“Another abnormal day,” says Paula, one of our expat doctors, in an exhausted voice. “Well, maybe we should say a normal abnormal day,” I replied. “Every day seems to be like this out in Don Bosco.”
Normal abnormal. We’ve become used to expecting the unexpected. But this day had been tough even by our normal abnormal standards. It started badly, with the news when we arrived that little Mbetimale, the baby born prematurely to an HIV-positive mother who had since died, had passed away during the night. We were just absorbing the news when a pregnant woman was carried in on a stretcher by her relatives, all desperately worried. They had taken her during the night to another clinic nearby, as she was bleeding; and she’d been referred to a hospital in Bangui. But for some reason they had brought her to us. Which was a pity, because what she needed was an urgent C-section; and, with no operating facilities here, the only thing we could do would be to refer her as well. By this stage she was in shock, no palpable pulse and very agitated with wide, staring eyes. We tried to stabilise her, but it was too late: within ten minutes, she had died.
I ask myself if she had been taken directly to the hospital in Bangui, could they have performed the caesarian in time to have saved her life? We will never know. What it highlighted for me was the toughness of life here for women, especially during pregnancy. In the developed world, we no longer expect to die during childbirth; in CAR the maternal mortality rate is a horrifyingly high figure.
Since the start of the conflict, access to health care has become increasingly difficult, if not impossible. The abortion rate has risen drastically, many unwanted pregnancies being a result of the war crime of gang rape. And in this stressful environment, premature deliveries are common; the mortality rate of newborns has also risen. At least here at Don Bosco we’re making a good contribution. “Eight safe deliveries today and six during the night,” Vittoria, our expat midwife, hot and dishevelled, told me at the end of one busy day recently. And every morning, the benches for the ante-natal clinic are full of women who have learned the importance of these visits in helping to ensure the delivery of a healthy baby to a healthy mother.
The death of the pregnant woman had been a bad start to the day. And so it continued. The next real emergency – after several cases of children with severe malaria for whom we had been able either to start treatment successfully or refer for a blood transfusion if dangerously anaemic – was the arrival of twin premature babies, just born at home and then rushed in to us. Both tiny, one was suffering from extreme respiratory distress, already tinged with blue from cyanosis, shortage of oxygen. We attached them both to the oxygen concentrator, but it soon became obvious that one would not make it. And soon its tiny body was limp and lifeless.
With the beginning of the rains, we’re approaching the annual peak of malaria. Every day the examination beds in the small emergency department are filled with small bodies, covered in damp cloths to try and bring down their high temperatures, with intravenous catheters inserted to administer the malaria treatment. But soon we hope to be starting a new approach to the annual malaria epidemic that takes millions of lives worldwide: that of prevention. While a vaccine is still being developed, a new drug strategy with a combination of drugs that proved successful in Niger last year and can offer a one-month protection from the malaria parasite will be implemented.
While all this action is taking place in the emergency department, the dressings room tells its own story: of people who let a wound develop until it’s almost gangrenous. Paula, on her first mission, is stunned by what she’s seen; for me, after many missions in Africa, it is, sadly, more of the normal abnormal. But some are indeed unbelievable. One man came in last week with an open, oozing, infected ulcer covering almost half of his lower leg. He’d travelled nearly 100 kms to reach the clinic, in despair at how a small wound, caused by a splinter of wood spiking his leg, had developed into what may now necessitate an amputation.
The backdrop to our work in the clinic is one of continuing violence. As I brought the vaccines to our small team the other morning, I found them talking agitatedly to each other, with shocked expressions on their faces. “It was one of our nurses,” one young man told me. “You remember her, we worked together in Castor”. This was the hospital I worked at when I first arrived. I now learned that the nurse, together with her husband and her two children, had been bludgeoned to death in her own house. A man had recently been murdered and his body put down a well, in an attempt to contaminate the water supply; the opposing armed faction had then gone on the rampage in retaliation. Nearly every day we hear the rattle of gunfire, sometimes close enough that we edge nervously away from the perimeter walls; and in our security briefings in the mornings we’re given the known details, who and where and sometimes the why.
And yet – outwardly, as we drive in convoy down the main road towards the clinic in the Salesian compound of Don Bosco, life seems to continue as normal. The heavy armoured cars, filled with African Union or French troops armed with machine guns, may not be normal for Bangui, but we’re all used to them now. The enormous container lorries jammed with people trying to reach Cameroon for trading purposes may be more than normal, and are guarded by troops, but they’re now a weekly occurrence. And otherwise it’s everyday Bangui life: taxis queue in endless lines for fuel; scores of people bid for the t-shirts being sold from the back of a lorry. A man carries on his head a tall load of freshly-baked baguettes, arranged in diminishing concentric circles; another man balances an even more improbable pyramid of eggs.
These are resilient people, I think as we enter the compound of the IDP camp and head for the clinic, where already scores of people are awaiting us for another normal abnormal day.