Why we still fly

People think I flew my mother to London because I did not believe Nigerian doctors could do the operation. That is not it, and I want to be precise about this, because the assumption is insulting and it is also the reason nobody fixes the actual problem.

The surgeon who operated on my mother in London trained in Ibadan. I looked him up afterwards. He qualified about four hundred metres from a hospital I had already decided was not safe enough for her. So no, I did not fly for the surgeon. The surgeon was already ours. We had simply arranged, as a country, to post him somewhere else and then buy him back at a hundred times the price.

I flew because the operation is not the thing you are buying. Anybody can do the operation on a good day. What you are buying is the bad night: the thing nobody told you might happen, happening at two in the morning, in a building you have never been inside, while you sit in a corridor with a phone at four per cent.

The brochure lists the operation. It does not list the night. And the night is the entire decision.

Here is what I wanted to know, next to what the hospital told me, next to where I could have gone to find out.

Read the third column. Every single answer is nowhere. Not no, not a bad number, not a number I did not like. Nowhere. There is no register, no rating, no published volume, no rota I can see, no price I can hold anybody to.

So I am not choosing between a Nigerian hospital and an Indian one on the evidence. I have no evidence. I am choosing between two countries, because the country is the only proxy available to me, and one of those countries has a body I could write to if my mother came home damaged.

In 2019 I sat in a ward in Lagos with my father, and the power went, and there was that pause. Everybody who has done it knows the pause. It is about four seconds and it is the longest unit of time I have ever experienced. Then the generator caught, and the lights came back, and a nurse carried on with what she was doing because for her it was Tuesday.

My father was not on anything that mattered in those four seconds. I have never stopped thinking about the person two floors up who was.

Nobody in this argument ever asks me about power, and it is the single most decisive thing I know. When somebody tells me a hospital has backup, I now know to ask three further questions and I know that almost nobody can answer them: how long is the changeover, what is on the supply that never breaks, and how many days of fuel are in the tank. I have asked those questions in four hospitals. I got a straight answer once.

The hospital in London never mentioned power to me at all, and that is the point. I did not have to think about it. A very large part of what wealthy countries sell is the right not to have to think about things.

The part nobody warns you about is that you become staff.

I carried the notes between departments, because nobody else was going to. I drove to a different laboratory for a test the hospital could not do that week. I bought consumables from a pharmacy on the road outside and brought them back in a bag. I told the story of my mother's illness eight or nine times, to different people, in the same building, and by the sixth telling I was getting it wrong, and nobody noticed that I was getting it wrong, which frightens me more than anything else about that fortnight.

When my mother needed blood I spent a night ringing relatives and colleagues to find donors. I did that while she was in the building. I want to be careful here, because the staff were not idle or unkind. They were three people doing the work of nine, and the system had quietly decided that the family is the spare capacity. It is free, it is instantly available, and it is desperate, so it will do anything.

In London a woman rang me twice a day. She was not a doctor. She had my mother's case, and she knew where everything was up to, and when I asked a question she either answered it or rang me back with the answer. I have thought many times about what that person costs, and I am fairly sure it is less than the flights.

This is the question that ends the conversation, and I have never once had a good answer to it at home.

If they harm her, what happens? Who do I tell? Is there anybody whose job it is to care, who is not employed by the people who did it? Will a letter be answered? Is there a register the consultant can be removed from? Can I find out what went wrong, or will I get sympathy and a bill?

Abroad, there is a process. I have never used it. I do not personally know anybody who has used it. But it exists, and I could look it up, and knowing that it exists is what allowed me to walk out of that building and leave my mother in it. That is what handing over is. You cannot hand somebody you love to an institution you have no recourse against, and that is not a fact about Nigeria. It is a fact about people.

Everybody frames this as Nigerians wasting money abroad on something available at home for less. It is almost the opposite, and the arithmetic is worth doing slowly.

I am paying out of my own pocket. There is no insurer behind me. That is true of most people doing this, because most health spending in this country comes straight out of the patient's own money. So I am not comparing a cheap option with an expensive one. I am comparing two ways of spending my savings, once, on my mother, with no second attempt available.

Now add the failure case. If I treat her here and it does not go well, I will fly her anyway. Except now she is sicker, I am poorer, and we have lost three weeks. So the real comparison is not local price against foreign price. It is foreign price against local price plus the probability of paying the foreign price anyway, on top, in worse condition.

Once you write it that way, flying is not extravagance. It is the conservative choice, and it stays the conservative choice until somebody gives me a reason to believe the local probability of failure is low. Nobody has ever given me that reason, because nobody publishes anything. The money is not leaving because we are foolish. It is leaving because we are being careful in the dark.

I will say the uncomfortable thing, because leaving it out would make this dishonest.

If I had kept her here and she had died, my relatives would have said that I was cheap. Some of them would have said it to my face at the funeral. That is a real cost and it lands entirely on me, and anybody who has been the child making this decision knows exactly what I am describing.

If I take her to London and she dies, I did everything. Nobody can say anything. I have bought, along with the treatment, the ability to live in my family afterwards.

This is not rational in the way an economist means the word and it is completely rational in every other way. It also means that any hospital hoping to keep us at home is not only competing on medicine. It is competing against what my aunts will say about me for the rest of my life, and it will have to be visibly, unarguably good to win that, because the standard of proof is not the clinical one. It is whether I can point at something afterwards.

The last thing, and it is the one that would worry me most if I were building a hospital here.

The person who told me to take my mother abroad was her Nigerian doctor. Not a stranger, not an advertisement. A man we trust, who has known her for years, who sat in his own consulting room in Lagos and told me that if she were his mother he would send her out.

I have thought about why he said that. Some of it is honest and correct: he knew what she needed and he knew where it reliably was, and he was not going to gamble with her. Some of it, in this market, is arrangements, and everybody knows those exist even though nobody will say so on a page like this.

But the consequence is the same either way, and it is brutal for anyone planning to capture this flow. The single most trusted voice in the whole decision, the one that outweighs every website and every brochure, is already pointing at the airport. You do not win me by advertising to me. You win me by convincing him, and he is harder to convince than I am, because he will know exactly which of your numbers are soft.

I have been asked this before and I want to be useful rather than bitter, so here it is as plainly as I can put it. Six things would have kept my mother in Lagos. Not one of them is a machine.

That is the part I would want somebody spending a great deal of money on a building to understand. I never once doubted that the equipment could be bought. I doubted everything around it, and everything around it is information, process and accountability rather than capital.

Which cuts both ways, and I am aware of it. It means the thing standing between a Nigerian hospital and my money is cheaper than a wing. It also means it is slower, because all six of those are promises that only become worth anything after you have kept them publicly for several years.

Stepping out of the voice, because the finding is the point of the page rather than the testimony.

The demand case for building in Nigeria rests on the observation that the money is already leaving, which is true, and on the inference that a local hospital delivering the same specialties would capture some of it, which does not follow. Every reason above is a reason the flow persists after the capability arrives. None of them is clinical. All of them are about evidence, accountability, ownership of the case and what happens on the bad night.

So the honest reading is that the outbound billion is not addressable demand. It is addressable demand multiplied by a trust factor that starts near zero and rises only with published performance over years. A hospital that builds the capability and does nothing about the evidence problem will be an excellent building with a reputation exactly as good as everybody else's, which is to say unknown, which is to say avoided by anybody who can afford the flight.

It also says something more hopeful, and it is the reason this page ends where it does rather than in despair. The barrier is informational and institutional rather than physical. Published volumes and outcomes, a named and guaranteed consultant, a written escalation path, a person who owns the case, a price fixed in advance and a route to complain are all cheap next to a building, and all of them are things a single operator can simply decide to do, unilaterally, without waiting for anybody else in the market.

And there is a connection worth holding onto, because it ties this page to the staffing argument rather than leaving it as a separate worry. The surgeon in the first chapter trained in Ibadan. The outbound patient and the outbound clinician are the same flow, seen from two ends, and both of them are leaving for the same reason: not an absence of ability, but an absence of the conditions that let ability be trusted and be used. Fix that and you are not running two strategies. You are running one.