End-of-life care is a tough sell, one doctor says, “because everybody wants a cure.”
Marcus Chukwu was having a hard time coming to terms with the idea that he should refrain from evangelizing to a patient on his deathbed. “Religion is always effective, when the patient gets to the end of the road,” said Chukwu, who works as a nurse at an Anglican hospital in the southwestern Nigerian city of Ibadan. “When you are seeking medical help, and you know there is nothing left to do, then the next step is God; even a Muslim, in that situation, 70 percent of them will go to church.”
An assistant pastor at Celestial Church of Christ leads the congregation in a bout of “deliverance”—prayer against spiritual attacks.
Chukwu and a handful of colleagues were gathered around a horseshoe of folding tables at the Center for Palliative Care in Ibadan, a cream-colored stucco bungalow that houses Nigeria’s oldest hospice program, established in 2007. The occasion was a three-day “Training for Carers”, which for the first time included a session on the role of spirituality and religion in end-of-life care. As an oversized fan hummed in one corner, Chukwu and other caregivers working for local religious organizations went over the basics and boundaries of palliative care.
Life-threatening illness can bring anyone face to face with the supernatural. In Nigeria, though, the supernatural peers out from posters and billboards everywhere. It invites you to attend “Miracle Arenas” and “Anointing Revivals,” and reminds you in block letters on hospital walls, “We care, God cures.” Nigeria is roughly 50 percent Christian, and an increasing number of the faithful are “Renewalists,” a subset of Protestant Christianity including Pentecostal and so-called Charismatic churches, whose adherents believe in God’s ongoing intervention in daily life. This is thought to occur through the physical presence of the Holy Spirit, which possesses believers and wards off illness and all manner of misfortune.
For these reasons, Nigerians, who attend church at rates that are among the highest in the world, often echo the words of their pastors when faced with a terminal diagnosis. “It’s not my portion, in Jesus’s name,” they declare. To say anything else would be to cast doubt on God’s power. That makes delivering end-of-life care difficult—particularly in a region, sub-Saharan Africa, where faith-based organizations administer 40 percent of hospitals and clinics.
The growth of Renewalist Christianity in Nigeria mirrors a trend throughout sub-Saharan Africa, and indeed much of the world. Renewalists represented just 6 percent of global Christendom in 1970; today, they account for one in four Christians worldwide, or more than 500 million people. In Nigeria, that increase has been spurred along by religious services that attract more people than the Super Bowl and showcase the power of miracles. While I was in Lagos, evangelists stood at busy intersections in neon-green vests advertising the “Only God can do this” crusade, to be held by the Lord’s Chosen Church the following week. The church’s general overseer billed the two-day gathering as a place where “problems that have defied solution will … receive solution.”
The challenge for Nigerian doctors providing palliative care, then, is to make the case for treatment that is explicitly not about solutions, or at least not about the sort of solutions you encounter at a Christian crusade. O.A. Soyannwo, an anesthesiologist who founded the Center for Palliative Care, says it’s difficult to persuade patients that some diseases can only be managed. “Everything about palliative care is new, because everybody wants a cure,” she notes.
If the country’s radio and television programming is any indication, Nigeria is a place where miracles happen every minute: HIV, tuberculosis, diabetes, and cancer melt away at church services every Sunday and at all-night prayer vigils on Fridays.
Across town from Soyannwo’s clinic, I visited the Apete branch of the Celestial Church of Christ, one of several popular churches where believers walk barefoot and wear white robes from head to toe. Pastor Emmanuel Adewale, known to his followers as Daddy, showed me a medical clinic his congregation had recently built in the church compound, where members are screened for diabetes and high blood pressure. He proceeded to tell me, however, that many medical problems are caused by “spiritual attacks” and therefore cannot be cured until they’re resolved spiritually. Accordingly, Daddy encourages members of his congregation to pray and ask for deliverance before seeking conventional medical treatment.
To demonstrate how commonplace miracles had become, he asked an aide to bring him artifacts from a kind of museum of miracles past. Exhibit A was a plastic water bottle filled with rusty nails, which he emptied onto a clean white sheet of paper on his desk. A nine-year-old boy, he explained, had vomited them up without explanation during a revival a few months earlier. At the service that same day—between choral singing backed by synth-keyboards and African drums, and fire-and-brimstone preaching by Daddy—a woman in her forties gave raucous testimony over a fuzzy PA system. Terrible stomach pains had plagued her for years before subsiding once and for all at a revival led by Daddy the year before; she blamed the problem on the Devil.
Pastor Emmanuel Adewale sifts through a pile of nails he says a nine-year-old follower vomited during a revival.
“There needs to be a re-orientation,” Soyannwo says, starting with the causes of illness. “If people believe a disease is caused by witchcraft, then they believe there’s nothing an orthodox hospital can do.”
Rather than contend with broken machines, brusque treatment at the hands of overburdened doctors, and lab tests they can’t afford, patients often seek cures at churches and alternative providers instead. Nigeria’s health system is vastly underfunded and ill-equipped to respond to the needs of a burgeoning population of 168 million (doctors in the country’s public hospitals were on strike for most of October over unpaid salaries stretching back several months). Fees for service in public hospitals, introduced in the 1980s, have risen steadily over the last 25 years, making treatment for chronic illnesses like diabetes and sickle cell anemia unaffordable for most Nigerians. It’s hard not to see the rising popularity of Christianity-as-medicine as an externality brought on by the failures of the health system.
“There’s inadequate provision of public services in Nigeria almost across the board, so people fill in through private services,” says Peter Lewis, a political scientist who chairs the African Studies Program at Johns Hopkins University. “If they have money, they go to private [medical] clinics. If they don’t have money, they go to traditional healers, churches, and elsewhere.”
According to Soyannwo, patients who do seek help at hospitals like UCH Ibadan commonly delay treatment for financial reasons while they try to gather the money for surgery or costly medication from friends and family. This delay can necessitate palliative care down the line rather than other forms of treatment—as illnesses like cancer worsen over time. Ultimately, Soyannwo says, “If you can’t get what the hospital has to offer, the patient is the loser, in terms of pain and suffering.”
Until recently, Nigerian hospitals also didn’t have a lot to offer patients battling late-stage cancer and other terminal illnesses. Access to morphine, which is widely used to manage chronic pain in the industrialized world, was restricted by treaties designed to control drug trafficking. It was only last year that the government began importing the drug in significant quantities—55 pounds in 2012, or enough for about 4,000 patients receiving palliative care. That’s a small fraction of what would be needed to provide pain relief to the 181,000 Nigerians who die with pain from cancer and HIV each year.
And only a handful of African countries offer formal medical training in palliative care; the nurse leading the training in Ibadan got her degree in Uganda. But as training expands alongside access to painkillers, Soyannwo says the widespread adoption of palliative care depends on both caregivers and patients accepting that some illnesses simply can’t be cured. “People talk about denial, but it’s not really denial,” she says. “It’s just a different conception of illness.”
O.A. Soyannwo, an anesthesiologist and one of Nigeria’s leading advocates for palliative care, talks with a group of nurses during training at the Center for Palliative Care, in Ibadan.
Obafemi Jegede, who lectures on African religion at the University of Ibadan, scoffed when I brought up the idea of incurable illness. “Incurability is your concept; it doesn’t exist in the African medical paradigm,” he said. Then again, it isn’t a concept that comes easily to Americans either. In the U.S., a 2012 survey of palliative care and hospice doctors found that more than half have had colleagues or patients’ relatives accuse them of practicing euthanasia or murder. The difference is that American resistance to palliative care usually comes in the form of demanding more medical interventions in the form of respirators and feeding tubes; in Nigeria, patients are more likely to seek life-extending treatment at church.
Mercy Awogboro, a health liaison for the Christ Apostolic Church who participated in Training for Carers alongside Chukwu, told me her congregation practices what the pastor calls “total healing,” where any ailment can be cured using a combination of anointed water, fasting, and prayer. When Awogboro herself falls ill, she says she appeals to God to learn whether she should speak with her pastor or with her doctor, then acts accordingly.
Others are more resolute. At the time of the training, Awogboro said, there was a woman in her congregation who’d just been healed of chronic kidney disease after fasting for 21 days, and steering clear of medical care of any kind. When I asked Awogboro about the woman’s choice to forgo medication, she said, simply, “that is her own faith.”
Tolu Ogunlesi, a Nigerian journalist who has written extensively on religion, says “Christianity has done a good job selling itself as a pipeline of solutions: you’ll never hear of the 999 people who went to church and never got a baby, but you’ll always hear of the one woman who went and got a set of twins.”
Since these victories are usually framed in terms of an individual’s faith, the failure to achieve a miracle—whether it’s childbirth or a permanent cure to an illness physicians have declared incurable—sometimes leads to shame and low self-esteem. Soyannwo says a large number of her patients request in-home care, and ask visiting nurses to arrive out of uniform, to avoid being judged either for having a chronic illness or seeking scientific treatment.
As Soyannwo sees it, advocates for palliative care in countries like Nigeria have to strike a delicate balance between preserving the hope miracles can offer, and preventing that hope from driving patients away from the hospital.
“There’s no point in criticizing churches,” she stressed when we met in October. “There’s good work they’re doing, in terms of social and psychological support…. I’m a believer myself.” If patients do benefit from a miracle, she added, it’s for the best. “But if they take medication and eventually they die, they’ll still go to God, so nothing is lost.”
Reporting for this story was sponsored by the International Reporting Project.