When I first visited a leading global health organization in the US in 2014, I was overwhelmed by its behemothic stature. I was also taken aback by how the African, mostly the African woman and child, were a constant fixture on the walls of the institution. There were very few pictures of men. My experience is that men are skittish and have learned to distrust foreigners with cameras. Also, for various reasons that I won’t go into right now, it is also quite challenging to get men to consent to participating in research in rural Africa. I walked through the hallways looking at the large posters of African women and children, stuck in time, looking back at me. Their images, some women pregnant, others bearing young children on their arms, in long lines in front of rural health facilities that were too familiar, followed me with their eyes. Large white eyes like beads set on a beautiful black canvas of faces. I felt as if they recognized me. And I too, them. As if we shared the secret of the poverty and broken healthcare systems that had occasioned us to be in this space. They on display as subjects, or potential subjects of research, I as a researcher, occupying a higher social space thanks to my education and other opportunities that have trickled down to me. These images of Africans trapped in the uncertainty of the healthcare system, lost in thought, yet so hopeful, are too common on the walls and websites of every major NGO working in the African continent.

How much should we pay the African woman?

While implementing research in rural Kenya between 2007 and 2014, we were paying mothers of subjects 150 shillings per study visit. That is less than two US dollars per visit. The reasoning around this, and mostly around research done in sub-Saharan Africa and other developing countries, is that the subject stipend for participating in research should not exceed what people typically make in a day. Essentially, subjects are paid the perceived lowest amount for unskilled workers in these rural areas, or they are paid the lowest amount that one can live on in a day in the rural areas. A dollar or two per day is considered adequate. It is thought that any amount exceeding that would be economic coercion of sorts, and the strongly desired act of voluntarism by the subject would be lost.

Since most of the research volunteers in sub–Saharan Africa are women, the discussion centres around what a typical woman selling vegetables in a local market, for example, would make. The discussion never strays into the question of what people in formal employment—for example, the local primary school teacher—make in a day. Any additional burden such as travel, which is mostly on foot or on motorcycles, is assumed to be the normal way of life. Others such as the pain from injections and the drawing of blood, and other adverse effects, are assumed to be mitigated by the free healthcare received. The summation of this reasoning ends with the subjects in rural Africa making very little money from research, even though participating in research causes major disruptions to their social lives. It also creates a neo-colonial mentality in research where the typical rural African woman or child is perceived as a ready pool of human subjects available at a bargain, rendered desperate by the failure of the local healthcare systems and by government neglect.

When thinking of money, we should think of the environment too

I was recently part of a team undertaking very interesting and important COVID vaccine research. Part of my job involved reviewing study documentation as well as taking part in discussions about subject compensation. I worked with research centres to provide justification for subjects to be paid specific amounts of money, always acting as an advocate, while also being a good steward of the research budget. I advocated for increased payment in some circumstances and argued against overpayment. During the discussions around compensation, two words took prominence. One is voluntarism. A study subject is assumed to be volunteering their time, blood and other samples and personal data while withstanding pain in their desire to advance research and the increase of alternative therapies for themselves and humanity. Based on this assumption, participation in research becomes a higher calling, an act of altruism by the subject. The alternative to this explanation would be that, in participating in research, the subjects respond to incentives, be they economic, social, or psychological. This is more in line with the reality of capitalism and the world we live in. The question, therefore, is not whether the typical rural African woman is joining research to advance science; her decision is part of the survival calculus in an environment where healthcare is stretched and the reality of poverty is ever present.

Coercion is also a very prominent word in research. Coercion here implies that the subject is responding to some form of active or passive persuasion from the researchers to join research. The promise of money as compensation for research is passive coercion to say the least. The promise of efficient and superior healthcare to that which is available within the local ministry of health system is coercive.

The promise of money as compensation for research is passive coercion to say the least.

The politics and ethics around the two words, voluntarism and coercion, is loaded. It gets even more confusing when it is apparent that the pharmaceutical company implementing the study is focused on profiting from their new therapy or device; in most cases, saving humanity is as important as profits for these companies.  And these companies will hold on to their patents for as long as they can, no matter the human suffering, until they realize the desired return on their investments. Why then would the pressure be on the subject to volunteer when the whole setup is for profit? In the developed world, subjects are always very aware of the cost of drugs and how the healthcare system works. Study subjects are very vocal in negotiating for themselves and subject advocates ensure that their subjects’ interests are protected. In Kenya and many African countries, the subjects take what they are given. This is because of the pressure brought to bear on the subject by the local researchers to have them believe in the alternative truth that research is charity, and not business.

How do they do it in the West?

While working in the West, I have waited to hear of benchmarking decisions formulated around subject compensation based on the amount of money that waiters and waitresses make. Or based on the hourly payment of anyone making anything below the minimum wage. So far, I haven’t. The benchmarking in clinical research in the West always considers what skilled workers would be making per hour, how difficult it is to recruit from the population, past precedent, and the economic incentives that would result in quick recruitment and in keeping the subjects in the study. It is not based on any preconceived ideas of the researcher, it is not based on their perception of poverty and on how little people can get by. It tends to be based on the reality of the market forces, equity and study needs.

In addition to this, any transport and accommodation requirements are met through provision of lodging and reimbursement for transport costs, among others. The word coercion is therefore not prominent in the West as it is in developing countries. The assumption in the Western world is that the subjects there deserve a better quality of life when participating in research. Their time is also more valuable. They are also capable of making complex decisions to join research. They are not just a pool of humans readily available for data mining. On the other hand, the decision to pay a very small stipend in developing countries is tied to the image of the local African woman, or man, in rural areas. This is the same image that is captured in photos during the field trips to Africa by Westerners. And in this image, the African is seen as one who is hardened in his environment and quite capable of surviving on very little, one who should be thankful for the little that they receive since the options available to them is either broken, or not working. This assumption is also supported by local researchers and institutions who consider any additional benefits towards the welfare of subjects to be secondary to the outcome of the research. The continued existence of these colonial attitudes in research is strengthened by an image of the African in research that is based on a single story, on single moments captured on a photograph. These are the images I saw on the walls of the prestigious research institution I visited.

Images are powerful tools

In the absence of a trophy, images are the proof of that rich encounter between those in power and the powerless in those far-flung places. Images are also proof of the need for funding. They are also proof of work done. They are proof of privilege and relevance. They are also proof of love. Of comradeship.

The images in the halls of international public health organisations have served to encourage donations for research, providing the much-needed momentum and acceleration of interventions to improve life. On the other hand, these images have also reduced the worth and the story of the African woman, man, or child into a single moment captured at the click of a camera. In that sense, such images on the websites and walls of research centres have focused on a single story, sometimes perpetuating a stereotype of the African, often the stereotype of people without choice, but who can provide the much-needed data at the lowest cost to the pharmaceutical world, their aspirations and hopes not mattering in the calculus of profit and power in international research. Do these people go to weddings? Do they have smart phones? Are they on Instagram? Do they enjoy Christmas? Or are they stuck in that moment, in that small health facility waiting to be saved by international researchers. Does their voice matter? Or is theirs already drowned by the strong collaboration between the ministries of health, the local administration and international researchers and pharmaceutical companies?

The assumption in the Western world is that the subjects there deserve a better quality of life when participating in research.

With increased human subject research in Africa, there needs to be benchmarking that is focused on justice and human rights. How much compensation for research is reasonable to cover transport and time and allow the African woman living in rural poverty to save some money for food for her family after a whole day spent traveling for research? How much does local skilled labour cost per day in the rural setting? Researchers should focus on financial justice rather than perpetuating financial oppression while hiding behind the principle of coercion and voluntarism. And beyond that, if the rural African woman and child are going to be forever immortalized as the face of international research, then there should be a balance between their desperation and their resilience in these challenging environments. That balance is self-worth. It is power. And this power and self-worth are tied to the representation of the conqueror as well as the conquered, the researcher and the researched, through images and films.

Anyone crossing the sea to escape a dangerous situation or to find a better life is in a vulnerable position, but women face the additional burdens of gender discrimination and, all too often, gender-based violence, along their routes. Women represent only a small proportion – around five per cent – of those who make the dangerous journey from Libya to Italy.

On board the Geo Barents, female survivors regularly disclose practices such as forced marriage or genital mutilation (affecting either themselves or their daughters) as being among the reasons they were forced to leave their homes. Women also face specific risks during their journeys – MSF medical teams report that women are proportionally more likely to suffer fuel burns during the Mediterranean crossing, as they tend to be placed in the middle of the boat where it is thought to be safest. . Many women rescued also report having experienced various forms of violence, including psychological and sexual violence and forced prostitution.

“The minute I was alone, they would have raped me.” Adanya, 34 years old, from Cameroon.

Among these women is Decrichelle, who fled a forced marriage to a violent husband with her baby. They left their home country of Nigeria and went via Niger to Algeria. When they arrived in the desert, Decrichelle’s daughter fell ill and she could not do anything to treat her because she had no access to care or medicine. The young girl died, and Decrichelle had to leave her behind before continuing the journey to Algeria: “an immense and inconsolable sadness” for her.

Decrichelle attempted to cross the sea once but was arrested and sent to prison, where she was released immediately, only to be taken by taxi to a brothel. Some Cameroonian friends helped her escape. For six months, she lived in the campos (the abandoned buildings or large outdoor spaces near the sea where traffickers gather migrants) before scraping together the money to pay her way for another crossing. “I want to be in a place where I can live like a normal person of my age. I want to be able to sleep at night,” she says. “I wanted to be here with my child. It hurts me to think that I am safe, and I left her in the desert.”

Beyond the difficulties women face on migration routes and in Libya, MSF teams on board the Geo Barents often witness the strong bonds that develop between survivors on the women’s deck. The women come together to support one another with daily tasks and childcare.

“In Libya, I was sleeping under trucks and buses as I did not have any money.” Afia, 24 years old, from Ghana.

“I want to tell women: it is not your fault. You are exactly the same person as you were before. You are even stronger,” says Lucia, deputy project coordinator aboard the Geo Barents, who has herself experienced rape. “I think it has been really moving to see these women, who actually escaped what I experienced for an hour of my life, and in their struggle, their strength and their hope, [they do not stop] this fight,” she adds.

Meanwhile, when male survivors are asked about the people they left behind or the reasons for their journey, a woman is always mentioned in their stories. Ahmed, 28 years old, was born in Sudan to Eritrean parents who moved to Sudan to escape the war. Having lived all his life as a refugee, Ahmed never felt that he belonged in Sudan. He wished to leave, but as an undocumented person, unable to return to Eritrea for fear of military conscription and an oppressive dictatorial regime, he decided to travel to Libya and cross the Mediterranean Sea to Europe.

Ahmed’s mother was the only one who stood by him when he decided to convert from Christianity to Islam, despite harassment from his other family members. “[Converting to Islam] affected me, affected my friendships… for sure [I faced issues because of that]. At first, from the family… in the beginning, I was secretive… until my family knew; then the harassment started. But my mother accepted me. She told me, ‘Whatever makes you comfortable, do it.’” Ahmed says his mother is one of the reason she was able to make the journey from Sudan through Egypt and into Libya. “She has a really big role in my life. She was continuously supportive and motivating me, wishing me the best. She is my inspiration… I hope to meet her again.”

“I know if I tell my mother I am in Libya, she will be crying every day.” Ibrahim, 28 years old, from Nigeria.

Nejma, cultural mediator on board the Geo Barents, explains her bond with survivors like Decrichelle and Ahmed: “I am African and I am Middle Eastern. I am a mother. I am a woman. There are so many things that link us together. Maybe also the fact that I had to flee. That is a big part of it. I think it helps me understand where people are at the moment we find them; it is an understanding that books could never teach me.”

Cultural Mediator Nejma Banks converses with some survivors aboard the Geo Barrents

As a refugee herself, Nejma shares what helped her to move forward in the places she fled to. “[Survivors need to] keep the strength… once they disembark in Europe, it is not the end of the journey,” she says. “It is a different challenge: to not let go of who they are, to never forget who they are, where they are from. To be very proud of their origins. Because you will not know where to go if you do not know where you came from. And I want my brothers and sisters from Africa and the Middle East, or anywhere, to remember who they are. It will make it easier to move forward.”

–

The photographers

These stories of the women on board the Geo Barents were collected during rotations of the ship at sea. The portraits and testimonies were captured by two female photographers, with a view to amplify women’s voices, while respecting cultural sensitivities:

Mahka Eslami is an Iranian photographer, who was born in Paris and lived there until the age of seven before her parents returned to Tehran. While studying engineering in Iran, she worked as a journalist for the Chelcheragh. She returned to France where she finished her engineering studies before branching out into documentary photography and transmedia writing to become an independent photographer. Her work has been published by Le Monde, Libération, Society, Néon and Les Inrockuptibles.

Nyancho NwaNri is a lens-based artist and documentarian from Lagos, Nigeria, whose work revolves around African history, culture and spiritual traditions, as well as social and environmental issues. Her documentary works have appeared in numerous publications including The New York Times, The Guardian, Aljazeera, Reuters, Quartz andGeographical Magazine.

Background information

MSF has been running search and rescue activities in the central Mediterranean since 2015, working on eight different search and rescue vessels, alone or in partnership with other NGOs. Since 2015, MSF teams have provided lifesaving assistance to more than 85,000 people in distress at sea. MSF relaunched search and rescue activities in the central Mediterranean in May 2021, chartering its own ship, the Geo Barents, to rescue people in distress, to provide emergency medical care to rescued people, and to amplify the voices of survivors of the world’s deadliest sea crossing. Since May 2021, the MSF team on board the Geo Barents has rescued 6,194 people, recovered the bodies of 11 people and assisted in the delivery of one baby.

This story was first published by Médecins Sans Frontières/Doctors without Borders (MSF).

Nairobi. A cacophony of matatu hoots and booming bongs from church bells. All in inexplicable harmony. Like a Beethoven piece. A muezzin’s melody moves the ummah from a minaret here, a bus conductor — shouting from the most pimped out mathree — moves umati there. A hawker here. An ambulance there. But there’s also a silent monotone. The sound of hope dying. Of someone stealing two billion every day, of the clock going tick-tock from your 9 to 5. There’s that saying: if a tree falls in a forest and no one is around to hear it, does it make a sound? But what if it’s in the middle of Waiyaki Way? Just because someone thinks giving us an expressway will absolve him of war crimes. While in reality, all it does is leave all the marabou storks homeless.

Nairobi. A labyrinth of lipstick-stained shot glasses and semi-filled ashtrays. Where a party starts regardless of where the limbs of the clock point. And only ends when everyone is browned out and on the brink of calling the one that got away. Nairobi is looking for coins during traffic because you want to help the beggar, who is patient enough to receive the donation before snatching your phone. It is being stagnant in that same traffic for long enough to buy crisps made with transformer oil and served in compact disk wrapping. And like clockwork, you put the window back up because Nairobbery isn’t just a play on words. But the ones that hurt the most are the conmen, because nigga I trusted you!

Nairobi. Where gluttony is second nature. A kaleidoscope of too much gold tequila and too many smokie pasuas. Of good pasta and wine in overpriced restaurants. Of ramen noodles and pre-cooked meat. Where nothing is ever enough. We drink and eat to our fill because life sucks. Why wouldn’t it? Our last president’s advisor was the bottom of a Jameson bottle and our current one’s advisor is Jesus. The spirit guides the nation either way, I guess. But still, Nairobi tastes like chances and do-overs. It tastes like anxieties and aspirations and I know it doesn’t feel like it but today you omoka na 3-piecer then one day you omoka, for real.

Nairobi. Reeks of piss and thrifted clothes. Fresh bakeries and Subway. Old currency and that one cologne every man in their early 20s wears. Smells like fighting your titans and sending a million job applications. Nairobi. Where you can go weeks without a lover’s touch but only days without a cop grabbing you by the wedgie into a mariamu because you shouldn’t be idle as you wait for your Uber outside Alchemist. Because of course in that time you should take up a sport, play an instrument, solve world peace, et cetera.

There are few occasions when pride will linger. Like when Kipchoge finishes a marathon in under two hours. When Lupita wins an Oscar. The hubris you feel when your copy makes it to the billboard on UN Avenue. Or when your lame joke gets five retweets because Kenyans on Twitter will massacre you if you think you’re the next Churchill. Orrrr that one time we were all watching Money Heist and so gassed that Nairobi was one of the characters.

Sadly, Nairobi pride also comes in with its individualism. Everyone is out here on their own trying to get some bread whether they’re in the upper class getting baguettes and rye bread or in the lower class getting Supaloaf. I get it though, the city doesn’t let anyone rest from the grind and the hustle and the drudgery. And the wealth gap is bigger than Vera Sidika’s bunda. But ironically, the city is a paradox. An optical illusion. Sometimes the people are so ready to convene in community that it kinda revives the fickle hope you have in humanity. From safe spaces to fundraisers to a simple hearty conversation with your Uber driver.

And there’s obviously that murky feeling of greed that comes from 90 per cent of our politicians. When you’re at the bottom of the food chain it’s called hunger, but the higher you climb the more you want and it becomes indulgence. Greed makes them say and do all kinds of things. Like apologising to Arab countries that are exploiting Kenyans because they don’t want to be cut off. Y’all know any juakali guys we can commission for guillotines? – Heads gotta roll. Because how will I steal cooking oil and flour and end up in a cold cell but they’ll steal billions and end up with a second five-year term?

I think wrath is the most Nairobi-esque of the cardinal sins. We’re angry at the police. At the government, at global warming, at nduthis, at KPLC, at Zuku, at Safaricom, at KCB, at each other. Agonizingly though, our anger fizzles out as fast as it blazes up. I don’t think we’re ever angry enough.

And then there’s the envy. You know you’ll get there eventually but that gets lost in translation when you see someone with better because that sparks something in you even though we are all on different paths at different paces. Whether it’s a BMW or an airfryer, the question stays: Why not me? And also I’m personally jealous of the people who’ve managed to move out of Nairobi to Naivasha, Watamu or wherever. It feels like they’ve figured their way out the maze while I’m still at a dead end wondering whether I can just hop out the sides. Doesn’t matter what it is, our eyes are as green as the parks and spaces we so desperately need in this godforsaken city.

Nairobi. The city of miniskirts and cheers baba jackets. Lust dripping down the sides of our mouths because we can’t seem to contain it under our tongues. I don’t even know why people bother to go to Vasha for WRC when they live in the city of sexual debauchery where the only thing that’s on heat more than the sun is whatever’s between people’s legs. Where even Christian Grey would pause and do a double-take. Where ropes aren’t just for skipping and leashes aren’t just for dogs. If you find ordered love in the city, you must have saved refugees and orphans in your past life. This is the city where the flesh is truly willing.

You know that intense sloth-like feeling when you wanna wake up for Sunday brunch at Brew Bistro or K1 and then later watch Hamilton race at around 4 when all the mimosas have hit your head and you’re surprised that your wig is still intact? Or the next day when you’re trying to get out of your covers and you’re thinking about that beastly Nairobi traffic you’re about to face and all you can do is tweet “Nimewacha pombe mimi”. Truthfully though, other than that and a few other instances, the pace is too fast for me. I just wanna be in a dera next to the beach drinking a passion caipiroska and eating viazi karai cause why are y’all always running?

And y’all are way too fast when coming up with new words too. There’s like a million words for currency, ass, sex, sherehe, et cetera. Truly, there is a certain linguistic je ne sais quoi when it comes to the Nairobian’s language. It stops being a transaction of random syllables and begins to become an understanding of feelings, emotions and behaviour. I, especially, like how we knead it into our art. We sneak it into our music and get phenomena like gengetone.

We compress it into our films and get Nairobi Half Life. We squeeze it into our visual pieces and get Michael Soi. One thing about Nairobians is we do not cower in silence, we have words to say and we shall say them. Even if that means running a president out of Twitter. That’s why our writers are as staggeringly sensational as they are. Ngartia. Sookie. Grey. Muthaka. Laria. Abu. And those are just my friends, dawg.

But it’s not just the writing. The fashion. Rosemary Wangari. Nicole Wendo. Samantha Nyakoe. The music. Mau from Nowhere, Vallerie Muthoni, Karun, Maya Amolo, XPRSO. Just a Band. The films. The painting. Muthoni Matu. Zolesa. The architecture. The cinema. The theatre. Too Early for Birds is back! et cetera. Man, I gotta tell ya, when God was cooking up the cauldron of this city, he went hard on the talent. Quote me on this: a lot of exceptional creatives from this city are gonna hit the world with a head-splitting bang in a couple of years.

Nairobi. Despite the crowds, the queues and the poor drainage, it still has a charm. Mysterious. Confusing. Alluring. Despite the fact that you can only truly enjoy the Nairobi experience if you’re a bird or an expat, me I love it still.

Nairobians, keep sinning, keep winning!