Book Excerpt from Ike Anya’s Small by Small

Book Excerpt from Ike Anya’s Small by Small

Small by Small, Ike Anya’s newly published memoir, charts his journey to become a doctor in Nigeria. A medical memoir unlike any from the West, it is filled with the colour and vibrancy of tempestuous 1990s Nigeria, where political unrest, social change and a worsening economy make his journey particularly challenging. In this excerpt, Military dictator Sani Abacha has recently seized power in a coup, following the disputed 1993 elections. Ike has suffered numerous disruptions to his training, as the university is periodically closed due to strikes, protests and political instability, but the country has returned to an uneasy calm as Abacha consolidates his power, allowing Ike and his fellow students to return to medical school. Ike is rotating through a series of different short postings in different fields. Here, he encounters the unpredictable atmosphere of Casualty (the Emergency Room).


Small by Small book cover‘Casualty’

The consultant in charge of Casualty, as the Accident and Emergency Department is called here, is tall, muscular, and has a luxuriant bristling moustache. A Russian trained surgeon, benefi­ciary of a Cold War scholarship, his strong Igbo-accented English booms through the cubicles of Casualty whenever he is present. Calm and efficient, often in sharply cut double-breasted suits, he directs his team of doctors and nurses with confidence, unflap­pable, even in the centre of the chaos that often erupts in Casualty.

Work here seems to ebb and flow without any discernible pattern. One minute it is quiet, with only one or two patients in the cubicles. The next minute it kicks off, with all the action of running feet, shouted orders and speeding trolleys of the film and television emergency room dramas. The loud wailing of patients and their relatives add something not often heard in the English and American dramas.

One day, about noon, a young man lying in a wheelbarrow is wheeled through the small gates in front of Casualty. A man dressed in the white woven shorts and loose top uniform of convicted prisoners pushes the barrow. The occupant of the wheelbarrow, similarly dressed, is dreadfully emaciated; the shiny steel handcuffs round his wrists seem in danger of sliding off. He slumps languidly in the bowl of the wheelbarrow. It is not clear if he is conscious. From time to time, his fragile frame is wracked by a hacking cough. Two prison officers in quasi mili­tary uniform accompany the men. It appears they have come from the nearby prison. We pass its ominously looming high walls each day on our way to the hospital.

The consultant approaches, trailed by a train of medical students. ‘What is the matter?’

‘He collapse this afternoon, sir, is like he fainted,’ the warden replies.

‘I am not surprised he collapsed, just look at him, look how thin he is. Unu a na e nye ya nni? Do you feed him at all?’

The prison officers exchange a fearful glance, then the pris­oner who has wheeled him in pipes up.

‘E no dey chop.’

Apparently, the patient refuses food and insists on only smoking cigarettes. When he has no cigarettes left, he cuts up pieces of his foam mattress, rolls them in paper and smokes those.

The consultant dips his hand in his suit pocket, extracts a note from a sleek wallet and asks a porter to go and buy a bottle of malt for the patient. He asks the other prisoner to wheel him into Casualty. As he does this, there is a gurgling sound and the patient slumps lower.

The consultant bends to examine him. He shouts for an ambubag, but we can tell from his face there is no hope. We are shocked by the suddenness of the death, but the prison officers and the other prisoner do not miss a beat. Immediately, they thank the consultant for his time and effort, swing around, wheelbarrow and its occupant making a 180-degree turn and head back to the prison.

The makeshift wheelbarrow ambulance has become a hearse.

The consultant calls them back, asking if they do not require a death certificate. The officers pause to confer in whispers and then, in unison, affirm that a death certificate will indeed be needed. As the patient has not even been registered, one of them is despatched to go and register and secure a case note folder for the now deceased patient. When he returns, the consultant inserts a single sheet recording his brief interaction with the man.

Bearing their sad burden, the party of three head back to the prison. Not long after they leave, the porter returns panting, a

sweating bottle of Maltex in one hand, change for the consultant in another.

We are on a ward round in Casualty, the consultant leading two or three medical students. It is quicker and much less elaborate than in medicine, until a staff nurse, peeking through one side of the curtained off cubicle, interrupts our steady progress. A young man has just been admitted, and Sister thinks the consultant should come and review immediately.

‘What’s the case?’

Her voice drops, forcing the consultant to lean forward. She whispers urgently, and the consultant booms, striding after the staff nurse, ‘Me-cal students!’ He has a way of eliding the second syllable in medical. ‘How many of you have come across a case of priapism before?’

The new patient, in his early thirties, neatly trimmed beard, well groomed, lies on the bed, a pile of cloths heaped above his middle. At the consultant’s urging, with eyes averted, he explains his predicament. Anticipating a new girlfriend’s first visit, his friend recommended he buy from the mai suya on his street, a sachet of bura ntashi, the legendary ‘manpower’ stimulant from Northern Nigeria. Taking it shortly before her agreed arrival time, he has waited and waited but she never arrives, leaving him with this implacable erection. Having tried masturbation, ice blocks, everything he can think of, he has become desperate and called a taxi to take him to Casualty.

The consultant despatches an urgent referral to the Urology team and the ward round continues.

Later we watch, wincing, as the Urology registrar inserts a wide-bore needle into the penis, syringing copious amounts of blood out. It looks excruciatingly painful, even though generous amounts of local anaesthetic are used. Process complete, the offending member is trussed up in white bandages, and covered with a sheet.


Ike Anya is a consultant in public health medicine working in Nigeria and the UK, most recently supporting the NHS response to COVID in Scotland. His writing has been published in the Guardian, Huffington Post, Granta, Catapult & Eclectica, and his new memoir, Small by Small, is published by Sandstone Press.

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