Sahel. In the context of growing instability and conflict, in Maradi and other parts of Niger, in neighboring Mali and Burkina Faso, the hospital materializes the growing need for upgraded health facilities particularly for conflict casualties. New referral hospitals become deterritorialized health enclaves which open avenues for the penetration of foreign public and private interest: treating their nationals, enhancing their humanitarian reputations, making profits, etc. Traditional donors and cooperation partners are absent from this new landscape of health infrastructure promises: France, Belgium and the EU are prioritizing other health development agendas, conducting laborious and technocratic negotiations on health system strengthening and universal health coverage while massive infrastructure transformations are underway.

The hospital is disruptive and truly multiple. It’s a contract between two States that bears the promise of unprecedented medical excellence. The new referral hospital in Niamey and its counterpart in Maradi are projects that assemble multiple and often contradictory expectations beyond the provision of specialized medical care in a hospital with state-of-the-art equipment. These promises of medical modernity are dependent on foreign powers – on their projects and their presence in local markets, in competition with other players. As much as being models for health sector reform, these hospitals condense hopes for broader change in society, for a more organized if not militarized society in a geopolitical moving terrain that attracts new South–South affinities (Duclos 2020). I have tried to give a glimpse of the infinite questions it raised, which make me anxious about failed promises, health inequalities and the future of care in Niger. I also remember its majestic architecture, its openness to air circulation and the beauty of its colors. The hospital is monumental.

Acknowledgments

I would like to express gratitude to colleagues at LASDEL in Niamey who contributed immensely to this exploratory research and particularly J.-P. Olivier de Sardan, M. Moha, J.-F. Caremel, I. Chaibou Argi, M. Detemple and M. S. Souley Issoufou (who also investigated the opening of the referral hospital in Maradi). A warm thank you to Janina Kehr for constant encouragement and to Rigas Arvanitis, who provided great insights to the text. Many thanks to Julene Knox, who has done precious work in revising the text.

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Fanny Chabrol holds a Ph.D. in sociology. Her research mainly focuses on infectious diseases and access to healthcare in public hospitals in Africa, the politics of health reform and Africa-China health cooperation, including through the building of new hospitals. More broadly, she’s interested in the political economy of health, global health and health infrastructures in Africa and beyond, in the present and the future. Twitter: @FannyChabrol

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Notes

[1] This type of rapid research is called ECRIS or Enquête Collective Rapide d’Identification des groupes Stratégiques (rapid collective investigation to identify strategic groups). This method, developed by LASDEL in the early 1990s, aims at identifying strategic actors or subjects in a new project and to collectively determine future topics for in-depth ethnographic research (Bierschenck & Olivier de Sardan, 1994).

[2] Human Development Report 2020, see http://hdr.undp.org/sites/default/files/hdr2020.pdf

[3] https://www.archdaily.com/798313/general-hospital-of-niger-cadi

[4] Interview professor of social sciences, Niamey university, June 2018

[5] Interview with hospital management team, April 2019.

[6] https://www.ingwb.com/insights/articles/improving-nigers-health

Works Cited

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Anand, Nikhil, Akhil Gupta & Hannah Appel. 2018. Promise of Infrastructure. Durham, NC: Duke University Press. https://doi.org/10.1215/9781478002031.

Bierschenk, Thomas & Jean-Pierre Olivier de Sardan. 1994. « ECRIS : Enquête Collective Rapide d’Identification des conflits et des groupes Stratégiques ». Bulletin de l’APAD, n°7. http://journals.openedition.org/apad/21

Cabestan, Jean-Pierre. 2018. “Beijing’s ‘Going Out’ Strategy and Belt and Road Initiative in the Sahel: The Case of China’s Growing Presence in Niger”. Journal of Contemporary China 0 (0): 1–22. https://doi.org/10.1080/10670564.2018.1557948.

Chabrol, Fanny. 2018 « Viral Hepatitis and a Hospital Infrastructure in Ruins in Cameroon ». Medical Anthropology 37(8): 645‑58. https://doi.org/10.1080/01459740.2018.1518981.

Chen, Shu, Michelle Pender, Nan Jin, Michael Merson, Shenglan Tang & Stephen Gloyd. 2019. “Chinese Medical Teams in Africa: A Flagship Program Facing Formidable Challenges”. Journal of Global Health 9 (1).

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Jaffré, Y., & J.-P. Olivier de Sardan. 2003. Une médecine inhospitalière: les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest. Paris: Karthala.

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Péclard, Didier, Antoine Kernen & Guive Khan-Mohammad. 2020. “États d’émergence. Le gouvernement de la croissance et du développement en Afrique”. Critique internationale 89 (4): 9–27.